“We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered to retired state police.

“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson said.

She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well.

“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus.

Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs. Last year, federal health officials recommended doctors discuss pain management with patients beforehand, including options such as lidocaine shots and topical anesthetics.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

It’s unclear how many Americans have such coverage. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of covered workers were still on “grandfathered” plans.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she said.

Mike McMullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

The Pennsylvania State Troopers Association, which offers some retirees the plan that covered Anderson, did not respond to requests for comment. Highmark Blue Cross Blue Shield, the insurer, referred questions to the state.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”

A benefit handbook for the plan identifies it as grandfathered and lists a variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, said Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

She said most insurers cover the devices, but coverage can vary, too. For instance, some cover only certain types or brands of contraceptives. Generally, an IUD insertion costs $500 to $1,500, she added.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she said.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income.

“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she said. The billing office, she said, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”

Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

With birth control, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn said. “It’s incredibly hard to be an advocate for yourself.”

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

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Trump’s order, titled “Protecting Children From Chemical and Surgical Mutilation,” is certain to face legal challenges and would require congressional or regulatory actions to be fully enacted. But transgender people and their advocates are concerned it will nonetheless discourage prescriptions and medical procedures they consider to be lifesaving in some cases, while complicating insurance coverage for gender-affirming care.

“It can’t be understated how harmful this executive order is, even though it doesn’t do anything on its own,” said Andrew Ortiz, a senior policy attorney at the Transgender Law Center. “It shows where the administration wants to go, where it wants the agencies to put their efforts and energies.”

The order is one of several Trump has issued, less than two weeks since taking office, that target the trans community. He has directed his administration to recognize only the male and female sex — and to abandon the term “gender” altogether. He ordered the State Department to issue passports identifying Americans only by their genders assigned at birth. He has encouraged the Justice Department to prosecute teachers and other school officials who help trans children transition, including by using their preferred names. And he signed an order that’s expected to lead to transgender people being banned from military service.

“We’re terrified. We cry every day. Hurting my family and my kid is winning politics for Republicans right now,” said the parent of a transgender child who lives in Missouri and asked not to be identified for fear of being targeted. “Every bone in my body is telling me I can’t keep my child safe from my government anymore, I can’t keep my family safe.”

About 300,000 American children ages 13-17 identify as transgender, according to the Williams Institute at the UCLA School of Law, which researches sexual orientation and gender identity law and public policy. But the number who seek gender-affirming care is believed to be far fewer. An examination by Reuters and Komodo Health of about 330 million health insurance claims filed from 2017 to 2021 found that fewer than 15,000 patients ages 6 to 17 with a diagnosis of gender dysphoria had received gender-affirming hormone therapy and fewer than 5,000 had started puberty-blocking medications — though the annual number of such patients more than doubled over the five-year span.

Trump’s order seeking to disrupt insurance coverage for young people, the Williams Institute said in a brief, “will likely at least limit the availability of gender-affirming care or make it more difficult to access in the short term and could increase risk for both providers and recipients of the care.”

Much of what the order calls for would require rule changes or other federal guidance, which can take weeks to months. Though it is mostly directed toward government health insurance programs, the order could have private-sector implications, too, and is likely to face litigation from states or advocacy organizations.

Specifically, the directive intends to limit insurance coverage for hormonal or surgical treatments that help young people transition.

It directs the secretary of the Department of Health and Human Services to “take all appropriate steps” to end insurance coverage of such treatments. It specifically names several government programs such as Tricare, which serves the military and its dependents; Medicare and Medicaid; federal and postal health benefit programs; and the Foreign Service Benefit Plan.

“The aim here is clearly targeted at federally funded plans, such as Medicare and Medicaid, but there’s a lack of clarity as to whether it would impact other plans, such as exchange plans, where essential health benefits are required,” said Lindsey Dawson, director of LGBTQ Health Policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

State Medicaid programs vary widely in their rules around transgender care, with a variety of limits or restrictions on what types of care can be covered for minors in just over half the states, according to a map provided by the Colorado-based Movement Advancement Project, a nonprofit think tank.

While little is likely to happen immediately from the order — one of more than 100 issued by the president since his inauguration last week — it could, nonetheless, have a chilling effect on medical professionals.

The order directs the Department of Justice to work with Congress to promote legislation that would allow children and parents a “private right of action” — the ability to file a lawsuit — against medical professionals who provide transgender care.

And the Justice Department was also directed to consider the application of existing laws to those who provide or promote access to gender care.

In addition, one section of the order directs agencies to “take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children,” a move that could affect hospitals or medical schools.

Julian Polaris, a partner at the consulting firm Manatt, said the order “displays the federal government’s willingness to use federal programs to restrict access to disfavored services even to providers and patients outside those federal programs.”

