How to Pay Less for Your Prescriptions and Brace for a Health Insurance Shake-Up

Summary

NerdWallet's Smart Money Podcast

Episode: How to Pay Less for Your Prescriptions and Brace for a Health Insurance Shake-Up

Date: August 18, 2025
Hosts: Sean Pyles & Elizabeth Ayoola
Expert Guests: Dan Weissman (host of "An Arm and a Leg"), Kate Ashford (NerdWallet Personal Finance Nerd)

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Episode Overview

This episode takes on two vital topics for American consumers:

1. How to navigate the high and often confusing costs of prescription drugs in the U.S., featuring actionable strategies from investigative healthcare journalist Dan Weissman.
2. How to prepare for a potential shake-up in the Affordable Care Act (ACA) health insurance marketplace, especially with enhanced tax credits set to expire, in an in-depth Q&A with NerdWallet’s Kate Ashford.

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Section 1: Why Are Prescription Drugs So Expensive in the U.S.?

Guest: Dan Weissman, host of NPR’s "An Arm and a Leg"
Segment Start: [03:24]

Key Discussion Points

• Unique U.S. Healthcare System:
  The U.S. stands apart from other countries by relying heavily on free-market pricing, with only limited government regulation (e.g., Medicare, Medicaid).
• Two Main Industry Players:
  • Pharmaceutical Companies: Can set prices freely, serving shareholder interests.
  • Pharmacy Benefit Managers (PBMs): Intermediaries (often owned by or owning insurance companies like Cigna, Aetna, UnitedHealth) determine which drugs are covered, what you pay, and negotiate prices—often benefiting corporate interests, not patients.

Notable Quote:

"The system is not designed to give us the care we need at a cost that we can afford." — Sean Pyles [06:21]
"It's designed to create profits, and it does that really, really well." — Dan Weissman [06:25]

Common Consumer Challenges

• Prescription drugs may not be covered by insurance.
• Prices can fluctuate wildly—even for the same drug at different pharmacies.
• Out-of-pocket costs can be astronomical even with insurance.

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Section 2: Strategies for Paying Less for Prescriptions

Segment Start: [07:07]

Actionable Tips & Resources

• At the Pharmacy Counter — Ask Questions:
  • Make sure the pharmacist has the correct, up-to-date insurance information. Sometimes, this simple step can drop your cost dramatically (e.g., $400 to $5).
    • “Hey, could you run my insurance one more time just to see if it's up to date?” — Dan Weissman [08:04]
  • Ask if there are manufacturer coupons or discount programs for your medication, especially for brand-name drugs.
• Compare Prices Using Apps and Websites:
  • Use resources like GoodRx, Mark Cuban’s Cost Plus Drugs, and other similar tools to compare prices at various pharmacies—even nearby locations. Sometimes paying cash without insurance is cheaper.
    • “I could have gone a couple miles down the road to another place with no insurance and paid $20 for this.” — Dan Weissman [08:05]
  • Each program negotiates different deals, so check several to find the best price.
• Ask About Alternatives:
  • Inquire whether your insurance covers a similar but more affordable or preferred medicine.
  • “Is there some other version of this kind of drug that my insurance will cover?” [10:20]
• Try Manufacturer Assistance and Doctor’s Samples:
  • Your doctor might have free samples to tide you over during insurance negotiations or appeals.
  • Requesting samples is a short-term fix but can fill a gap if you're fighting a denial.
• Escalate When Necessary:
  • If insurance denies a prescription, treat it as the start of a negotiation, not the end.
  • Enlist your healthcare provider to help with insurance appeals; multiple appeal rounds are possible.
• Advanced Step — Super Sleuthing:
  • For expensive regular medications, consider making a spreadsheet to track prices across various pharmacies, discount programs, and insurance options.

Notable Quote:

“When Dan pays $5 at the counter for this medicine, like you get $2 out of that and you know you can kick us a nickel, it’s fine. Right? That’s how that works for them.” — Dan Weissman on how PBMs and apps like GoodRx profit [09:15]

Memorable Moment:

“Your mileage may vary — so do the easy things first, right there at the pharmacy counter: coupons, alternatives, checking nearby prices. If you need to, then dig in with appeals or spreadsheets.” — Dan Weissman [10:28–13:23]

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Section 3: How to Ensure Prescriptions Are Covered for Next Year

Segment Start: [14:14]

Open Enrollment Preparation Advice

• Check the Formulary:
  • Every insurance plan is required to publish a "formulary," a list (often a long PDF) specifying which drugs are covered and at what cost (broken into coverage tiers).
  • Use Control+F to search for your prescriptions and see if they are included and what tier/cost applies.
• Comparative Shopping:
  • Before open enrollment, compare new plans to see if alternate coverage offers better support for your medications.
  • If an affordable preferred drug won’t be covered next year, talk to your doctor about switching, or seek another plan if possible.

