Posts in category: Insurance & Health Policy Trends

This past summer, the state of Louisiana sent text messages to just over 13,000 Medicaid enrollees, directing them to a website where they could confirm their incomes. The pilot program was part of a broader effort to test digital tools the Trump administration claims will help Medicaid recipients meet new requirements—working, studying, job training, or volunteering at least 80 hours per month—set to take effect in just over a year.

But the initial results were underwhelming. Only 894 recipients completed the quarterly wage check—a participation rate of less than 7 percent—according to Drew Maranto, Undersecretary for the Louisiana Department of Health. “We’re hoping to get more to opt in,” Maranto said. “We plan to raise awareness.”

The stakes are high. Officials in 42 states, plus Washington, D.C., must verify that roughly 18.5 million Medicaid enrollees meet these new work rules by the end of next year. The federal government has allocated $200 million to help states implement systems to track compliance. However, despite the funding, questions remain about the feasibility of these technological solutions.

The policy changes stem from a broader tax and spending law signed under Trump, aimed at freeing funds for priorities such as border security and tax cuts. Nonpartisan analysis by the Congressional Budget Office predicts that the new Medicaid work rules will reduce access to coverage for millions of Americans over the next decade, estimating 10 million fewer people will be insured by 2034—more than half due to the eligibility requirements.

Federal officials, including Mehmet Oz, director of the Centers for Medicare & Medicaid Services (CMS), have promoted these digital tools as a fast and easy way for enrollees to verify their incomes. Oz has suggested the process could be completed “within seven minutes,” claiming that today’s technology makes compliance simpler than ever before. Similarly, Brian Blase, president of the conservative Paragon Health Institute, has argued that artificial intelligence could allow enrollees to report their work or volunteer hours seamlessly.

Yet independent reporting by KFF Health News shows little evidence to support these claims. Federal and state agencies have released scant information on the pilots’ effectiveness. The technology currently being tested in Louisiana and Arizona connects directly to enrollees’ payroll websites but does not use AI to verify volunteer work, educational hours, or other qualifying activities.

State officials and health policy researchers worry the federal government may be overpromising. Medicaid is a state-administered program funded jointly by states and the federal government, meaning that even if federal officials tout a digital solution, the states must implement it themselves. “Oz can say, ‘Oh no, we’re going to fix this,’ but they don’t actually run the program,” said Joan Alker, a researcher at Georgetown University’s Center for Children and Families.

The pilot programs have raised more questions than answers. Arizona officials would not disclose participation numbers or outcomes for their pilot, noting it had only been used for SNAP eligibility verification, a smaller program than Medicaid. Similarly, in Louisiana, the pilot could only confirm income—not whether enrollees were meeting the broader work or volunteer requirements.

Other hurdles remain. Millions of Medicaid enrollees live in rural areas with limited internet access or unreliable cell service, making mobile-first digital solutions inaccessible to some of the very people the program aims to help. Even when tools exist, enrollees need to know about them and understand how to use them—a challenge not solved by technology alone.

Meanwhile, private vendors are pitching apps to states to help track work requirements, but many of these solutions are limited in scope and can only verify income. There is no “magical solution” that guarantees eligible individuals will maintain coverage, according to Jennifer Wagner, a researcher at the Center on Budget and Policy Priorities.

Louisiana and Arizona’s pilot programs underscore the complexity of administering Medicaid work rules in a country where systems vary widely, staffing is limited, and technology alone cannot solve structural issues. State and federal officials continue to experiment, but for millions of Americans, the threat remains that access to health care could be lost simply because the verification process is too complicated or the tools are inadequate.

As the deadline approaches, policymakers, advocates, and enrollees alike are watching closely, hoping that technology can meet the ambitious promises—but preparing for the reality that it might not.