The move drew immediate criticism from groups supporting LBGTQ+ people’s rights.

“It is unconscionable that less than 24 hours after trying to take away Head Start programs and school meals for kids, President Trump issued an order demonizing transgender youth and spreading dangerous lies about gender-affirming care,” Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America, wrote in a press release.

Because it defines “youths” as those under age 19, the order would apply the directives to medical treatments provided to 18-year-olds, who otherwise are considered adults in making legal choices, voting, or serving in the military.

“There’s also just a problem with not seeing young people as capable in making decisions around their health and their futures, and so blurring that line and trying to move it up and taking more control over more people is obviously concerning,” Ortiz said. “But having the line hard at 18 also doesn’t make it any better.”

Ortiz noted that the order contains misinformation about medical care for young people who are transitioning and targets a small subset of U.S. residents: transgender youths in families that can access and afford gender-affirming care.

“That should be concerning to everybody,” he said, “that they are pulling out populations to target, to say that, ‘We don’t think that you deserve access to best-practice medical care.’”

Trump’s order explained that the action was necessary because such medical treatment could cause young people to regret the move later, once they “grasp the horrifying tragedy that they will never be able to conceive children of their own or nurture their children through breastfeeding.”

KFF Health News Midwest correspondent Bram Sable-Smith contributed to this report.

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La orden de Trump, titulada “Proteger a los niños de la mutilación química y quirúrgica”, seguramente enfrentará batallas legales, y requerirá medidas legislativas o cambios reglamentarios para implementarse por completo.

Sin embargo, las personas transgénero y sus defensores temen que la medida desaliente el uso de medicamentos y los tratamientos médicos que, en algunos casos, consideran vitales, además de complicar la cobertura de los procedimientos de afirmación de género.

“No se puede subestimar lo perjudicial que es esta orden ejecutiva, incluso aunque no tenga efecto inmediato por sí sola”, dijo Andrew Ortiz, abogado senior de políticas en el Transgender Law Center. “Muestra hacia dónde quiere ir la administración y en qué áreas pretende que las agencias enfoquen sus esfuerzos y energías”.

La orden  es una de las varias normas dirigidas a la comunidad trans que Trump ha emitido a menos de dos semanas de asumir el cargo. El presidente ha ordenado a su administración que solo reconozca los sexos masculino y femenino, y que abandone por completo el término “género”.

También instruyó al Departamento de Estado para que emita pasaportes que solo identifiquen a los ciudadanos estadounidenses según el género asignado al nacer.

Y alentó al Departamento de Justicia para que procese a los profesores y otros funcionarios escolares que ayuden a los niños trans a hacer su transición, aunque solo se limiten a permitirles usar el nombre que prefieran. Y ha firmado una orden que llevaría a prohibir que las personas trans formen parte de las Fuerzas Armadas.

“Estamos aterrados. Lloramos todos los días. En este momento, para los republicanos es una victoria política lastimar a mi familia y a mi hijo”, dijo el padre de un niño transgénero que vive en Missouri, y pidió no ser identificado por miedo a convertirse en blanco de ataques. “Cada fibra de mi ser me dice que ya no puedo proteger a mi hijo de mi gobierno, ni puedo mantener a mi familia a salvo”, agregó.

Cerca de 300.000 niños estadounidenses de entre 13 y 17 años se identifican como transgénero, según el Williams Institute de la Facultad de Derecho de la UCLA, que investiga las leyes y políticas públicas sobre orientación sexual e identidad de género.

Pero, se cree que el número de quienes buscan atención de afirmación de género es mucho menor.

Un análisis de Reuters y Komodo Health sobre aproximadamente 330 millones de solicitudes de seguros de salud presentadas entre 2017 y 2021 encontró que menos de 15.000 pacientes de entre 6 y 17 años con un diagnóstico de disforia de género habían recibido terapia hormonal de afirmación de género, y menos de 5.000 habían comenzado a tomar bloqueadores de la pubertad.

Aun así, el número anual de estos pacientes se incrementó en más del doble en ese período de cinco años.

Al buscar interrumpir la cobertura para los jóvenes, la orden de Trump “probablemente, como mínimo, limitará la disponibilidad de la atención de afirmación de género o hará que sea más difícil acceder a ella a corto plazo. También podría aumentar el riesgo tanto para los proveedores como para los pacientes”, aseguró en un informe el Williams Institute.

La implementación de la orden ejecutiva podría tardar semanas o meses porque gran parte de lo que exige requeriría cambios normativos o nuevas directrices federales.

Aunque está dirigida principalmente a programas de salud del gobierno, la orden también podría tener implicaciones para el sector privado y es probable que enfrente litigios por parte de los estados o grupos de defensa.

