Dan Weissmann
Massive cuts to medical analysis and Medicaid. Waves of layoffs throughout the Department of Health and Human Services. Ongoing uncertainty round federal subsidies to purchase medical health insurance on Affordable Care Act marketplaces. 2025 has been a tough 12 months for federal well being applications.
But in the meantime, within the states, there have been some wins for well being care entry. “An Arm and a Leg” host Dan Weissmann examines how lawmakers from throughout the political spectrum completed significant reforms. This episode takes listeners to Nebraska, which instituted aggressive new restrictions on prior authorization, and Virginia, the place lawmakers banned wage garnishment and capped rates of interest for sure medical money owed.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a workers reporter for Marketplace and Chicago’s WBEZ. His work additionally seems on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Transcript: A Few Good Things From 2025 (Really)
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Dan: Hey there, you don’t want me to let you know. 2025 has been rather a lot.
I imply, simply with well being care: As I file this, the US authorities has been shut down for greater than a month over whether or not to increase medical health insurance subsidies that greater than 20 million individuals depend on.
I imply, if Congress resolves this tomorrow– and I’m not holding my breath–it’s nonetheless gonna be an enormous mess.
And I may positively go on. But I’m not gonna try this.
Instead, I’ve been spending my time these previous few weeks taking a look at what’s occurred this 12 months that didn’t suck and what we are able to be taught from that.
And it seems, on the state degree, there’s rather a lot to have a look at.
All over the nation, state governments took motion this 12 months to make issues suck rather less — on issues like medical debt and medical health insurance and the worth of medication.
And it occurred dozens of instances this 12 months in loads of states.
Nebraska Newscaster: New tonight, new Nebraska laws will make it simpler for sufferers to entry healthcare.
Maine Newscaster: We’re in your facet tonight as a brand new regulation aimed toward defending Maine customers from the impacts of medical debt goes into impact.
Virginia newscaster: Virginians are just one medical disaster away from chapter in accordance with advocates. That’s why the General Assembly handed a invoice to create some protections for individuals going through medical debt.
Dan: And I’ve been speaking with individuals who helped get new non-sucky legal guidelines handed this 12 months. In crimson states, blue states, purple states.
And I can not wait to begin introducing you to a few of these people and to share what I’ve discovered about what they bought performed — and possibly most essential: how they did it…’trigger we want extra non-sucky legal guidelines handed in as many locations as attainable.
This is An Arm and a leg, a present about why well being care prices so freaking a lot, and what we are able to possibly do about it. I’m Dan Weissmann. I’m a reporter, and I like a problem. So the job we’ve chosen on this present is to take probably the most enraging, terrifying, miserable elements of American life and convey you a present that’s entertaining, empowering, and helpful.
Here. Let me introduce you to any person.
Eliot Bostar: My identify is Eliot Bostar and I’m a legislator in Nebraska. I signify Legislative District 29, which covers basically South Lincoln, our capital metropolis.
Dan: I assumed Nebraska was attention-grabbing. One ’trigger it’s a state we don’t hear from as usually. It’s not a blue coastal state.
Eliot Bostar: Whatever the alternative of that’s, that’s what we’re. Yes.
Dan: And Eliot Bostar sponsored and handed laws this 12 months imposing new guidelines on prior authorization.
That’s the place your physician or your supplier tells you you want one thing, a drug, a take a look at, a process, and the insurance coverage firm comes again and says, yeah, not so quick. Your supplier has to indicate us why that’s mandatory.
And look, simply to zoom out:
There’s an argument right here that not every little thing that will get prescribed or ordered is definitely mandatory and even applicable. But in apply, prior authorization may end up in therapy getting delayed or denied in ways in which appear arbitrary and unreasonable and which have large penalties.
In a current survey from the American Medical Association, nearly 30% of docs mentioned issues with prior authorization had led to a affected person getting hospitalized or changing into completely disabled, or sustaining different everlasting injury, or nearly dying, or truly dying.
Amy Killelea is a professor with Georgetown University’s Center on Health Insurance Reforms.
They’re a part of a analysis crew monitoring prior authorization, and each time they provide a chat to school college students, to coverage nerds, to teams of sufferers with situations like diabetes, they’ll say this.