The federal government shutdown has cast a long shadow over American households, with the effects rippling far beyond Washington, D.C. At the center of this stalemate is health care, particularly the future of Affordable Care Act (ACA) tax credits, which have become a key bargaining chip in negotiations to reopen the government. Families and federal employees alike are beginning to feel the real-world consequences of the impasse—uncertainty that could impact everything from grocery bills to paychecks.

Food assistance programs, like the Supplemental Nutrition Assistance Program (SNAP), are teetering on the edge of depletion. Millions of Americans who rely on this support for basic sustenance are bracing for cuts that could leave them scrambling for resources. At the same time, federal health agencies, including the Centers for Disease Control and Prevention (CDC), are confronting layoffs, forcing staff to juggle public health responsibilities with the stress of job insecurity.

Julie Rovner, chief Washington correspondent for KFF Health News, appeared on WAMU’s Oct. 22 “Health Hub” to unpack the political and practical stakes of the shutdown. She explained that the crux of the deadlock lies in lawmakers’ conflicting positions on ACA subsidies, which help make health coverage affordable for millions of low- and middle-income Americans. With tax credits set to expire at the end of the year, families face the prospect of skyrocketing insurance costs and even gaps in coverage, compounding the economic strain caused by frozen paychecks and potential cuts to essential programs.

Rovner highlighted that while lawmakers debate compromises behind closed doors, the human consequences are unfolding in living rooms, kitchens, and workplaces across the nation. Parents are already weighing difficult choices about whether to prioritize rent, groceries, or medical care. Federal employees face delayed paychecks, leaving them in limbo and unsure how to meet monthly obligations. Meanwhile, public health staff are tasked with maintaining essential services under increasingly constrained conditions, raising concerns about the nation’s readiness to respond to emergencies and disease outbreaks.

The shutdown serves as a stark reminder that political gridlock has tangible effects on everyday Americans. While debates over ACA tax credits and government funding continue in the halls of Congress, families and workers across the country are caught in a tightening squeeze, forced to navigate hunger, financial uncertainty, and mounting anxiety about the future.

Julie Rovner’s insights on WAMU’s “Health Hub” underscore the complexity and urgency of the situation: resolving the shutdown is not just a matter of policy—it is a matter of preventing immediate and widespread hardship for millions of people who depend on federal support for their basic needs.

As the federal government shutdown stretches into its fourth week, Americans are feeling the pinch in unexpected ways. The stalemate in Washington over health insurance for millions on Affordable Care Act (ACA) plans has cast a long shadow, but the ripple effects are reaching far beyond the marketplaces. A newly released report from KFF Health News paints a stark picture: over 154 million Americans who receive coverage through their employers now face rising premiums and deductibles, threatening to stretch family budgets to the breaking point.

According to the survey of employers released Oct. 22, premiums for job-based family health coverage rose 6% in 2025, reaching an average of $26,993 per year. That’s the highest three-year increase in more than two decades, reflecting a troubling trend in the cost of healthcare. Over the past five years, the average premium has jumped 26%, outpacing wage growth and approaching the pace of inflation. To put it in perspective, families are now paying roughly as much for coverage as they would for a new Toyota Corolla Hybrid.

Individual coverage isn’t faring much better. The average annual premium for a single worker climbed 5% to $9,325, nearly $3,000 higher than it was in 2016. For workers and families, the cost of health insurance is no longer just an expense—it’s a significant financial commitment that rivals major household purchases.

Eric Trump, controller at Steve Reiff Inc., a small Indiana company specializing in sandblasting and heavy equipment painting, sees the impact firsthand. (No relation to the former president.) He explains that his firm’s premiums rose 8% for 2026, in line with recent years, with employees shouldering about half the costs. Many choose to decline coverage altogether if they can access health insurance through a spouse or parent. “There’s not much we can do,” Trump says. “With only 20 employees, we can’t spread costs out much further.”

