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Insurance premiums have been rising for decades now, but the rise for next year is expected to be higher than usual. KFF Health News reports that "insurers nationally are seeking a median rate increase ... of 15% ... That's up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%." Exacerbating the situation is that federal subsidies for premiums are slated to expire at the end of this year. While Congress might extend the subsidies, if they do not, "policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%."

One complicating factor seems to be that at least some insurers are "tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes." The logic appears to be that if premiums are too expensive, then the healthy are more likely to drop coverage, leaving those who need more medical care. To compensate, insurers might need to raise premiums even more the subsequent year, perhaps leading to more healthy people dropping out of the insurance pool. If this cycle repeats, it can lead to what is known as an "insurance death spiral."

Some time ago, Congress passed legislation to protect patients from surprise billing. As KFF Health News points out, though, such protection mostly extends to out-of-network patients (including uninsured and self-pay). Apparently, the legislation also included wording regarding in-network patients, requiring "what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not been implemented, since, nearly five years later, the government still has not issued rules about exactly what form it should take."

Oddly enough, out-of-network (including uninsured) patients appear to have more rights under the No Surprises Act than insured patients. Patients with insurance can request an estimate, but providers appear to not be bound by those estimates. When patients are shocked by some charges (the article cited an example of a provider charging $2,700 for a nasal swab), it seems that providers can simply say "Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause."

Behind the sad personal story that KFF Health News opened their piece with, there is an interesting policy question of who should pay for ambulance rides, and what limits should apply. As background, the No Surprises Act "says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network." However, it appears that ground ambulances were not included in the emergency services covered by the law. As a result, calling for an ambulance ride could trigger an expensive out-of-network bill. Patients do not choose which ambulance service provider is dispatched, and even if patients could select the service, such a choice does not seem practical in light of an emergency.

It seems that 20 states have legislated patient protection against surprise out-of-network bills for ambulance services, but the other states have not. One concern is that "forcing insurers to pay more would lead to higher health coverage costs for everyone." It is probably the case that such policy of requiring insurers to cover ambulance rides would not lead to an immediate and massive jump in premiums, but there remains the policy question of whether the change might cause people to become too cavalier with expensive rides. Still, patients delaying emergency room treatments out of a fear of financial costs may cost the system even more.

The recent budget bill has many provisions, and some of them affect health care. KFF Health News highlighted some changes. Perhaps most significantly, Medicaid comes with a so-called "work requirement", which requires beneficiaries to either have a qualifying exemption ("such as caring for a young child") or "regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month." Another change is to limit a practice known as "provider taxes," where states impose taxes on providers to match federal Medicaid dollars, ultimately bringing in more revenue to the providers. Additionally, enrollees in Affordable Care Act policies "will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll," making it more difficult for people to maintain coverage.

The Medicaid work requirement sounds reasonable on paper (requiring able-bodied adults to show evidence of being "productive"), but the article points out the "astronomical" costs of administering the program. Georgia implemented such a requirement in 2023, spending over $90 million on Medicaid. Of that amount, only $26 million was spent on health benefits (according to one research organization). It seems incredulous that a state would spend more money on overhead than on benefits.

Prior authorizations, the practice of requiring physicians to check with insurers before proceeding with a procedure, has been a source of much frustration within the medical and patient communities. KFF Health News published an article on how some insurers have agreed to various measures to alleviate the frustration, including "making fewer medical procedures subject to prior authorization and speeding up the review process." The article seems pretty clear that insurers are responding to public sentiment and "are hoping to stave off 'more draconian' legislation or regulation in the future."

Interestingly, the federal government is recommending that prior authorization not be required for vaginal deliveries, suggesting that some insurers require approval before agreeing to pay for births. On a separate, but also interesting, note, some states have passed legislation to not require prior authorizations for physicians who have a high rate of approval -- an idea that makes intuitive sense in reducing administrative burden while giving physicians a reason to comply with guidelines.