Notable Quote:

“If you are lucky enough to be able to choose an insurance policy and that formulary tells you, hey man, next year your inhaler is going to be $500 ... see if there’s another policy that covers it for less.” — Dan Weissman [15:09]

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Section 4: The ACA Health Insurance Subsidy Shake-Up

Listener Q&A Start: [19:17]

Listener Question from Rebecca (Vermont):
Concerned about expiring enhanced ACA tax credits, losing access to affordable insurance as a partially self-employed worker. Wanted to know:

1. The outlook for ACA subsidies post-2025.
2. Strategies to reduce health insurance costs.
3. Whether to seek a job mainly for insurance, even at lower pay.
4. The risks of going uninsured.

Key Insights From Kate Ashford (NerdWallet’s Personal Finance Nerd)

• Expiring ACA Subsidies:
  • The enhanced premium tax credits under the ACA will sunset at the end of 2025 absent new legislation. This means millions will get smaller subsidies or none at all, leading to much higher premiums.
    • “Premiums are expected to go up dramatically—the Congressional Budget Office predicts more than 4 million people will lose insurance by 2034.” — Kate Ashford [22:05]
  • Nonprofit KFF predicts premiums will surge by more than 75% on average, with some people facing a doubling of health costs.
• Practical Steps to Prepare:
  • Calculate what your premiums would look like if they jump 75%.
  • Explore shifting income (e.g., using retirement contributions) to qualify for remaining subsidies.
  • Consider moving from a Silver to a Bronze plan or a high-deductible plan—tradeoff: lower monthly premiums but higher costs if you need care.
  • For the self-employed: Health insurance is often a deductible expense, but check with a tax advisor.
• Prescription Drug Savings Recap:
  • Reuse strategies discussed earlier (GoodRx, manufacturer discounts, etc.).
  • Use all preventive care benefits, which ACA-compliant plans must provide at no out-of-pocket cost.

Notable Quotes:

“Can you do back-of-the-napkin math for what your premiums would look like if they went up 75% ... and can you afford that?” — Kate Ashford [23:41]

“Employer-sponsored health insurance ... is likely going to be cheaper if subsidies go away.” — Kate Ashford [26:17]

• Risks of Going Uninsured:
  • Not just financial (potential for bankrupting medical bills from an accident or sudden illness), but also impacts on health outcomes and credit score.
  • Even those in good current health are vulnerable to unexpected events—medical debt is a top cause of bankruptcy.

“It’s a gamble for healthy people too. No one plans to have a serious accident or sudden illness, but it can happen at any time.” — Kate Ashford [27:30]

Why Is U.S. Health Insurance Tied to Employment?

Quick History:

• Originated during WWII wage freezes (insurance offered instead of raises).
• 1943: Employer-provided health insurance declared tax-exempt, supercharging its popularity.
• U.S. stuck with this employer-based model, never achieving universal coverage.

Hosts’ Take:

“So what I’m hearing is that our current situation is somewhere between a mistake and a horribly unhappy accident.” — Sean Pyles [28:40]

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Timestamps of Key Segments

• [03:24] Why are prescription drugs so expensive in the U.S.?
• [07:07] Strategies to lower prescription costs (what to do at the pharmacy counter)
• [08:51] How discount programs like GoodRx work, ethical implications
• [10:20] Advanced strategies—spreadsheets, appeals, and leveraging your doctor
• [13:23] Using drug samples to bridge temporary access gaps
• [14:32] Preparing for open enrollment, checking your insurance formulary
• [19:17] Listener Q&A: ACA subsidy expiration & self-employed health insurance dilemmas
• [21:12] Explaining the ACA’s enhanced tax credits and likely impacts
• [22:27] Projections: average premium increases and their impact on consumers
• [24:57] Choosing between ACA, employer-sponsored plans, or going uninsured
• [26:50] Real risks and financial dangers of going without health insurance
• [28:06] History lesson: Why is American healthcare tied to employment?

