A teacher’s aide in Melbourne, Florida, Hill is a single mom who works shifts at J.Crew on the weekends to send her daughter to college. Hill and her mother, who lives with her, had been enrolled in an insurance plan through HealthFirst.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

Hill was on the hook for a $2,966.93 MRI, as well as more than half a dozen doctor visits costing about $200 or $300 each. Without that kind of money on hand, Hill said, she put a few of the bills on payment plans and tried to figure out what had gone wrong.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Premium subsidies for ACA plans are automatically recalculated every time coverage is changed because of a life event, such as marriage, a change of job, or a child turning 26. In June, Hill removed her mother from the family’s group plan because she turned 65 and became eligible for Medicare and Medicaid.

The change triggered a recalculation of Hill’s monthly premium contribution, increasing it from $0 to 1 cent. She said she thought the amount was so small that she couldn’t pay it with her credit card.

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

But she said that her doctors collected the usual copayments during subsequent visits and that her insurance broker told her not to worry, reassuring her that the plan was “active.” Hill figured the 1-cent monthly premium was probably a rounding error that couldn’t result in termination, she said.

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

She made an appointment the next day with her broker, who called HealthFirst for clarification. The news was even worse: Not only had her insurance been canceled, but the 5-cent bill could be sent to a collection agency.

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

Others have lost their coverage over owing small amounts, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “This woman’s situation is not so unusual with the enhanced subsidies,” she said.

The American Rescue Plan, passed in 2021, increased the amount of government assistance available to ACA plan holders. Those enhanced subsidies, which Congress let expire at the end of last year, meant enrollees with lower incomes had to pay little or nothing toward their premiums.

The Biden administration found that, in 2023, about 81,000 subsidized ACA insurance policies were terminated because the enrollee owed $5 or less. Nearly 103,000 more were canceled for owing less than $10.

To prevent that kind of coverage loss, most likely hitting people with little income, Biden administration health officials to allow ACA enrollees to retain coverage if they owed less than $10, or less than 95% of premium costs.

Insurers were required to keep insurance active for a 90-day “grace period” to give enrollees time to respond. That’s why Hill’s doctors initially took her copayments and sent no bill, as if nothing had changed.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She filed a complaint in December with HealthFirst and the Florida Department of Financial Services asking for a write-off of her 5-cent balance and retroactive restoration of her policy, citing state and federal laws that seemed to apply to her situation.

In particular, she wrote, “creditors are not required to collect, and consumers are not required to pay, credit-card balances of $1.00 or less,” adding that “all major insurers and payment processors in Florida follow a 1-cent write-off policy.”

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

Weeks after a reporter’s query to the insurer, Hill said she looked at her billing statements for all the medical services she received in 2025 and was pleasantly surprised that the balances owed had been adjusted to $0.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

And while insurance policies have grace periods allowing coverage to remain in place if you miss a payment, some are not very long. For subsidized ACA marketplace plans, the period is 90 days, but others last just 30 or 45.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

Bill of the Month is a crowdsourced investigation by Ñî¹óåú´«Ã½Ò•îl Health NewsÌý²¹²Ô»åÌý that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

Jamie Estrada, de Albuquerque, Nuevo México, recibió en dos ocasiones inyecciones de lidocaína en la parte superior de la columna vertebral para probar si una ablación permanente del nervio trataría su dolor crónico de cuello.

El dolor desapareció hasta que el anestésico dejó de hacer efecto unas seis horas después. Lo más impactante: a su aseguradora le facturaron $28.000 por cada procedimiento de 10 minutos.

A Mark McCullick, de Longmont, Colorado, lo mandaron a hacerse una tomografía por emisión de positrones (PET) de cuerpo completo para averiguar si su cáncer de próstata había regresado. El estudio, de dos horas, no mostró evidencia de cáncer, pero la factura de $77.000 enviada a la empresa que administra su seguro lo alarmó.

La inflación médica la inflación general durante años, y las facturas de muchos procedimientos breves y de rutina llegan a decenas de miles de dólares.

Estos casos destacan las preguntas que afectan al sistema de salud estadounidense y a los pacientes atrapados en él: ¿Cuál es un precio razonable para cualquier consulta o procedimiento médico y cómo se determina? ¿Qué tanto luchan las aseguradoras, supuestas administradoras del dinero de salud que los pacientes ganan con esfuerzo, para reducir los cargos y qué tan de cerca revisan las facturas para verificar su exactitud?

Los casos de Smith, Estrada y McCullick son facturas del “chargemaster”, calculadas a partir de la lista madre de precios que los proveedores de salud asignan a los servicios.

Los pacientes que tienen seguro generalmente no las pagan. Pero son importantes porque a menudo son el punto de partida para el precio negociado que la aseguradora acepta como razonable por los servicios.

Por lo general, los pacientes son responsables de entre el 10 % y el 20 % del precio negociado, su coseguro, y cuando los precios son tan altos, esa puede ser una cifra muy grande. Además, esas tarifas negociadas son difíciles de conocer para los pacientes (hasta que reciben la factura) y parecen arbitrarias.