Workers’ contributions add another layer of strain. On average, employees pay $1,440 per year for individual coverage and $6,850 for family coverage. Deductibles, meanwhile, continue to climb. More than one-third of workers with employer-based insurance now face individual deductibles exceeding $2,000, up 32% in just the last five years and 77% over the past decade. High deductibles, combined with soaring premiums, force families into difficult choices: pay more upfront for comprehensive coverage, or risk exposure with cheaper plans that carry massive out-of-pocket costs.

Rising drug prices, hospital expenses, and costly new treatments are primary culprits behind the increases. One particular headache for employers has been the proliferation of GLP-1 medications for weight loss. While employees highly value access to these drugs, their steep prices have caused some companies to reconsider coverage or limit access, highlighting the tension between offering competitive benefits and controlling costs.

“Large employers recognize the value of these medications for their workforce,” said Gary Claxton, senior vice president at KFF. “But costs often exceed expectations, forcing some companies to rethink coverage.”

The survey also reveals growing anxiety among workers about their cost-sharing responsibilities. Nearly half of large employers report that employees express moderate or high concern about out-of-pocket expenses, a sign that financial stress is now a common feature of employer-sponsored insurance.

Meanwhile, the broader policy landscape adds uncertainty. Medicaid funding cuts from recent tax and spending legislation are projected to increase the number of uninsured Americans, compounding the pressures already faced by families. Without action from Congress to extend ACA tax credits—which currently help about 22 million Americans—premiums on the marketplaces could double for some consumers as early as January.

KFF’s survey, conducted with 1,862 randomly selected nonfederal public and private employers with at least 10 employees, underscores a sobering reality: healthcare costs are outpacing wage growth, inflation, and most household budgets. Families are now forced to make stark choices—whether to put a new car in the driveway or cover the soaring costs of keeping everyone healthy.

In short, healthcare has become a major line item, rivaling mortgages, car payments, and tuition. The question facing millions of American families isn’t hypothetical anymore: what can you afford, and what will you sacrifice?

Yes, we might be some of the only people who celebrate Open Enrollment like a major holiday—and we can’t help it. We love this time of year! But we get it: not everyone shares our enthusiasm. That’s why we created this friendly, comprehensive guide to help you navigate Open Enrollment 2026 with confidence. If this is your first time buying individual health insurance, consider this your new best friend.

Updated for 2026 Open Enrollment!

This guide is for employees offered an HRA by their employer, whether a Qualified Small Employer HRA (QSEHRA) or an Individual Coverage HRA (ICHRA), who want clear guidance for shopping for individual health insurance.

Every year, we hear the same questions from people navigating health coverage outside of a traditional group plan. Don’t worry—we’ve got you. Our platform will guide you step by step, helping you choose a plan that works for both you and your HRA for 2026.

Section 1: What is Open Enrollment?

Open Enrollment is the annual window when you can enroll in a health insurance plan. For 2026, it runs November 1 – January 15 in most states, with some exceptions:

• Extended deadlines: California, Nevada, New Jersey, New York, Rhode Island, and Washington, D.C. through January 31; Massachusetts through January 23.
• Coverage starting January 1, 2026: You must enroll by December 15, 2025, nationwide.
• Enroll after December 15 but before January 15? Coverage will generally start February 1, 2026.

Medicare enrollees (65+): Open Enrollment runs October 15 – December 7, for coverage starting January 1.

Why the dates are limited
Insurers limit enrollment to prevent adverse selection, which happens when sick people enroll while healthy people don’t, creating unbalanced risk for health plans.

Where to Buy Individual Insurance

During Open Enrollment, you can shop plans through the ACA Marketplace (Healthcare.gov) or your state’s exchange. Plans sold here are called “on-exchange” plans, eligible for subsidies like premium tax credits.

Some insurers also sell “off-exchange” plans directly through their websites. These plans are identical in coverage but do not qualify for subsidies.

Our Take Command platform lets you compare all available plans side by side—including off-exchange options—and highlights Easy Enroll plans, which simplify the sign-up process with our support.