---

Memorable Moments & Quotes

• “You show up at the pharmacist, like, ‘That’s going to be $500.’ ... That’s your chance to ask, ‘Hey, could you run my insurance one more time just to see if it’s up to date?’ ... It went from $400 to $5.” — Dan Weissman [08:04]
• “The idea here is not that [free samples] are a kind of permanent supply for you, but that it’s while you’re fighting with your insurance ... to get them to cover this for you.” — Dan Weissman [13:30]
• “Employers started offering health insurance as a fringe benefit because they couldn’t offer higher salaries—then we just ... kept going.” — Kate Ashford [28:06]

---

Tone & Takeaways

True to NerdWallet’s style, hosts Sean and Elizabeth keep the tone relatable and encouraging, interspersing empathy, humor, and a little frustration (“our current situation is ... a horribly unhappy accident.”). Their expert guests break down complex systems with clarity, offering practical, research-backed strategies for both recurring consumer headaches: prescription drug costs and impending health insurance premium hikes.

Big picture: The U.S. healthcare system remains convoluted and profit-driven, but consumers aren’t powerless. By carefully researching, checking every option, and leveraging timing (open enrollment), pharmacy couponing, and appeals, you can drastically reduce some costs—though not all. But with the ACA landscape poised for turmoil, vigilance and flexibility will be more essential than ever.

---

If you only have five minutes:

• Always ask the pharmacist to double-check your insurance.
• Use apps like GoodRx to find the best price—even sometimes beating your insurance.
• Appeal insurance denials and seek help from your doctor or clinic (including asking about free samples).
• Ahead of open enrollment, search your plan’s formulary to avoid prescription sticker shock next year.
• If ACA subsidies expire, premiums may jump. Re-calculate your budget and consider employment options offering group coverage.

---

For more details, see Dan Weissman’s coverage at “An Arm and a Leg” or NerdWallet’s deep dives on the ACA and prescription savings.

Transcript

[A]

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[A]

[e-mail] have you ever gone to pick up a prescription and found it cost much more than you were expecting or your insurance suddenly decided to stop paying for your medicine?

[B]

The former has happened, Sean, and unfortunately I had to pay for it because I still needed the prescription. So what's a girl to do?

[A]

Yeah, what a bind. Well, I know a lot of folks have found themselves in the same exact situation, so this episode will have some tips for how people can make prescriptions a little More manageable foreign welcome to Nerd Wallet's Smart Money podcast where you send us your money questions and we answer them with the help of our genius nerds. I'm Sean Pyles.

[B]

And I'm Elizabeth Ayola. This episode we answer listeners question about how to manage healthcare expenses if healthcare tax credits expire later this year, which is expected to make Affordable Care act plans 75% more expensive on average.

[A]

But first, we're going to dive deep into another aspect of healthcare. Prescription drugs. I don't know about you, Elizabeth, but paying for prescriptions can sometimes feel like a weird hybrid game of hide and seek and whack a mole. Like it's hard to find the best price for your prescription and then once you have it settled, your insurance suddenly decides to change the pricing or drop coverage for the drug entirely.

[B]

This sounds like a nightmare. I mean, luckily I don't have prescription drugs often, but the few times I have, I've been shocked at the cost of them. Now, as a girl coming from London where we had universal health care, I still marvel how much I pay out of pocket for prescriptions and how much work can go into finding a cost effective option.

[A]

Well, this episode we're joined by Dan Weissman, host of the NPR podcast An Arm and a Leg, which helps listeners navigate the truly dysfunctional and absolutely maddening world of healthcare in the United States. Dan's going to help us figure out how to make these often vital prescriptions a little more affordable. Dan, welcome to Smart Money.

[C]

Thanks for having me.

[A]

So you did a really helpful two part series just about how people can navigate the cost of prescription drugs. And even though you folks don't need to take notes because you have a really helpful newsletter, I was taking notes while listening to your podcast. But before we get into your tips that I think are just super helpful for everyone, I'd love if we could just zoom out a little bit and hear from you why prescription drugs are just so expensive in the United States. I mean, we are paying a lot more for the same drugs than folks in other countries.