Además, como las aseguradoras pueden compensar gastos altos en un año aumentando las primas y los deducibles al siguiente, tienen poco incentivo para negociar con firmeza buenos acuerdos para los pacientes que cubren. Así, de forma indirecta, todos los pacientes pagan sin saberlo.

En los casos de Smith y Estrada, sus aseguradoras pagaron la mayor parte sin cuestionamientos. El Centro Médico Hershey de Penn State, que trató a Smith, recibió $61.000, o el 62% de lo que facturó. New Mexico Surgery Center Orthopaedics, que trató a Estrada, recibió $46.000, o el 82%.

La aseguradora de McCullick, en cambio, dijo que pagaría a Intermountain Health solo el 28 % de su factura de $77.000. Luego hubo otro giro: el hospital, que dijo que había obtenido una preautorización, descubrió después que el estudio no estaba cubierto. Entonces le facturó a McCullick la tarifa completa del chargemaster de $77.000 o le ofreció que podía pagar la tarifa en efectivo de $14.259.

En un comunicado enviado por correo electrónico, Chris Bond, vocero de AHIP, el principal grupo comercial de las aseguradoras de salud, responsabilizó a los hospitales por el problema y dijo que los planes están “enfocados en hacer que los beneficios y la cobertura sean lo más asequibles posible para sus miembros”.

Agregó que: “como la categoría más grande por cada dólar de prima gastado, los aumentos en el costo de la atención hospitalaria tienen un impacto desproporcionado en las primas”.

En un sistema de salud en el que los precios pueden variar de manera exponencial con poca transparencia, ¿cómo pueden los pacientes permitirse enfermarse?

“No tiene sentido”

Los estadounidenses como una de las principales prioridades para el gobierno en 2026, según una encuesta de The Associated Press-NORC, y expresaron especial preocupación por el costo, el acceso y la cobertura.

La primera administración Trump exigió a aseguradoras y hospitales que publicaran archivos con precios en efectivo, brutos y negociados para diversos artículos y servicios. Estas listas de precios sin procesar —a menudo cientos de páginas llenas de códigos de facturación médica— para los pacientes.

Cinco años después, han sido recopiladas, analizadas y ampliadas por académicos y empresas emergentes, lo que ha arrojado luz sobre las disparidades en los precios y cómo han surgido.

“Cuando miramos los datos, ya sea del chargemaster o de lo que pagaron las aseguradoras, están por todos lados; no tienen sentido”, dijo Marcus Dorstel, vicepresidente senior de operaciones de Turquoise Health, una empresa emergente de transparencia de precios con pagadores y proveedores como clientes. “La variación es enorme, incluso en una zona específica”.

Cuando investigadores de la Escuela de Salud Pública Bloomberg de Johns Hopkins analizaron los datos, descubrieron que el precio que distintas aseguradoras pagan por los mismos cargos facturados “puede ser tres o más veces diferente en el mismo hospital”, dijo Ge Bai, profesora de contabilidad en salud que participó en la investigación.

Los precios que pagan las aseguradoras se determinan por numerosos factores, incluidos los que establecen sus contratos con los sistemas de salud. Algunos planes, como el de Smith, pagan automáticamente un porcentaje de los cargos facturados por el hospital, lo que incentiva a los hospitales a aumentar sus tarifas.

 El Centro Médico Hershey aumentó sus precios para 11 códigos comunes de facturación hospitalaria en un promedio de alrededor de 30% entre 2023 y 2025, calculó para este artículo Dan Snow, científico de datos de Turquoise Health. Pero esos precios no eran muy diferentes de los de otros hospitales en Pennsylvania.

En otros casos, una aseguradora puede acordar pagar a un sistema de salud una tarifa por caso, una tarifa estándar para un tipo de atención, como una colonoscopía o una hospitalización por neumonía.

Pero hay un elemento adicional lucrativo, llamado “carve-out”, que se refiere a un beneficio específico que se negocia y se paga por separado. Por ejemplo, si el hospital utilizó medicamentos o dispositivos costosos, pueden facturarse además de la tarifa global por caso, sin límites en los recargos del hospital.

Ese fue el caso de la tomografía PET de McCullick; alrededor del 80% del cargo no fue por el estudio en sí, sino por un nuevo tipo de medicamento inyectado antes del estudio para detectar el cáncer.

La mayoría de las veces, los precios finales dependen del poder de negociación relativo de la aseguradora y el sistema de salud: ¿Cuál de las partes tiene suficiente influencia en el mercado como para retirarse si la otra no cumple con sus exigencias?

Esos factores “pueden explicar las variaciones y patrones de precios que vemos”, dijo Dorstel. “En algunos mercados, las aseguradoras fijan los precios y, en otros, los aceptan”.

Para las aseguradoras, pagar más es rentable

Las aseguradoras no tienen incentivos para bajar los precios porque los precios altos significan que “reciben una parte del pastel más grande”, dijo Bai.

Por ley, las aseguradoras deben gastar el 80 % u 85% de las primas en la atención de los pacientes. Pero cuando los precios suben, pueden trasladar el aumento a los clientes en forma de primas más altas y aun así cumplir con su obligación legal.

