In preliminary filings with state regulators, insurers are seeking a median rate increase of 14% for 2027, according to in 16 states and the District of Columbia by the Peterson-Ñî¹óåú´«Ã½Ò•îl Health System Tracker.

If those rates are ultimately approved, it would be the second-highest increase since 2018.

That would be a “triple whammy” for consumers, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF, because they have already had to pay higher premiums in 2026 and saw the expiration of more generous tax credits to offset their premiums at the end of last year.

President Joe Biden sought to bolster the program known as Obamacare by enacting more generous tax subsidies, driving down out-of-pocket costs for consumers and increasing enrollment to more than 20 million Americans. But under President Donald Trump, Republicans have sought to scale back taxpayer support for ACA coverage, allowing the Biden-era enhanced subsidies to expire.

As of February, ACA enrollment had fallen by about 3 million people compared with the same time last year. While Cox and other policy experts say that’s because increased costs for the plans drove out people who feel they can get by without insurance, the Trump administration asserts that much of the enrollment growth under Biden .

The main factor driving proposed premium increases for 2027, as in most years, is the rising cost and use of medical care.

There’s growing demand for costly specialty medications and for the weight loss drugs known as GLP-1s, the Peterson-KFF report notes.

But the report also said that about 4 percentage points’ worth of the premium increases insurers proposed are due to lasting effects of the expiration of enhanced subsidies. Insurers expect that with young and healthy people leaving the program rather than paying higher premiums, their remaining customers will be older, sicker, and therefore costlier on average.

 “It’s likely that the people who dropped their coverage were also the healthier people, because sicker people were probably going to try to make it work however they could, to stretch their budget to keep their health insurance,” said Cox, of KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

In their rate filings, some insurers also said they had to raise premiums partly because of policy changes by the Trump administration that are expected to make it harder for some people to enroll.

Together with the expiration of the larger subsidies, the new rules “account for 12.7% of the requested rate change,” the insurer UnitedHealthcare wrote in its rate filing with New York state, according to the Peterson-KFF report.

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“He was on a nasty, dirty ground in front of a store,” recalled Sonja Smith, who is enraged about the circumstances that led to her husband’s heart failure. “He didn’t deserve to die like that.”

Problems started last year when the couple learned the monthly premium payment for their Federal Employees Health Benefits plan would more than double to $307 and their deductible would also go up. They decided to switch Blackman’s primary coverage to CHAMPVA, a health benefits program for dependents of disabled veterans, which had no premium and a $3,000 deductible.

Smith thought she and Blackman had carefully prepared so that the transition between health plans would be seamless. It was anything but.

After the new health plan became active in January, Smith said, Blackman faced one hurdle after another getting approval for the antirejection medications needed to prevent his body from attacking his transplanted heart. Patients who rely on these drugs can develop severe and life-threatening heart issues if they miss even a few days. She said Blackman had enough medication to last only about a month into the new plan year. He told her just before his death that he had run out.

“I screamed at CHAMPVA. I screamed at the Trump administration. I screamed at the overall healthcare system in this godforsaken country,” she said. “Everybody played a part in what happened to my husband.”

The Department of Veterans Affairs declined to comment on the record about Blackman’s case.

While the couple’s situation was extreme, their challenge of trying to continue a treatment is faced by many who shop for cheaper options as health insurance costs have soared across the country. The United States already has a fragmented health system, in which insurers, clinicians, and drugmakers are largely left on their own to hash out the cost of each medication or service. That lack of standardization leads to layers of bureaucracy for patients; moving to a new plan can ensnare patients in a thicket of red tape, keeping them from care.

Making matters more challenging, Congress didn’t renew covid pandemic-era subsidies that helped lower premiums for Affordable Care Act marketplace plans before this year. The Trump administration is also adding hurdles for people to access Medicaid, a state-federal health insurance program for Americans with low incomes or disabilities, so more people may lose their current coverage.

“We’ve basically set up a series of cracks in our healthcare system that we ask people to jump over,” said , an assistant professor of health policy at the Harvard T.H. Chan School of Public Health. “But if you don’t jump over those cracks, you can lose coverage, or lose access to your doctor, or lose access to your medications.”

‘This Is a Lot’

Insurers calibrate plan prices by negotiating rates with individual clinicians, hospital systems, and drugmakers, leading to varying levels of coverage. Plans with lower monthly costs of doctors and hospitals, and less generous drug coverage.

As a result, when patients choose an insurer — or even a new plan with the same insurer — they may lose access to medications or doctors that they have had for years, said , a research professor in health policy at Georgetown University. There are so many ways “patients could get tripped up,” she said. “When you switch to a new insurance company, they’re going to apply their rules.”

In announced by the Trump administration last year, many insurers voluntarily agreed to reduce some red tape by honoring existing prior authorizations for 90 days when a patient switches health plans. As required by law, they also offer resources such as plain-language plan descriptions and searchable online clinician directories to help patients coordinate care, according to , the main health insurance industry trade group.

“The goal is to ensure every member understands their benefits and can access the care they need without interruption,” said Conner Coles, an AHIP spokesperson.