[C]

Prescription drugs are part of our whole healthcare system, obviously, which is unlike the healthcare systems of other developed countries. More than any other place, we're just like, let the market figure things out and we'll and the government will do a little regulation and supplement with things like Medicare and Medicaid, but the market will do its thing is a kind of basic idea. And when I started making an arm and a leg, I was like, yeah, what's the deal with the cost of healthier this is like a whole sub genre of the show Planet Money. Like, why market failures? Like, what happens when markets don't actually solve problems except for, like, shareholders? So here we are. There's kind of two big sets of players in the world of prescription drugs. And one of them we know well, the makers of pharmaceuticals who can charge whatever price they want because it's a free country in that or a free market country in that respect. And the other is a set of players that most of us don't know about called pharmacy benefit managers. And these are entities that essentially subcontract or used to subcontract to insurance companies. Many of them are now essentially owned by or own insurance companies like Cigna and Aetna and others, and UnitedHealth Group. All the three of them own or are owned by the three biggest pharmacy benefit managers. So just to let you know, that's a big piece of the puzzle is we have this. Not only do we have a big corporate health care system, it's consolidated more and more. So those guys, their job is to say, like, oh, our insurance plan obviously has to cover prescription drugs. Which ones will we pay for? How much will our people that we cover pay for this drug versus that drug, this ADHD drug versus that ADHD drug? This blood pressure drug versus that blood pressure drug? We could go on a very long time about this. But essentially, the pharmacy benefit managers have the job of getting the best deal for themselves and the insurer, but not necessarily making sure that you get the medicine that you need at a price you can afford. They make more money other ways. So we are caught essentially between the rock of the pharma companies who are beholden to their shareholders, and the hard place of the pharmacy benefit managers who are beholden to the shareholders of the giant companies that they're parts of.

[A]

The system is not designed to give us the care we need at a cost that we can afford.

[C]

It's designed to create profits, and it does that really, really well.

[B]

So you made a good point, Dan, which is that these systems aren't necessarily caring about how much it's going to cost the consumer out of pocket to pay for these drugs. Can you outline some of the common challenges people face when trying to get prescription drugs? Is it that their insurance denies their coverage or that even with insurance, the drugs are too expensive? Or is it both?

[C]

It's both. It's all of the above. And things can seem so backwards that if you're taking what your pharmacy benefit manager considers to be the wrong drug, the price to you can be super enormous. And there may be places you could get that same drug outside of using your insurance for a lot less.

[B]

So then how would someone be able to determine which one is the best route then? What kind of research do they need to do?

[C]

Oh, boy. Yeah. So we at the beginning of this year asked our listeners and a bunch of experts, and a bunch of our listeners are experts, like, what have you done when, you know, you've gotten this kind of sticker shock at the pharmacy counter? And people told us all kinds of things and it was super interesting. It's a dizzying array of strategies. And I think the thing that I came away from it most making tell you some of the details that we got, but is that you start with the things that are the kind of easiest. It's kind of like when your doctor is like, well, have you tried taking some Advil? Or have you tried turning your computer off and turning it back on again? And this list by itself is a bit of a pain, but the kind of quote unquote easy things are like, you show up the pharmacist, like, that's going to be $500. And this is your chance to ask, hey, could you run my insurance one more time just to see if it's up to date? That happened to me once. It was super interesting. It went from $400 to five.

[B]

Shut the front door.

[C]

Yeah, man, it happened. It was January and the Walgreens just hadn't taken in my new insurance yet. And they were like, our price based on what we do with this old line prescription drug is cash, $400. And what I found from looking at coupons online from sites like Goodrx was, was that I could have gone a couple miles down the road to another place with no insurance and paid $20 for this. Oh, wow. So that's a next step is like, have you got my insurance right? Like, and let me check my phone for a second. GoodRx is one of a number of sites and each of them has different deals that will tell you if you kind of scan a barcode from our site at your pharmacy, at the pharmacy you're at, it's going to cost you X. At the pharmacy down the road, it could cost you Y.

[A]

Using Goodrx I found to be really helpful. But it underlines how much of a sham the system is where if I just drive half a mile down the road to a Walgreens versus the CVS that I'm currently at, I can save a lot of money on what is the same exact drug. And I'm always wondering, why is that the case? Why do these companies, Goodrx and the other ones work in this way? Are they selling my marketing data? What's the catch?

[C]

Yeah, it's super interesting. Basically each one of them is negotiating behind the scenes with different pharmacy benefit managers. And they're saying, oh, you have this array where like on the back end it's super complicated but like money moves around. And when Dan pays $5 at the counter for this medicine, like you get $2 out of that and you know you can kick us a nickel, it's fine. Right? That's how that works for them. And they're doing all that stuff in the back end. So eat GoodRx is one. There's several others worth looking up. We have notes on our website, but like, yeah, look it up. Like, can I get a better deal someplace else? Another question you can ask the pharmacist right then. You can ask the pharmacist right then. And there is like, hey, is there like a manufacturer's coupon for this thing often? There is for brand name drugs often. And you know what's in it for them? The brand name drug company wants to give you a coupon to make up your share of the kind of co pay or whatever because eventually they figure your insurance will kick in. And then finally the other question you ask the pharmacist is like, hey, is there some other version of this kind of drug that my insurance will cover?