Why Open Enrollment Matters

If your employer offers an HRA, Open Enrollment is the time to purchase a plan for 2026 coverage. You need a plan that works with your HRA, whether it’s an ICHRA or QSEHRA.

• ICHRA: Major medical plans (Bronze, Silver, Gold), Medicare (Part A+B or Part C), Catastrophic plans (under 30 or hardship), Student Health Insurance.
• QSEHRA: ACA-compliant major medical plans, government plans (Medicare, Medicaid, CHIP, TRICARE, VA), dental & vision, limited benefit plans (short-term, accident, indemnity).

Pro tip: If you see a plan with a metal tier (Bronze, Silver, Gold, Platinum), it’s usually HRA-compliant.

Section 2: How to Buy Individual Insurance

Shopping for insurance can feel overwhelming. Start by asking yourself:

• Do I want a lower premium or lower deductible?
• Do I need specific specialists or prescriptions?
• Do I anticipate ongoing medical needs this year (therapy, surgery, pregnancy)?

These factors largely drive your costs. Unpredictable events, like a cold or minor accident, shouldn’t dictate your plan choice.

Our platform lets you:

• Search by provider to see if they’re in-network
• Check if prescriptions are covered
• Compare all options side by side

Good news: Prices for the same plan are the same everywhere—Marketplace, state exchange, or broker.

Medicare and HRAs

Medicare plans (Parts A+B or C) can be reimbursed with your HRA.

We’ve partnered with Chapter, a white-glove service that simplifies Medicare Advantage and Supplemental enrollment, helping cover deductibles, co-pays, and coinsurance costs.

Medicare Open Enrollment: October 15 – December 7

Things to Avoid

• Don’t assume you’re ineligible for premium tax credits—you might qualify!
• Watch out for short-term or indemnity plans; they typically don’t qualify for HRAs.
• COBRA is often more expensive than alternatives. You could pay up to 102% of your previous plan.

Section 3: Premium Tax Credits (PTCs)

Premium Tax Credits are refundable credits that help eligible individuals cover health insurance premiums. Eligibility depends on:

• Household size and income
• Filing status (not Married Filing Separately)
• Marketplace enrollment
• No access to affordable employer coverage

QSEHRA & PTCs: Your employer contribution reduces your premium tax credit dollar-for-dollar.

ICHRA & PTCs: You cannot claim both. If you opt into ICHRA, you forfeit tax credits for that year. If you opt out, you may claim credits depending on affordability.

Section 4: Other FAQs

On-exchange vs. Off-exchange: On-exchange plans qualify for subsidies. Off-exchange plans don’t, but may still be HRA-compliant.

Metal Tiers:

• Bronze: Low coverage, higher out-of-pocket (~40% you, 60% insurer)
• Silver: Moderate coverage (~30% you, 70% insurer)
• Gold: Higher coverage (~20% you, 80% insurer)
• Platinum: Highest coverage (~10% you, 90% insurer)

Network types:

• HMO: Affordable, less flexible, referrals required
• PPO: Flexible, in- and out-of-network access
• EPO: Hybrid of HMO & PPO
• POS: Hybrid; referrals required but allows out-of-network access

Special Enrollment Periods: Big life events (marriage, baby, job change, HRA offer) allow you to enroll outside Open Enrollment.

Dental Coverage:

• Marketplace health plans may include dental.
• Otherwise, purchase separate dental plans—premium reimbursable through your HRA if eligible.

Next Steps

We’re thrilled to be part of your Open Enrollment journey!

1. Log in to your Take Command portal.
2. Compare plans side by side.
3. Select a plan that fits your HRA and coverage needs.
4. Cancel your old plan if switching, to avoid double billing.

Open Enrollment is your chance to take control of your health coverage and make the most of your HRA. We’re here to make the process simple, clear, and even a little fun.