Amy Killelea: Raise your hand for those who’ve ever had an issue or um, an emotional response to prior authorization, and each hand within the room goes up. It’s so ubiquitous. It’s one thing that everyone can relate to on like a basic, visceral degree.
Dan: Amy Killelea says this type of anger is beginning to present outcomes. The Georgetown Center tracks state legal guidelines on prior authorization.
In 2024 they know of 10 that handed.
In 2025, up to now, they’ve logged 20.
And trying over their checklist, a few issues stand out. One is these are 20 politically various states. Alaska, Rhode Island, Arkansas, California, Montana.
You get the concept. The different factor that stands out is this stuff they’re regulating typically make you go, wait. There was no regulation towards that earlier than?
I imply, Nebraska’s new regulation regulating prior authorizations is about as aggressive as something I’m seeing on this checklist. And the outcomes are simply, like, widespread sense.
Like for one large instance: if an insurance coverage firm denies your prior authorization request, or an attraction, that denial now has to come back from a licensed clinician with related expertise.
And after I talked with Eliot Bostar, I used to be like, wait, like this wasn’t required earlier than?
Eliot Bostar: You’d be shocked. So, I’ll offer you an instance. A neurosurgeon was trying to get approval for fusing of a cervical disc within the backbone, proper? There was an individual that was prone to actually paralysis and bought an preliminary denial, appealed, and bought one other denial. And that denial got here from a pediatrician.
Dan: Like a common…
Eliot Bostar: General apply pediatrician.
Dan: How previous was the affected person?
Eliot Bostar: An grownup.
Dan: Okay. Not, not, not, not a candidate for pediatric care. All proper.
Eliot Bostar: Or, a request is put in for a drugs by a prescribing doctor and a denial comes again from a dentist.
Dan: Yeah. None of that was unlawful underneath Nebraska regulation, till now.
And not simply Nebraska. Four different states handed related guidelines simply this 12 months
And there are extra what I’ll name, “wait, what?” sort of provisions in Nebraska’s new regulation.
Like it units a deadline for the way lengthy your insurance coverage could make you await a sure or no on prior authorization, or like, they’ll’t make you await prior authorization to approve an ambulance journey to the ER.
And Nebraska’s regulation additionally includes a technical provision that I don’t assume anyone would’ve imagined a number of years in the past.
It outlaws using AI as the only foundation for denying protection.
And Eliot Bostar says insurance coverage corporations don’t say they’re doing that, however he’s seen examples that look rather a lot prefer it.
Eliot Bostar: Physicians placing in a request by means of a digital platform, um, placing in all the data, hitting submit, after which immediately getting a denial. There’s not loads of methods that may occur, proper? It’s not that there was a human who sat there and browse all of it and was considerate, analyzed the case, and made a willpower of denial inside half a second. So one thing else occurred in that point, and so that ought to not occur anymore.
Dan: Two different states, Maryland and Texas restricted using AI this 12 months, in accordance with that cheat sheet I bought from Georgetown.
So, Elliot Bostar and his colleagues bought a giant win. He says the state medical society, Nebraska’s chapter of the American Medical Association and the state hospital affiliation had been large allies.
But medical health insurance corporations are highly effective opponents. Eliot says, in earlier years, he and his allies had tried taking smaller swings at prior authorization– and gotten swatted away. This time, they went large.
Eliot Bostar: The resolution was made that we had been gonna, we had been gonna actually go in spite of everything of it. We’re gonna go in spite of everything of it.
Dan: He says loads of that call got here all the way down to sheer frustration and a bit of little bit of political calculation. A giant swing can rally individuals to you and provides the opposite facet good motive to take you severely.
Eliot Bostar: I feel it’s essential to clarify that we’re not going to place up with a system that’s this damaged, any longer. You will be actually direct. So you may inform the insurance coverage corporations, we’re gonna do one thing. And you may both sort of work with us on how to try this or, or not.
Dan: And then he got down to divide and conquer.
Eliot Bostar: If insurance coverage corporations themselves don’t essentially agree with one another, or they’re not absolutely aligned on a invoice or on a coverage, that may successfully neutralize the business.
Dan: I requested him:, how’d you determine who you would possibly be capable to decide off?