Específicamente, la directiva busca limitar la cobertura para tratamientos hormonales o quirúrgicos destinados a ayudar a los jóvenes en su transición.

La directiva ordena al secretario del Departamento de Salud y Servicios Humanos (HHS) que tome “todas las medidas apropiadas” para eliminar la cobertura de estos tratamientos. Menciona específicamente varios programas gubernamentales como Tricare, que atiende al personal del ejército y sus familias; Medicare y Medicaid; los programas de atención de la salud para trabajadores y jubilados del gobierno federal y del servicio postal, y el Foreign Service Benefit Plan, para empleados del Servicio Exterior.

“El objetivo aquí está claramente dirigido a los planes financiados por el gobierno federal, como Medicare y Medicaid, pero no está claro si la orden afectaría a otros planes, como los del mercado de seguros en los que se garantiza la cobertura de ciertos servicios de salud considerados esenciales”, explicó Lindsey Dawson, directora de Políticas de Salud LGBTQ en KFF.

Los programas estatales de Medicaid tienen reglas muy diferentes sobre la atención médica para personas transgénero. En poco más de la mitad de los estados, existen límites o restricciones sobre los tipos de tratamientos que pueden cubrirse para los menores, según un mapa realizado por el Movement Advancement Project, un grupo de investigación sin fines de lucro con sede en Colorado.

Aunque es poco probable que la orden tenga un impacto inmediato —es solo una de las más de las 100 que el presidente ha firmado desde que asumió el cargo—, podría hacer que muchos médicos se sientan intimidados o temerosos de brindar este tipo de atención.

La orden instruye al Departamento de Justicia para que trabaje con el Congreso en la elaboración de una legislación que permita a los niños y sus padres una “acción de derecho privado” —esto es, la capacidad de presentar una demanda— contra los profesionales médicos que brinden atención a personas transgénero.

Además, se le indicó que considere la aplicación de las leyes existentes a quienes brinden o faciliten el acceso a la atención de género.

Otra sección de la orden les pide a las agencias que “tomen medidas para asegurarse de que las instituciones que reciban fondos federales para investigación o educación terminen con la mutilación química y quirúrgica de los niños”, lo que podría afectar a hospitales o escuelas de medicina.

Julian Polaris, un socio de la firma de consultoría Manatt, comentó que la orden “muestra que el gobierno federal está dispuesto a usar sus programas para restringir el acceso a servicios que desaprueba, incluso para médicos y pacientes que no estén dentro de esos programas federales”.

De inmediato, la medida recibió críticas de grupos defensores de los derechos de las personas LGBTQ+.

“Es inconcebible que, menos de 24 horas después de intentar eliminar programas de alimentación escolar y Head Start para niños, el presidente Trump emita una orden demonizando a los jóvenes transgénero y difundiendo mentiras peligrosas sobre la atención de afirmación de género”, manifestó en un comunicado de prensa Alexis McGill Johnson, presidenta y CEO de Planned Parenthood Federation of America.

Dado que la orden define a “jóvenes” como aquellos menores de 19 años, también afectaría las directrices de los tratamientos médicos proporcionados a los mayores de 18 años, quienes sin embargo son considerados adultos con derecho a tomar decisiones legales, votar o servir en el ejército.

“También es problemático no reconocer a los jóvenes como capaces de tomar decisiones sobre su salud y su futuro. Diluir esa línea y tratar de moverla hacia arriba para tener más control sobre más personas es, obviamente, preocupante”, dijo Andrew Ortiz. “Pero incluso fijar un límite estricto en los 18 años tampoco lo hace mejor”.

Ortiz señaló que la orden contiene información errónea sobre la atención médica para jóvenes en transición y se enfoca a un pequeño grupo de la población: los jóvenes transgénero cuyas familias pueden acceder y costear la atención de afirmación de género.

“Eso nos debería preocupar a todos”, concluyó, “porque están seleccionando poblaciones específicas para atacarlas y decirles que ‘no merecen acceso a una atención médica basada en las mejores prácticas’”.

Trump justificó la orden argumentando que el tratamiento médico para jóvenes trans podría llevar al arrepentimiento en el futuro, “cuando se den cuenta de la horrible tragedia de que nunca podrán concebir hijos propios ni amamantarlos”.

Bram Sable-Smith, corresponsal en el Medio Oeste de KFF Health News, colaboró con este artículo.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The orders he issued soon after reentering the White House have policymakers, health care executives, and patient advocates trying to read the tea leaves to determine what’s to come. The directives, while less expansive than orders he issued at the beginning of his first term, provide a possible road map that health researchers say could increase the number of uninsured Americans and weaken safety-net protections for low-income people.

However, Trump’s initial orders will have little immediate impact. His administration will have to take further regulatory steps to fully reverse Biden’s policies, and the actions left unclear the direction the new president aims to steer the U.S. health care system.