But patients say understanding their benefits can still be a challenge.

Monique Acosta, 54, had to navigate two health insurance changes after she was laid off from her job at a disability nonprofit in October. The heart transplant recipient and cancer survivor said she paid nearly $900 a month to continue her employer coverage under COBRA, the Consolidated Omnibus Budget Reconciliation Act. Then, in January, the Woodbridge, Virginia, resident switched to Medicaid.

During the transitions, Acosta said, she lost coverage for a postchemotherapy drug. So, she changed her care team to qualify for lower-cost medications through a local hospital’s charity program. Then one of her new doctors reduced the frequency of an injection she had gotten for years. During that time, she said, her red and white blood cell counts plummeted and she struggled to recover from a heart catheterization procedure.

Eventually, her new physician upped the frequency of her injections back to twice a month. “He needed to document it so he could see it himself,” Acosta said. “I was very, very fatigued, very weak, and it’s unnecessarily so.”

Acosta said she is putting off a mammogram until she can better understand her Medicaid plan or find a job with better benefits. “This is overwhelming,” she said. “This is a lot.”

Burden on the Patient

Federal regulations, 43 states, and Washington, D.C., have that require health plans to continue covering doctors and drugs when there is a network change, like when a clinician or hospital that a patient goes to is terminated from the insurer’s network of providers.

But Corlette said that not all the protections address the trip wires people face when they switch insurers on their own, such as during open enrollment or after a major life change.

Still, people can be proactive in a few ways about maintaining care when they change plans, said Shelli Quenga, an insurance agent in South Carolina.

She advises patients to keep written records of their medical and drug history for new providers. Quenga tells her customers to get their new insurance information to their doctors as soon as they switch, not to wait until an appointment. In addition, she said patients can request a case manager with their insurer so they don’t have to repeat their concerns to different staffers.

Even when a patient does homework, doctors can drop out of a network and insurers can change the contours of their plans, McIntyre said.

“Nobody has an incentive to make it make sense,” she said. “This puts a lot of burden on the patient.”

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When Congress allowed covid-era subsidies for health insurance to expire, California used its own funds to offset the hike in Obamacare premium costs for residents with low incomes.

But the reach has been limited.

As Gov. Gavin Newsom negotiates his last budget with the legislature, the Democrat wants to offer financial help to more than 1 in 4 enrollees in Covered California, the nation’s largest state-run health insurance marketplace. Democratic lawmakers, who hold a supermajority, are still debating the plan.

“My budget proposal would KEEP $0 monthly plans for low-income Californians to help clean up the financial disaster Trump created,” Newsom , where he often chides the president and GOP Congress.

have put up their own funds to keep Affordable Care Act plans affordable and residents insured as the rising cost of healthcare has emerged as a among voters. Newsom’s $300 million proposal would make California’s program among the most generous, but even the nation’s richest state can’t patch a left by the expiration of enhanced subsides at the end of last year.

“The gap between what people can pay in their monthly budget and what health insurance costs is so big that it’s a lot for states to take on,” said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “They’re going to have to figure out how they can finance that.”

New Mexico lawmakers have of the lost federal subsidies with state money. It seems to have worked; New Mexico saw in marketplace enrollment this year, but state analysts that the subsidy program isn’t sustainable.

and , which, like California, tax residents , are also spending hundreds of millions of dollars to try to keep premium payments low. Their hope, healthcare experts say, is to avoid the exodus seen in states such as Georgia that didn’t offer enrollees help.

Since the enhanced subsidies expired, have seen their premium payments increase by $65 a month on average.

Conservatives including have long argued that the subsidy expansion was too generous to high-income enrollees and .

“There are never enough subsidies to make health insurance affordable because subsidies are the problem,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “They are causing people to turn a blind eye to fraud and waste and excessive prices because it’s someone else’s money that they’re spending, not their own.”

Helping the Poorest?

People who earn too much to qualify for Medicaid got relief starting in January after Newsom and legislators softened the blow for about 300,000 of the lowest-income enrollees. They offset lost federal premium tax credits for individuals who last year and partially filled the gap for those who earned up to $25,823.

The governor now wants to expand subsidies to those who earn up to $31,920 this year for an individual and $66,000 for a family of four — an estimated 218,000 additional people.

Veronica and William Walter, who live in the San Francisco Bay Area, earn less than $40,000 a year in one of the nation’s most expensive regions. They’re counting on a more generous state healthcare tax credit if they have to pay for health insurance next year.

A car accident two years ago left William temporarily disabled, qualifying the couple for Medi-Cal, the state’s Medicaid program.

Now he’s back at work as a security guard, and Veronica said she’s worried they’ll be kicked off Medi-Cal. She’s even more worried about how they’ll get by with federal premium tax credits not nearly as generous as before.

“Without it, we’re going to be facing worse problems than we have now,” she said. Under Newsom’s proposal, Veronica and others in the highest eligible income bracket could receive an average monthly subsidy of $36 a person.

“For them, $36 a month is the sort of thing that can make a difference between keeping coverage and losing coverage,” said Peter Lee, former executive director of Covered California. “We can’t fix everything with that gap, but we can focus the dollars on those who need it most.”

