Healthcare access: Policy, tech and price increases

One year has passed since President Donald Trump signed the HR 1 Reconciliation Bill, commonly known as the One Big Beautiful Bill. Amid the swath of concerns over expected cuts to healthcare coverage, Medicaid programs and health services in rural and tribal areas of Arizona, Hosts Linda O’Bryon and Nicole Cox sit down with two health experts on Navigating Our Financial Times to discuss what changes are coming. Emma Wager, a senior analyst for the nonpartisan health policy organization KFF, and Dr. Daniel Derksen, Director of the University of Arizona Center for Rural Health share insights on policy changes to the healthcare landscape, and how telehealth initiatives and AI tools are paving the way to transform access for rural patients.

Nicole Cox: Hello, my name is Nicole Cox, Radio Program Director of AZPM. Thank you for listening to Navigating Our Financial Times. My co-host is nationally recognized journalist and broadcaster Linda O'Bryon. Millions of Americans find themselves facing higher healthcare premiums after enhanced premium tax credits for the Affordable Care Act Marketplace Insurance expired at the end of 2025. I'm Nicole Cox. 

Linda O’Bryon: And I'm Linda O'Bryon. Thank you for joining us for Navigating Our Financial Times. According to a 2023 report by the NIHCM Foundation, 80% of rural America is medically underserved. And the average lifespan of residents in rural areas is two years less than metropolitan residents.

NC: And with high healthcare costs leading to people putting off needed care or not having prescriptions filled, what does this mean for those who have trouble affording healthcare costs, and how can those gaps in the healthcare area be addressed?

LO: Joining us is Emma Wager with KFF, a nonpartisan health policy research, polling, and news organization. Emma is a senior policy analyst for the program on the ACA and the Peterson-Kaiser Health System Tracker. Thank you for joining us today.

Emma Wager: Thank you very much for having me.

NC: Emma, you work on research covering the ACA and healthcare costs. Can you share with us a bit about what you do?

EW: Yes, so I work for KFF, which, as Linda explained, is a nonpartisan health policy research organization. My focus is primarily on the US healthcare system, particularly on the private individual and employer-sponsored health insurance, which includes the exchanges established by the Affordable Care Act. So, we keep track of which insurers are in the ACA marketplace, how much their premiums are that they're charging, and who is purchasing that coverage.

LO: And speaking of those premiums, KFF was one of the groups that predicted a major increase in the ACA premium payments after Congress did not extend the enhanced subsidies. Can you explain what we're seeing right now and just how much higher premiums are for the typical individual or family on ACA going up this year?

EW: Well, last fall, we predicted that if everyone who was enrolled in the ACA marketplaces stuck with their same plans for 2026, we would see the average premium payment more than double, and that was just the average. So, in some cases, people could see their payments triple or even more, but of course, not everyone keeps their same plan every year, especially in a year where these big changes in federal policy have happened. Our polling suggests a Lot of people have switched to a cheaper plan or they've left the ACA marketplace altogether, so all that to say, it's still a bit too early to tell what's happened to the average premium payment amount. We'll get more of that data later in the summer, but we know from the polling that our organization has done that 80% of returning marketplace enrollees say their costs in 2026 are higher than their costs in 2025, and over half of them say that they're a lot higher. So, we do know that people are seeing pretty big increases in the amount that they're paying for coverage. NC: With first quarter earnings reports from large insurers revealing enrollment in Affordable Care Act insurance, commonly known as Obamacare, is down by several million people, can you share what kind of impact this is having?

EW: Yes, so we do know enrollment has declined substantially since 2025, and of course, the first question that you ask is what happened to those people who dropped coverage; where are they going? So, our polling suggests that some of them are able to successfully transition to another source of coverage. For example, some got on an employer-sponsored plan, which could be through a spouse, or it could be due to them changing jobs, to one that offers insurance, but a significant portion didn't get on another plan. So, we saw that about 9% of respondents who had ACA marketplace coverage in 2025 are uninsured now. That's a pretty big number. Obviously, if you can't afford your premium payments, it's more than likely that you can't afford the bills if you do get sick or injured. So that's just a population that's become much more vulnerable.

LO: And by vulnerable, what happens to these people? Are they going to be going to emergency rooms? Are they going without healthcare? What happens?

EW: Yeah, so we know that when people don't have health insurance, they're much less likely to seek out healthcare. They're less likely to get preventive care, checkups, cancer screenings, those sorts of things. But they do still get sick, and they do still get injured. And when that happens, they do typically wind up in the emergency room. They will receive care—that is the law—but the care that the hospital provides will probably become uncompensated care. So, the hospital will take care of the patient, but then the hospital's costs go up if they're seeing an increase in this uncompensated care that they're providing. And then from the hospital's perspective, they may feel like they have to raise prices for everybody if they're suddenly treating far more uninsured patients. And this is a large group because, in reading your reports, KFF reports that employer-sponsored health insurance is the largest source of healthcare for US residents under age 65, with about 60%, having some sort of employment-sponsored health insurance. But for the other 40% who don't have an employer, that's the group we're talking about here. Is that right?