Eliot Bostar: So Blue Cross Blue Shield in Nebraska is only a Nebraska firm, proper? They’re a part of the bigger Blue Cross, you already know, community, however they’re only a Nebraska firm versus United shouldn’t be.
Dan: He mentioned by the point the invoice got here up for a listening to, he’d been negotiating with insurance coverage corporations for months and he didn’t get every little thing he needed. But you already know, it handed.
Eliot Bostar: I don’t assume anybody voted towards it.
Dan: Eliot Bostar says his technique bought a lift from some specifics of Nebraska’s legislative construction.
Like there’s only one home, a Senate. 49 members smallest within the nation, and elections are nonpartisan. So issues work otherwise than they do in most locations.
Eliot Bostar: There’s no majority chief. There’s no whip, there’s no any of that.
Dan: He says that setup allowed him at hand promote this proposal to at least one colleague at a time.
So some classes right here:
One, go large. Why the heck not?
Two: Figure out who you may decide off within the opposition.
Three: However the political construction works in your state, work it.
Because, you already know, lawmakers in 20 states made new guidelines on prior authorization this 12 months. They don’t all work like Nebraska.
One caveat right here, states don’t have all the facility. With medical health insurance, that’s very true.
You know, we’ve talked about this earlier than. If you get your medical health insurance from work– particularly for those who work for a great sized firm– your well being plan might be arrange in a means the place state insurance coverage rules don’t apply.
But Eliot Bostar says he offers native employers a two-part pitch to supply their staff related protections.
One, they’ll lower your expenses as a result of delaying care now can imply more-expensive care later.
Two, as a result of new state protections elevate all people’s expectations.
Eliot Bostar: And how a lot of a unlucky disgrace could be if their staff didn’t obtain the identical advantages that maybe their neighbors are.
Dan: In different phrases, you wish to piss off your staff? He says generally it really works.
Just forward: In Virginia, a brand new regulation bans wage garnishment for medical money owed — and caps curiosity at simply three p.c. Democrats handed it. The Republican governor signed it. How’d they pull it off?
That’s subsequent.
This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom overlaying healthcare in America. These people are wonderful journalists. Their reporting wins all types of awards yearly. We are honored to work with them.
Ok, let’s meet a pair people from Virginia.
Amanda Gago Silcox: I’m Amanda Gago Silcox. I’m the training and useful resource supervisor right here at Virginia Poverty Law Center.
Jay Speer: I’m Jay Speer. I’m the Executive director and client rights lawyer on the Virginia Poverty Law Center.
Dan: Their group, VLPC, for brief, does a bunch of stuff.
Among different issues, they function toll free helplines for people struggling to pay utility payments. They coordinate with native authorized help workplaces throughout the state and. They foyer within the state capital.
Medical debt is a giant subject for them, and this 12 months they helped cross a regulation that can restrict how far Virginians can get chased for medical debt particularly, it caps curiosity on medical debt at 3%.
Amanda Gago Silcox: And then the invoice additionally bans garnishing the wages of anybody qualifying for monetary help.
Dan: …which looks as if widespread sense. like for those who qualify for monetary help from a hospital, you need to be getting your invoice lowered or canceled, not getting cash grabbed out of your paycheck. Or having your property foreclosed on to pay a hospital invoice, which has additionally occurred, and which the brand new regulation may also ban. Along with … getting arrested over a hospital invoice. Yeah.
And there’s one other provision that VPLC actually pushed for on this invoice. It’s gonna sound technical, however that is large.
Amanda Gago Silcox: It prohibits, the sale of medical debt to a debt purchaser except they observe principally the identical necessities as are required of medical collectors.
Dan: Here’s why that’s large. There are two sorts of assortment companies. There’s the sort that work for a hospital or whoever and receives a commission principally on fee after which — as Jay explains– there debt patrons. Those are totally different.
Jay Speer: They’re those that pay wherever from one to five% of what’s owed after which sue you for the entire quantity. Debt patrons deal in quantity. They get, they purchase hundreds and hundreds of money owed and so they sue all people.
Dan:Yeah, Jay says VPLC has analyzed information from throughout the entire state court docket system- and noticed simply what number of lawsuits debt patrons had been truly submitting.