Happy Open Enrollment 2026! 🎉

The Affordable Care Act (ACA) marketplaces, which serve as the lifeline for millions of Americans seeking health coverage, have once again become the center of a heated political debate. This time, the focus is on whether these marketplaces are teeming with “phantom” enrollees—individuals who, according to some analyses, are signed up for coverage but do not actually use any medical care during the year. Republican lawmakers have seized on this narrative as part of a broader argument against extending the enhanced premium tax credits that have helped make ACA coverage affordable for low- and middle-income Americans. These subsidies, set to expire at the end of 2025, have become a flashpoint amid the ongoing government funding stalemate in Washington.

Vice President JD Vance recently stated during a CBS News interview, “The tax credits go to some people deservedly. And we think the tax credits actually go to a lot of waste and fraud within the insurance industry. We want to make sure the tax credits go to the people who need them.” This statement encapsulates the GOP’s position: that the ACA subsidies are rife with inefficiencies, if not outright fraud.

Central to the Republican talking point is a report released in August by the Paragon Health Institute, a think tank aligned with conservative policy circles. Paragon claims to have identified a growing number of “phantom enrollees” in ACA marketplaces—individuals who, according to their data, do not make any claims on their insurance during the year. Paragon president Brian Blase argues that these zero-claim enrollees exceed what one would expect in a typical, functioning health insurance market. According to Blase, this trend points to a system in which insurers and brokers are profiting while consumers, some of whom may not even realize they are enrolled, are left out of the healthcare process.

Paragon’s analysis relies on Centers for Medicare & Medicaid Services (CMS) data, which tracks plan enrollments rather than unique enrollees. This distinction is critical because individuals who switch plans during the year may be counted more than once, inflating the number of zero-claim enrollees. For instance, CMS data shows that in 2021, about 19% of plan enrollments had no associated medical claims. By 2024, that figure had jumped to 35%, a statistic Paragon interprets as evidence of widespread fraud.

Yet health policy experts urge caution in drawing sweeping conclusions from these numbers. Cynthia Cox, vice president and director of the Program on the ACA at KFF Health News, points out that plan-switching, extended open enrollment periods, and partial-year coverage can all artificially inflate the proportion of zero-claim enrollees. “We’re not trying to argue there is no fraud—it exists,” Cox explains. “But the question is, how big is this problem? Just suggesting that anyone who doesn’t use their insurance is committing fraud isn’t accurate. Plenty of people simply don’t need care in a given year.”

Indeed, it is entirely plausible—and statistically expected—for healthy individuals to go a year without filing any claims. The enhanced ACA subsidies implemented under the American Rescue Plan Act of 2021, and extended by the Inflation Reduction Act of 2022, made coverage more accessible and attractive to younger, healthier populations, who are naturally less likely to use their insurance. Research shows that even in employer-sponsored plans, an average of 23% of enrollees made no claims from 2018 to 2022.

Some analysts see the GOP narrative as more about political messaging than a reflection of systemic fraud. Paragon, founded by Blase in 2021, has become highly influential in Republican health policy circles. Alumni from the organization have held positions in the Trump administration and in the office of House Speaker Mike Johnson, which helps explain why the idea of “phantom enrollees” has become a centerpiece in Republican arguments during the federal government shutdown.

Democrats, by contrast, focus on the very real consequences of letting the enhanced subsidies expire. They warn that without Congressional action, premiums will spike, leaving millions of Americans struggling to afford coverage. Speaker Johnson and other Republican leaders counter that the subsidies primarily benefit insurance companies and drive up healthcare costs, framing the debate as a matter of fiscal responsibility and program integrity.

Experts caution that the reality is far more nuanced than either political party suggests. “Somehow the idea that people not using health insurance is a problem—well, it might appear so superficially, but in principle it isn’t,” says Joseph Antos, senior fellow emeritus at the American Enterprise Institute. “Insurance works because some people pay in and don’t make claims. That’s the foundation of risk pooling.”