[B]

Daniel, in your two part series you mentioned how your mileage may vary. So how can people determine which options might give them the best mileage?

[C]

Trial and error. So this is why I'm like, okay, you got get your list of the quote unquote easy things first. Do the easy things. And you can do these things pretty quickly. You can run down this part of the checklist in a few minutes if you have it handy. Hey pharmacist, is there a coupon for this thing? Hey, pharmacist, my, this asthma medication that I've been taking is supposed to cost me $500. Now does my insurance cover some other inhaler that works just as good that I could use? I mean this is all right here. Like let me look at my phone for a second and see if I can go to CVS down the road and get this for less. And then like those are all things you can do pretty quickly. There are other websites like Mark Cuban's Cost Plus Drugs, which is a mail order site for many generic drugs, will give You a super good deal. You're going to pay five bucks for shipping. So it kind of works best, I think, for people who take multiple generic drugs and whose insurance is kind of like not making that easy for them. But for. If that's your situation, that could be great for you. One listener that we talked to, you know, had to go farther, right? His daughter's medicine. The insurance company was like, the best we can do for you. It's like 150 bucks. And that was a lot. And he was like, can I get a better deal by using one of these Goodrx type sites or Mark Cuban's Cost Plus. And he built a spreadsheet. He was like, okay, I'm gonna look at all of them. I'm gonna see what the best deal is where. And like, we adapted and expanded that spreadsheet. You can do that. That's obviously more homework, but the easy parts that you can do at the pharmacy. And then there's like, okay, I gotta go and crank on this. So one is like, all right, my insurance isn't doing it for me. I'm gonna make a spreadsheet. I'm gonna figure this out. What's my best deal the next level is. Or another level at the same time is like, all right, my insurance said no to this. As. As one listener said, like, you should do. Like, I'm gonna take that as a suggestion, right? It's not an answer. That's a suggestion. They're saying no. I'm like, okay, well, let's. Let's talk about that. I mean, they will have their rationale. This is where you get your provider involved. And, you know, this is a problem for a lot of us. Like, my primary care doc, Love the guy. It's a bit of work to get him on the phone, right? This is a problem a lot of us have, but. So you're gonna look for somebody who can do that for you. And especially if you're taking a drug with a specialist, like, you can get this help from them and be like, let's do an appeal. And there are rounds of appeals. You can do all these things, take time, right? Like, you're like, hey, My. My physician's fighting for an appeal, but meanwhile, I need this medicine now. Like, I can't breathe without this inhaler. This is where you ask your provider a second question. Do you get any free samples from the pharma company that tied me over while we're doing this? Right? This. This was a suggestion that came from a listener who's a Farmer rep. So, you know, that's his job.

[A]

Because they may well have the inhaler in the office and they can just give you one until you can sort through all of the issues with your insurance.

[C]

Yes. And it's not going to be necessarily a permanent solution. I mean, they may be like, I got these. I got a closet of these day and come back every week is totally fine. They may. Or they may be like, I hate farmer reps, or our whole system does not allow farmer reps in the complex that we operate. Apparently, they could still go online for you and say, could somebody please drop off these samples for Dan? But the idea here is not that this is a kind of permanent supply for you, but that it's. While you're fighting with your insurance to get them to come around and be like, okay, we will. We will cover this for you because. Because this is the drug you need, we thought you could take that other asthma medication. You and your doctor have convinced us that that one has a specific risk for you. You need this one.

[A]

So basically, at every step of the process, you need to be not taking no for an answer and finding some sort of other alternative route. So, Dan, looking ahead, open enrollment is going to be here pretty soon. What should folks do now so they can ensure that their prescriptions are actually covered by their insurance next year?