Así, primas más altas significan menos dinero para el paciente y más ganancias para la aseguradora.

Por cada inyección espinal que recibió Estrada, la tarifa contratada por su compañía de seguros fue de $23.237,50. El coseguro de Estrada fue de $5.166,20. Con un plan con deducible alto, se le pidió que pagara la totalidad de esa factura de más de $5.000.

Cuando llamó para cuestionar la factura, dijo que el administrador del centro quirúrgico le explicó que los cargos eran resultado de un “contrato heredado” con la aseguradora que es “ventajoso” y “favorable” para el centro.

Los cargos de New Mexico Surgery Center Orthopaedics son muchas veces mayores que los del hospital donde los médicos del centro admiten pacientes; allí, la tarifa contratada por la aseguradora de Estrada para la misma inyección es de solo $2.058,67. Y en comparación con los cerca de $20.000 que la aseguradora pagó por cada inyección de Estrada, otras aseguradoras pagan al centro alrededor de $700 por el mismo procedimiento, encontró Snow.

El centro quirúrgico forma parte de un grupo nacional que tiene más de 535 instalaciones quirúrgicas, United Surgical Partners International, que a su vez es propiedad de Tenet Healthcare, un conglomerado de salud con fines de lucro. Ese tipo de dominio del mercado puede dar a las empresas el poder de negociación para cobrar —y recibir— lo que quieran, explicó Bai.

El centro quirúrgico, United Surgical Partners International y Tenet Healthcare no respondieron a múltiples solicitudes de comentarios de Ñî¹óåú´«Ã½Ò•îl Health News.

Con cargos prenegociados, las aseguradoras tienen pocos incentivos para revisar facturas cuestionables. Cuando Smith pidió una factura detallada de su cirugía, descubrió que le habían facturado dos intervenciones: una por la extracción del embarazo ectópico y otra porque el cirujano notó signos de endometriosis y realizó una biopsia. Ambas fueron facturadas a la tarifa contratada de $37.923.

Se indignó por los cargos, que a su juicio parecían un cobro duplicado. “Fue una sola cirugía”, dijo. “Hubo una sola incisión”.

Abogada formada en la Universidad de Yale, Smith consultó las pautas federales de codificación correcta de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), que señalan que los dos códigos de facturación utilizados para su cirugía por lo general no pueden “facturarse juntos para el mismo encuentro con el paciente” porque uno está incluido en el otro.

Smith dijo que se comunicó con el hospital de Penn State, la aseguradora e incluso con el fiscal general del estado sin lograr una resolución. Por eso espera que, a regañadientes, tendrá que pagar el coseguro de $5.250 que el hospital y la aseguradora dicen que debe.

En respuesta a preguntas de Ñî¹óåú´«Ã½Ò•îl Health News, Scott Gilbert, vocero del sistema de salud, no respondió a los detalles específicos de este caso, pero escribió: “Penn State Health reconoce que la facturación de la atención médica puede ser confusa y a menudo abrumadora para los pacientes. El proceso implica muchos factores, incluidos el tipo de atención brindada, dónde se presta y los detalles de la cobertura de seguro del paciente”.

¿Un precio “razonable”?

Después de que un reportero envió múltiples consultas a Intermountain Health, McCullick dijo que un representante le preguntó cuál sería “una cantidad razonable para resolver la situación”.

Sara Quale, portavoz del Hospital Good Samaritan, afiliado de Intermountain donde se realizó la tomografía PET, escribió: “Lamentamos sinceramente la frustración que esta situación ha causado al señor McCullick”, y señaló que “hemos estado en contacto constante con él y continuaremos dando seguimiento según sea necesario”.

McCullick dijo que quiere pagar la parte que le corresponde, pero aún intenta determinar cuál es, sin duda menos que los distintos precios de pago directo que le han ofrecido, todos superiores a $10.000. “La naturaleza cambiante de estas cifras es sorprendente”, escribió en un correo electrónico.

En cuanto a Estrada, estaba tan molesto que decidió no seguir adelante con la ablación del nervio. Mientras lo preparaban para el procedimiento, recordó, el médico dijo que había “escuchado que podría demandar” y lo regañó por ser problemático. El hospital no respondió a una solicitud de comentarios sobre las acusaciones y Estrada dijo que nunca había amenazado con emprender acciones legales.

Estrada se bajó de la camilla y se volvió a poner la camisa. “No voy a dejar que esta persona me introduzca una aguja grande en la espalda”.

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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Jamie Estrada of Albuquerque, New Mexico, twice received injections of lidocaine in his upper spine to test if a permanent nerve ablation would treat his chronic neck pain. His pain vanished — until the numbing agent wore off about six hours later. The real zinger: His insurer was billed $28,000 for each 10-minute procedure.

Mark McCullick of Longmont, Colorado, was sent for a whole-body PET scan to find out whether his prostate cancer was back. The two-hour scan showed no evidence of cancer, but the $77,000 bill sent to the company that administered his insurance alarmed him.

Medical inflation has general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars.