Trade associations such as the American Hospital Association (AHA) and the American Health Insurance Plans (AHIP) have also challenged Paragon’s claims, emphasizing that ACA plans have strict profit caps and that the enhanced subsidies have reduced out-of-pocket costs for millions of Americans without enriching insurers unduly.

In short, the “phantom enrollees” debate illustrates the complex intersection of policy, politics, and perception. While there is some evidence of enrollment irregularities, much of the data reflects routine behavior in insurance markets rather than massive fraud. At the same time, the discussion underscores the high stakes of the ACA subsidy debate, which directly affects the cost and accessibility of healthcare for tens of millions of Americans.

As Congress continues to grapple with the future of these subsidies amid the federal government shutdown, both sides of the aisle will continue to interpret the numbers in ways that support their broader political goals. For everyday Americans, the takeaway is clear: understanding the nuances of the ACA marketplace is more important than ever, as the consequences of legislative inaction—or overreach—could dramatically alter healthcare access and affordability in 2026.

Amplifying HR Impact with ICHRA: Part 2 – Transform Savings into Retention and Recruitment Power

Continuing our four-part series on leveraging ICHRA savings to elevate your HR strategy, Part 2 focuses on a powerful way to reinvest in your workforce and strengthen company culture. As an HR leader in the tech space, my goal is to empower both the business and our employees. ICHRA isn’t just a benefits tool—it’s a way to elevate your influence at the leadership table and drive meaningful results.

HR Retention Strategies to Consider

You’ve successfully implemented (or are exploring) an ICHRA, captured significant savings, and now you’re ready for the next strategic move: reinvesting in your people. Beyond expanding the HR department, one of the most impactful strategies is directly incentivizing your employees to become your best recruiters and most loyal team members.

Employee Recruitment Incentive Programs

Boosting referral and retention bonuses is a straightforward, powerful way to put your ICHRA savings to work. By reinforcing your commitment to employees while improving talent acquisition and retention, you create a win-win for both your workforce and your company.

Financial incentives are among the most effective tools in the HR toolbox. A generous referral bonus program, for example, turns engaged employees into brand ambassadors. They understand your company culture, know the skills needed for the role, and are perfectly positioned to recommend top-tier candidates from their own professional networks.

Increasing referral bonuses—perhaps by 50% or even doubling them—transforms a simple recommendation into a highly motivated, personal recruitment effort.

Why this works:

• Referral hires typically have higher retention rates.
• They ramp up faster, already equipped with internal support and an understanding of your culture.
• It’s often more cost-effective than job boards or external recruiters.

By channeling ICHRA savings into this program, you’re not just saving money—you’re cultivating a stronger, more cohesive workforce from the inside out.

HR Strategies for Employee Retention

Recruitment is just the beginning. Retention is equally critical. Financial incentives for loyalty and performance send a clear signal that your employees’ contributions are valued. In a job market where hopping from company to company is common, retention bonuses can be the deciding factor that keeps top talent engaged and committed.

Consider:

• Tiered loyalty bonuses for employees reaching tenure milestones.
• Performance-based rewards for team or individual long-term achievements.

These tangible rewards, funded by ICHRA savings, turn loyalty into a mutually beneficial partnership. Employees feel secure, appreciated, and motivated to invest in their long-term growth within your company.

Increasing referral and retention bonuses also levels the playing field for small and mid-sized businesses competing against larger companies with more extensive benefits packages. While ICHRA offers flexible, personalized health coverage, direct financial incentives add another layer of appeal that can attract and retain talent who might otherwise go to bigger names.

The added bonus: A transparent referral program empowers employees to actively contribute to company growth, fostering a sense of shared ownership. In today’s workforce, employees want more than a paycheck—they want their contributions recognized and rewarded. Smartly deployed bonuses communicate that loyalty and effort are not only noticed but celebrated, creating a virtuous cycle of attracting great talent and keeping them for the long haul.

