Rehab hospitals that help people recover from major surgeries and injuries have become a highly lucrative slice of the health care business. But federal data and inspection reports show that some run by the dominant company, Encompass Health Corp., and other for-profit corporations have had rare but serious incidents of patient harm and perform below average on two key safety measures tracked by Medicare.

Yet even when inspections reveal grave cases of injury, federal health officials do not inform consumers or impose fines the way they do for nursing homes. And Medicare doesn’t provide easy-to-understand five-star ratings as it does for general hospitals.

In the most serious problems documented by regulators, rehab hospital errors involved patient deaths.

In Encompass Health’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak during construction at the facility.

At its hospital in Jackson, Tennessee, a patient, 68, was found dead overnight, lying on the floor in a “pool of blood” after an alarm that was supposed to alert nurses that he had gotten out of bed had been turned off.

In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the wrong drug, one of 26 medication errors the hospital made over six months. He died two days later at another hospital.

“I can still see Fred laying in the bed as they shut each little machine off,” said his widow, Susan Roufs. “They clicked four of them, and then the love of my life was gone.”

Encompass, which owns 168 hospitals and admitted 248,000 patients last year, has led the transformation of this niche industry. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits as the places where the majority of annual patient admissions occur, a KFF Health News and New York Times analysis found. A third of all admissions were to Encompass hospitals. Such facilities are required to provide three hours of therapy a day, five days a week.

Across the nation, there are now nearly 400 stand-alone rehab hospitals, the bulk of which are for-profit. These hospitals collectively generate profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency.

At the same time, the number of small, specialized units within acute care hospitals — where most rehab used to be provided — has dwindled. There are now around 800 of those, and most are nonprofits.

In its latest annual report, Encompass, which is publicly traded, reported an 11% net profit in 2024, earning $597 million last year on revenues of $5.4 billion.

Federal data on the performance of about 1,100 of the rehab facilities show Encompass tends to be better at helping most patients return home and remain there. In a two-year period ending in September 2023, Medicare rated 233 rehab facilities as performing better than the national rate for this major metric, called “discharge to community.” Most rehabs with better community discharge rates are for-profit, and Encompass owns 79 of them.

But data from Medicare also reveals Encompass owns many of the rehabs with worse rates of potentially preventable, unplanned readmissions to general hospitals. Medicare evaluates how often patients are rehospitalized for conditions that might have been averted with proper care, including infections, bedsores, dehydration, and kidney failures.

Encompass accounts for about 1 in 7 rehab facilities nationally, but owned 34 of the 41 inpatient rehab facilities that Medicare rated as having statistically significantly worse rates of potentially preventable readmissions for discharged patients. (Overall, rates of readmission after discharge ranged from 7% to 12%, with a median of 9%.)

And it owned 28 of the 87 rehab facilities — 65 of which were for-profit — that had worse rates of potentially preventable readmissions to general hospitals during patient stays. (The median for these kinds of readmissions was 5%, and rates for individual rehabs ranged from 3% to 9%.)

Patrick Darby, the executive vice president and general counsel of Encompass, strongly defended the company’s record in written responses to questions. He dismissed Medicare’s readmissions ratings of “better,” “worse,” and “no different than the national rate” as “a crude scoring measure” and said “performance is so similar across the board.” He called the violations found during health inspections “rare occurrences” that “do not support an inference of widespread quality concerns.”

“The simplest and most accurate reason for EHC’s success is that our hospitals provide superior care to patients,” he said, referring to Encompass by its corporate initials.

Chih-Ying Li, an associate professor of occupational therapy at the University of Texas Medical Branch at Galveston School of Health Professions, said in an interview that a research study she conducted found the profit status of a rehab facility was the only characteristic associated with higher unplanned readmissions.

“The finding is pretty robust,” she said. “It’s not like huge, huge differences, but there are differences.”