“Everyone is looking for signals on what Trump might do on a host of health issues. On the early EOs, Trump doesn’t show his cards,” said Larry Levitt, executive vice president for health policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

A flurry of executive orders and other actions Trump issued on his first day back in office included rescinding directives by his predecessor, former President Joe Biden, that had promoted lowering drug costs and expanding coverage under the Affordable Care Act and Medicaid.

Executive orders “as a general matter are nothing more than gussied up internal memoranda saying, ‘Hey, agency, could you do something?’” said Nicholas Bagley, a law professor at the University of Michigan. “There may be reason to be concerned, but it’s down the line.”

That’s because making changes to established law like the ACA or programs like Medicaid generally requires new rulemaking or congressional action, either of which could take months. Trump has yet to win Senate confirmation for any of his picks to lead federal health agencies, including Robert F. Kennedy Jr., the anti-vaccine activist and former Democratic presidential candidate he has nominated the lead the Department of Health and Human Services. On Monday, he appointed Dorothy Fink, a physician who directs the HHS Office on Women’s Health, as acting secretary for the department.

“We’re getting rid of all of the cancer — I call it cancer — the cancer caused by the Biden administration,” Trump told reporters as he signed some of the executive orders in the Oval Office on Jan. 20. His order rescinding more than 70 Biden directives, including some of the former president’s health policies, said that “the previous administration has embedded deeply unpopular, inflationary, illegal, and radical practices within every office of the Federal Government.”

During Biden’s term, his administration did implement changes consistent with his health orders, including lengthening the enrollment period for the ACA, increasing funding for groups that help people enroll, and supporting the Inflation Reduction Act, which boosted subsidies to help people buy coverage. After falling during the Trump administration, enrollment in ACA plans soared under Biden, hitting record highs each year. More than 24 million people are enrolled in ACA plans for 2025.

The drug order Trump rescinded called on the Centers for Medicare & Medicaid Services to consider tests to lower drug costs. The agency came up with some ideas, such as setting a flat $2 copay for some generic drugs in Medicare, the health program for people 65 and older, and having states try to get better prices by banding together to buy certain expensive cell and gene therapies.

That Trump included the Biden drug order among his revocations may indicate he expects to do less on drug pricing this term or even roll back drug price negotiation in Medicare. Or it may have been slipped in as simply one more Biden order to erase.

The White House did not respond to a request for comment.

Biden’s experiments in lowering drug prices didn’t fully get off the ground, said Joseph Antos of the American Enterprise Institute, a right-leaning research group. Antos said he’s a bit puzzled by Trump’s executive order ending the pilot programs, given that he has backed the idea of tying drug costs in the U.S. to lower prices paid by other nations.

“As you know, Trump is a big fan of that,” Antos said. “Lowering drug prices is an easy thing for people to identify with.”

In other moves, Trump also rescinded Biden orders on racial and gender equity and issued an order asserting that there are only two sexes, male and female. HHS under the Biden administration supported gender-affirming health care for transgender people and provided guidance on civil rights protections for transgender youths. Trump’s missive on gender has intensified concerns within the LGBTQ+ community that he will seek to restrict such care.

“The administration has forecast that it will fail to protect and will seek to discriminate against transgender people and anyone else it considers an ‘other,’” said Omar Gonzalez-Pagan, senior counsel and health care strategist at Lambda Legal, a civil rights advocacy group. “We stand ready to respond to the administration’s discriminatory acts, as we have previously done to much success, and to defend the ability of transgender people to access the care that they need, including through Medicaid and Medicare.”

Trump also halted new regulations that were under development until they are reviewed by the new administration. He could abandon some proposals that were yet to be finalized by the Biden administration, including expanded coverage of anti-obesity medications through Medicare and Medicaid and a rule that would limit nicotine levels in tobacco products, Katie Keith, a Georgetown University professor who was deputy director of the White House Gender Policy Council under Biden, wrote in an article for Health Affairs Forefront.

“Interestingly, he did not disturb President Biden’s three executive orders and a presidential memorandum on reproductive health care,” she wrote.

However, Trump instructed top brass in his administration to look for additional orders or memorandums to rescind. (He revoked the Biden order that created the Gender Policy Council.)

Democrats criticized Trump’s health actions. A spokesman for the Democratic National Committee, Alex Floyd, said in a statement that “Trump is again proving that he lied to the American people and doesn’t care about lowering costs — only what’s best for himself and his ultra-rich friends.”

Trump’s decision to end a Biden-era executive order aimed at improving the ACA and Medicaid probably portends coming cuts and changes to both programs, some policy experts say. His administration previously opened the door to work requirements in Medicaid — the federal-state program for low-income adults, children, and people with disabilities — and previously issued guidance enabling states to cap federal Medicaid funding. Medicaid and the related Children’s Health Insurance Program cover more than 79 million people.

