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Compromised Coverage

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Caroline Catherman

Healthcare Brew delivers the latest news and trends in healthcare.

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About 1.3 million people could lose health insurance in 2026 due to marketplace and Medicaid changes in the 

, the independent Congressional Budget Office estimated Aug. 11.

 ways of paying for healthcare will have 1.3+ million more potential customers amid a “perfect storm” of insurance coverage losses, Sabrina Corlette, founder and director of the Georgetown University Center on Health Insurance Reforms, told us.

 protections, allowing them to charge some customers less in exchange for covering less.

Though some analysts argue these plans offer a good alternative to people who might otherwise go uninsured, the American Hospital Association says their growth could increase the billions of dollars per year hospitals and health systems spend on uncompensated care if these plans stick patients with medical bills they can’t pay.

“We’re going to see a lot more people experiencing medical debt, and the [healthcare] system is not going to be able to absorb all of that,” Molly Smith, group VP of public policy at the American Hospital Association (AHA), told us.

If a patient’s non-ACA plan can’t cover their expenses and they can’t pay, it “erodes the relationship” between patients and hospitals, Ariel Levin, AHA’s director for coverage policy, told us.

(Patients’ trust in hospitals is already low, down to 40% in January 2024, according to a July 2024 JAMA Network Open 

Not to mention, hospitals sometimes waste time and resources going through the traditional billing process for these plans, which often fails, Levin said.

 in the journal Health Affairs Scholar, administrative expenses for 5,639 hospitals were $166 billion, or 17% of total expenses.

“This is obviously a huge problem for hospitals,” Levin added.

In theory, if a patient knows what they’re getting into with these plans and is able to foot the medical bill themselves in the case of an emergency expense, hospitals still get paid. But 8 out of 31 sales representatives for these plans engaged in “potentially deceptive” marketing, like claiming a preexisting condition was covered when it wasn’t, in a 2020 secret shopper 

 from independent watchdog the Government Accountability Office.

Deceptive marketing can lead members to think they have full insurance coverage, then get shocked by hefty bills for 

, both of which ACA-compliant plans are required to cover.

And that marketing seems to be ramping up again.

“Purveyors of these products and arrangements will take advantage of shifts in public policy or periods of consumer confusion to market their products, often deceptively, to try to drive people to buy more,” Corlette said.

Insurance alternatives like healthcare sharing ministries—arrangements defined as nonprofits, not insurance, where members with shared religious beliefs pay a fee each month to cover each others’ medical bills—are using policy changes as a marketing hook to make their case to customers.

“With new ACA restrictions taking effect, many Americans are reevaluating their healthcare options. HCSMs offer a values-based, cost-sharing alternative,” a July 9 

 from self-described healthcare sharing ministry NetWell reads.

On Aug. 15, neither the release nor the main page of NetWell’s website disclosed that this arrangement isn’t insurance, though a small link at the bottom of the site led to disclaimers. After Healthcare Brew reached out for comment, the organization added a line to its main page saying it “is not an insurance company but a religious healthcare sharing ministry.”

A nondenominational crowdfunding company, 

, made a case for the benefit of its plans in a July 21 

 where it argues its ACA-exempt arrangement “shines for healthy families or individuals losing ACA subsidies.” CrowdHealth’s post specifies in the third paragraph that it isn’t insurance.

Netwell and CrowdHealth didn’t respond to requests for comment.

Promotional efforts will likely ramp up more when the ACA marketplace open enrollment period begins Nov. 1 and people see their 

If enough people are swayed away from the marketplace, 

 say the growth of arrangements like short-term, limited-duration plans could alter the risk pool and drive up premiums, which are already expected to 

Close up of a healthcare cross in a transparent box with "low cost" and "buy now!" stickers.

Insurance alternatives ramp up advertising ahead of ACA changes

With millions potentially set to lose coverage in 2026, it may just be their time to shine. 

With pandemic-era Affordable Care Act (ACA) subsidies due to expire at the end of the year, health insurance alternatives could take advantage.

A June 11 report from global professional services firm Alvarez & Marsal (A&M) predicts that more beneficiaries might soon ditch insurance coverage for options like 

 plans or healthcare sharing ministries (

), which aren’t regulated like health insurance and aren’t required to comply with ACA protections like covering maternity care or pre-existing conditions.