[C]

This is such an important question. So there's a document that you are legally entitled to see from whatever your insurance is or any insurance plan that you're considering for next year is called the Formulary. And it's going to be a long PDF and you may have to ask somebody where you find it, but you're entitled to have it. It is the list that says, if you're taking this drug, it's going to cost you this much. If you take that drug, it's going to cost you that much. And these things can be confusing. And last year I spent several. I spent a morning trying to figure out why I'd gone to one pharmacy and paid $35 for this drug. And the next month I'd gone to a slightly different pharmacy and paid $75 for it. And I eventually figured it out. That was some advanced stuff. But generally you can see it like they're. It's. They're broken into classes. Like, these are the statins, these are the blood pressure drugs. These are the antidepressants. And they list every single one. And generally the formulary will say rather than have a dollar amount, it'll have what are called tiers. So, like tier one drugs, you pay $5 for. Tier two drugs, you pay $20 for tier three drugs, you pay $50. For tier four drugs, you pay 20% of whatever. And again, those numbers are going to be different for every insurance plan, but they all have tiers. And you will find your drug. You'll do a control f hit find on that PDF and find the name of the medicine that you need or the class of medicine that you need and it'll tell you and that if you are lucky enough to be able to choose an insurance policy and that formula tells you, hey man, next year your inhaler is going to be 500 bucks. You can be like, okay, cool, let me just check. There's another policy I have access to. If there's a, if they will let me have that inhaler or less. Or if this, if the formula for this one is like, but you could have this other inhaler for 20 bucks, do it now, right? Call your doctor and be like, hey doc, with this other inhaler, work for me another time.

[A]

We have to do a lot of homework to get what you would hope would be basic and just given from your insurance. Well, Dan, thank you so much for coming on and sharing your insights with us. I'm really going to encourage our listeners to check out that two part series that you guys put out. I found it again extremely helpful.

[C]

Thank you so much.

[B]

All right, we're about to get into this episode's money question where we talk about what folks need to know about potential changes to the cost of their Affordable Care act plans.

[A]

But before we move on, a quick reminder to send us your money questions. We're at a transitional moment in the year where summer is beginning to wind down. We're looking forward to fall. At least I know I am. I really want wear a sweater and stop sweating. And with this new time of year comes a new batch of financial decisions like how should I navigate tariffs this holiday shopping season? Should I change my healthcare plan so I'm eligible for an hsa? And when is the best time to buy tickets for holiday travel? Elizabeth, do you have any money questions at the moment?

[B]

Well, this is kind of random, but I do. I'm wondering how to negotiate the best rental agreement because I'm tired of paying to cut my grass. Yeah, I've also been thinking about how to ensure your emergency fund keeps pace with inflation.

[A]

Well, we know those high yield savings accounts we always talk about are a good place to start.

[B]

Absolutely.

[A]

Well, folks, whatever your money question, we nerds are here to help. Leave us a voicemail or text us on the Nerd Hotline at 901-730-6373. That's 901730, NERD. Or email us at podcastnerdwallet.com alright, let's.

[B]

Get to this episode's Money Questions segment. That's up next. Stay with us.

[D]

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You say you'll never join the Navy, that living on a submarine would be too hard. You'd never power a whole ship with nuclear energy, never bring a patient back.

[E]

To life.

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Or play the national anthem.

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For a sold out crowd.

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Joining the Navy sounds crazy.

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Saying never actually is. Start your [e-mail] America's Navy forged by.

[B]

The Sea we're back and we're answering your money questions to help you make smarter financial decisions. This episode's question comes from an email from a listener named Rebecca who lives in Vermont. Here it is and it's going to be read by our fabulous producer Tess Wiglund.

[F]

I have to tell you, you guys, the first line is my favorite from any email we've ever gotten. I love your show than thanks for the work you do.

[A]

You are so welcome Rebecca.

[F]

All right, here's the question. I'm aware that the enhanced tax credits for ACA insurance plans are set to expire at the end of 2025. I currently work two part time jobs. One is a W2 job in the education field and I have access to good insurance through that job. The other is a self employment job where I work as a contractor. After a long career in education, I assumed my current part time role would be my last before an exit from the and that I might have a year or maybe two left before I pursue my self employment full time. But the outlook for health insurance costs is frankly freaking me out. I live in Vermont where ACA healthcare premium rates are some of the highest in the country. If the subsidies expire, I could probably still afford it, but many other things would have to be cut or scaled way back, such as saving for retirement. Here are my questions. 1. What's the outlook for these ACA subsidies going into 2026 and into the future?

[E]

2.

[F]

What are some potential strategies to reduce the cost of health insurance if you have to buy it for yourself? 3. Should I seek out a job that might pay less than my self employed contracting but offer me decent insurance? And four, what are the risks of going uninsured? I'm healthy and could afford to pay for preventive care out of pocket, but I worry that a disaster will happen like cancer and bankrupt me if I go uninsured. I hate that we tie affordable insurance to employment in the U.S. thanks for your help, Rebecca.