“Medicaid will be a focus because it’s become so sprawling,” said Chris Pope, a senior fellow at the Manhattan Institute, a conservative policy group. “It’s grown after the pandemic. Provisions have expanded, such as using social determinants of health.”

The administration may reevaluate steps taken by the Biden administration to allow Medicaid to pay for everyday expenses some states have argued affect its beneficiaries’ health, including air conditioners, meals, and housing.

One of Trump’s directives orders agencies to deliver emergency price relief and “eliminate unnecessary administrative expenses and rent-seeking practices that increase healthcare costs.” (Rent-seeking is an economic concept describing efforts to exploit the political system for financial gain without creating other benefits for society.)

“It is not clear what this refers to, and it will be interesting to see how agencies respond,” Keith wrote in her Health Affairs article.

Policy experts like Edwin Park at Georgetown University have also noted that, separately, Republicans are working on budget proposals that could lead to large cuts in Medicaid funding, in part to pay for tax cuts.

Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning research group, also pointed to Congress: “On one hand, what we see coming from the executive orders by Trump is important because it shows us the direction they are going with policy changes. But the other track is that on the Hill, there are active conversations about what goes into budget legislation. They are considering some pretty huge cuts to Medicaid.”

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But nearly four years after the first Trump administration’s regulations forced hospitals to post massive amounts of pricing information online, the effect on patients’ costs is unclear. And while President Joe Biden added requirements to make pricing information more user-friendly, Donald Trump’s imminent return to the White House has raised questions about what’s next, even though posting prices is an area of rare bipartisan agreement.

The uncertainty of what might happen next led some proponents to lobby Congress to include hospital and insurer price transparency in must-pass legislation before Trump takes office. That would turn both his and Biden’s regulations into law, making them less susceptible to being weakened or repealed by a future administration. But that effort failed.

The legislative step could also help protect against legal challenges in the wake of a Supreme Court decision that limited government agencies’ regulatory authority.

Employers are using transparency data to try to slow growth of their health care costs, and “the last thing you want to do is start over,” said James Gelfand, president and CEO of the ERISA Industry Committee, which represents large employers who finance their own health plans. His group is among the organizations pressing Congress to act.

“Congress’ failure to act is deeply disappointing, but employers and other advocates will redouble our efforts,” Gelfand said. “This will get done.”

While there are reports that many hospitals are not fully complying, federal regulators have sent thousands of warning letters to hospitals and fined just over a dozen.

The transparency rules require hospitals to list the prices they accept from all insurers for thousands of items and services, from stitches to delivery room costs to X-rays. For consumers, hospitals must also provide a list of 300 “shoppable” services, including bundled prices accepted for common services such as having a baby or getting a hip replacement. Insurers in July 2022 were similarly required to list their negotiated prices, not only for care at hospitals, but also surgery centers, imaging facilities, laboratories, and doctors’ offices.

It’s a massive and often confusing amount of data that has drawn interest from researchers and commercial outlets like Turquoise Health, which has sought to organize the information to better help ordinary consumers shopping for medical services or employers overseeing workers’ health plans.

The data shows a huge variation in prices, both in what hospitals charge and what insurers pay, for the same services. But the result of making those prices public is so far hard to quantify.

A recent study by Turquoise looked at negotiated rates in the nation’s 10 largest metro areas for a set of common health care services. It found that rates in the top quarter tier — the most expensive category — declined by 6.3% from December 2021 to June 2024, during the time the transparency rules were in place. But negotiated rates for the lowest-cost tier of services rose by 3.4%.

That may indicate hospitals and insurers — who can now see what rivals are charging and paying — have either cut prices or demanded better rates, at least for the costliest services.

Even so, Gerard Anderson, who oversees research into the data as a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the changes Turquoise noted were small and are not reflective of what his team has seen in their own studies.

“So far we have not detected any impact of this data on behavior, of where insurers decide to go or what hospitals do to change prices once they realize what others are charging,” Anderson said.

Some health policy experts think it’s unlikely the incoming Trump administration would reverse its prior commitment to price transparency.

“I don’t see a world where he tanks his own regulations,” said Joe Wisniewski, an associate vice president at Turquoise Health. “There is also so much broad bipartisan support on the Hill.”

The current price-posting rules began with requirements in the Affordable Care Act, which the initial Trump administration more fully defined. The hospital industry failed in a legal challenge to block those rules, and the Trump-era requirements became effective in January 2021.

But even after the Biden administration made the data more user-friendly, it’s still not very helpful to consumers, Anderson said.