These cases highlight the questions that haunt the American health system and the patients caught in its grip: What is a reasonable price for any health care visit or procedure, and how is it determined? How hard do insurers, the purported stewards of the patient’s hard-earned health dollars, fight to lower charges, and how closely do they scrutinize bills for accuracy?

Smith, Estrada, and McCullick’s cases are all “chargemaster” bills, calculated from the master price list that health providers place on services. Patients who have insurance don’t generally pay them. But they matter because they are often the starting point for the negotiated price the insurer agrees is reasonable to pay for the services. Patients are typically responsible for 10% to 20% of the negotiated price, their coinsurance — and when prices are this high, that can be a big number. What’s more, those negotiated rates are difficult for patients to access (until they get the bill) and seemingly arbitrary.

Also, because health insurers can offset high outlays one year by raising premiums and deductibles the next, they have little incentive to bargain hard for good deals for the patients they cover. So patients all pay unknowingly, indirectly.

In the cases of Smith and Estrada, their insurers paid the majority without questions. Penn State’s Hershey Medical Center, which treated Smith, received $61,000, or 62% of what it charged. New Mexico Surgery Center Orthopaedics, which treated Estrada, received $46,000, or 82%.

McCullick’s insurer, on the other hand, said it would pay Intermountain Health just 28% of his $77,000 bill. Then came another curveball: The hospital, which said it had gotten preauthorization, discovered after the fact that his scan was not covered. So it billed McCullick the full chargemaster rate of $77,000 — or, it offered, he could pay the cash rate of $14,259.

In an emailed statement, Chris Bond, a spokesperson for AHIP, the leading trade group for health insurers, blamed hospitals for the trouble, saying that plans are “focused on making benefits and coverage as affordable as possible for their members,” and that: “As the largest single category per premium dollar spent, increases in the cost of hospital-based care have an outsized impact on premiums.”

In a health system in which prices can vary exponentially with little transparency, how can patients afford to get sick?

‘It Makes No Sense’

Americans as a top priority for government in 2026, according to an Associated Press-NORC poll, expressing particular concern about cost, access, and insurance coverage.

The first Trump administration required insurers and hospitals to publish files containing cash, gross, and negotiated prices for various items and services. These raw, machine-readable price lists — often hundreds of pages filled with medical billing codes — to patient-customers.

Five years later, they’ve been ingested, parsed, and enriched by academics and startups, shedding light on the often-shocking disparities in prices and how they’ve come to exist.

“When we look at the data, whether it’s from a chargemaster or what insurers paid, it’s all over the map — it makes no sense,” said Marcus Dorstel, senior vice president of operations at Turquoise Health, a price transparency startup with payers and providers as clients. “The variation is huge, even in a specific area.”

When researchers at the Johns Hopkins Bloomberg School of Public Health looked at the data, they discovered that the price different insurers pay for the same billed charges “can be three or more times different at the same hospital,” said Ge Bai, a professor of health care accounting who was among the researchers.

The prices insurers pay are determined by numerous factors, including what’s in their contracts with health systems. Some health plans, such as Smith’s, automatically pay a percentage of the hospital’s billed charges, incentivizing hospitals to increase their rates. Hershey Medical Center increased its prices for 11 common hospital billing codes by an average of about 30% from 2023 to 2025, Dan Snow, a data scientist at Turquoise Health, calculated for this article. But those prices were not much different than those of other hospitals in Pennsylvania.

In other cases, an insurer might agree to pay a health system a case rate — a standard rate for a type of care, say a colonoscopy or an inpatient stay for pneumonia.

But there’s a lucrative catch, called a “carve-out,” which refers to a particular benefit that’s negotiated and paid separately. If the hospital used expensive drugs or devices, for instance, they can be billed in addition to the bundled case rate, with no limits on hospital markups. That was the case with McCullick’s PET scan; about 80% of the charge was not for the scan, but for a new kind of drug injected before the scan to detect cancer.

Most often the final prices depend on the relative negotiating power of the insurer and the health system: Which side has enough market sway to walk away if the other doesn’t meet its demands?

Such factors “can explain the price variations and patterns that we see,” Dorstel said. “In some markets insurers are price-makers, and in others they are price-takers.”

For Insurers, Paying More Is Profitable

Insurers aren’t incentivized to lower prices, because high prices mean they “get a slice of a bigger pie,” Bai said.

By law, insurers must spend 80% or 85% of premiums on patient care. But when prices rise, they can pass on the increase to customers in the form of higher premium costs and still meet their legal obligation. So higher premiums mean less money for the patient and more profit for the insurer.

For each spinal injection Estrada received, his insurance company’s contracted rate was $23,237.50. Estrada’s coinsurance was $5,166.20. With a high-deductible plan, he was asked to pay all of that more than $5,000 bill.

When he called to challenge the big bill, he said, the surgery center’s administrator told him the charges were the result of a “legacy contract” with the insurer that is “advantageous” and “favorable” to the center.