EW: Yeah, so of that 40% who don't have employer coverage, who are under 65, some of them, a good portion of them do have Medicaid coverage. So, when you have Medicaid coverage, you're not in the individual ACA market. You get your care through Medicaid. So that's a separate system, but you are still, there's been big changes that have happened to Medicaid as well. But the people who've seen these big spikes in the premium payments are primarily people who are enrolled in the private market, in the individual market, so ACA exchanges.

NC: Does the data tell us anything about the costs of employer-sponsored healthcare? Are these costs expected to increase more than usual with all these changes?

EW: Yeah, so employer-sponsored coverage is different from the ACA marketplaces. So, in the marketplace, most people, they pay a portion of their premium out of pocket, and the rest is paid in the form of a tax credit by the government. So, in the proportion that you pay out of pocket is based on your income. So, when that amount of that government subsidy changes, as happened last winter, there's a big change in the amount that you, as the enrollee, are responsible for paying. However, when your health insurance is covered by your employer, you also pay a portion of that premium taken out of your paycheck, and your employer is the one who covers the rest. And the amount that you pay and the amount that they pay isn't determined by your income. It's determined by your employer, so they decide. So, because the federal government isn't subsidizing that coverage, you don't see the same big spike in the amount of the premium that you, the enrollee, are going to be paying. But that does not mean that employer-sponsored premiums aren't rising. They are, and they're rising quite quickly and substantially. The average premium for a family at a US employer was almost $27,000 for the year 2025. So that's the total cost between what the employer and the employee pay put together. But that's mostly due to the reality that paying for any amount of healthcare is expensive and just getting more expensive by the year.

LO: You mentioned earlier Medicaid and what's happening there. So, the One Big Beautiful Bill, we know that they called, Congress called for more restrictions for Medicaid recipients. That has not yet gone into effect but will shortly. What will the impact be? What does KFF believe that impact will be?

EW: So work requirements, which is the primary big change to Medicaid that the One Big Beautiful Bill Act put into place, are designed to make sure that healthy people who get Medicaid coverage are working or enrolled in school or caregiving for a certain number of hours per month in order to remain enrolled. This has been a very popular policy among Republicans for quite a few years now. And I think it's important to note that most people who receive Medicaid do already work or they're disabled or they're a full-time caregiver. So, it's a pretty small proportion of people who have the time and the health to work but choose not to. But with these reporting requirements, everyone who receives Medicaid will now have to properly report their working hours or their exemptions in accordance with their state policies. And the main argument from people who are opposed to these requirements is that this is very burdensome, especially for people who are already living their life pretty close to the federal poverty line. So, if you don't get your reporting right, you can be kicked off your Medicaid coverage, even if you do work and you are eligible. And when you're lower income, a lot of the time, your job changes a lot, your address changes a lot. There’s just a pretty big burden and people do fall through the cracks when it's implemented this widely. It also costs the state something to do this. They need additional staff, they need additional resources, communication channels in order to make a change this big to a program that is as big as Medicaid. So, these policies, they're designed to save the states money overall, but there are trade-offs.

NC: For Arizona, azaccess.gov reports starting in January 2027.This law requires certain Medicaid expansion adults, as Emma mentioned, to work, go to school, volunteer, or participate in another defined qualified activity for 80 hours each month, or to have earned at least $580 in the month to maintain their AHCCSS coverage. AHCCSS is the state Medicaid for Arizona. H.R. 1 will also require certain Medicaid expansion adults to renew their access coverage twice each year instead of once. We’re already hearing about the impact federal policy is having on Arizona. 

AZPM's L.M. Boyd spoke with Dr. Dan Dirksen, Director of the University of Arizona Center for Rural Health, who warns of a bureaucratic shift that could leave up to 400,000 Arizonans without Medicaid coverage by 2027.

Dr. Dan Derksen: Starting in January 2027—so, not very far down the road, there’s new eligibility enrollment and redetermination processes for staying on Medicaid. And it’s estimated that as many as 250,000 to 400,000 Arizonans will lose their Medicaid coverage because of those new requirements. You don’t save money by throwing people off of coverage, you just shift who absorbs the costs. See the full report: A doctor and a mother navigate the gaps in rural health care in Cochise County

LO: Emma, these are big changes that we're seeing, and people will be finding themselves, many people without any kind of healthcare. Has there been any research on what kind of effect all of this could have on mental health?

EW: Obviously, people who have mental health conditions and substance use disorders rely pretty heavily on their healthcare coverage to pay for a lot of the treatment and support that they need to stay active in their day-to-day lives. So, any cuts or barriers to accessing Medicaid or ACA coverage for this population can have a major impact. When we look at crises like the epidemic of opioid overdose deaths, it’s critical to make sure that people who have these disorders have access to treatment, which often includes prescribed medication to reduce their risk. So, while we can't say for sure what will happen, we can tell that putting additional obstacles or additional costs in front of people who are already dealing with a serious mental illness or addiction is not likely to get more people connected with the care they need.