Craig Savage, A&M managing director and health plans and managed care practice leader, told Healthcare Brew that A&M has recently worked with “one of the larger” HCSMs—which he declined to name—to help the ministry scale in anticipation of more enrollment.

“They are really gearing up for growth in membership,” he said. “The market dynamics, the environment in which we find ourselves, I think, is going to lend itself to those health sharing ministries.”

Health insurance policy changes proposed in President Trump’s “big beautiful bill” would 

 of people, potentially sending them in search of a cheaper health plan alternative, Savage explained.

 at the end of 2025, and neither the Trump administration nor Congress has yet moved to extend them. CVS Health’s Aetna is 

 the ACA marketplace, affecting about 1 million beneficiaries in 17 states—and more payers 

Republicans in Congress have also proposed 

 significantly or adding work requirements.

The Congressional Budget Office predicted on June 4 that the expiration of subsidies could cause 4.2 million people to lose health insurance coverage by 2034, and that further changes to Medicaid and marketplace rules could impact millions more.

Savage also thinks it’s possible the Trump administration may expand flexibilities in some way for alternatives like short-term, limited duration plans—like he did 

“I think they will show greater flexibility in the structure and the requirements of these short-term duration products. I don't know how that will manifest itself,” Savage said.

Right now, enrollment in insurance alternatives is relatively low compared with more traditional options: In 2023, about 305.2 million people had health insurance at some point, according to the US Census Bureau, compared to at least 1.5 million in HCSMs, per a 

 from Colorado’s state insurance regulator.

The most recent enrollment count for short-term plans comes from a 2020 Democratic Committee staff’s oversight investigation, which found there were about 3 million people enrolled during 2019 across nine companies.

Savage also said that payers are promoting a type of plan that became available in 2020: individual coverage health reimbursement arrangements (

), where employers give workers money to buy their own individual market plan through the ACA marketplace.

In contrast with short-term plans and HCSMs, these plans are governed by the Affordable Care Act and are required to provide minimum coverage for things like pregnancy and pre-existing conditions.

He pointed to Centene as an example. In a February call, the insurance company’s CEO Sarah London called ICHRA “the future of health insurance for working Americans.”

“I haven’t heard health plans…talk a lot about these short-term duration products as much as I’ve heard, you know, a Centene talk about ICHRA products,” he said.

Doctor and patient on the left and white house on the right

As ACA uncertainty grows, so do health plan alternatives

A&M says looming policy shifts could drive millions away from the ACA-regulated market.

The most common form of employer-sponsored health coverage is getting a modern twist.

In 2024, nearly two-thirds of people in the US with employer-sponsored health insurance were in 

 plans where businesses pay their employees’ medical bills directly rather than using a health insurance carrier.

But in recent years, employers have increasingly hiked up deductibles and employees’ cost-sharing liability for self-funded plans to avoid steep premium increases, Ariel Levin, the American Hospital Association’s (AHA) director of coverage policy, told Healthcare Brew. This transfers costs to patients who can’t always pay, adding to a mountain of medical debt US hospitals already face. (

 of US hospital bills go unpaid, Becker’s Hospital Review reported in February 2024.)

Enter companies like Centivo, a health plan for self-funded employers that covers about 77,000 members from 160 businesses, Centivo CEO and co-founder Ashok Subramanian told Healthcare Brew.

Centivo started in 2017 and is backed by investors like Bain Capital Ventures and JPMorgan Chase’s 

. Most Centivo enrollees don’t have deductibles at all, Subramanian said, while individuals on employer-sponsored plans shoulder an average deductible per person of $1,930 nationwide, according to KFF.

The average Centivo enrollee pays $409 out of pocket per year, according to the company’s website, compared to a national annual average of more than $1,142, per the 2024 Milliman Medical Index.

“We are seeing more and more companies enter the market that are really trying to get at that high patient cost-sharing issue,” Levin said.

At this point, readers of Healthcare Brew’s 

 might have alarm bells going off in their heads. Because often, if a health plan sounds too good to be true, it is.