The Walter family, though, may still face a nearly $200 monthly premium payment to cover both of them, $130 more than they previously paid for healthcare and prescriptions through Covered California.

“I can’t afford that, not really,” said Veronica, a pet sitter who works part-time at a school. “A giant state like this with this many people, and this many resources? You can’t just leave the people with nothing for healthcare or healthcare they can’t afford.”

California policy researchers and health advocates acknowledge the limits of a partial subsidy but say that concentrating funds on those who earn less is the most efficient way to maximize impact. People who drop coverage are , healthier, and less likely to have high healthcare costs — all factors that help stabilize the insurance risk pool. Without coverage, Lee said, they’re also more likely to experience debt from medical emergencies or leave unpaid hospital bills that strain the .

Cary Sanders, senior policy director at the California Pan-Ethnic Health Network, a health advocacy group, said the state’s move last year kept low-income enrollment in Covered California steady and reduced racial disparities in coverage.

“It’s working; it’s just that it’s not enough,” Sanders said. “We need the federal subsidies back.”

Still No Help for Many

When Congress passed enhanced subsidies in 2021, it capped monthly premium payments for even the highest earners at 8.5% of income. Those temporary enhancements allowed about 8 million Americans to choose robust plans with no monthly premium payment last year and helped double Obamacare enrollment to of 24 million.

At the end of last year, 22 million of them lost that help when the GOP-led Congress blocked the extension.

The pressures on Obamacare enrollees don’t stop at premiums. Federal legislation Republicans passed last summer known as the also shortens enrollment windows, tightens income verification requirements for subsidies, and requires enrollees who earn more than they projected to pay back the full amount.

Even if Newsom’s proposal passes, most Covered California customers won’t get state help. Nearly 1 million enrollees — 52% — earn above the $31,300-a-year individual earning cutoff.

Victoria Garzouzi was one of many middle-income retirees hit with one of the most extreme premium increases: The monthly payment for her low-level bronze plan jumped eightfold to $1,600.

To make ends meet, she came out of retirement and dipped into her savings. “I’m working to pay for my insurance,” she said. “I am an army of one.”

Despite a $6,000 deductible, her health insurance premium payment is more than the mortgage on her two-bedroom house. She’s putting off a needed cataract surgery until October, when she turns 65 and qualifies for Medicare.

While GOP leaders have not publicly weighed in on the state subsidies, some Democratic lawmakers have questioned why more help hasn’t been proposed.

Assembly member Dawn Addis, who chairs the chamber’s budget subcommittee on health, suggested Newsom could tap an additional $230 million from a fund for healthcare cost relief — money raised from a state penalty levied on those who can afford to enroll in health insurance but choose not to.

Lawmakers have previously criticized state officials for socking away much of the penalty revenue, which was supposed to go toward healthcare affordability. After California discontinued its premium subsidies thanks to increased federal assistance, the Newsom administration said the state was saving to help consumers once those temporary subsidies expired. Instead, California borrowed from the subsidy fund to cover state budget shortfalls, to the tune of $771 million. Starting this year, the subsidy fund should see an influx of cash as the state pays back the loan.

At a May legislative hearing, Joseph Donaldson, then a Department of Finance analyst, said maintaining the reserve was a prudent and financially sustainable approach.

Dylan Roby, a public health professor at the University of California-Irvine who consults for Covered California, said the focus on lower-income enrollees is deliberate. They qualify for federal subsidies that higher earners don’t, maximizing federal investment and strengthening the broader system.

“You end up with more advanced premium tax credits flowing into the state that you would have been leaving on the table,” he said.

State lawmakers have until June 15 to pass a state budget. Then, Covered California’s board would decide eligibility and benefit amounts, a decision that could come this summer, with new subsidies starting Jan. 1.

Even with the extra help, Walter and her husband worry they won’t be able to afford a potential $200 monthly premium payment. Walter said she’d likely have to rely on free clinics or ration medications.

“I take so many pills, I rattle,” she said. “That, on top of the $200? For us, it really adds up.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

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The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.

Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the of an average hospital stay.

“I don’t gamble. But I may as well,” she said. “This is gambling.”

Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance — plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options — some sold by major insurers, others by small companies or nonprofits — can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.

There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.

Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even .

Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment from 2025, and a of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.

Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February — a 50% increase since last June, it said in a statement.

Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

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Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace — — failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from Ñî¹óåú´«Ã½Ò•îl Health News about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A KFF analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history — growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year — enacted as the One Big Beautiful Bill Act — that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help — such as backfilling part or all of the reduced subsidy amounts with state money — or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample — New Mexico — saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up — either through auto reenrollment or by taking initiative to shop — than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 — the year before covid emerged and two years before enhanced subsidies kicked in — he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles — the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections — growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas — such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

Ñî¹óåú´«Ã½Ò•îl Health News reporter Rachel Spears contributed to this article.

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Public schools and her church’s pantry help Lafortune accomplish the first two goals. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants at a traumatic brain injury rehab center near Tampa, Florida, Lafortune and her husband cannot afford the health insurance benefits offered by their employer. And they earn too much for their daughters to qualify for subsidized coverage through , the state’s safety net health insurance program for children in low-income families.