Jay Speer: In Virginia final 12 months, they filed 45% of the lawsuits in Virginia. Um, so it’s an enormous quantity.
Dan: 45% all lawsuits, like..?
Jay Speer: …of all lawsuits had been filed by debt patrons.
Dan: The new regulation goals to place the brakes on that, no less than from medical money owed.
Jay Speer: It says for those who promote the debt to a debt purchaser, you need to have an settlement with that debt purchaser that they’ll observe these guidelines.
Dan: That is, they gained’t cost greater than 3% curiosity. No garnishing wages, no foreclosing on houses, no arrests. Jay thinks requiring these sorts of agreements may principally imply suppliers simply gained’t be capable to promote to debt patrons. ‘Cause he’s been finding out how that entire facet of medical debt truly works.
Jay Speer: I’ll let you know proper now, there isn’t a such factor as these agreements between suppliers and debt patrons.
Dan: Hmm.
Jay Speer: All debt patrons purchase is a spreadsheet with names and numbers on it. They’re not gonna enter into these agreements. Maybe I’m flawed. I imply, they may change their entire apply, however I’d be shocked.
Dan: That’s the sort of perception VPLC delivered to the push for this regulation. But Amanda admits that push wasn’t a part of some grasp plan.
Amanda Gago Silcox: And you already know, I want that we had deliberate many, many days and months, to work on this invoice, but it surely sort of fell in our laps.
Dan: She says late final 12 months, she heard from an advocate with a nationwide group referred to as Blood Cancer United– they advocate for most cancers sufferers, not most cancers–with a pitch for the concept.
Amanda Gago Silcox: I’ll be fairly trustworthy, I used to be like, wow, that is actually aggressive. I don’t find out about this.
Dan: Jay was skeptical too. Getting a invoice like this handed could be one factor, even with Democrats holding majorities in each legislative homes, however then Republican Governor Glenn Youngkin would want to signal it.
Jay Speer: And the governor additionally has a historical past of vetoing tons and tons and tons of payments, 5 instances greater than another governor’s ever vetoed. And in order that’s hanging over the entire thing.
Dan: But Amanda says The people at Blood Cancer United had been very gung-ho. They promised to deliver sufferers with highly effective tales to inform
… and so they thought VPLC’s technical experience, together with their analysis on debt patrons, would add rather a lot.
And they’d already lined up a sponsor: Delegate Carrie Delaney, who had simply succeeded in passing a invoice to maintain medical money owed off of credit score reviews.
Jay Speer: So we knew she was critical about it. I imply, that’s at all times a consideration whenever you’re fascinated by laws is, who’s your patron? Are they actually critical about it?
Dan: VPLC determined to affix up. Amanda took level on their lobbying, she says. It wasn’t simple.
Amanda Gago Silcox: I bear in mind there being a day the place it simply felt like we had been giving up little items right here and there, and I used to be like, I simply don’t know if what we’re gonna get out of that is price it. We’ve given up every little thing. This doesn’t even do something anymore.
Dan: Specifically, she says the cap on curiosity appeared prefer it was gone.
Amanda Gago Silcox: Yeah. I assumed we had been gonna have to offer that up.
Dan: Somehow the curiosity cap got here again in. Amanda bought her religion again.
And she says there have been additionally moments that gave her confidence, like simply making the rounds of legislators workplaces to drop off info and join a time to satisfy with the lawmakers.
Amanda Gago Silcox: When we had been speaking to their administrative assistants and we talked about that we had been there to speak about medical debt and plenty of, lots of the administrative assistants talked about, oh yeah, like my husband had most cancers and we had X, Y, Z, Or I had a good friend who had breast most cancers and she or he had this occur to her. So it actually resonated with, with legislators’ workers, with the oldsters that they’re surrounded with. So I feel that actually helped us proceed pushing.
Dan: And they gained. Both homes. Now It was the governor’s transfer.
Jay Speer: So Virginia has a bizarre course of. Where they ship the payments to the governor. The governor both indicators the payments, vetoes the payments, or makes a quote advice. In this case, he made a advice.
Dan: He needed to weaken the invoice, in order that sends it again to the legislature.