A recent federal watchdog report has raised serious questions about the accessibility of mental health care under private Medicare and Medicaid insurance plans, revealing that many patients may be facing “ghost networks” of providers that exist more on paper than in practice.

According to the Office of Inspector General (OIG) for the Department of Health and Human Services, which oversees the nation’s massive Medicare and Medicaid programs, numerous insurers inaccurately list mental health professionals—psychiatrists, psychologists, and therapists—as available to treat plan members. In reality, many of these professionals either do not have contracts with the plans, are no longer working at the locations listed, or have retired entirely.

The report focused on Medicare Advantage plans and privately managed Medicaid programs, which together cover roughly 30% of all Americans and involve hundreds of billions of federal dollars annually. These insurers receive fixed payments per enrollee and are expected to maintain adequate networks of providers to ensure timely access to care. Yet the findings show a significant gap between expectation and reality.

The OIG discovered that 55% of mental health professionals listed as in-network by Medicare Advantage plans were not actually providing care to plan members. For Medicaid managed care plans, the figure stood at 28%. Investigators found cases in which a provider was listed at multiple practice locations, only for investigators to learn the individual had retired years ago.

Patients are feeling the impact firsthand. Jeanine Simpkins of Mesa, Arizona, experienced the challenge when a 40-year-old family member required mental health care. The family’s Medicare Advantage plan listed numerous rehab facilities, yet when Simpkins called about 20 programs, none could accept her relative due to insurance restrictions. The patient ultimately enrolled in part-time hospital care instead of an inpatient rehabilitation program.

The consequences of these phantom networks are particularly acute for those seeking mental health care. Jodi Nudelman, a regional inspector general who helped author the report, highlighted the vulnerability of these patients. “Acknowledging a need for mental health care is already difficult for many people,” she said. “Any roadblock—like inaccurate provider listings—can discourage patients from seeking help when they most need it.”

The report examined a sample of 10 counties across five states—Arizona, Iowa, Ohio, Oregon, and Tennessee—including both urban and rural areas. Forty Medicare Advantage plans and 20 Medicaid managed care plans were analyzed. While the OIG did not disclose specific insurers, the findings suggest that misleading provider directories may be a widespread issue.

Industry representatives acknowledged the challenges but emphasized ongoing efforts to improve access. Susan Reilly, vice president of communications for the Better Medicare Alliance, noted, “While this report covers a small sample of plans, we agree there is more work to do. Managed care companies remain committed to improving access and ensuring accurate provider networks for our members, working closely with policymakers and regulators.”

To address the problem, the OIG recommends that government administrators make better use of medical billing data to verify whether listed providers are actively seeing patients. Additionally, the watchdogs urge the creation of a national, searchable directory of mental health providers, detailing which Medicare and Medicaid plans each professional accepts. Such a resource would help patients find reliable care quickly and enable regulators to hold insurers accountable for their network claims.

Federal administrators overseeing Medicare and Medicaid have already begun steps toward building such a directory, and managed care companies have expressed support for the initiative. However, the report underscores a persistent disconnect between the promise of mental health coverage and the reality on the ground, leaving many Americans at risk of inadequate care despite being technically “covered.”

In an era where mental health needs are rapidly growing, the watchdogs’ findings serve as a stark reminder: having insurance does not always guarantee access to care. Without proper oversight and accurate information, patients may find themselves navigating networks that exist only on paper, not in practice.

Across the United States, families are waking up to startling news about their health insurance for 2026. In Virginia Beach, one household discovered their deductible will skyrocket from $800 to a staggering $20,000. About 200 miles north, a Maryland family learned they’ll pay an extra $500 every month to keep their coverage. Meanwhile, thousands of Idaho residents were greeted with premium increases averaging $100 per month. The picture is the same nationwide: millions of Americans are facing sticker shock as open enrollment for Affordable Care Act plans begins in select states.

The cause? The enhanced federal subsidies introduced in 2021 to make ACA coverage more affordable are set to expire at the end of this year—unless Congress acts. But lawmakers remain gridlocked, leaving states, insurers, and consumers scrambling to prepare for every possible scenario.