Her family also can’t afford the $525 monthly cost to enroll her two daughters in KidCare at full price, so she purchased a family plan for $500 a month on the Affordable Care Act marketplace with no dental coverage and higher out-of-pocket costs.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare to close the gaps for families like Lafortune’s, raising the eligibility threshold so that coverage would extend to more than 40,000 children. But the expanded coverage has not taken effect — even after it was approved by federal regulators following a federal lawsuit — because the administration of Florida Gov. Ron DeSantis, a Republican, has not implemented the changes.

Instead, Florida’s KidCare expansion has been mired in lawsuits and ongoing negotiations between the state and federal regulators. While the delay continues, Florida could be violating the law.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Asked to comment on the delay, DeSantis’ office referred Ñî¹óåú´«Ã½Ò•îl Health News to a on March 31, during which the governor directed questions to the state’s Agency for Health Care Administration, which oversees KidCare. The state agency did not respond to Ñî¹óåú´«Ã½Ò•îl Health News’ repeated requests for an interview or information on the delayed expansion.

Entitlement vs. Personal Responsibility

At issue is a , adopted under the Biden administration, that requires all states to continue to provide 12 months of coverage for children in Medicaid and in the Children’s Health Insurance Program, known as KidCare in Florida. That means insurance coverage would not lapse even if parents miss a monthly premium payment.

But only Florida has challenged the rule in court, suing the federal government for the right to disenroll children from KidCare for unpaid premiums and delaying the planned expansion.

“We’ve had to do a lot of back and forth with CMS on various things,” DeSantis said during the March press conference, referring to the Centers for Medicare & Medicaid Services, which regulates public health insurance programs.

In December, Texas also said it opposed the rule. Cecile Erwin Young, who was then the executive commissioner of Texas Health and Human Services, wrote to Mehmet Oz, the CMS administrator, asking him to rescind CHIP rules that require states to keep children enrolled for 12 months at a time, prohibit waiting periods for coverage, and prevent states from imposing financial benefit limits.

“These policy changes effectively redefine CHIP to be more like an entitlement program — a strategy not supported by law and which conflicts with the core program design adopted by Texas,” Young wrote.

Like Texas, Florida views KidCare as a “personal responsibility program” designed to help families by “supporting independence and a ladder towards economic self sufficiency,” according to legal filings and .

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said , policy director for the Florida Health Justice Project. The nonprofit legal aid group, together with the National Health Law Program, on March 9, asking a judge to order the state to implement the approved expansion.

The state agencies had not filed a response to that lawsuit as of April 22. The court ordered the state to explain by mid-May why the expansion should not be implemented.

Williams called the state’s tactic “largely political theater.”

Health policy researchers and advocates also noted that Florida’s refusal to implement the KidCare expansion goes against the Trump administration’s strategy to “.” Last year, a commission appointed by President Donald Trump recommended a series of policy changes, including a collaboration between CMS and state CHIP programs, to promote “evidence-based prevention and wellness initiatives for children at the local level.”

Numerous studies have found that CHIP coverage can improve children’s health by , , and .

“This should go without saying, but you can’t make children healthy again by taking away their health coverage,” said , chief strategy and development officer for Florida Policy Institute, a nonprofit that has advocated for the state to implement the KidCare expansion.

The White House did not respond to a request for comment on Florida’s and Texas’ opposition to the rule requiring continuous enrollment in CHIP.

Those two states have among the . In Texas, more than 1 million children, or 13.5%, have no health insurance, while in Florida more than 400,000 children, or 8.5%, are uninsured.

Texas has followed the federal rule on continuous coverage despite its opposition, but Florida has ignored the requirement and continues to disenroll children for unpaid premiums.

Choosing Between School Supplies and Health Insurance

According to the Florida Healthy Kids Corp., the nonprofit contracted by the state to determine eligibility for and administer KidCare, about 250,000 children received subsidized coverage from Dec. 1, 2024, to Nov. 30, 2025. Of those, 43,000 children were disenrolled after their parents failed to pay the premium.

, director of the Center for Children and Families at Georgetown University, said the Trump administration should act on the evidence that Florida is the only state defying the rule.

“Thousands and thousands of children are routinely losing their coverage in violation of federal law,” she said, “and the Trump administration has done nothing about that. At the same time, they’re pulling money from states like Minnesota for alleged fraud violations that haven’t even been proven yet.”

Families tend to miss premium payments in July and August, when it’s time to buy back-to-school supplies, and again in December and January, around the holidays, Alker said.

“That is very, very sad,” Alker said. “You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance.”

This year, enrollment in KidCare has fallen below the state’s projections, leading to a $32 million surplus in the program. On April 17, legislators from the program and redirect it to the general fund, with that the expansion had not yet been implemented.

Lawmakers voted to expand KidCare eligibility to families earning up to 300% of the federal poverty level. The change would raise the income threshold for a family of four from about $5,500 a month to about $8,250 a month. Monthly premiums for subsidized coverage would also rise, from the current $15 to $20 a month to a maximum of $195 a month, regardless of the number of children a family enrolls.