Jay Speer: And they both settle for his advice, which places the invoice in, into regulation, or they reject it. Then it goes again to the governor. And the governor then has two selections. He may veto it or signal it. So it’s a dangerous enterprise to reject his advice since you’re nearly taunting him to veto it.
Dan: So when legislators DID reject the governor’s advice, Jay and Amanda say they had been shocked.
Amanda Gago Silcox: We had been shocked when it went again to the governor and he did the truth is signal it. I imply, I assumed we had been, it was gonna be vetoed.
Jay Speer: I used to be certain he was gonna veto it. I imply, like I mentioned, he’s vetoed like God 5 instances extra payments than another governor.
Jay Speer: I feel the one clarification is he’s nervous about this and it makes him look dangerous to not assist individuals out with medical debt.
Dan: They didn’t get every little thing they needed.
The regulation doesn’t take impact until July, 2026,, and it exempts bank cards, together with medical credit score merchandise like CareCredit score, which points a plastic card– and fees 33% curiosity after a promotional interval.
Amanda Gago Silcox: So that is positively an space the place there’s some work to be performed.
Dan: Yeah, like me, these people are by no means gonna run outta materials. Meanwhile, they gained a victory this 12 months. They actually didn’t assume they’d get. And speak about having loads of materials. I reported an entire story about how Maine handed a regulation to maintain medical money owed off of credit score reviews. State Senator Donna Bailey sponsored that invoice, which handed unanimously, and an identical invoice had failed earlier than, however this time she says:
Donna Bailey: I don’t bear in mind loads of heavy pushback, which was pleasantly shocking to me, fairly actually.
Dan: We’ll get to that one.
By the best way, 5 different states did the identical factor this 12 months, complete of 15 since 2023, and a bunch of states handed new rules on pharmacy profit managers. The most aggressive was in all probability Arkansas. So yeah, there’s extra information that didn’t suck coming.
And talking of issues that don’t suck as we deliver you this episode, it’s November, which implies I get to check one thing I’ve been saying to my colleagues for a very long time. Reaching extra individuals with An Arm and a Leg is each our mission crucial, ’trigger we wanna be of probably the most use to the most individuals. And it’s our enterprise mannequin ’trigger the best way we’ve gotten this far is by asking you listeners, will you assist us maintain doing this? And a sure fraction of individuals have at all times mentioned sure. And I’ve mentioned, if we are able to attain extra individuals, nicely that’s extra individuals to say sure. And that can enable us to do extra and continue to grow. And this 12 months I get to check that as a result of Seattle’s Public Radio Station, KUOW, grew to become our distributor this 12 months, and so they’re serving to us attain much more individuals than we did a 12 months in the past, like twice as many.
And so I get to check this concept and underneath actually favorable situations as a result of. November is the start of a venture referred to as News Match from the Institute for Nonprofit News. Now information match matches particular person presents of as much as a thousand {dollars}. And this month by means of a particular reward from the Jonathan Logan Family Foundation, particularly for an arm and a leg information match is double matching your presents.
So for those who’ve been listening, if in case you have discovered this present entertaining and empowering and helpful, for those who assume it’s cool to listen to what states are doing to make issues suck much less and the way they’re doing it, for those who discovered it helpful after we ran down methods to save cash on prescribed drugs. If you assume it’s superior that Arm and a Leg listeners have been coming collectively to construct instruments to assist folks keep out of medical debt, then that is your probability to make much more of that occur. ’trigger each greenback you give us this month is matched two for one. You give us 50 bucks, it turns into $150. You give us 100, bam it’s 300.
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Thank you a lot. We’ll be again earlier than Thanksgiving with our subsequent episode. Till then. Take care of your self.
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This episode of An Arm and a Leg was produced by me, Dan Weissmann, with assist from Emily Pisacreta — and edited by Ellen Weiss.
Adam Raymonda is our audio wizard.
Our music is by Dave Weiner and Blue Dot Sessions.
Claire Davenport is our engagement producer.
Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations.
An Arm and a Leg is produced in partnership with KFF Health News. That’s a nationwide newsroom producing in-depth journalism about well being points in America and a core program at KFF, an unbiased supply of well being coverage analysis, polling, and journalism.
Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this present.
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