Readers Sound Off on NIH Staff Cuts, Work Requirements, and More

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

‘The Federal Government’s Loss Is the County’s Gain’

I wanted to thank Rachana Pradhan and Katheryn Houghton for their coverage of the loss of staff at the National Institutes of Health (“Six Federal Scientists Run Out by Trump Talk About the Work Left Undone,” March 6). In December 2024, I had accepted a tentative job offer for a dream job at NIH after eight years of being a federal contractor supporting data science work with the Centers for Disease Control and Prevention’s Global Health Center and the National Center for Immunization and Respiratory Diseases during the covid response, and later with the U.S. Agency for International Development, where I supported HIV program monitoring and response data visualization.

On Jan. 10, 2025, I went to the Bethesda campus to get my badge photo taken and my fingerprints documented. The next week, I received confirmation that I would soon receive my final salary offer. But on Jan. 20, an email informed me that, due to the federal hiring freeze, my job had been canceled. I was devastated. I reached out and thanked everyone who had been helping bring me on board, but I never heard back. I can only imagine how chaotic it was for them on the inside.

I was fortunate to have not yet left my job as a contractor, but I decided to switch from federal to local government. My dream had always been to be a federal employee supporting public health research, and I realized that the trust I put in that working out was broken. I was very fortunate to connect with leaders in the IT department of my local health department and even more fortunate they had a job available for me. I was relieved — still a contractor, but gainfully employed in my field.

Over the next year, I continued to stay in touch with my federal public health friends and colleagues and connect them with opportunities when possible. It’s been an absolutely awful year for public health, and they’re the only ones who really understand. It feels isolating, but we’re all in it together.

My story has about the happiest ending it could. This month, I secured a full-time merit (not contract) role with my local county. I am absolutely thrilled. I know several other former feds who’ve recently joined the county as well. The federal government’s loss is the county’s gain.

Thank you for your compassionate coverage of this incredible upheaval in my field.

— Jessica Hoehner, Fairfax County, Virginia

On Work Requirements: Working Out Solutions

Eighty hours a month works out to about 20 hours a week, and I think if people can work or study from home, they should be able to meet the requirements (“New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard,” Feb. 11). More importantly, though, “navigators” will help people get exemptions if they qualify. I wonder why there is so much moaning about the law and nothing about the means to fix the problems it creates. It seems like a lot of hot air. We know it’s a problem. So how about exploring solutions?

— Therese Shellabarger, North Hollywood, California

The Flip Side of a Drug’s Benefits

I read Phillip Reese’s report on antianxiety medications, adults who take them, and their concerns about this administration’s policies regarding them (“As More Americans Embrace Anxiety Treatment, MAHA Derides Medications,” Feb. 23). If the antianxiety medications provide solace to adults such as Sadia Zapp — a 40-year-old woman who survived cancer — then she should be able to continue them. Unfortunately, the same is not true for many other people, particularly patients such as myself.

When I was 16, I went through an unnecessarily painful and traumatic year. I was sent away from home three times, sent to a wilderness therapy “troubled teen industry” camp that has now been shut down, sent to a new boarding school that I hated, and was away from my family for many months. Of course, I felt depressed and anxious, so my psychiatrist at Kaiser prescribed citalopram. At first, it caused extreme agitation and violent ideation, stuff that is commonly reported to the point it has an empirically justified black-box warning. Thankfully, it calmed down. And when I lowered the dose, my life was calm, stable, and productive.

Unfortunately, that did not last long. Over time, the effects wore out, so I tried to go off. I was not given any safety instructions on how to taper slowly and safely, so I went off multiple times. Each time caused extreme withdrawal symptoms, including self-harm, crying spells, and worse depression than ever before. Also, the sexual “side effects” persisted and even worsened upon cessation to this day. It is a condition called PSSD, and it is very rarely covered. While the worst symptoms of withdrawal went away, I still live with a worsened sexuality than a young adult my age is supposed to have.