NC: The ACA allowed for the creation of health insurance marketplaces in rural areas, meaning individuals and businesses could purchase health plans where group plans weren't possible. The Arizona Republic reported about 423,000 Arizonans signed up for ACA coverage for 2025.Do we know what kind of impact all of this will have on farmers and ranchers?

EW: Yes, we do know that the ACA marketplaces are designed for people who don't work for a big organization and who don't have that offer of coverage from their employer. If you have a job at a small business or you're a farmer, you're a rancher, a freelancer, an entrepreneur, and you earn a decent living, you probably don't qualify for Medicaid, but you still need some form of insurance to protect you from serious medical costs if you get sick or injured. And we've seen that these are the people who are the most represented in ACA marketplaces, the farmers and the ranchers specifically, but also people who are hair stylists, musicians, or any occupation where you sort of work for yourself. And these people are very important to our society. I think we all understand the importance of farmers, but they're often not wealthy, and a big jump in their health insurance premiums is likely to have a major impact on their personal finances. And in some cases, it may impact whether they can stay in business. So, it's something that's just critical to understand that we're talking about real people who are being forced into extremely tough decisions.

LO: Has there been any suggestion or research that shows that Congress may go back and readdress some of these issues, especially rural areas?

EW: So, Congress worked throughout most of the winter to propose different solutions to these expiring, enhanced, premium tax credits, but they were not able to find a solution that worked for enough people to pass. So, there's still a possibility that there's a form of a solution that could materialize here, but from what we can understand, it seems like the tax credits are going to stay at their current levels for the foreseeable future.

LO: And what do the polls tell us about healthcare in comparison to other issues voters want to see the government address? Where does healthcare stand on that spectrum?

EW: We know voters care about healthcare a Lot, which obviously makes sense. Everybody comes into contact with the healthcare system every year, or they have a Loved one who is sick and needs a lot of care. So, our recent polling at KFF says that it’s one of the top issues, if not the top issue that voters really care about going into this election year. More than half of people are worried about affording healthcare costs right now, and 30% are very worried, which is more than they say are very worried about affording food, more than are worried about affording rent. People really want the amount that they payout of pocket for healthcare to come down. So, it's a top-of-mind issue, and it's something that is going to be very important, especially as we approach these midterm elections.

LO: Have these polls been done though after we've seen gasoline prices go up, which has caused a lot of concern by consumers?

EW: This polling is from April 2026. So, it's recent.

LO: So, it's still very top of mind for a lot of consumers. And how do healthcare costs in the United States compare to other nations? We know the services may be different, but just purely from a cost basis.

EW: In terms of other nations, the US has always been an outlier in how much we spend per capita on healthcare. Most wealthy nations that we compare ourselves to, so places like Japan, Australia, Canada, a lot of Europe, they’ve figured out how to spend less per person, and their life expectancies are consistently higher than ours. So, the American system is unique when it comes to how we get healthcare, and the different ways that one person may be covered throughout their lifetime. But one of the cons is that there's these big groups of people who aren't eligible for assistance from the government, and they also really struggle to pay for their coverage and for their care out of pocket.

NC: We learned from our interview with Planet Money that insurers are a leading indicator of where things are going. What could the current insurance rates tell us about some of the trade-offs people are facing, or could face?

EW: Insurers spend a lot of time in resources projecting how healthcare costs will grow, because they wind up paying for so many of them. At KFF, we every year Look at how much insurers in the individual markets are increasing their rates, and why. So, this past year, when they filed their rate increases with their state governments, insurers talked a Lot about general inflation and increasing costs, but few also mentioned provider consolidation. So, when one big health system starts buying up smaller hospitals and health systems in a geographic area, they can raise the price of their services, because a Lot of times people can't go anywhere else, and that can cause health costs to increase for insurers. There are also new medications on the market that a Lot of these insurers are being asked to cover. The notable example here is GLP-1 drugs, so the weight loss drugs like Wegovy and Zepbound. They’re expensive, but they're very popular. So, in some cases, insurers have decided we cover these drugs for everybody and increase our premiums to pay for them, or do you stop covering them to keep premiums lower, but then people who need them, they're no longer covered. That’s the kind of trade-off that we're talking about.

LO: You know, you're talking about consolidation among insurers, but we're also seeing it among healthcare providers, and getting back to rural areas. There were a lot of fears that rural hospitals would end up going out of operation. Has that started yet? Do you see any trend lines about rural hospitals?

EW: We haven't gotten great data about this yet. I think the main concern, especially with rural hospitals, is they rely very heavily on Medicaid patients. And so, when there's a decrease in the number of people who have Medicaid and an increase in the number of people who are uninsured, then they're facing a larger uninsured patient population, and they're potentially not getting paid and they're not getting adequately reimbursed for the care that they're providing. So I think, you know, time will tell. There was some additional money set aside in the One Big Beautiful Bill Act for rural hospitals specifically, but we are watching that very closely to see what happens.

LO: Is there anything the individual can do when faced with these enormous increases in healthcare costs?