New Mexico Surgery Center Orthopaedics’ charges are many times those of the hospital where the center’s doctors admit patients, for example; there, Estrada’s insurance company’s contracted rate for the same spinal injection is just $2,058.67. And compared with the roughly $20,000 the insurer paid for each of Estrada’s injections, other insurers pay the center about $700 for the same procedure, Snow found.

The surgery center is part of a national group that owns more than 535 surgical facilities, United Surgical Partners International, which in turn is owned by Tenet Healthcare, a for-profit health conglomerate. That kind of market dominance can lend companies the negotiating power to charge — and get paid — what they want, Bai said.

The surgery center, United Surgical Partners International, and Tenet Healthcare did not reply to multiple requests for comment from Ñî¹óåú´«Ã½Ò•îl Health News.

With charges prenegotiated, insurers have little incentive to scrutinize questionable bills. When Smith asked for an itemized bill for her surgery, she discovered that she had been billed for two surgeries: one for the ectopic pregnancy removal and another because the surgeon noticed signs of endometriosis and performed a biopsy. Both were billed at the contracted rate of $37,923.

She was livid at the charges, which to her seemed like double-dipping. “That was one surgery,” she said. “There was one incision.”

A Yale University-trained lawyer, Smith consulted the federal Centers for Medicare & Medicaid Services’ , which note the two billing codes used for her surgery generally can’t be “billed together for the same patient encounter” because one more or less is bundled with the other.

Smith said she reached out to the Penn State hospital, the insurer, and even the state attorney general without resolution. So she expects she will, reluctantly, have to pay the $5,250 coinsurance that the hospital and insurer say she owes.

In response to questions from Ñî¹óåú´«Ã½Ò•îl Health News, Scott Gilbert, a spokesperson for the health system, did not respond to the specifics of this case, but wrote: “Penn State Health recognizes that health care billing can be confusing and often overwhelming for patients. The process involves many factors, including the type of care provided, where it’s delivered and the details of a patient’s insurance coverage.”

A ‘Reasonable’ Price?

After a reporter sent multiple inquiries to Intermountain Health, McCullick said an agent asked him what would be “a reasonable amount to resolve the situation.”

Sara Quale, a spokesperson for Good Samaritan Hospital, the Intermountain affiliate where he got the PET scan, wrote: “We sincerely regret the frustration this situation has caused Mr. McCullick,” noting that “we have been in consistent contact with him and will continue to follow up as needed.”

McCullick said he wants to pay his fair share but is still trying to figure out what that is — certainly less than the different self-pay prices he’s been offered, which all top $10,000. “The fluid nature of these numbers is mind blowing,” he wrote in an email.

As for Estrada, he was so angry that he decided not to go ahead with the nerve ablation. While he was being prepped for the procedure, Estrada recalled, the physician said he had “heard he might sue” and chastised him for being a troublemaker. The hospital did not respond to a request for comment on the allegations, and Estrada said he had never threatened legal action.

Estrada got off the table and put his shirt back on. “I’m not going to let this person put a big needle into my back.”

Bill of the Month is a crowdsourced investigation by Ñî¹óåú´«Ã½Ò•îl Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

But by September he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: The skin lesions disappeared, and the joint pain that kept him up at night dissipated. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen — she estimated $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx — another subsidiary of the same parent company, UnitedHealth Group — showed it did not provide a negotiated discount and covered just $308.34 of the full $5,253.85 charge for a 30-day supply. The charges for the second month depleted the copay card and left Mishra owing the balance.

The Billing Problem: Copay Card ‘Tug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program toward a patient’s deductible.

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug — not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply emptied the card — which he originally expected to last a year — and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, good for $9,450, which again wasn’t sufficient to pay for two months’ supply. He again paid the remaining balance in February from his HSA to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them Ìý²¹²Ô»åÌý that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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

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

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

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

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

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

Then the bill came — about two years later.

The Medical Procedure

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

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

The Final Bill

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

The Problem: Ghost Bills From Visits Past

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

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

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

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

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to Ñî¹óåú´«Ã½Ò•îl Health News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”

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

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

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

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

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

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

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

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

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

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

The Resolution

Within hours of Ñî¹óåú´«Ã½Ò•îl Health News contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.

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

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

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

The Takeaway

Ñî¹óåú´«Ã½Ò•îl Health News’ “Bill of the Month” series receives complaints every year about ghost bills — bills that arrive long after a service is rendered.

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

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

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

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

Bill of the Month is a crowdsourced investigation by Ñî¹óåú´«Ã½Ò•îl Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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But there’s another driver of escalating costs and prices playing out in a far broader, more impactful way: the rapid consolidation of insurers, hospital systems, doctors’ groups, and pharmacies into behemoths, effectively giving them monopoly power. 

Calling it “mutually enforced monopolization,” Barak Richman, the Alexander Hamilton professor of business law at George Washington University, told me: “It’s not competition. It’s more like collusion. They don’t care about price.” 

In our market-based system, the price of each service is determined through a complex set of negotiations between an insurer and a provider. An insurer might agree to pay grossly inflated prices for a hospital system’s labs to gain access to that system’s must-have cancer center – and that cancer center might be in a town halfway across the country, where the insurer has a lot of clients. 