Back to the article, which seems to focus on adults. Its only named profile is Zapp, and when it cites statistics, it begins at age 18. Solely showing statistics of adults is unethical because it obscures the high and rising prescription rates among minors. Minors are also more likely to suffer permanent developmental damage to their sexualities and experience suicidal ideation. This is a major problem that warrants further conversations.

When covering the downsides of SSRIs, the article mentioned only mild side effects, like upset stomach, decreased libido, and mild discontinuation effects, without covering the major concerns of suicidal ideation, akathisia, PSSD, and severe withdrawal. I believe that framing antidepressants as an unequivocal good is equivalent to framing them as an unequivocal evil; both misguide patients through harm and deception.

Lastly, I want to finish on this brief, nuanced op-ed by the brilliant psychiatrist Awais Aftab.

— Eli Malakoff, San Francisco

A Rigged System?

Insurers pay these exorbitant amounts because they set them in the first place (Bill of the Month: “Even Patients Are Shocked by the Prices Their Insurers Will Pay — And It Costs All of Us,” March 3). They have been doing this for years. I learned this over 15 years ago, when I dislocated and broke my elbow. I had no insurance and, as a “self-pay” patient, paid the surgeon, hospital, and radiology center myself. They set the prices high enough that people will buy insurance out of fear, ensuring they make a profit.

The first thing I learned was that there is not a set price for all; for the insured, it is a fixed system controlled by contracts and codes. As a self-pay patient, the cost may vary.

It was late in the evening and I tripped over a snow shovel, slammed my arm up against a gate post, and it was hanging like a puppet without a string! I called an ambulance and, at the hospital, they strapped me up and told me that I must see the orthopedic surgeon the next day. He sent me to a radiology facility for an X-ray; I paid for it and took it to the surgeon. When I received a bill from the radiology center, I called to say that I had paid. They said it was for the radiologist (who, as far as I knew, never analyzed it). The contract with the insurance company required that every patient had to be billed, whether or not a radiologist reviewed scans. If not, they would lose their contract.

My elbow was dislocated, with a fracture, and I needed surgery. The surgeon’s office called the hospital for pricing, and he told me it would be about $2,000 for outpatient surgery. I called the hospital to confirm the appointment for outpatient surgery, and they wanted $8,000! When I objected, and told them what the surgeon had quoted, they checked. “Oh, you are a self-pay!” Cost would be $2,000. I gave them my card number and prepaid it before they could change their minds.

I had a friend in New Jersey who had the very same injury and surgery. She had insurance through her employer, and she paid more in copays than I paid when paying directly.

Insurance companies are SHARKS!

— Stephanie Hunt-Crowley, Chamberet, Nouvelle Aquitaine, France (formerly Frederick, Maryland)

US vs. Canada

Re: the article about nurses moving to Canada (“‘You Aren’t Trapped’: Hundreds of US Nurses Choose Canada Over Trump’s America,” Feb. 26). You neglect the “rest of the story” — or maybe you don’t know it? I had my medical office in Los Angeles for about 30 years and had dozens of Canadians come to L.A., where some had to self-pay for care, but chose to because of the superior level of medicine available. One man, a son of a gynecologist in Canada, had a draining abscess from a years-old appendectomy. The reason was, after investigation, that the Canadian practice had used silk suture (organic material), which can harbor microbes and carry a greater risk of infection. The trend has been to discontinue silk in favor of nylon. The Canadians were obliged to “use up” the silk suture they had before switching to nylon. The surgeons at my hospital were astounded.

— Kathryn Sobieski, Jackson, Wyoming

On the NET Recovery Device’s Track Record — And Detractors

I read your piece about the NET Recovery device with interest (Payback: Tracking Opioid Cash: “Maker of Device To Treat Addiction Withdrawal Seeks Counties’ Opioid Settlement Cash,” March 18), and I am grateful to you for pointing to one of our many success stories — the story of Michelle Warfield, whom the NET device helped get off opioids.

I also wanted to note a couple of instances where I see the facts differently than they were portrayed in your piece. Your piece seemed to imply that the NET device is new, and I wanted to note that the device has been around for decades (it helped Eric Clapton and members of The Who and the Rolling Stones get sober back in their heyday), and is based on a proven technology that stimulates both the brain and the vagus nerve to help patients with their cravings and withdrawal. There are countless studies that prove the power of neurostimulation, including our recent peer-reviewed study that showed significant reductions in opioid and stimulant use without medication for a polysubstance population receiving at least 24 hours of stimulation.