The program provides coverage than ACA marketplace plans. KidCare has no deductible or coinsurance, and maximum copayments of $15. It also includes dental and vision coverage.

With her ACA plan, Lafortune must pay a $35 copayment for doctor visits. Her family deductible is $1,600, and the coinsurance — or the share of covered services she must pay after meeting the deductible — is 20%. The plan’s maximum out-of-pocket cost is $7,250.

“I tried to get something cheaper, but it’s not like I cannot have it,” Lafortune said of the need for health insurance. “I have to do something.”

The state’s initial lawsuit challenging the continuous eligibility rule was dismissed in May 2024, and a second lawsuit was withdrawn this February. The state and CMS told the judge they were “working to determine the most expeditious way to resolve the dispute” and have yet to update the court on their discussions.

But three days after withdrawing the lawsuit, Florida sued CMS for a third time, accusing the federal agency of ignoring the state’s public records request related to CMS’ approval of the KidCare expansion.

As the legal wrangling continues, the cost of health insurance has skyrocketed.

For those with ACA marketplace coverage, the expiration of enhanced subsidies has hit hard. About half of those who re-enrolled in ACA marketplace coverage for 2026 said their healthcare costs are “a lot higher” this year, according to .

For Lafortune, Florida’s KidCare expansion can’t come soon enough.

“Children are the ones who are going to replace everyone here,” she said. “When you give them opportunities — for their health, for school, to eat — you make your country healthy and better.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

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They discussed the pivotal role the president of the United States plays in health policy — whether it is building support for or opposition to new plans and proposals. “Presidents have a level of authority which is often underappreciated, especially in health care,” Blumenthal said.

Blumenthal and Rovner also discussed the historical reasons the U.S. has been unable to enact universal health care, incrementalism versus sweeping change, and what he described as “the dance” between proponents and opponents — usually a clear party-line split between Democrats and Republicans — of major health care reforms.

Today, the split seems to have come to a head, as public health, science, and expertise are being viewed by one end of the political spectrum as “the opposition,” Blumenthal said, which will complicate efforts. Still, he outlined ideas for moving forward.

An abbreviated version of this interview aired April 23 on Episode 443 of What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News: “RFK Jr. vs. Congress.”

Blumenthal’s latest book, Whiplash: From the Battle for Obamacare to the War on Science, co-written with James A. Morone, offers a behind-the-scenes look at how three presidential administrations pursued very different health policy goals.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

McLeod, who lives near Charleston, South Carolina, is still paying off chemotherapy bills that followed her 2017 diagnosis. She also now faces an onslaught of out-of-pocket costs for follow-up monitoring and care, including regular visits to a pulmonologist and allergist.

McLeod, 45, said she had already spent $2,500 in the first two months of the year and owes an additional $1,300 from a January colonoscopy. That’s on top of the $895 monthly premium for a health insurance plan that covers her family of six.

Those costs have led McLeod to ration her other care. Despite feeling intense chest pain since February, for example, she is putting off a CT scan and a visit to a heart specialist.

“You’re forced to pick and choose as to where your priorities really need to be,” said McLeod, director of strategic programs and partnerships at the Cancer Hope Network, a nonprofit that supports cancer patients. Even in that role, she struggles to navigate the financial aftermath of surviving the disease.

The cost of postcancer care often “keeps us hostage,” she said.

McLeod is one of nearly 19 million U.S. cancer survivors, many of whom continue to need prescriptions, doctor visits, and procedures to monitor their condition and manage posttreatment side effects. Of more than 1,200 cancer patients and survivors , about 47% said they had carried medical debt, with nearly half having owed more than $5,000, according to the American Cancer Society Cancer Action Network.

Yet health policy researchers and patient advocates said the experiences of cancer survivors reveal the limits of the Trump administration’s proposals to lower premiums, which may not help patients who accumulate large medical bills year after year. The proposals center on increasing the availability of high-deductible health plans, which have lower monthly payments but require patients to pay thousands of dollars out-of-pocket before coverage kicks in.

In addition, the administration has supported allowing insurers more leeway to sell plans that are not compliant with the Affordable Care Act. Such plans could bar people who have preexisting health conditions, like a cancer diagnosis, and exclude that ACA plans are required to cover.

The administration did not answer a request for comment on how its proposals would affect cancer survivors. But its supporters say, in general, people would have more flexibility to personalize coverage and more options for plans with lower monthly fees.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, believes patients would have better control over spending, and the option to choose what kind of care gets covered, if health plans were exempted from the ACA’s regulations. A person could opt for a plan that includes cancer treatment but not maternity care, for example.

History proves insurance coverage is not that simple, especially for people with preexisting conditions, said Jennifer Hoque, an associate policy principal with the American Cancer Society Cancer Action Network. When health plans could “pick and choose” enrollees based on preexisting conditions prior to the ACA, people needing the costliest care often struggled to find coverage, she said.

“They’re not going to choose a cancer survivor,” Hoque said of health insurers.