But unlike plans that sidestep federal coverage rules (like short-term, 

 plans), self-funded plans are still subject to some of those requirements and must cover services like inpatient care, Molly Smith, AHA group VP of public policy, told Healthcare Brew.

“The way the rules are set up is that it really is supposed to be comprehensive coverage,” she said.

Subramanian said the company meets or exceeds traditional coverage standards.

“We’re not saving money by reducing access to care,” Subramanian said. “If you’re having a baby, if you need mental health coverage, if you need primary care, if you need a heart transplant, all of that is covered.”

Centivo saves money in part by prioritizing primary care, going so far as to launch a virtual clinic with free appointments for members earlier this year, Subramanian said.

The company charges employers a flat fee per employee per month, incentivizing the health plan to keep costs low, he added. It also charges a bonus if Centivo saves the employer money compared to the employer’s old health plan arrangement.

Centivo also contracts directly with healthcare providers, intentionally choosing affordable health systems.

On top of that, Centivo performs the duties of a third-party administrator that self-funded employers often hire to handle insurance company-esque tasks like processing claims and collecting premiums.

Centivo’s model is winning over major health systems, too. In October 2024, Centivo announced it had partnered with Mercy, which became its only in-network provider in the St. Louis area.

David Thompson—Mercy’s SVP, chief growth officer, and president of population health—told us Centivo started selling in the market in February, and based on the health plan’s growth in other markets, said Mercy hopes Centivo will help bring in about 20,000 more patients and 30–35 total employers by the end of 2026.

He said Centivo’s model is “a perfect example of a solution” to rising healthcare costs.

Centivo also offers a plan for self-funded employers in the Orlando market.

The twist: In both St. Louis and Orlando, the plan is a narrow network, meaning only one health system is in-network (Mercy and Orlando Health, respectively).

This is in contrast with a broad network, where providers at most—if not all—major health systems in the area are in-network.

The tradeoff: In narrow networks like these, partnering systems may be motivated to give health plans lower prices because they expect to get nearly 100% of the plan’s patients, according to a 

 in the journal Medical Care Research and Review.

Mike Stubee, VP of payer strategy at Orlando Health, told us the Florida system gives discounted rates to Centivo and other exclusive partners for that reason.

The question now is how long programs like Centivo will take to catch on.

Both Mercy and Orlando Health have other programs to cut down health costs through direct contracting, which is when self-funded employers negotiate and partner directly with providers without insurance companies in the middle.

“If the issue is the employer can no longer afford to provide coverage, that’s an existential threat for us…so we would rather give an employer a discount on the front end,” Stubee said.

But uptake hasn’t been as fast as expected in Orlando, Stubee said. He believes a mix of pandemic-related disruption and employee hesitancy around narrow network plans may be to blame. (It’s worth noting the pandemic may have 

 uptake of direct contracting in other markets.)

“To not see more employers going down this pathway, it does make you wonder: What else is it going to take for people to get there?” he said.

A new wave of self-funded plans is shifting from cost cutting to value building, with health systems along for the ride.

Amid rising costs, self-funded health plans are getting a makeover

series, where we explore insurance plans and alternatives and the problems that come with them. Read the

Five months after regulations curbed short-term, limited-duration health plans to four months maximum, their future is once again in flux.

 on Jan. 10 that, if passed, would undo last year’s changes, reverting the maximum coverage period back to a 36-month limit enacted during the first Trump administration.The bill would also revoke a requirement for payers to provide disclaimers saying that these plans are not comprehensive coverage.

The plans were originally designed to fill gaps in coverage—like when someone transitions between employers—and generally receive a special carve-out from minimum coverage requirements because they don’t qualify as “individual health insurance coverage” under the Public Health Service Act, according to the Centers for Medicare and Medicaid Services.

The quality of these plans varies dramatically, and consumers often end up with expensive consequences, experts told Healthcare Brew.

“These plans really create financial barriers to people getting care that they need to stay healthy,” Molly Smith, group VP of public policy at the industry’s largest trade group, the American Hospital Association, told Healthcare Brew.

Some states have their own limits on short-term, limited-duration plans, ranging from banning them altogether to imposing time limits below the federal cutoff.