[A]

To help us answer Rebecca's many questions on this episode of the podcast, we're joined by personal finance nerd Kate Ashford. Kate, welcome back to Smart money. We seem to always have you for some of the heaviest and most difficult topics. So here we go.

[E]

Let's do it.

[A]

Sure. So let's start by diving into the enhanced premium tax credits that the listener referred to. Can you explain how these work under the aca?

[E]

Absolutely. So if you are buying health insurance for yourself on the marketplace, there are subsidies available to help you pay for it, depending on your income. These are tax credits you either claim at the end of the year or that are credited in advance to lower the cost of your premiums. And right now there are bigger subsidies in place and expanded eligibility because of legislation that was put in place in 2021. There are more than 24 million people enrolled in marketplace plans right now, and the vast majority of them are getting subsidies.

[B]

These enhanced tax credits are going to sunset at the end of 2025, and that means we go back to the smaller, more limited tax subsidies from before. So Kate, what impact could that have on people going through the ACA for their health care plans?

[E]

Well, it's hard to understate the effect that this would have for people getting subsidies. And remember, that's most people buying from the marketplace. Premiums are expected to go up dramatically and the Congressional Budget Office predicts that more than 4 million people will lose insurance by 2034.

[B]

And then what types of increases could consumers see in health care costs, especially premiums?

[E]

Well, kff, which is a health policy nonprofit, is predicting that premium payments will go up by more than 75% on average. And in some states, people are going to see their payments more than double. So a lot. The Commonwealth Fund also has some estimates on this. And depending on where people fall on the income scale, they could pay anywhere from $387 more to $2,900 more per year. And that's just the average, and that's just the cost effect of losing enhanced subsidies. But insurance companies are also requesting higher base premiums next year. So it's also that the base price of health insurance is going to go up. And that's because, among other things, companies predict that if enhanced subsidies aren't extended, healthy people are going to drop their coverage because it's going to be expensive, and that leaves mostly sick people in the system, and that makes costs go up for everybody.

[A]

So these changes could really upend people's budgets. If they end up needing to pay 75% more for their health insurance, it's going to be pretty devastating to people's household incomes, I'd imagine, for sure.

[E]

Big, big impact.

[A]

So what can folks do now to prepare for these potential changes? A lot of folks are probably eyeing open enrollment coming up in just a few short months and thinking now is the time to plan.

[E]

Exactly. For states using the federal marketplace, Open enrollment starts November 1, and people have to sign up by December 15 for coverage to start next year. So that's going to be here before you know it. If you've got subsidized health insurance through the ACA marketplace, the first step is to see how you might be affected if these subsidies expire. The big question is if you're making more than four times the federal poverty level, because if you are, you could go from subsidies to full price next year, but subsidies are going to get smaller even for people who are under that line. So you may want to do some back of the napkin math to see what your premiums would look like if they went up 75%, which is the expected average increase, or on November 1st, you can price it out. And can you afford that if you were on the line for subsidies? No subsidies. Can you put more money into a retirement account or a health savings account to get your income under that line? And if you can't move income around and your costs are going to go up so much that you really can't afford it, you may want to think about whether formal employment offering benefits makes more sense for your health insurance needs.

[A]

People are going to have some really tough decisions to make.

[E]

Yes.

[A]

So for people who buy their own health insurance, what are some general cost saving strategies that can help them make this a little more manageable given how expensive it all is?

[E]

Yeah, there are some ways to save on costs, but they're not all super. You can move from a silver plan to a bronze plan on the marketplace, although your out of pocket costs for care will be higher. You can opt for a high deductible health plan which typically has lower monthly premiums, but you have to be prepared to cover the deductible if you need care beyond preventive care, and that deductible will be several thousand dollars. Definitely shop extensively. Definitely compare plans. Compare pricing. Make sure you're looking at plans that include your doctors and hospitals so you can stay and network. If you're self employed, your health insurance premiums may be a deductible expense, so that's something to keep in mind. Although as always, check with a tax professional for prescription drugs. You can look into programs like Goodrx or single care or manufacturer discount programs that may be available. And this bears saying, use your preventive care benefits. ACA compliant plans are required to cover most preventive services at no cost and it can help you catch health issues before they get out of hand.

[A]

And that would be things like an annual checkup, a physical?

[E]

Absolutely, yes.