“This data is not telling them the price they will pay. It’s telling them the average price people paid last month or last quarter for a similar type of service,” he said.

More useful, Anderson and other experts say, are requirements in the price transparency rules that demand insurers offer online calculators for hundreds of nonemergency services. The detailed cost estimates must take into account how much patients have paid toward annual deductibles.

For uninsured consumers or others who don’t have access to online calculators, it remains difficult to piece together how much a service might cost from the information hospitals post online. For one thing, not every hospital has posted its negotiated rates.

The Department of Health and Human Services’ inspector general said in November an audit of 100 hospitals found that 63 complied with the price transparency rule, while the rest failed to meet one or more requirements.

The advocacy group Patient Rights Advocate, which looked at a sample of 2,000 hospitals, says that only 21% were fully compliant, although it used broader measures for compliance than the inspector general.

“By keeping their prices hidden, hospitals continue to block American consumers from their right to compare prices and protect themselves from overcharges,” said Cynthia Fisher, founder and chairman of the group, which has called for stricter rules and enforcement.

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First up, enrollment.

New and returning sign-ups through healthcare.gov — the federal marketplace that serves 31 states — are well below last year’s rate. New enrollments were just over 730,000 in early December, compared with 1.5 million at the same time last year.

To give consumers in those states more time to enroll, the Centers for Medicare and Medicaid Services extended the deadline to Wednesday to sign up for coverage that starts Jan. 1. (Open enrollment itself ends in most states on Jan. 15, for coverage that would begin Feb. 1.)

Meanwhile, the Biden administration is seeking to put on hold an order by a federal judge in North Dakota who ruled in favor of 19 states that challenged a rule allowing — for the first time — enrollment in ACA coverage by “dreamers,” people brought to the United States as children without immigration paperwork.

The Dec. 9 ruling effectively barred those who qualified for the Deferred Action for Childhood Arrivals (DACA) program in the 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case have said.

On Monday, the U.S. Court of Appeals for the 8th Circuit granted a temporary stay of the order at the government’s request. A final decision, expected any day, could extend the stay while the court hears the appeal.

The Biden administration argues that North Dakota hasn’t proved it would be harmed by the rule — and that not granting a stay would be disruptive. The Dec. 9 order would cause the federal government to incur financial costs if it has to retool the marketplace to reflect the change and notify those who have already enrolled that their plans are canceled, the administration argued.

The original case was filed in August in U.S. District Court in North Dakota and is being heard by District Judge Daniel Traynor, who was nominated in 2019 by then-President Donald Trump.

Previously, the federal government estimated that about 100,000 uninsured people out of a half-million DACA recipients might sign up for 2025 coverage. In its new filing, the government says 2,700 have enrolled through the federal marketplace, and an unknown number in states involved in the litigation that run their own state-based marketplaces.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purpose of enrolling in plans under the ACA.

All the states challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the United States when they don’t have permanent legal authorization.

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Donald Trump’s election to a second term has cast uncertainty around the future of the health law. In addition, the Biden administration implemented cumbersome policies to reduce fraudulent enrollment and is combating a lawsuit that aims to block immigrants who lack legal residency from buying insurance under the program.

So far, the number of new and returning enrollees using healthcare.gov — the federal marketplace that serves 31 states — is below last year’s. New enrollments were just over 730,000 in early December, compared with 1.5 million at the same time last year.

To give consumers in federal marketplace states more time to enroll, the Centers for Medicare & Medicaid Services extended to Dec. 18 the deadline to sign up for coverage that starts Jan. 1. (The Jan. 15 deadline is for coverage that would begin Feb. 1.)

Also in flux is a rule issued by the Biden administration allowing — for the first time — enrollment in ACA coverage by people brought to the U.S. as children without immigration paperwork, known as “Dreamers.”

The Biden team was granted a temporary stay on Dec. 16 by the U.S. Court of Appeals for the 8th Circuit regarding a Dec. 9 order by a federal judge in North Dakota. That district court judge had ruled in favor of 19 states that sought to block the Biden administration’s Dreamers directive. Without a stay, the decision in that case, Kansas v. the United States, effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in the 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case have said.

A final decision on the temporary stay was expected any day now. If granted, it could allow Dreamers to continue enrolling while the government’s appeal of the district court ruling is heard, which is unlikely to occur before Trump takes office.

In its court filings, the Biden administration argues that not granting a stay would be very disruptive in the middle of open enrollment, causing the federal government to incur costs in retooling its marketplace to reflect the change, and notifying those who have already enrolled that their plans are canceled.

The original case was filed in August in the U.S. District Court for the District of North Dakota and is being heard by District Judge Daniel Traynor, who was nominated in 2019 by then-President Trump.