When federal regulations first defined them in 1997, short-term plans weren’t subject to rules except one: People couldn’t be on them for more than 12 months.

The Obama administration shrank that limit to three months, effective in 2016. Then the Trump administration stretched it to three years in August 2018 by allowing the plans to last 12 months for an initial period and be renewed for up to 36 in total, according to an August release.

The Biden administration retracted the limit to four months total for any plans sold after Sept. 1, 2024.

A federal register document from last April cited an Illinois man who was diagnosed with Stage IV cancer a month after enrolling in a short-term plan. His cancer was deemed a pre-existing condition, leaving him on the hook for $800,000 of medical debt.

“For the people who are getting the skimpier short-term plans, I think there is good reason to be concerned that they’re not adequately protected against the financial risk associated with getting sick,” Matthew Fiedler, a senior fellow with the Center on Health Policy at nonprofit research organization Brookings Institution, told Healthcare Brew.

But there’s no guarantee Biden’s resolution will stick.

“I would expect the second Trump administration to go back to the first Trump administration’s rule,” Fiedler said.

While Trump has not mentioned these health insurance alternatives during his campaign or his first few weeks in office, under his last term, business for these short-term plans boomed. The White House did not respond to a request for comment.

A 2020 Democratic Committee staff’s oversight investigation found an increase of over 600,000 patients enrolled in short-term, limited-duration plans after Trump relaxed regulations, from 2.36 million in 2018 to about 3 million consumers in 2019.

The plans’ supporters argue these non-ACA regulated plans, through individual underwriting, can offer healthier people cheaper premiums and get more people insured. This is a similar argument for other insurance alternatives, like 

“The Biden administration’s rule limiting Americans’ healthcare choices is misguided and costly,” Congressman Vern Buchanan (R-FL), one of the House members trying to repeal the limitations, said in a statement on Jan. 15.

The 2020 congressional oversight report found, however, that though these plans can offer cheaper premiums, their sometimes “bare bones” coverage may contribute to higher out-of-pocket expenses when patients fall ill.

 by Milliman, a health benefits consulting firm, had a similar conclusion, calculating that someone with lymphoma may pay $16,800 more in out-of-pocket expenses over six months with this kind of plan than with an ACA-protected one, for instance.

Smith told Healthcare Brew that hospitals are taking financial losses because they are absorbing unexpected costs from people on these short-term plans.

“They are increasingly putting financial assistance toward individuals who supposedly have coverage, but who have cost-sharing obligations that they can’t pay,” Smith said.

At the same time, a limited plan is better than no plan.

Fiedler added that there may be more demand for these plans if and when the currently expanded ACA marketplace subsidies 

“Once you go back to the base ACA subsidies, there are going to be a lot more people for whom they could get a lower premium by going with a short-term plan,” Fiedler said.

Woman calculating expenses and bills. Credit: staticnak1983/Getty Images

Short-term health plans: Bargain or burden?

These plans are like a bargain bin mystery box for healthcare.

Nicole Ortiz

The end of the year is finally here, and we’re reflecting back on some of our favorite reporting from our talented colleagues.

This year saw changes that included a presidential election to a reckoning in the retail pharma space as companies like 

 struggle to climate change-fueled hurricanes impacting 

Here’s what we’ve enjoyed reading the most from each other.

Abortion protections are on the ballot in 10 states this November. Here’s what’s at stake

I loved this story because of the amount of time and research 

 poured into giving readers an in-depth look at a topic that is deeply important and personal for so many. From the sources she spoke with to the quotes she selected, Caroline did a great job telling this story from multiple angles.

Pharma companies are going all in on rare disease treatments

 is great at looking beyond the surface of healthcare trends, and this article is a prime example. The Orphan Drug Act was effective—was it too effective? She does a fantastic job of laying out the pros, cons, and lasting impact of a law that was published more than a decade before she was born.

From pigs to payouts, weighing solutions for the US kidney shortage

Apparently, there’s no such thing as a free kidney. I loved how this story from Caroline got into the weird weeds surrounding compensation and reimbursements associated with donating and accepting a kidney. The best thing is the somewhat happy ending: There are solutions in the works to solve the organ shortage.