EW: Unfortunately, it's very difficult, and a Lot of the time you don't have that many choices. So I think the best thing that you can do from my standpoint is to make sure that you f9ully explore your options during your open enrollment period, to pick the plan that makes the most sense for you or your family, and to look into how best to use, say, an HSA or an FSA, if you have one. And in general, just open and click around your plan documents as much as you can, just to see what your provider network is and your cost sharing structure and minimize any potential surprises. Just an example, but some plans have a higher co-pay for an ER visit than for an urgent care visit. So, if you're in a situation where you can safely choose urgent care, doing that may reduce your costs compared to paying the co-pay for an ER visit. But unfortunately, there's no magic hack here. You know, health costs in the US have just grown extremely quickly and will probably continue to do so.

LO: Thank you. More information about KFF is available at KFF.org. Emma Wager, thank you for joining us today.

EW: Thank you.

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NC: Thanks for listening to Navigating Our Financial times. I’m Nicole Cox.

LO: And I’m Linda O’Bryon. A person’s zip code plays a role in the barriers they face. KFF reports rural populations have a lower income, are less likely to have health care coverage through a job, and frequently face a limited supply of providers.

NC: And affordable insurance products and markets can create higher administrative costs for insurers and don't allow for sufficient risk pooling resulting in insurance companies not wanting to offer coverage in rural areas, adding to the coverage gaps Linda mentioned.

LO: Here to talk about some of the initiatives working to address geographic and social barriers to health care is Dr. Daniel Derksen, director of the University of Arizona Center for Rural Health. Thank you for joining us, Dr. Derksen.

Dr. Daniel Derksen: My pleasure. Thank you.

LO: Your current work is focusing on rural health workforce development initiatives. Can you tell us about some of the biggest challenges facing hospitals and clinics in both urban and rural Arizona?

DD: Well, I think the three major issues facing our rural hospitals and clinics, first is the health workforce. We've had intractable shortages of health providers, whether you're talking about nurses or primary care physicians or other health professionals. The second is really struggling with making sure that there's the financing to support these rural hospitals and clinics. Many of these rural hospitals and clinics exist on very thin fiscal margins, two to three percent. And the third is really the worry, which is not free-floating anxiety, about people getting thrown off of the coverage that they have with the changes in HR1, specifically Medicaid.

NC: We did talk earlier on the podcast about federal budget that will result in huge cuts to Medicaid and other health care programs. You recently gave a presentation on how HR1 will affect Arizona's rural, tribal and border areas. What did you discover? What will be the impact on Arizona?

DD: Well, it's estimated starting in January of 2027 when these onerous new requirements for twice-yearly redetermination for people on Medicaid start, along with new work requirements for a significant portion of our Medicaid population in Arizona. 

It's estimated that somewhere between 200,000 and 400,000 people currently on Medicaid will lose that coverage starting in January of 2027. Arizona will experience what's estimated about a $34 billion loss over the next 10 years. That's $3.4 billion per year in less federal funding.

NC: So I have a follow-up question to that. In your experience, how are those kinds of changes, cost changes, absorbed into the community long term?

DD: Well, it's hard to absorb a loss of that magnitude in terms of safety net providers, those rural clinics, those rural hospitals, the Indian Health Service, and tribal operated sites, because they're operating on thin margins already, if suddenly they have to absorb a 10 to 15 percent increase in uncompensated care, what's also known as charity care. 

It's going to be very hard for them to keep their doors open, or they have to make difficult choices about cutting programs like obstetric services. And we already have a shortage of obstetric providers for maternal health in Arizona.

NC: Which does lead to another cost in the community, correct?

DD: Yes, so…

NC: I mean also, people being able to go to work…

DD: That's correct. So what we see is the economic ripple effect of when you cut that magnitude of funding to states. It means it will affect the nursing homes, it will affect pharmacies, it will affect a lot of the health infrastructure that we have. So these aren't imaginary. These are going to start happening in January. 

Already we've seen 120,000 people lose coverage in Affordable Care Act health insurance, because the advanced premium tax credits that were existing were not extended in HR1, the bill that was signed into law in July of last year. So we've lost—comparing March of 2025 to March of 2026—120,000 individuals in Arizona who can no longer afford insurance, because their premiums went up in some cases by $1,000 per month.

LO: AZPM’s L.M. Boyd’s series on rural health care examined some of the current hurdles that people are facing before these cuts that you're talking about, when trying to find care:

L.M. Boyd: In the high desert of the region, the distance between a patient and a doctor can be measured in more than just miles. It is measured in AHCCCS, equity, and trust. The ratio of primary care providers to patients in Cochise County is high, roughly one provider for every 1,800 people.

DD: Cochise County is a population of about 125,000. They have about 30 percent of their population that relies on Medicaid for their health coverage. Another 30 percent who are eligible for Medicare, and what that means down the road for places like Cochise County and the health providers that take care of people, whether it's in a hospital or in a clinic, they'll have to absorb more charity care as people lose their coverage and become uninsured.

See the full report: A doctor and a mother navigate the gaps in rural health care in Cochise County.