I also noted you quoted detractors of our device, and I’d simply urge anyone looking at the issue of opioid addiction abatement to consider who those detractors are; organizations that now find themselves competing for grant dollars from counties increasingly choosing to fund innovation. It is not surprising that those with the most to lose financially would prefer the status quo. But the counties and jails leading this charge are doing so because they have seen what works, and their constituents, real patients, are the proof.

The success stories of our patients speak for themselves, and our only motivation at NET Recovery is to help as many people as possible get truly clean and sober by helping to break that initial grip the opioids have on them. When the NET device works, and it works an astounding 98% of the time (producing a clinically meaningful reduction in opioid withdrawal symptom severity in one hour), our patients are experiencing the return of choice and true freedom.

Thank you for your interest in our work and for the coverage you provide.

— Joe Winston, NET Recovery CEO, Costa Mesa, California

Who Really Collects in the Wage Garnishment Game?

I was a consumer bankruptcy attorney for years during the global financial crisis of 2008 (pre-Affordable Care Act). Around 40% of the bankruptcies were caused by medical debts uncovered by insurance. With the effectiveness of the ACA, the number of bankruptcies in Colorado plummeted.

My comment on “State Lawmakers Seek Restraints on Wage Garnishment for Medical Debt” (Feb. 20)? BC Services acts as if it is garnishing these wages to keep rural hospitals, medical providers, etc. in business. The likely reality is that BC Services (and other collection operations) takes “90-day-overdue” bills — which may or may not have ever been delivered to the patient — usually disregards whether the hospital has offered the patient a reasonable repayment schedule, and then keeps 50% or more of the debt, along with its attorneys’ fees and costs. The medical provider receives very little of the money sent to collections.

— Bill Myers, Denver

Education Is the First Step in Lowering Health Care Prices

After reading this article about making hospital prices more transparent, I realized the information alone could help drive medical prices down (“Trump Required Hospitals To Post Their Prices for Patients. Mostly It’s the Industry Using the Data,” Feb. 17). Your publication shows good use of evidence-based research — it’s timeless and informative.

As a student at Thomas Jefferson University on the path to serving in the health care arena, I understand the struggles and complexities of medical decision-making. In the medical setting, the topic of price is always overshadowed by patient care and clear communication on the part of both professionals and patients, and it does not reflect how patients would navigate comparison-shopping for care. Almost every patient relies on the help of a physician or gets help from an insurance network and not from online price matching.

I believe that many people should engage with this article even if they aren’t entering the health profession; it would benefit everyone. Although price transparency may help insurers and care providers more than patients, if their goal is to lower prices, they must look beyond the simple posting or sharing of prices. I appreciate the effort to try to bring awareness to this major issue and encourage thoughtful policy discussion about lowering medical prices.

— Jan Rodriguez, Philadelphia

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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States Pay Deloitte, Others Millions To Comply With Trump Law To Cut Medicaid Rolls

States are paying contractors such as Deloitte, Accenture, and Optum millions of dollars to help them comply with the One Big Beautiful Bill Act — a law that will strip safety-net health and food benefits from millions.

State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a KFF Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by KFF Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause 7.5 million people to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly 2.4 million people will lose access to monthly cash assistance for food, including those with children.

In five states alone, company estimates developed for state officials and reviewed by KFF Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting firm Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will cost nearly $6 million. Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which Deloitte drafted for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, according to an estimate prepared by Accenture, a consulting firm that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — estimated that it could cost roughly $1.8 million to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, have cost the state $1.6 million. And in Illinois, Deloitte estimated modifications will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — nearly half of those enrolled.

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was worth $125.6 million as of October.

Nearly two-thirds of adult Medicaid enrollees nationally are already working, according to KFF. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the CBO reported.