The result is high prices: A patient who visits a hospital lab for a simple blood test could be stuck with $1,000 or more in deductibles, copays, and coinsurance.

Studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%. 

At first, anti-competitive consolidation was easy for government regulators such as the Federal Trade Commission and the Justice Department to spot, because it involved hospitals acquiring other hospitals or providers in their own market area. But in recent years, new types of deals have been harder to police. Giant hospital systems now acquire providers far away, deals known as trans-market mergers. Insurers acquire doctors’ practices and specialty pharmacies, often called vertical mergers. 

President Joe Biden had made oversight of health care mergers a priority, issuing that included these new types of consolidation. His FTC chair, Lina Khan, was vocal in her criticism of the trend. 

Her successor under President Donald Trump has signaled a more moderate approach. But in an exclusive interview with Ñî¹óåú´«Ã½Ò•îl Health News, Daniel Guarnera, the director of the FTC’s Bureau of Competition, said that the new leadership at the FTC and the Justice Department has endorsed the 2023 guidelines “as a framing device” for companies contemplating a merger. 

What this means going forward remains unclear. Khan is now advising New York City Mayor-elect Zohran Mamdani.

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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And even well-insured patients receive unaffordable bills in this era of high-deductible health plans, narrow insurance networks, and 20% cost sharing.

Health systems, doctor groups, and insurers are merging and coalescing into ever-bigger giants. While these mergers are good for business, studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%.

These new deals are “mutually enforced monopolization,” said Barak Richman, the Alexander Hamilton professor of business law at George Washington University. “It’s not competition. It’s more like collusion. They don’t care about price.”

Those market factors contributed to a landscape where a dose of the antiviral Paxlovid given in a hospital ; magnetic resonance imaging ; and joint replacements .

President Donald Trump has talked about the burden of health care costs since his first campaign, but he has signaled that his administration’s regulators are less inclined than his predecessor’s to intervene in health mergers.

This summer, President Joe Biden’s that all federal agencies make sure markets remain competitive, reversing course from Biden’s more expansive interpretation of antitrust law. And in a scathing statement upon taking over the Federal Trade Commission, Trump-appointed chair Andrew Ferguson , implying that she had overstepped the agency’s legal authority, as well as criticizing what he called her “clumsy” and “breathless” rhetoric and her focus on the incursion of private equity into health care.

What this will mean in practice is unclear.

In an interview with Ñî¹óåú´«Ã½Ò•îl Health News, Daniel Guarnera, the director of the FTC’s Bureau of Competition, said that the leadership at the FTC and the Justice Department has endorsed guidelines issued by the Biden administration, which he characterized as a “framing device” for companies contemplating a merger.

The expanded , issued in 2023, focused for the first time on a wide variety of new types of anti-competitive practices that had become common in health care, such as hospitals and private equity firms buying doctors’ practices and insurers owning what are known as specialty pharmacies to dispense complicated and often expensive drugs.

Guarnera noted that regulators’ strongest enforcement tool is convincing a judge that mergers violate the Clayton Antitrust Act, a statute that is the foundation of antitrust law. But administrations can interpret this statute differently, and it’s unclear what cases the Trump administration’s FTC will choose to bring.

“The Biden administration tried to be more innovative,” said a professor of health services, policy, and practice at Brown University’s School of Public Health. “The Trump administration has signaled a more traditional approach — that it’s unwilling to push the envelope.”

In the battle for profits between insurers and providers, each side insists it needs to grow bigger to hold sway in the negotiations that determine health care prices. But evidence shows the prices that make sense in industry-level dealmaking have little to do with the actual value of the services involved. Instead, they’re merely a data point in large-scale calculations that, at best, reflect the power balance between opposing parties.

Under Trump, the FTC has already sued to block two mergers of medical-device makers and has continued the Biden administration’s challenges of individual drug patents.

“Helping improve the health care system though ensuring that there is more and better competition are very, very high priorities for us at the FTC,” Guarnera said, noting that health care has “enormous effects on both Americans’ pocketbooks as well as well-being.”

But it is far more difficult to take on the more massive entities, and though the number of new mergers dipped as companies navigated the uncertain effects of tariffs and interest rates, consolidation continues.

A recent identified “28 large health systems growing bigger,” noting, “This is not an exhaustive list.”

For example, in May, Northwell Health of New York Connecticut’s Nuvance to become a 28-hospital behemoth with over 1,000 outpatient clinics. That was a more traditional merger, where hospitals in the same region joined to extend their reach and increase their market power.

Meanwhile, companies are creating powerhouses not previously seen in health care, by racking up smaller purchases that aren’t expensive enough to trigger federal review. They include what are known as vertical mergers, which combine companies that provide different functions in the same industry — most commonly, hospital systems or insurers buying doctors’ practices or specialty pharmacies.

For instance, UnitedHealth Group, the , now owns health insurance plans; physician practices and other providers; data and analytics services; payment processors; a pharmacy benefits manager; and pharmacies themselves. Jonathan Kanter, the competition czar in Biden’s Justice Department, has likened the UnitedHealth amalgamation to Amazon.