Previously, the federal government estimated that about 100,000 uninsured people out of a half-million DACA recipients might sign up for 2025 coverage. In its new filing, the government says 2,700 have enrolled in those states that brought the suit and use the federal marketplace.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to citizens and those who are called “lawfully present” immigrants.

The federal lawyers argue that North Dakota has not proved it would be harmed by the rule, so it has no standing to bring the case. North Dakota argued that it incurs costs for approximately 130 DACA recipients who live in its state, and that it would not have those expenses if they were barred from enrolling in the ACA and thus decided to leave the country. An exodus is unlikely, the federal government argued. The legal brief also questioned North Dakota’s calculation that it incurs costs of $585 to issue driver’s licenses to the DACA recipients and about $14,000 annually to educate at least one DACA member or dependent.

All the states challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The plaintiff states are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.

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La reelección de Donald Trump para un segundo mandato ha generado incertidumbre sobre el futuro de la ley de salud. Además, el gobierno implementó normas complejas para reducir las inscripciones fraudulentas y está combatiendo una demanda que busca evitar que un grupo de inmigrantes sin residencia legal adquieran cobertura en los mercados de seguros de salud.

Hasta ahora, el número de nuevos inscritos y reinscritos que utilizan cuidadodesalud.gov, el sitio del mercado federal que usan 31 estados, está por debajo del año pasado. A principios de diciembre, las nuevas inscripciones apenas superaban las 730,000, en comparación con 1.5 millones en el mismo período de 2023.

Para dar más tiempo a los consumidores de los estados del mercado federal para inscribirse, los Centros de Servicios de Medicare y Medicaid (CMS) extendieron hasta el 18 de diciembre el plazo para adquirir cobertura que comienza el 1 de enero. (El plazo del 15 de enero es para la que comenzaría el 1 de febrero).

También está en juego una regla emitida por la administración Biden que permite, por primera vez, que los Dreamers, las personas traídas al país de niños sin papeles, puedan inscribirse en los mercados y obtener subsidios.

El 9 de diciembre, un juez federal de Dakota del Norte falló a favor de 19 estados que buscaban bloquear esta directiva de la administración Biden.

El 16, el equipo de Biden obtuvo una suspensión temporal, pero el destino de esta opción todavía está por verse.

De prevalecer, la decisión en este caso, Kansas vs Estados Unidos, efectivamente prohíbiría a quienes han calificado para el programa de Acción Diferida para los Llegados en la Infancia (DACA) inscribirse o recibir subsidios para los planes de ACA en los 19 estados. Según los abogados que siguen el caso, no parece afectar la inscripción o la cobertura en otros estados.

Se espera una decisión final sobre la suspensión temporal en cualquier momento. Si se concede, podría permitir que los Dreamers sigan inscribiéndose mientras se escucha la apelación del gobierno a la decisión del tribunal de distrito, lo cual es poco probable que ocurra antes de que Trump asuma el cargo.

En sus documentos judiciales, la administración Biden argumenta que no conceder una suspensión sería muy disruptivo en medio del período de inscripción abierta, lo que causaría que el gobierno federal incurra en costos para reajustar su mercado para reflejar el cambio y notificar a aquellos que ya se han inscrito que sus planes han sido cancelados.

El caso original fue presentado en agosto en el Tribunal de Distrito de los Estados Unidos para el Distrito de Dakota del Norte y está siendo escuchado por el juez de distrito Daniel Traynor, nominado en 2019 por el entonces presidente Trump.

Previamente, el gobierno federal estimó que alrededor de 100,000 personas sin seguro de un total de medio millón de beneficiarios de DACA podrían inscribirse para tener cobertura de 2025. En su nuevo escrito, el gobierno dice que 2,700 se han inscrito en los estados que presentaron la demanda y que usan el mercado federal.

La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados “legalmente presentes” para los propósitos de inscribirse en planes bajo ACA, los cuales están abiertos a ciudadanos y aquellos denominados inmigrantes “legalmente presentes”.

Los abogados federales argumentan que Dakota del Norte no ha demostrado que sería perjudicado por la regla, por lo que no tiene legitimidad para presentar el caso. El estado argumentó que incurre en costos para aproximadamente 130 beneficiarios de DACA que viven allí, y que no tendría esos gastos si se les prohibiera inscribirse en ACA y, por lo tanto, decidieran abandonar el país.

Por su parte, el gobierno federal argumentó que un éxodo es poco probable. El escrito legal también cuestionó el cálculo de Dakota del Norte de que incurre en costos de $585 para emitir licencias de conducir a los beneficiarios de DACA y alrededor de $14,000 anuales para educar al menos a un miembro o dependiente de DACA.

Todos los estados que impugnan esta regla argumentan que causará cargas administrativas y económicas a medida que más individuos se inscriban, y que alentará a más personas a permanecer en Estados Unidos sin documentos.