In Wisconsin, state officials estimate roughly 63,000 adults could lose coverage after work requirements take effect. Not covering those people would save $532.6 million in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — was implemented statewide in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year contract worth more than $157 million. According to documents obtained by KFF Health News, initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — covers 90% of state costs to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is —­ I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to KFF Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” KFF Health News found that Deloitte, a global consultancy that generated $70.5 billion in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a contract worth more than $60 million.

Adding the ability to verify work status would cost up to $7 million, an Accenture estimate from March 2025 showed. By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions skyrocketed to roughly $20.3 million. Accenture’s analysis said the federal law necessitated additional changes to Iowa’s system. An estimated 32,000 Iowans could lose coverage by making employment a condition of Medicaid benefits, according to a 2025 state document.

Cutting 32,000 people from coverage could save $183 million in one year, a fraction of the $8.9 billion Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently $33,000 for a family of four.

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that most of the work detailed in one of Deloitte’s estimates — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have promised to offer discounts and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” said Daniel Brillman, the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum pledged to offer discounts for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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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She Owed Her Insurer a Nickel, So It Canceled Her Coverage

Last summer, Lorena Alvarado Hill received a series of unexpected medical bills.

A teacher’s aide in Melbourne, Florida, Hill is a single mom who works shifts at J.Crew on the weekends to send her daughter to college. Hill and her mother, who lives with her, had been enrolled in an insurance plan through HealthFirst.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

Hill was on the hook for a $2,966.93 MRI, as well as more than half a dozen doctor visits costing about $200 or $300 each. Without that kind of money on hand, Hill said, she put a few of the bills on payment plans and tried to figure out what had gone wrong.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Premium subsidies for ACA plans are automatically recalculated every time coverage is changed because of a life event, such as marriage, a change of job, or a child turning 26. In June, Hill removed her mother from the family’s group plan because she turned 65 and became eligible for Medicare and Medicaid.

The change triggered a recalculation of Hill’s monthly premium contribution, increasing it from $0 to 1 cent. She said she thought the amount was so small that she couldn’t pay it with her credit card.

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

But she said that her doctors collected the usual copayments during subsequent visits and that her insurance broker told her not to worry, reassuring her that the plan was “active.” Hill figured the 1-cent monthly premium was probably a rounding error that couldn’t result in termination, she said.

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

She made an appointment the next day with her broker, who called HealthFirst for clarification. The news was even worse: Not only had her insurance been canceled, but the 5-cent bill could be sent to a collection agency.

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

Others have lost their coverage over owing small amounts, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “This woman’s situation is not so unusual with the enhanced subsidies,” she said.

The American Rescue Plan, passed in 2021, increased the amount of government assistance available to ACA plan holders. Those enhanced subsidies, which Congress let expire at the end of last year, meant enrollees with lower incomes had to pay little or nothing toward their premiums.

The Biden administration found that, in 2023, about 81,000 subsidized ACA insurance policies were terminated because the enrollee owed $5 or less. Nearly 103,000 more were canceled for owing less than $10.

To prevent that kind of coverage loss, most likely hitting people with little income, Biden administration health officials gave insurers the flexibility to allow ACA enrollees to retain coverage if they owed less than $10, or less than 95% of premium costs.

Insurers were required to keep insurance active for a 90-day “grace period” to give enrollees time to respond. That’s why Hill’s doctors initially took her copayments and sent no bill, as if nothing had changed.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She filed a complaint in December with HealthFirst and the Florida Department of Financial Services asking for a write-off of her 5-cent balance and retroactive restoration of her policy, citing state and federal laws that seemed to apply to her situation.

In particular, she wrote, “creditors are not required to collect, and consumers are not required to pay, credit-card balances of $1.00 or less,” adding that “all major insurers and payment processors in Florida follow a 1-cent write-off policy.”

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had followed the law in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

Weeks after a reporter’s query to the insurer, Hill said she looked at her billing statements for all the medical services she received in 2025 and was pleasantly surprised that the balances owed had been adjusted to $0.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

And while insurance policies have grace periods allowing coverage to remain in place if you miss a payment, some are not very long. For subsidized ACA marketplace plans, the period is 90 days, but others last just 30 or 45.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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