LO: Dr. Derksen, you were featured in this series and warning about the bureaucratic shift that could leave up to 400,000 Arizonans without Medicaid coverage by 2027, and you said you were concerned about the provisions of the plan that are basically implementing things that make it harder for people to stay enrolled in Medicaid.

On top of what's happened federally, in April, GOP lawmakers in Arizona advanced budget bills, making across-the-board cuts to state agencies and add new eligibility requirements for AHCCCS, the state's Medicaid program. What are you seeing so far?

DD: Well, as I mentioned, we're already seeing a significant decrease in the number of people with Affordable Care Act health insurance. That magnitude is 120,000 individuals just over the course of the first few months of the new open enrollment period for Affordable Care Act insurance. We've already seen a decrease over the last year and a half in the number of Medicaid enrollees. It's almost 750,000 that we've lost in Medicaid coverage already since the peak of pandemic, where our enrollment was about 2.5 million of our 7.5 million population on Medicaid. So we're now a little less than 1.8 million people on Medicaid and headed down to 1.2 million if some of these provisions get put into place on work requirements and twice a yearly eligibility enrollment.

LO: And what happens when people go off Medicaid in terms of their health care?

DD: So I'm a family physician by training, and what happens is people often put off the primary and preventive services that they really need to keep them healthy. And we don't want to see that, because what happens then is that people may not take their diabetes medicine or their high blood pressure medicine or other things that really keep them healthy. And we don't save money by throwing people off of coverage, especially low-income individuals. We just shift who has to absorb the costs of that care. And that's often in the form of the clinics and hospitals, the physicians and nurses that take care of them and have to shoulder somehow in their system almost an overwhelming burden of uncompensated care.

So we're not saving costs, we're just shifting it. And not to mention the cost that shift to families who often cannot afford to pay for that cost out of pocket. So we still, in the United States, medical bankruptcy is still the number one cause of bankruptcy in the United States. We're going to see that go up by two to threefold if these provisions are allowed to stand starting in January of 2027.

LO: You know, before the Affordable Care Act, we did see a lot of people going to emergency rooms when they had no other place to go. Will we see that increasing as well?

DD: And that's the part that people really need to understand. Even those with employer-sponsored insurance, which is how many Arizonans get their coverage, it'll affect them as well. When they need help, when they become injured or in an accident or something like that, these emergency rooms, urgent care centers other places become really filled with folks who have no other place to go because they haven't been able to get in to see their primary care provider for primary and preventive services.

NC: It's been a year since President Trump signed the HR1 reconciliation bill, known as the One Big Beautiful Bill, into law. The changes introduced by state GOP lawmakers are based on that bill. At the time, you were not optimistic about the coming cuts, citing concerns of a loss in health care coverage, which could lead to hospital closures, personal bankruptcy and delayed care. One year later, what are your thoughts? Have they changed at all?

DD: No. I'd say that the data is becoming clearer as we get the early data back about people already losing coverage because of the failure to those advanced premium tax credits that were part of the Affordable Care Act that made it affordable for so many people in Arizona.

We are going to start seeing—we've already started to see—more people already through the redetermination processes that were put in place losing Medicaid coverage. These aren't people that no longer qualify because they're low-income.They still qualify. But starting in January is when we have this double-barrel problem of twice-yearly eligibility enrollment that seems deliberately designed to throw eligible people off of Medicaid. 

And then the other part is the Medicaid work requirements. Now, that doesn't affect everyone on Medicaid, but it does affect about 500,000 individuals of that 1.8 million or so that we have on Medicaid currently. So if you don't keep up, if you change addresses, if you change phone numbers, suddenly you may go in and find out you're no longer on Medicaid. And that's a real problem. Again, it's not saving money. It's really shifting the costs of who has to absorb the care, especially for low-income people.

LO: Well, a lot of those people, I'm sure Dr. Derksen, don't have full-time jobs. They may have part-time jobs, multiple part-time jobs. So the record-keeping has to be formidable?

DD: The state of Arizona and the Arizona Health Care Cost Containment System, AHCCCS, and the Department of Economic Security, who helps individuals with the eligibility and enrollment redetermination processes, are working very hard to be prepared for January 1 when these new requirements are in place. And they're already testing it. They're getting some help with information technology systems to get the data entry fields in place so that people aren't inadvertently thrown off of coverage that really are eligible. So I know the state's working very hard, the governor's office, the state agency's responsible, including AHCCCS and the Department of Economic Security to make sure that happens. 

But I also had experience helping New Mexico set up their health insurance marketplace back in the day when the Affordable Care Act was put in place. And no matter how well prepared you are and how much money you spend on upgrading your IT systems, it's still going to be difficult in those first few months as we learn what obstacles people are doing. 

And some of those obstacles include, like, if English isn't your first language, if you speak Spanish as your first language, if you're from the Navajo Nation and that's not – you know, English is not your first language, you have to also beta test those individuals who are most likely to be affected by this. I know the state's working hard to do that and trying to get the information out, but it's, tick-tock, we're very close to implementation of some of these onerous provisions.

LO: Well, you talked about the impact and cost shifting, but what about those who contend that these programs don't need any more resources and that it will save the state $180 million and reduce fraud in government programs?