Likewise, hospital systems and private companies — often private equity firms — are increasingly expanding their reach to different regions, gobbling up hospitals, medical practices, and surgery centers. This kind of consolidation, known as a , allows companies to accumulate huge collections of doctors — and significant market power — across the country in particular specialties, such as gastroenterology, ophthalmology, pediatrics, or obstetrics.

Research shows a change in ownership means a change in prices. While pediatrics and obstetrics have traditionally been poorly paid specialties, for instance, they represent a land of opportunity to investors because parents are willing to pay more when it comes to care for their kids.

It used to be relatively simple for regulators to discern when a hospital that merged with its nearby competitor gained monopoly power, rendering it anti-competitive and driving up prices. Health researchers say these new, more complicated types of deals, creating a more complex interplay between insurers and medical providers, have made that tipping point to define.

In health care, even more traditional, vertical consolidation can be problematic, Richman said. “Economic theory says it could be innocuous, like a suit manufacturer opening a store, even though studies show in health care it’s dangerous — higher prices, poorer quality, less choice,” he said.

For example, patients who have Cigna health plans and need an array of more expensive, often injectable prescriptions must use Accredo, the specialty pharmacy in 2018, even though a different pharmacy may have a better price.

Economists have developed computer modeling to predict when patients will experience higher prices and less choice because of these new types of consolidation. But judges who could nix the transactions are so far “not convinced,” said Daniel Arnold, a health economist at Brown’s School of Public Health.

Experts such as Fuse Brown say new laws and enforcement tools are needed.

“The old laws,” she said, “are just not calibrated to the complexity and novel types of mergers.”

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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Many young adults are staring down an “insurance cliff” as they turn 26. That’s the age when many can no longer stay on their parents’ health insurance. If they can’t get coverage through their job, they’ll need to start looking for their own. The search can be nerve-racking and confusing. Ñî¹óåú´«Ã½Ò•îl Health News senior contributing editor Elisabeth Rosenthal appeared on WAMU’s “Health Hub” on Sept. 24 to share some tips for finding the right plan.

Read her full article for more help starting your search.

Already have an Affordable Care Act insurance plan? Check out KFF’s to find out how much more you may have to pay next year if enhanced tax credits expire.

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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Hay que considerar que, entre 2000 y 2020, el fluctuó entre poco menos de $1 y aproximadamente $3 la docena; alcanzó los $6,23 en marzo, pero luego bajó a $3,78 en junio.

El precio promedio de la gasolina, tras oscilar entre $2 y $4 el galón durante más de una década a partir de 2005, alcanzó un máximo de $4,93 en 2022 y recientemente volvió a bajar a poco más de $3.

Mientras tanto, desde 1999, las primas de los seguros médicos para las personas con cobertura médica a través del empleador se han . Solo entre 2023 y 2024, aumentaron más del 6% tanto para la cobertura individual como familiar, un alza y la inflación general.

Para muchas personas que tienen planes médicos creados por la Ley de Cuidado de Salud a Bajo Precio (ACA) —porque trabajan para pequeñas empresas o pagan su propia cobertura— es probable que las tarifas hayan aumentado de forma aún más drástica. En este mercado, los reguladores estatales los aumentos de tarifas propuestos por las aseguradoras, pero solo si superan el 15%.

Y la situación está a punto de empeorar: para 2026, las aseguradoras en los mercados de ACA han propuesto : en Nueva York, UnitedHealthcare propuso un aumento del 66,4%. HMO Colorado solicitó un aumento promedio de en ese estado. En Washington, el por todas las aseguradoras es del 21,2%, y en Rhode Island es del 23,7%.

Según Business Group on Health, un consorcio de grandes empleadores, “los costos reales de la atención médica desde 2017”. En una publicada en 2021, el 87% de las empresas afirmó que, en los próximos cinco a 10 años, el costo de proporcionar seguro médico a sus trabajadores se volvería “insostenible”.

Y las aseguradoras del mercado de ACA están aumentando las primas un promedio del 20% para el próximo año, según . Imaginemos que los pagos de alquiler o hipoteca de decenas de millones de estadounidenses aumentaran repentinamente en esa cantidad.

En teoría, los que regulan los seguros que se redujeran las tarifas propuestas, y esto sucede a menudo. Sin embargo, algunos estados son más activos que otros en este sentido. Y todos temen que una interferencia regulatoria excesiva pueda expulsar a las aseguradoras de sus mercados.

Las aseguradoras ofrecen muchas explicaciones para sus cálculos, algunas de las cuales están relacionadas con las recientes medidas del Congreso y del presidente Donald Trump.

Por ejemplo, se espera que los nuevos aranceles a los socios comerciales de Estados Unidos aumenten el costo de los medicamentos y los suministros médicos. Mientras tanto, las incluidas en el proyecto de ley de presupuesto del Partido Republicano, junto con la expiración de algunos subsidios a las primas de la era Biden a finales de este año, provocarán que muchas personas pierdan su seguro médico.