That was the case for Veronika Panagiotou, who said private insurers refused her coverage back in September 2013 because she had a high body mass index. Two months later, as a 25-year-old uninsured graduate student, she was diagnosed with non-Hodgkin lymphoma. The hospital treated her, she recalled, “and sent me all the bills.”

In January 2014, Panagiotou was able to buy one of the first ACA plans that went into effect. It covered chemotherapy and immunotherapy treatment, imaging, medications, hospital stays, weekly blood draws, a blood transfusion, and emergency room visits.

Now Panagiotou, 37, is cancer-free and works as director of advocacy and programs at Cancer Nation, a nonprofit advocacy group. Even though she is covered through her employer, Panagiotou said treatment-related expenses weigh heavily on her life decisions.

“Every choice I make, I think about cancer,” she said.

Chris Bond, a spokesperson for AHIP, the main health insurance trade association, said its members are working to improve access to coverage. But that can be a challenge when doctors and drugmakers are hiking prices, he said. Health plans are trying to “shield Americans from the full impact of those rising costs,” Bond said.

The Lymphoma Research Foundation has seen a 10% increase in applications to its patient aid fund this year, CEO Meghan Gutierrez said. “This trajectory suggests that financial safety nets, when they exist, are straining,” she said.

Rising prices are affecting everyone, regardless of the kind of health insurance they have, if any, said Brian Blase, president of Paragon Health Institute, a Republican-aligned think tank. “The biggest challenge for cancer patients isn’t the type of coverage,” he said. “It’s the underlying cost of care.”

Blase pointed to President Donald Trump’s as potentially helpful to cancer survivors. The Medicare Drug Price Negotiation Program, established by the Inflation Reduction Act of 2022, required the Department of Health and Human Services to negotiate prices for certain high-cost drugs, to lower prices for the federal health insurance program for people ages 65 and older. Drugs for breast, prostate, and kidney cancers are already on that list, .

Yet Hoque fears efforts to weaken ACA protections and financial support for marketplace plans will give cancer survivors — who she said tend to “hang on to insurance for dear life” — fewer options, especially between jobs or during career changes.

Erin Jones, a 31-year-old food policy researcher living in Fort Collins, Colorado, who was diagnosed with Hodgkin lymphoma as a young adult, is now cancer-free but still sees two oncologists, visits a high-risk breast clinic, and gets a breast MRI annually. Jones gets health insurance through the university where she works, and said she recently deferred acceptance to a PhD program partly due to uncertainty over affordable coverage.

“I don’t have the freedom to do the things I want to do as easily,” she said, “because I am constantly worried about health insurance.”

Costs related to surviving cancer, including monitoring for recurrence and treatment of side effects, were expected to reach $246 billion by 2030, up from $183 billion in 2015, according to .

Advancements in both detecting and curing cancer have resulted in a higher percentage of people surviving five years or more after diagnosis, according to the American Cancer Society. The number of survivors is expected to grow to more than 22 million people by 2035, .

Despite these advancements, the cost of treatment can steal the spotlight, said Ezekiel Emanuel, a co-director of the Healthcare Transformation Institute at the University of Pennsylvania and a onetime health policy adviser to former President Barack Obama.

An oncologist, Emanuel said he had observed patients make the difficult decision to delay or skip postcancer care as a result.

“Even when we triumph,” he said, “we don’t seem to be able to have a celebration.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

More changes lie ahead that make it important for those getting subsidies in 2026 to track their income and take steps to protect against that kind of financial hit.

First, the basics of how the subsidies work.

Enrollees pay a percentage of their household income toward their health insurance premiums based on a sliding scale, ranging in 2025 from nothing for very low-income people to 8.5% at higher income levels. Subsidies, usually paid directly to insurers, cover the rest.

The income calculation done during open enrollment is an estimate of what a household thinks it will earn in the coming year. At tax time, ACA enrollees must reconcile what they received in subsidies with what they actually earned. If their income rose, they might owe some of the subsidies back.

But don’t skip filing! People who get ACA subsidies must file tax returns no matter their income, and that is becoming even more important: The Trump administration people from subsidy eligibility if they have gone two consecutive years without filing, and it is proposing lowering that to one year.

Beware Surprise Tax Bills

All enrollees who received subsidies for ACA coverage in 2025 — — need to include a special form, the , with their tax filings. That form is used to reconcile a person’s actual income with the amount of subsidies they received, information the IRS mails them on a separate, . Subsidy amounts are based in part on the income projections they made when they enrolled in their ACA plans.

And that can lead to surprises. Some may find they get money back if their income was less than they estimated. But, if their income went above their initial or updated estimates, they probably qualify for less in assistance and will have to pay money back.

Groups that help people file their taxes say it’s not always easy for people to accurately estimate their income for the year ahead, especially those who run their own businesses, work multiple jobs, or have work that comes with varying hours.

Clients will say, “I can make anywhere between $20,000 and $45,000 next year. I just don’t know,” said Katie Alexander, director of training and volunteers for the health and economic opportunity program at Pisgah Legal Services, a western North Carolina nonprofit that provides free tax and health insurance help to people with low incomes.