DD: Well, they're just wrong. We know from past experience, because we were in the days, not that long ago, where we had almost one in five Arizonans that lacked health insurance. Twenty percent of our population had no health insurance. And the single most important stabilizing factor for rural providers, for rural clinics and hospitals, was expanding Medicaid as allowed by the Affordable Care Act. It helped really fuel some of the economic growth that we've been experiencing in Arizona for the last few years.

So we've been there before. I don't know why you would return to that. As a family physician myself, when people don't have health insurance, they put off necessary care. They cut back on the pills they take because they can't really afford to go to the pharmacy and get those filled. So again, this is something we've been through before. The health outcomes, the data shows clearly, are worse when people do not have health insurance coverage. Why would we go back to those days? That just makes no sense from a humanistic perspective. But also, it's just the right thing to do, to make sure people can access the care they need when they need it and not have the fiscal obstacles in the way of people getting the care they need in Arizona.

LO: Could you go back and show or tell us about the through line from people being on health care and adequate coverage to economic development?

DD: Yeah, I mean, you know, in the days when we had 20 percent uninsured, people really lacked access to care and they couldn't go and they put things off. So we did a very good job in Arizona, both expanding Medicaid, but also including those provisions to get marketplace coverage. So we went from 20 percent uninsured to 10 percent uninsured. And what happened is, is before we were seeing rural hospitals close, we were seeing clinics close, we were seeing services close, because people had to run these businesses on very thin margins and they couldn't make it work when 20 percent of their business was uncompensated care. 

We're down now to a record 9.5 percent as of last year, 2025, of uninsured. We've already crept back up just in these first few months of this calendar year to 12 percent uninsured. So we've gone from 750,000 people uninsured, which to me as a family physician is still unconscionably high. We're now at over 900,000 uninsured by my calculations.

And this affects every service that's provided. The health insurers have less business. You know, we re-channel a lot of our Medicaid business through private health insurers, and people really like that. Arizona's been a model of that since they started the Medicaid program. 

So the insurers, are going to be affected by this, are already being affected by this. The hospitals are already absorbing increased uncompensated care with 120,000 who've already lost coverage compared to March of last year, and also the health providers, so the nurses, the physicians, the clinics, and the hospitals. And the other part is some of our most underserved areas, where it's very long distances between clinics and hospitals, include our tribal communities. And they really depend on Medicaid payment sources, Medicare, and other public payers and public benefits to help make it work, because the federal government does not sufficiently fund our Veterans Administration or our Indian Health Service system. 

So these are important components, and there's just this ripple effect when you throw hundreds of thousands of people off of Medicaid coverage.

NC: The budget bill has a provision called the Rural Health Transformation Program. It's designed to help rural health clinics with technological improvements such as AI programs and telemedicine. Is this provision transformative?

DD: It really is. The HR 1,or the One Big Beautiful Bill Act, is 870 pages. The Rural Health Transformation Program in that is 17 pages. The 17 pages are very good. It's very well written. I'd love to know who actually designed it because this is a real opportunity for Arizona.

The Centers for Medicare and Medicaid Services just approved our plan a few months ago for $167 million a year for the next five years. It's on the mandatory side of the budget. So this is already budgeted, in the budget. This is there. We have three state agencies who are responsible for carrying out the priorities that Arizona put in their plan that they submitted to CMS. So the Arizona Department of Health Services, our state Medicaid program, the Arizona Health Care Cost Containment System, and then the Office of Economic Opportunity. They are getting ready.

We were told at our conference that I presented at recently that they plan on sending out the request for proposals this month. We're a little bit behind other states. About 75 percent of the states have already posted theirs. Every state got an award. But I'm confident that this will be a really big opportunity for us to help our rural health infrastructure, something that we have not invested in for many years, if not decades.

LO: And what kind of investments specifically are being made through the Rural Health Transformation Program, and what impact will that have ultimately on rural health?

DD: Well, about half of that $167 million will be the responsibility of our state Medicaid program, AHCCCS. And in their portfolio of responsibilities to carry this out include digital transformation, artificial intelligence, making sure that care is available, maybe through mobile clinics and other innovative approaches. 

Artificial intelligence, both the generative artificial intelligence, but also the sentient or the ambient artificial intelligence, can really help the clinics and hospitals in rural areas become much more cost efficient. So it's going to change the way we teach. It's going to change the way we deliver care. It's going to change the way we receive care. But it's also going to change the way we learn.

There are some guardrails that need to be put into place to make sure that there aren't unintended consequences like a violation of patient privacy and things like that. There is a balancing act that needs to occur, but a big portion of this funding will go to really those transformative digital technologies that could really advance care in the hardest to reach places in Arizona.

LO: How would generative AI help in this process? Is it going to help the providers or consumers or both?

DD: I think it will help across the board. It can help. We've already seen just the advance of this. The evolution of this is absolutely astonishing.