I’m going to cheat and pick both stories in Caroline’s Compromised Coverage series so far. One piece dove into 

 and how patients are paying millions into plans that aren’t regulated by the federal government. The other looked into 

, which a number of farmers around the US turn to for coverage even though that disqualifies them for Affordable Care Act subsidies. I’m totally inspired by Caroline’s dedication to break down and uncover the ways people are trying to access healthcare in this country along with what it means about the industry and, more importantly, patient health.

A look at how Mass General Brigham recovered from the CrowdStrike outage

The CrowdStrike outage was much talked about this year when it knocked hospitals across the country offline and forced healthcare workers to do something they likely haven’t done in years (or maybe ever in their careers): take notes on paper. 

 spoke with the team at Mass General Brigham about what their day looked like as they navigated this unanticipated scenario, and how it has helped them prepare for potential future outages.

a gif of Miranda Priestly from The Devil Wears Prada saying "don't be silly darling, everybody wants to be us"

A roundup of our favorite stories from our Healthcare Brew colleagues

We’re our own biggest fans.

 series, where we explore insurance plans and alternatives and the problems that come with them. Read the 

Farmers have long been at the mercy of seasonal and unpredictable earnings, making health insurance far from straightforward.

One year, they might barely break even and get some financial help with coverage. The next, they might make a hefty profit but find themselves ineligible for any Affordable Care Act (ACA) subsidies.

When the latter happens, their options are to go to the private market, get unsubsidized ACA insurance, rely on a spouse who has insurance through an employer, or go uninsured, Nebraska Farm Bureau Federation Chief Administrator Rob Robertson told Healthcare Brew. In any case, it can be costly for his state farm bureau’s 55,000+ member families.

“[Health costs are] a really big family farm disruptor,” Robertson said.

In 2015, the US Department of Agriculture and Economic Research Service found that nearly 11% of household members across the nation’s 2+ million family farms were uninsured, compared to about 9% of the general population.

Local offices of the American Farm Bureau Federation, a membership and advocacy organization, have a unique solution: farm bureau health plans.

These plans generally advertise their affordability compared to others, but they come with a twist: Health insurance alternatives like farm bureau coverage are not typically subjected to state or federal regulations, like those created by the ACA, John Dicken, director of healthcare for public health and private markets at the nonpartisan Government Accountability Office (GAO), told Healthcare Brew.

“It’s hard to make apples-to-apples comparisons, since these are not providing the same types of benefits or insurance for the same types of individuals,” he said.

Farm bureau plans are permitted thanks to state laws that say farm bureaus are not insurers, and thus don’t have to play by insurer rules.

These plans were first codified in Tennessee in 1993. To this day, the state has the most members—75% of the country’s total 130,000 counted as of March 2023, according to a GAO report. Since then, more plans have been cleared in several other agriculture-heavy states—the most recent being this year in Nebraska, where coverage is set to begin on January 1.

Eric Dunning, director of insurance at the Nebraska Department of Insurance, argued during the Nebraska Legislature’s hearing on the law that these non-ACA plans provide a more affordable option for some farm families.

But the effectiveness of these alternative plans is hard to prove because there’s so little data available, Dicken said.

“It’s difficult to know to what extent they’re meeting individuals’ needs differently,” he said.

, which Dicken led, compared these plans alongside other health insurance alternatives like 

One of the two farm bureau plans reviewed in the report had a waiting period before a member could receive benefits for maternity care and pre-existing conditions. The other had per-incident, annual, or lifetime benefit maximums—so, for instance, if a patient’s $100,000 healthcare bill exceeds the threshold, they’re out of luck.

The report found that both plans also did individual underwriting, meaning they can reject people with certain pre-existing conditions and charge varying premiums based on health and demographic information.

The ACA doesn’t allow insurers to do any of those things.

According to Robertson, the thought is that having healthier members allows the insurer to offer lower premiums because no one in the insurance pool would have very high medical costs.

“People say…‘What about the high-risk folks?’ And we said, ‘Well, there’s still the Affordable Care Act out there. It’s not like we’re taking that option away,’” Robertson said.