Se prevé que cerca de se quedarán sin seguro en 2034, en muchos casos porque mantenerlo se volverá inasequible.

Dado que es probable que la mayoría de estas personas sean jóvenes o sanas, el grupo de riesgo de quienes permanezcan asegurados será mayor y más enfermo, y por lo tanto, .

“En última instancia, creemos que el mercado de ACA probablemente será más pequeño y estará más orientado a la necesidad del paciente el próximo año”, escribió Janey Kiryluik, vicepresidenta de comunicaciones corporativas de Elevance Health (anteriormente conocida como Anthem), en un correo electrónico. Agregó: “Nuestra postura refleja una acción disciplinada temprana”.

Recuerda que la mayoría de las aseguradoras en el país son empresas públicas con fines de lucro; por lo tanto, tienden a actuar en beneficio de sus accionistas, no de los pacientes cuya atención médica cubren.

Las grandes empresas que gestionan sus propios planes de salud podrían negociar mejores condiciones para sus trabajadores. Pero las empresas más pequeñas, en su mayoría, tendrán que aceptar las ofertas.

Las primas no son el único aspecto del seguro médico que se está volviendo más caro. Los deducibles (el dinero que los beneficiarios deben pagar de su bolsillo antes que el seguro entre en vigencia) también están aumentando. El deducible promedio para un plan plata estándar de ACA en 2025 era de , aproximadamente el doble que en 2014. (Para quienes tienen seguro médico a través de su empleador, el promedio es de poco menos de ).

Algunos estados intentan frenar la tendencia ofreciendo una “opción pública” estatal, un plan de seguro básico y asequible que los pacientes pueden elegir. Sin embargo, han porque una tasa de pago más baja para los trabajadores generalmente significa menos proveedores participantes y un acceso reducido a la atención médica.

Si los votantes prestaran tanta atención al precio del seguro médico como al costo de la gasolina y los huevos, tal vez los funcionarios electos responderían con más medidas.

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Consider that, from 2000 to 2020, fluctuated between just under $1 and about $3 a dozen; they reached $6.23 in March but then fell to $3.78 in June. Average , after seesawing between $2 and $4 a gallon for more than a decade starting in 2005, peaked at $4.93 in 2022 and recently fell back to just over $3.

Meanwhile, since 1999, health insurance premiums for people with employer-provided coverage have . From 2023 to 2024 alone, they rose more than 6% for both individuals and family coverage — and overall inflation.

For many people who have the kind of insurance plans created by the Affordable Care Act (because they work for small companies or insure themselves), rates have probably risen even more drastically. In this market, insurers’ proposed rate increases, but only if they exceed 15%.

And the situation is about to get worse: For 2026, ACA marketplace insurers have proposed : In New York, UnitedHealthcare has proposed a 66.4% rise. HMO Colorado has asked for an average increase of in that state. In Washington, the across all insurers is 21.2%, and in Rhode Island it’s 23.7%.

According to Business Group on Health, a consortium of major employers, “actual health care costs have since 2017.” In a published in 2021, 87% of companies said that in the next five to 10 years, the cost of providing health insurance for their workers would become “unsustainable.”

And insurers in the ACA marketplace are increasing premiums by an average of 20% for next year, according to a . Imagine if tens of millions of Americans’ rent or mortgage payments were to suddenly increase by that amount.

Insurance regulators theoretically that these proposed rates be lowered — and this often happens. But some states are more active than others in this regard. And all are wary that too much regulatory interference could drive insurers from their markets.

Insurers offer many explanations for their calculations, some of which are tied to recent actions by Congress and President Donald Trump. New tariffs on America’s trading partners, for example, are expected to push up the cost of drugs and medical supplies.

Meanwhile, included in the GOP budget bill, along with the expiration of some Biden-era premium subsidies at the end of this year, will cause many people to lose their health insurance. About are expected to become uninsured by 2034, in many cases because keeping insurance will become unaffordable.

Because most of these people are likely to be young and/or healthy, the “risk pool” of those remaining insured will become older and sicker — and therefore .

“Ultimately, we believe the ACA market will likely be smaller and higher acuity-driven next year,” Janey Kiryluik, vice president of corporate communications for Elevance Health (formerly known as Anthem), wrote in an email. She added: “Our position reflects early disciplined action.”

Remember, most insurers in the United States are public, for-profit companies; as such, they tend to act in the interests of their shareholders, not the patients whose health care they cover.

Large employers that manage their own health care plans might be able to negotiate better deals for their workers. But smaller companies, for the most part, will need to accept what’s on offer.

Premiums are not the only part of health insurance that’s getting more expensive. Deductibles — the money that beneficiaries must spend out-of-pocket before insurance kicks in — are also rising. The average deductible for a standard ACA silver plan in 2025 , about double what it was in 2014. (For those with employer-based insurance, the average number is .)

A few states are trying to stem the tide by offering a state-run “public option,” a basic affordable insurance plan that patients can choose. But they because a lower payment rate for workers generally means fewer participating providers and reduced access to care.

If voters paid as much attention to the price of health insurance as they do to the cost of gas and eggs, maybe elected officials would respond with more action.

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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