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Policy analysts have predicted dire consequences on rural health because of lower Medicaid reimbursement, and KFF Health News published an article on the challenges presented by the ending of dialysis service at one rural hospital. One patient profiled has to drive an additional hour (one-way) to get treatment. An extra hour might not sound that bad until realizing that the patient makes three round trips a week. Another patient decided to rent a place to be closer to treatment. Dialysis is a relatively common procedure, so one can imagine the effect of rural hospitals closing, where patients who are unable to get adequate treatment die earlier.

In this case, the leader of the rural hospital tried to keep the dialysis service going, even reaching out to private companies to gauge their interest in taking over the service's operation. Unfortunately, the hospital "lost $1 million a year on its dialysis service due to low reimbursement rates that didn't cover operational costs" and "they [private companies that might have taken over the service] all passed after realizing they would lose money."

While the legislation that reduced Medicaid reimbursement also introduced a Rural Health Transformation Program, "States can use only up to 15% of their funding to pay providers for patient care," limiting the applicability of that program to cases like the one outlined in this article. The intention of the program is to find better ways of delivering care (for example, new mobile dialysis units or home dialysis), but those ideas do not apply to this case because the program that reimburses the hospital for dialysis would not "cover outpatient dialysis." One of the patients profiled in the article also said that doctors told him that he is not suitable for home dialysis. Even in the optimistic case that new innovations in healthcare delivery are able to challenge many of issues posed by reduced Medicaid funding (it is unclear if anyone truly thinks that case will come to pass), there is still the question of how patients will be affected before those innovations take root.

The Affordable Care Act standardized many aspects of health insurance and granted more protections to patients -- including the guarantee that patients cannot be denied insurance coverage because of pre-existing health conditions. However, such patient protections came with a cost, and the cost of health insurance has risen substantially since then. KFF Health News published an article about how some people are trying to skirt at least some of those patient protections and offer insurance coverage for a lower cost through an option available in fourteen states known as farm bureau health plans. Notably, however, these health plans are not required to accept all patients. As a result, "farm bureau plans may be 30% to 50% cheaper than unsubsidized marketplace plans." Leadership at Tennessee's Farm Bureau Health Plans noted that "People don't like that we underwrite, but if we did everything like the ACA, we'd be just like an ACA plan."

While these plans might sound like a relief to patients looking for lower premiums, they will likely undermine the intent of the Affordable Care Act if they become popular. Essentially, these farm bureau plans will be able to cherry-pick the healthy patients while denying coverage to the expensive patients, leaving those patients for the plans on the Affordable Care Act exchanges. Over time, premiums for Affordable Care Act plans would grow faster than the premiums of these farm bureau plans because the plans would need to pay more for medical care. The article notes that "This creates an uneven playing field for insurers and drives up premiums for the people who can't get into farm bureau plans." Left in place long-enough, these plans could cause the insurance landscape to look similar to what was in place before the Affordable Care Act: healthy people being able to secure more reasonable premiums, and unhealthy people paying for very expensive coverage. It seems that these plans -- which appear to be a perfect substitute for mainstream insurance plans, other than regulatory quirks -- should probably be regulated with the same requirements as mainstream insurance plans.

One tactic that insurance companies use to help contain costs is to require providers to seek approvals before actually performing specific operations (a practice known as prior authorization). It is not difficult to imagine how this practice can go wrong. KFF Health News published an article about one family's struggle with an insurer's delayed approval. The article notes "His family didn't expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life." and that "The insurer said the procedure wasn't medically necessary and that it was considered 'experimental and investigational.'" When the insurer finally did reverse course, "Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure." Notably, the procedure in question (histotripsy) "was a less expensive alternative to chemotherapy, which his insurer had already authorized."

The main question in this context is: who gets to decide whether the insurance company should authorize a procedure? The insurer authorized chemotherapy, but apparently, the family opted not to continue that treatment. Should the insurer be allowed to deny the histotripsy treatment, even if medical experts believe it would help? It appears that enough of the public has tired of challenges with the practice of prior authorization that "By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books." For the state in question for this article (West Virginia), the new law seems rather limited in scope. Presumably, if patients and providers continue to face challenges with prior authorization, stronger regulation will be considered.

A KFF Health News article highlights how a rise in premiums (and loss of subsidies) have prompted people to delay medical care. The article focused on older Americans who might be a few years away from Medicare eligibility, but the rise in effective premiums is quite alarming: "his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income." As another example, "her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum."

While subsidies provide some short-term relief, they do not address the underlying growth in medical costs. Subsidies might actually give providers less incentive to reduce costs, as they mask the cost (which eventually show up in higher premiums) to patients. Subsidies might make sense as a short-term policy, but ultimately, the underlying cost trend needs to be addressed.

KFF Health News outlined the struggles of some primary care physicians: "primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists." The lower salaries (relative to other specialties) has contributed to a shortage of primary care physicians. However, the article also points out that "primary care providers need time and money to manage or prevent illness ... and their insurance reimbursement rates should take that into account," meaning that declining or even stagnant reimbursement rates from insurance companies can have an outsized impact on primary care providers. The article also highlights why many of primary care physicians are keen to retain their independence, rather than, say, work at a large hospital system or for a practice owned by private equity.

One way that some primary care doctors have reacted is to adopt a business model known as "direct primary care," which "bypasses insurance altogether" (and is therefore less accessible to the average patient). However, some other doctors are banding together in what are known as independent physician associations (IPAs), which gives the doctors "power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies." IPAs can also be reimbursed for value-based care where "the medical practice is given a budgeted amount for each patient's care, which provides an incentive to keep them healthy so they need fewer treatments. ... If there is money left at the end of the year, it's split between the practice and the insurer." Many people in the industry have hopes that valued-based care will help slow the growth in healthcare costs.