Los estados demandantes son: Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Dakota del Norte, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.

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La decisión prohíbe a los beneficiarios del programa de Acción Diferida para los Llegados en la Infancia (DACA) en esos 19 estados inscribirse o recibir subsidios para pagar los planes de ACA.

Abogados que siguen el caso dijeron que este fallo no parece afectar la inscripción ni la cobertura en otros estados.

La administración Biden probablemente apelará, aunque un representante de los Centros de Servicios de Medicare y Medicaid (CMS,) la entidad federal que coordina estos mercados, dijo por correo electrónico que la agencia no comentará sobre el litigio.

Aunque se podría presentar una apelación rápidamente, una decisión final podría no ocurrir antes de que comience la próxima administración Trump. “Podrían tomar una posición diferente sobre el litigio”, dijo Zachary Baron, experto legal de Georgetown Law, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Mientras tanto, no está claro qué sucederá con los Dreamers inscritos en los 19 estados cuya cobertura ya comenzó o comienza a principios del próximo año, aunque la decisión del juez no menciona que sea retroactiva, señaló Baron.

El caso fue presentado en agosto en el Tribunal de Distrito de los EE.UU. para el Distrito de Dakota del Norte.

Anteriormente, el gobierno federal estimó que alrededor de 100.000 personas sin seguro, de medio millón de beneficiarios de DACA, podrían inscribirse a partir del 1 de noviembre, la fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados como “presentes legalmente” en el país a los propósitos de inscripción en planes de salud de ACA, que están disponibles para ciudadanos estadounidenses e inmigrantes denominados “presentes legalmente”.

Al otorgar una orden judicial preliminar y una suspensión, el juez federal Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, señaló en su fallo del lunes 9 de diciembre que es probable que los demandantes ganaran gracias a los méritos de su argumento.

Los estados que impugnan la regla de ACA argumentan que causará cargas administrativas y de recursos al aumentar el número de inscritos y que alentará a más personas a permanecer en el país sin documentos legales.

Además de Kansas y Dakota del Norte, los estados que se unieron a la demanda son Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.

“El fallo del juez Traynor es tanto decepcionante como erróneo en cuanto a la ley”, dijo Nicholas Espíritu, subdirector legal del Centro Nacional de Leyes de Inmigración, en un comunicado por correo electrónico.

“Mientras estudiamos la decisión del tribunal para evaluar los próximos pasos en este caso, continuaremos luchando en nombre de nuestros clientes y cientos de miles de beneficiarios de DACA que han esperado más de una década para acceder a atención vital bajo la Ley de Cuidado de Salud a Bajo Precio”.

DACA fue establecido mediante acción ejecutiva en junio de 2012 por el presidente Barack Obama, protegiendo de la deportación y proporcionando permiso de trabajo a algunos residentes no autorizados traídos al país de niños. Debían cumplir con ciertos requisites para calificar: haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o servir en el ejército.

Antes de la orden judicial, otros 19 estados y el Distrito de Columbia presentaron un informe en apoyo de la regla de la administración Biden. Liderados por Nueva Jersey, esos estados incluyen muchos en el Este y Oeste del país, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

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The move effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in those 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case said Tuesday.

The Biden administration is likely to appeal, although a Centers for Medicare & Medicaid Services representative said in an email that the agency would not comment on the litigation.

While an appeal may be filed quickly, a final decision may not occur before the incoming Trump administration takes office. “They could take a different position on the litigation,” said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

In the meantime, it is not clear what will happen to Dreamer enrollees in the 19 states whose coverage has already started or begins early next year, although the judge’s ruling does not say it is retroactive, Baron noted.

The case was filed in August in U.S. District Court for the District of North Dakota.

Previously, the federal government estimated that about 100,000 uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, the sign-up season start date in all states except Idaho.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to American citizens and what are called “lawfully present” immigrants.

In granting a preliminary injunction and stay, U.S District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, noted in his Monday ruling that the plaintiffs were likely to win on the merits of their argument.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. In addition to Kansas and North Dakota, the states that joined the lawsuit are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.

“Judge Traynor’s ruling is both disappointing and wrong on the law,” said Nicholas Espíritu, a deputy legal director of the National Immigration Law Center, in an emailed statement. “While we study the court’s ruling to evaluate the next steps in this case, we will continue to fight on behalf of our clients and hundreds of thousands of DACA recipients who have been waiting over a decade to access life-sustaining care under the Affordable Care Act.”

DACA was established through executive action in June 2012 by President Barack Obama, protecting from deportation and providing work authorization to some unauthorized residents brought to the U.S. as children by their families. It had certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were serving in the military.

Before the injunction, 19 other states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many in the East and West, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

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