So it used to be a hand-write notes when I started seeing patients. And then we're all welcoming in the door electronic health records. Well, that actually turned out to be not the most efficient thing. But now you can, during an interview, it captures and translates that to a medical record. So some of the larger systems have already taken a lot of advantage of that. So it's not just the ambient AI that goes from voice to digital transcription, but the generative part of this is also. Well, what do we need to do in screening for this person? So you know how old they are. You know kind of what some of their risk factors are, can go in and search and see what medications they might be on. So before you prescribe or before you order a test, you kind of have a sense of what would be most effective to get to the answers you need to improve the care for this individual patient.

LO: Fascinating.

NC: When it comes to historically marginalized and underserved populations facing challenges accessing care, who is affected most by the HR1 Medicaid cuts and how could the Arizona Rural Health Transformation Program reduce those challenges?

DD: Well, it's the usual suspects in that case. So in certain parts of the state, like along the US-Mexico border, it's the Hispanic-Latino population that has historically been underserved. In other parts of the state, in one of our 22 federally recognized tribes, which comprise about 27% of Arizona's land area, those are other places where I think this transformation can really improve the care and improve the reach of our care. 

There's exciting things going on through public and private partnerships around, how do we make sure that when we train health professionals, they're trained in areas of need and the pathway programs so that we identify early on in middle and high school? For example, individuals who might be good candidates to pursue health professions training, but helping them prepare successfully for applying to those programs and then matriculating successfully through that training. And most importantly, from my perspective as an academician is, how do we make sure they get the training they need to really practice in underserved areas? Because it's quite different than when you have the full array of services in an academic tertiary care center, as when you're the go-to person in a rural area. And so that's a different kind of skill set. So we need to really transform the way we train to include the places that are most needed, such as Indian Health Service, tribal operated sites and rural clinics.

NC: And I can see how the skill set of knowing and understanding, not just another language, but also the medical terminology and other descriptives in that language. I mean, you have people that are still relying on young family members to translate when going to a physician, which in and of itself has challenges. So that could be another skill set you potentially screen for, look for and train for.

DD: Yeah, the nice thing about Arizona’s rural health transformation, is it included a broader array than the usual physicians and nurses to include, like community health workers or community health representatives in our tribal areas, to help ease the transition, to help people navigate what can be a very complex system to sign up in these redetermination processes to make sure that if they're eligible for a public benefits program like Medicaid, that they can get the assistance they need right there in their community to get signed up and make sure that they're able to get the services they need. And then they can end up, and make sure that they can access the care in an affordable way to get their medications or follow-up or labs or other things that they need.

LO: You know, Dr. Derksen, earlier you talked about rural health care clinics and hospitals in danger of closing. Would some of this new technology, especially telehealth, help supplement those issues? And then ultimately, what effect will the technology have on affordability?

DD: Well, that's really the promise and why so many of us are so optimistic about some of this transformative digital technology. There's a lot of caveats with that. We have to be careful. We've learned in the past about that. But going forward in the future, I think it can be really transformative. We've certainly seen, for example, in behavioral health, telepsychiatry has really made, you know, when I was in medical school, not very many people went into psychiatry as a profession for residency training. Now it's quite appealing. They do very well in the national match as far as getting, you know, people applying to the residency programs and things like that. And I think you have to make that balance of being both in-person but also digital allows people to have a better work-life balance. And we've certainly seen that in things like telepsychiatry, even things more, you know, like teleradiology. A lot of that work can now be done at home. And with artificial intelligence, it also helps with the accuracy of reading, for example, an EKG or, you know, an X-ray image.

It really is a time of transformation. I just hope that as a state, we invest wisely and all the money doesn't stay where it usually goes, which is like Phoenix and Tucson, but really doesn't just trickle out but flows out to our rural, tribal and border communities.

LO: Well, a project that is aiming to close the gap is CoDiRA, the Convergent Digital Health for Remote Access. And I understand that the project unites 14 University of Arizona researchers with a variety of expertise, working to advance equity and promote wellness. Can you tell us a bit more about this project in particular?

DD: Well, I think it's incredibly important that a lot of the technology and the digital technology that goes on, a lot of the expertise really is around our University of Arizona experts. They've been very involved in planning for these requests for proposals that will be coming out soon from our three state agencies for the rural health transformation. I really hope that they'll be successful in helping sites. And the way I term it is, community-academic partnerships, with community first, is that you really need the community engaged to be part of what do we really need? How do our folks in our community really learn best? And how can they better manage their own health care? And that's the exciting thing about some of this transformative work going on in a very creative way by this group.

NC: So are those some of the differences to how CoDiRA is perhaps not quite the same as traditional telehealth services or what are some of the significant differences there?

DD: Well, telehealth means different things to different people. There's a lot of platforms and they evolve constantly. What's really happening because of these new tools that we have in both generative artificial intelligence and digital transformation is that we have far more tools. It’s just, you have to get out there too. There's some of the stuff that you can do remotely, but you have to get out and be there in person and see what they can really handle in the community, how can we really balance that, and how do we make it work fiscally in a bidirectional manner? So it's not just Phoenix and Tucson and the urban tertiary care centers that benefit, but also therural health clinics, the federally qualified health centers, the critical access hospitals, the pharmacies, the nursing homes, and other things that really work out in the communities. 