Nebraska’s plan, administered by Tennessee-based Farm Bureau Health Plans, does underwriting, doesn’t take on people with certain pre-existing conditions, and has a nine-month waiting period for maternity care, he said.

“We probably won’t accept everyone, but we’ll accept the lion’s share of them in terms of underwriting guidelines,” Robertson said.

The flip side to trying to put a bunch of healthy people on one kind of plan is that other plans could disproportionately get people with higher medical costs—and that could drive up premiums, GAO’s report authors noted.

Dicken told Healthcare Brew that though this is hard to evaluate, GAO did not find evidence that enough people have enrolled in these plans to impact the rest of the insurance market.

But enrollment could change in the future.

Farm Bureau officials told GAO that the 2021 American Rescue Plan Act’s 

 led to a slight decline in enrollment in farm bureau plans in 2021 and 2022. These subsidies are set to expire at the end of 2025.

Farmer with a clipboard in hand working on a farm

What are farm bureau health plans?

No ACA? No problem, says the American Farm Bureau Federation.

 series, where we explore insurance plans and alternatives and the problems that come with them.

Healthcare sharing arrangements (HCSAs) are built on a premise that, at first glance, might sound like health insurance: You pay a monthly fee and pool your money with like-minded people to pay each other’s medical bills.

Many of these HCSAs are Christian nonprofits known as healthcare sharing ministries. Members—who often must abide by a code of conduct—join to “support each other as the early Christians in the Book of Acts joined together to meet each other’s needs,” the Alliance of Health Care Sharing Ministries shares on its website.

While healthcare sharing ministries may offer 

 than traditional insurance, they don’t typically cover as much. HCSAs are not health insurance plans and are not required to comply with the protections offered by the Affordable Care Act.

 from the Colorado Department of Regulatory Agencies’s Division of Insurance, the state’s insurance regulator, sheds some light on HCSAs’ practices and prevalence.

Since October 2022, Colorado has required HCSAs with members in the state to report annual data such as member guidelines, enrollment numbers, money collected, and money reimbursed for care.

 have safe harbor laws that exempt nonprofit health ministries from state insurance regulation. No other state but Colorado requires HCSAs to make this data public. 

Colorado’s annual report is one of the rare comprehensive sources of public data available about this niche method of paying for healthcare costs.

 The report found that in 2023, at least 1,521,668 people were members of 17 HCSAs nationwide, including at least 62,461 members residing in Colorado. That’s just the ones that reported data to the state, however: The Alliance of Health Care Sharing Ministries states on its website that there are more than 100 total.

Only 12 HCSAs reported financial information. One called United Health Share Ministries requested its information be kept private in the report. The 11 that reported their finances publicly collected about $39.5 million from members.

 Members of the 11 publicly reporting HCSAs submitted about $96.2 million in healthcare costs in 2023.

But not all those costs were eligible for reimbursement: Some HCSAs exclude things like contraception coverage, maternity care, ADHD treatment, vaccinations, mental health treatment, and diabetic medications/supplies, the report said. In addition, 12 of the arrangements require members to “pursue other payment options” like commercial insurance, crowdfunding, or grants before submitting costs for sharing, according to the report.

After accounting for duplicate charges, ineligible charges, discounts, and other factors, about $58.6 million of Colorado participants’ total healthcare costs were found eligible for sharing.

Of that amount, HCSAs paid out about $34.3 million to Colorado-based members by the end of the year. The amount of member payment that went to administrative and program expenses varied by plan, from under 10% to over 80%, per the report.

It’s difficult to determine exactly what percent of total care HCSAs covered.

The report noted that actual healthcare costs for members were “likely different” when taking into account factors such as ineligible care that wasn’t submitted for reimbursement and each HCSA’s varying “annual unshared amount” that members need to pay before becoming eligible for sharing (similar to a deductible on a marketplace health plan). 

That being said, using the $58.6 million figure, the $34.3 million payout works out to be about 58% of covered expenses after the annual unshared amount. Meanwhile, marketplace insurance can have higher monthly payments, but these plans typically foot the bill for between 60% and 90% of covered expenses after an enrollee meets their deductible, according to healthcare.gov.

Heart with a heart monitor line through the middle under a red umbrella