Still, for taxes being filed now for the 2025 tax year, on what many people must repay.

That cap is $375 for a single individual who earned less than $31,300 in 2025, or . The maximum owed under that sliding scale for people whose income is on the higher end of the range is $1,625 for an individual and $3,250 for a family.

There is no repayment cap for people earning more than four times the federal poverty level — totaling $62,600 in 2025 for an individual or $106,600 for a family of three — so they could owe back all amounts that exceeded their eligibility.

“The amount is just so staggering for folks,” Alexander said.

One woman whom Pisgah staff helped with pulling together her taxes for 2025 made just above $50,000, which was more than she initially estimated. Her repayment was capped at $1,625, Alexander said. Without that cap, she would have owed $4,000, a substantial chunk of her annual income.

Plan Ahead: The Rules Will Be Tougher Next Tax Season

Congressional Republicans’ One Big Beautiful Bill Act, signed into law by President Donald Trump last summer, . That means come next year’s tax season, there will be no sliding-scale limit to how much people could owe back in subsidies for 2026 if their income exceeds their projections.

“That’s just going to be absolutely devastating,” Alexander said.

There are at least two other things to keep in mind, both stemming from covid-era enhanced tax credits, which expired at the end of last year because Congress did not extend them. One is that the amount of household income people must pay toward their premiums this year before subsidies kick in has risen to just over 2% on the low end of the income scale and up to nearly 10% for higher-income earners.

The second is that households earning over four times the federal poverty level no longer qualify for ACA subsidies.

The biggest financial hit could be felt by enrollees whose income rises enough during the year to exceed four times the poverty level. In that case, they would owe back all the subsidies they receive in 2026.

And that could be a lot.

In 2025, for example, the average monthly premium for ACA coverage was $619, but the average enrollee received subsidies worth enough to offset all but $74 of that, according to the .

There’s another twist for some. Because the enhanced credits were not extended, people are paying, on average, double the amount toward their premiums this year, so they may be looking to add to their incomes to cover the cost. A found that 43% of people who remained enrolled in coverage this year are planning to work more hours or get additional work to cover those costs.

“That makes sense, but it can also present a risk of being eligible for less subsidy money than they thought, or even mean they would have to repay the entire tax credit,” said Cynthia Cox, senior vice president and director of the Program on the ACA at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

People can update their projected income at the marketplace website as it changes during the year.

Pisgah staff are calling people they’ve worked with and saying, “Please, please, please, if your income changes, call us so we can adjust your income through the marketplace,” Alexander said.

As much as possible, keep track of income during the year. This isn’t easy, especially for workers who don’t have a job with regular paychecks.

“If you’re meeting with a CPA to talk about taxes, have a conversation to make sure you’re making enough money to afford your costs, but not too much to lose eligibility for a subsidy,” Cox said. “Contributing toward a retirement plan or a health savings account can lower part of your income that counts toward subsidy eligibility.”

Others might choose to dial back their work hours or forgo a new client contract.

“If taking that extra shift means putting you over the line of 400% of the federal poverty level and that’s going to cost you $10,000 in repayments, maybe don’t take that shift,” said Jason Levitis, a senior fellow at the Urban Institute who follows ACA and tax policy issues.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

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Now, the Trump administration in reducing the problem while simultaneously saying more controls are needed.

It has proposed a for next year, including stepped-up requirements for some applicants to prove eligibility for subsidies or enrollment and new scrutiny of sales agents and marketing practices.

While there is a general acknowledgment that there is fraud in the ACA marketplace, some health policy analysts say these new requirements miss that mark and instead will make it harder for people who are eligible to enroll.

“There is a trade-off, particularly with the provisions focused on consumers, that maybe it will prevent some fraudulent enrollment, but also potentially a large number of valid applicants,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at the Brookings Institution.

In its proposal, though, the administration expresses optimism that efforts already in place will continue to pay off, despite the fact that the number of complaints about unauthorized enrollment or switching rose to 341,906 in 2025, compared with 229,734 the year before Donald Trump took office. Still, according to the rule, “program integrity measures implemented during the past year,” along with the expiration of enhanced tax credits, “are likely to lead to a decrease” in complaints in 2026.

The end of those tax credits also means the amount people pay toward their coverage has increased. Data released Jan. 28 by federal officials showed a year-over-year  enrollments across the federal healthcare.gov marketplace and those run by states. And from KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News, found that of those who remained covered this year, 80% said their premiums or other costs are higher than they were last year, with 51% saying they are “a lot higher.”

Katie Keith, a director at Georgetown University’s O’Neill Institute for National and Global Health Law, said the administration was sending mixed messages, on one hand “talking about its fraud-fighting efforts” being successful, but releasing a proposed rule “that says we have to have all these restrictions on consumers because of fraud.”

Closing Consumer Windows

Last year, the Trump administration reversed some of the Biden administration’s ACA efforts, including eliminating a special enrollment period for low-income people that let them sign up year-round.

This year’s rule includes proposed changes aimed at preventing people from fudging their incomes — higher or lower — to qualify for subsidies.