On October 1, the federal government shut down after Congress failed to allocate the roughly $353 billion over the next decade needed to extend these subsidies for roughly 24 million Americans. Republicans have insisted that Senate Democrats must first vote to reopen the government before they will negotiate on ACA costs. Democrats, meanwhile, are calling for a continuation of these subsidies to avoid leaving millions uninsured or underinsured.

The stakes are enormous. If a deal is reached in the coming days or weeks, it could drastically alter the types of plans available, the prices consumers pay, and the very mechanics of open enrollment, which begins on November 1 in most states. Yet the uncertainty has left state-run exchanges in a race against time.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, described the challenge: “We will do whatever it takes to make sure we can provide Marylanders with the most affordable health coverage,” she said. “The mechanics of how that gets done, we don’t really know until we figure out what Congress might do. Everyone realizes that we just can’t flip a switch overnight.”

Even with backup plans in place, Maryland residents face higher premiums, with the state expecting an average increase of 35% next year. Notices reflecting these hikes—based on the assumption that federal subsidies will expire—are already in households and inboxes. One middle-income Maryland family of four, for instance, will see their monthly premium jump from $916 to $1,427.

Most states still rely on healthcare.gov, the federal marketplace, for enrollment. The Centers for Medicare & Medicaid Services (CMS), which manages the site, declined to speculate on how quickly they could implement changes if Congress acts after enrollment begins. “CMS does not speculate on potential Congressional action,” said Emily Hilliard, a spokesperson for Health and Human Services.

States that run their own ACA exchanges, like California, are preparing contingency plans as well. Letters have gone out to policyholders detailing 2026 costs under the assumption that federal subsidies will end. “At no point is it too late,” said Jessica Altman, executive director of Covered California. “We are ready to move any mountain we can possibly move to make changes as quickly as possible.”

California estimates that it could take about a week to reprogram its online marketplace to reflect new pricing if Congress approves the subsidies exactly as they currently exist. Insurers themselves have submitted two sets of premium rates this year: one assuming subsidies continue and another assuming they expire. Many shoppers, however, are being presented with the higher rates that would take effect without federal assistance.

These increases are not arbitrary. Insurers warn that if subsidies expire, healthier, younger customers may drop coverage rather than pay more, leaving a sicker, older pool behind. If Congress reaches a deal, premiums could be adjusted downward—but timing is critical.

The complexity of the situation is evident from state to state. In Virginia, some households face premiums that seem manageable but come with prohibitive deductibles. Deepak Madala, director of Enroll Virginia, described the challenge: a family in Virginia Beach with an $800 deductible now faces a potential $20,000 out-of-pocket cost to keep a similar monthly premium. “They’re deciding whether to go without coverage or switch to a plan with a very high deductible,” he said.

In Pennsylvania, the state-based exchange reports a 102% premium increase for its roughly 500,000 customers, with about a third expected to drop coverage entirely. Idaho, which opened enrollment early on October 15 and will close by December 15, faces a particularly tight timeline. With average increases around 75%, about 20% of enrollees may exit the marketplace. Pat Kelly, executive director of Your Health Idaho, explained that any congressional action after mid-December would leave the state with insufficient time to make changes before the enrollment window closes.

Across the country, states are racing against the clock. Exchanges are ready to update plans, insurers are ready to adjust premiums, and consumers are bracing for dramatic changes in what they’ll pay for healthcare. The looming deadline creates unprecedented uncertainty—one that could affect millions of Americans’ access to coverage, financial stability, and peace of mind.

In short, the countdown to open enrollment this year is more than a calendar—it’s a test of coordination, flexibility, and political compromise. Every day that Congress delays a resolution increases the stakes for families, insurers, and states alike. For millions of Americans, the clock is ticking, and the race for affordable, accessible healthcare has never been more urgent.