[A]

Okay, so how can people weigh whether it's more cost effective to get employer sponsored healthcare or buy it on their own via the health insurance marketplaces or other avenues? I'm sure like the listener, many self employed people may be wondering whether it's cheaper to go the employer sponsored route so they could potentially get more affordable coverage.

[E]

Unfortunately, if enhanced subsidies go away, employer sponsored health insurance is likely going to be cheaper because employers cover some percentage of your premiums. I think if subsidies disappear, a lot of people are going to be looking for jobs or hanging onto jobs if they were planning to leave them that offer these benefits instead of continuing on their own or they're going to drop coverage.

[B]

This potential new change could make healthcare unaffordable for some Americans and it could lead to them going uninsured. As the listener is considering. So what are some risks of going without insurance?

[E]

Well, so clearly you're risking getting really sick and having to pay for care out of pocket. Suppose you take this bet and as the listener mentioned, you develop cancer or you have a heart attack. The medical bills are going to be significant. And other things to consider are the consequences of medical debt like a lower credit score and just general financial stress. People without health insurance are more likely to delay preventive care and screenings, which means you might not catch something until it's more serious.

[B]

If the listener is anything like me, thankfully for now I have been healthy and not had any serious health conditions. So you know, do healthy people have the same risk as maybe people with existing health conditions?

[E]

It's riskier to go without Health insurance if you have a chronic illness, of course, but it's a gamble for healthy people too. No one plans to have a serious accident or develop a sudden illness, but it can happen at any time to anyone, regardless of how healthy you are now. And the financial consequences can be catastrophic. Medical issues, including medical debt, are one of the biggest causes of personal bankruptcy.

[A]

In the U.S. so our listener ended their question by saying that they hate that we tie health care to employment in the U.S. kate, I'm wondering if you have any insight into the history here. Why and how did we get to this place?

[E]

Well, I've done a little research on this and this is just the way the system evolved in the US during World War II, the government put wage freezes in place to control inflation, so employers started offering health insurance as a fringe benefit instead, since they couldn't offer higher salaries. And in 1943, the IRS made employer provided health insurance tax exempt, so that was a big incentive. After the war, we just continued down this path and insurance from your employer became the primary method of coverage. The US has talked about a universal or single payer healthcare model since then, but we've never made it happen.

[A]

So what I'm hearing is that our current situation is somewhere between a mistake and a horribly unhappy accident.

[E]

I think that sums it up, yes.

[A]

Okay, well, do you have anything else to add, Kate?

[E]

Yeah, only to say that even with all of this information, this is all up in the air. There's still time for Congress to put something together and extend these subsidies and we'll all be waiting to see how that goes. So pay attention to the news because this could all change and we may.

[A]

Well drag you back on to talk about it again.

[E]

Happy to come back.

[A]

Thanks, Kate.

[E]

Sure. Absolutely.

[A]

That's all we have for this episode. Remember, listener, that we are here to answer your money questions. So turn to the nerds and call or text us your questions at 901-730-6373. That's 901730, nerd. You can also email us at podcastnerdwallet.com don't forget we want to help you with your budget. Visit the link in the episode description to fill out the Google form with your budget info and we might talk about it with you on a future episode. Join us next time to hear the first episode of this new budget rehab series where we take a deep dive into a listener's budget and look for ways to improve it. Follow Smart Money on your favorite podcast app, including Spotify, Apple Podcasts, and IHEARTRADIO to automatically download new episodes.

[B]

And here's our brief disclaimer. We are not your financial or investment advisors. This nerdy information is provided for general educational and entertainment purposes and it may not apply to your specific circumstances. This episode was produced by Tess Vigeland and Anna Helhovsky. Hilary Georgi helps with editing. Nick Karisimi mixed our audio and a huge thank you to NerdWallet's editors for all of the wonderful ways they help us.

[A]

And with that said, until next time, turn to the nerds.

[B]

Okay, before we let you go, Sean and I want to give another reminder about our giveaway. You could be one of seven winners of some really nice Smart Money merch. One person's gonna get a pair of Sony ULT Wireless noise canceling headphones and six winners will get the Bagu Cloud Carry on bag, which I heard Sean has and is really nice. All you have to do is fill out our listener survey, which only takes a few minutes. You'll not only be helping us make the Smart Money podcast even better, but you'll also be entered for a chance to win those awesome prizes. Just go to nerdwallet.com podsurvey and complete the survey form by September 15th for a chance to win. You can read the official rules for more details, which again can be [e-mail] PodSurvey thank you and good luck.