So I think measure of how successful it is, does it really benefit economically the community as well as the traditional folks who have benefited from these health dollars when they're invested in transformation?

LO: There is also an issue to think about and that is the percentage of the population not using the Internet. A report by the Arizona Commerce Authority indicates 21 percent of the Arizona population is not using Internet and 38 percent not using a PC or tablet computer. How do you work within that community if they don't have that infrastructure?

DD: I think there's a number of creative ways, and already we've seen some of the creative ways to approach this. Not every individual or household in some of our most frontier areas of the state will have Internet access. The technology is getting better even on that, even in our most remote areas. But you may have to really take advantage of things like the library services, or whether it's a middle school or a high school, where you can create these access points for broadband and other things that people will really need in order to learn, in order to teach, in order to deliver care and receive care. I think we're being quite creative, but that being said, there's still a significant portion of our state where people don't have running water, let alone broadband access. 

We have to balance those needs with the reality of, how do we really get this out in a way that really accomplishes the thing, is improving health outcomes for not just certain populations or certain urban populations, but for all Arizonans. I think that comes with enhancing both patient experience of that care, but also the provider experience of delivering that care. We have to do the work-life balance better than what we've been doing, because we're still seeing a significant burnout in our nurses, in our physicians, and other health professionals. They really take care of people, and we want people to have a long, successful, and happy career in health professions. We're going to have to pay a bit more attention to the things we're loading on to individuals that are out there, both receiving that care, but also delivering that care.

NC: As you mentioned, telehealth means different things to different people, and certainly with the variety of tools that are being introduced and AI, having the potential to transform the practice of medicine and delivery of health care. With things changing so quickly, is it possible to completely predict what kind of role AI will ultimately play in health care?

DD: I think it's very difficult, because it's changing so quickly. Some of the estimates of how quickly the efficiency and capability of this artificial intelligence is pretty astounding. Things that may be applicable today, and we might make a 10-year plan for how we really transform things. Well, realistically right now, a 24- to 36-month plan might be more realistic, because the platforms will change, they'll improve.

What we don't want, though, is rural hospitals and clinics and other health services in rural and tribal areas to make mistakes in buying very expensive things that in two years or five years might no longer be helpful. That's why I think it really is important to have these community-academic partnerships to make sure that the best equipment, the best providers, the best trained folks are really helping plan for those types of things, given the variables changing almost every day.

NC: Or another potential concern, “set it and forget it.” Oh, the rural health industry, well, they received this top of the line, and then how do you adapt to these changes against biases, data breaches, hallucinations? Because things are so rapidly changing, I would imagine that would be a danger, is you can't just set it and forget it, especially for rural communities.

DD: And I think that's where we can be of assistance at the University of Arizona with evaluation. How do we really look at data and translate that data to analyses and reports so that people can use that to continuously improve? You have to really take a good look at it. 

You use the word, I had to look up “hallucinations” in the context of artificial intelligence. In our world, when we look at things and we hallucinate, we think it's there. I mean, it looks very real, like a mirage in the desert. It might look like there's water there.

But these digital hallucinations, they're taking data and trying to translate that to some sort of real-time data, and sometimes it makes mistakes. And that's where we have to be doubly careful about not coming to conclusions about things that really aren't in existence. So there's checks and balances with this. I think that systems will get better as time goes on. But without data and real-time evaluation of those things, how will we improve? We have to make sure we're using that on a real-time basis to continuously improve the systems.

LO: Just one final question. You've talked in a compelling way about people who are going to be dropping off a Medicaid, lose insurance. What should the individual do if they're facing a long-term health crisis and they don't have insurance, and where do they go?

DD: A lot of my career has been working in places like federally qualified health centers and rural areas out and about both New Mexico and Arizona and even down into Mexico. And when you don't have coverage, it's pretty desperate. When you have to make decisions about, "Well, I can't take my diabetes medicine, so I'll halve them." And then someone goes into diabetic ketoacidosis and requires emergency care and hospitalization, or people don't get the immunizations they need to prevent things that long ago we determined the evidence base that these are preventable types of things, like we're seeing with measles. Even the more concerning things coming from places that we're not really prepared for, like Ebola coming out and how will that happen? The screw worm happening in some of the places that we thought we had pretty much defeated, but they're coming around. It really requires a surveillance that prepares us for these types of things. Even the things that we don't anticipate we have to have those types of systems in place and be realistic about, we have to get on top of these things right away.

LO: Thank you, Dr. Derksen. For more information about the Arizona Center for Rural Health, you can go to crh.arizona.edu. Dr. Daniel Derksen, we appreciate your joining us today.

DD: Thank you.

NC: Thank you for listening to Navigating Our Financial Times. This program is not intended to provide investment, tax, or financial advice. You should consult your own tax, legal, and accounting advisors before engaging in any transaction. The views and opinions expressed by guests are their own and do not imply an endorsement or recommendation, or necessarily reflect the views of AZPM.

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