For instance, applicants whose federal data shows they were previously below the poverty level — and thus not eligible for subsidies — would have to submit additional income verification to show they expect to earn above the poverty level in the coming year.

Another part of the proposed rule would require the federal marketplace, used by 30 states, to step up verification efforts for people who want to sign up outside of the ACA’s annual open enrollment period, for reasons including getting married, adopting a baby, or losing other coverage. Currently, the marketplaces conduct such reviews only when people say they qualify because they lost other insurance, according to an .

The income verification requirements “will be burdensome,” she said.

Some ACA applicants, especially those running small businesses or working several part-time jobs, find it more difficult to estimate or document their anticipated income and might find they’re prevented from getting subsidies, Keith and other analysts said.

These proposals are among policies reprised from last year’s ACA rule and initially intended to take effect in 2026. But several cities filed a lawsuit to challenge those regulations. The judge overseeing the case pending its outcome.

In his order issuing a temporary stay, questioned whether the government adequately responded to questions about the accuracy of data it used in citing widespread fraud.

Additionally, many of the provisions purportedly targeting fraud are “unsupported by data showing that if enacted, they will, in fact, reduce any such fraud,” the judge wrote.

The proposal for 2027 has “new supporting information since the original policies were established” that includes clarifying what documentation is needed for some of the verification processes, Centers for Medicare & Medicaid Services spokesperson Catherine Howden said in an email. In addition, she said that CMS is now reviewing public comments that have been submitted before finalizing the provisions.

Targeting Fraud by Agents, Marketers

Critics of the ACA argue that more-generous subsidies put in place as a response to the covid pandemic, in addition to other changes during the Biden administration, led rogue brokers to enroll or switch people without their consent, seeking to collect commissions. That could be done easily, critics say, because with many plans, subsidies covered the entire premium. The lack of a monthly bill made it easier to sign people up without their knowledge — a long-running problem . When that happens it can leave people unable to access their coverage .

Those expanded subsidies have now expired, but the administration’s proposed rule would still add requirements for agents. For example, they would be barred from providing cash or most other freebies as incentives to enroll, have to use a standard consent form that must be signed by the consumer, and be held responsible if they hired a marketing firm that used questionable advertising to lure customers. That includes touting nonexistent gift cards or making websites look like official government ACA portals. Such websites would have to be removed.

“This would help ensure no additional consumers would see the advertisement and be misled,” the proposal says.

Insurance agents told Ñî¹óåú´«Ã½Ò•îl Health News that some of the proposals, such as delineating what counts as a misleading marketing effort, are good first steps but might not fully address concerns about unauthorized enrollment.

It doesn’t “address all the system vulnerabilities,” said Jason Fine, who runs a brokerage in Florida. He said he has filed more than 100 reports about unauthorized rivals accessing his clients’ coverage over the past two years but has yet to see any of those agents removed from the federal marketplace.

More than 850 agents had their certification suspended with little notice in late 2024 under the Biden administration, which said it was looking into complaints about them. The Trump administration told the Government Accountability Office in May that it had reinstated all or most of those agents to fulfill its “statutory and regulatory” responsibilities, according from the independent oversight group. The report, which outlined long-running fraud problems in the ACA, noted that CMS would continue to monitor those agents and could take “further enforcement action” against them.

Another Biden rule, this one aimed at combating unauthorized sign-ups, remains in place and requires agents to have three-way calls with the client and a federal marketplace call center representative for some enrollments or plan changes.

But Fine and other agents said bad actors are finding ways around that requirement, including by faking that they are the customer during the calls. That contention is backed up in the administration’s new proposal, which notes that federal regulators have received reports that some brokers “may be using artificial intelligence to impersonate consumers and falsely attest to household income.”

Still, the proposal does not include some of the measures agents say would improve the situation.

Fine, for example, said the federal marketplace should more proactively flag unusual activity on consumer accounts, such as multiple agent changes or switches to new insurers within a short period of time, or changes made in the dead of night.

“Overnight is when a lot of this fraud occurs,” Fine said. “No one is changing their insurance at 4 a.m., and that should trigger an automatic fraud alert.” He also wants to see a proposal to rein in overseas call centers that contact U.S. residents — often repeatedly, sometimes making claims about free gift cards or other nonexistent perks — then send their information to agents looking to enroll them or switch their ACA plans.

Others, including Ronnell Nolan, president of Health Agents for America, have also long called for two-factor authentication, similar to what banks require, to confirm that enrollments or switches are approved by the consumer. The 20 states, plus the District of Columbia, that run their own marketplaces incorporate additional measures, including two-factor authentication, few of the types of problems that the federal market has seen, Nolan said. The administration’s proposed rule does not call for this protection.

A conservative think tank, the , estimates there are several million fraudulent enrollments, but other groups — including the GAO, using a different methodology — have put the estimate far lower.

Based on its preliminary analysis, the GAO estimated there were “at least 160,000 applications in plan year 2024 that had likely unauthorized changes,” representing about 1.5% of all applications.

Meanwhile, Brookings’ Fiedler said the debate around the proposal highlights an ongoing question — not just how much fraud exists or what to do about it, but “how much government should help people get covered at all.”

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