Alarming Mistakes

VanBibber was admitted to Encompass’ Huntington hospital in 2021 for therapy to strengthen her lungs. At the time, the hospital was undergoing a $3 million expansion, and state regulators had warned the company that areas of the hospital occupied by patients had to be isolated from the construction “using airtight barriers,” according to a health inspection report.

In her room, which was about 66 feet from the construction zone, she began having trouble breathing, the report said. When she told the staff, they ignored her and shut her door, according to a lawsuit brought by her estate. Staff members eventually noticed that she was “lethargic and gasping for air,” and called 911.

When the emergency medical squad arrived, the carbon monoxide detectors they wore sounded. By that time, VanBibber’s blood oxygen levels were dangerously low, the inspection report said. She died three days later from respiratory failure and carbon monoxide poisoning, according to the inspection report and the lawsuit. A plumber had been using a gas-powered saw in the construction area, but there were no carbon monoxide detectors in the hallways, the report said.

In court papers, Encompass and its construction contractors denied negligence for VanBibber’s death. The case is pending.

Inspectors determined Encompass failed to maintain a safe environment for all patients during construction and didn’t properly evaluate other patients for signs of poisoning, the report said.

Since 2021, the federal Centers for Medicare and Medicaid Services, or CMS, which oversees health inspections, has found that 10 Encompass hospitals, including the one that cared for VanBibber, had immediate jeopardy violations, federal records show. Such violations — like the ones that Medicare also found in connection with the deaths of Roufs and the patient who fell after leaving his bed — mean a hospital’s failure to comply with federal rules has put patients at risk for serious injury, serious harm, serious impairment, or death.

Darby, the general counsel for Encompass, said the company regretted any clinical problems and had promptly addressed all such findings to the satisfaction of inspectors. He said Encompass that has an “excellent compliance record,” including superior results from its accreditation agency, and that its overall number of health citations was tiny given how many hospitals Encompass owns and how many patients it treats.

Six other corporate-operated for-profit hospitals were also cited, while none of the 31 stand-alone nonprofit rehab hospitals received such violations from 2021 to 2024. (Inspection reports for general hospitals do not systematically specify in which part of the building a violation occurred, so rehab unit violations cannot be identified.)

An alert called a bed alarm was at the root of immediate jeopardies at Encompass hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The devices are pressure- and motion-sensitive and emit a sound and display a light to alert staff members that someone at a high risk of falls has left his or her bed.

In its Morgantown hospital, a nurse technician discovered a patient face down on the floor with a large gash on her head after a defective alarm did not go off, an inspection report said. After she died, the nurse told inspectors: “We are having a lot of problems with the bed alarms.”

Medicare is not authorized by law to fine rehab hospitals for safety rule violations, even ones involving deaths uncovered during inspections, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000.

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used because of its draconian consequences.

“Termination is typically a last resort after working with the provider to come back into compliance,” Catherine Howden, a CMS spokesperson, said in an email.

As a result, because there’s no graduated penalty, even the most serious — and rare — immediate jeopardy violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems.

“Only having a nuclear weapon has really hurt patient safety,” said Michael Millenson, a medical quality advocate.

One immediate jeopardy incident did result in a punishment, but only because the hospital was in California, which allows its health department to issue penalties. Encompass’ Bakersfield hospital paid a $75,000 fine last year for failing to control the blood sugar of a patient who died after her heart stopped.

Rapid Growth and a Troubled History

Encompass has accelerated its expansion in recent years and now operates in 38 states and Puerto Rico. It plans to open 17 more hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the end of 2027, according to its latest report.

It frequently moves into new markets by persuading local nonprofit hospitals to shutter their rehab units in exchange for an equity stake in a newly built Encompass hospital, company executives have told investors.

The president of Encompass, Mark Tarr, calls it a “win-win proposition”: The local hospitals can use their emptied space for a more lucrative line of service and Encompass gets a “jump start” into a new market, with partner hospitals often referring patients.

Tarr, who was paid $9.3 million in compensation last year, told investors that Encompass requires that the existing hospitals sign a noncompete deal. Sixty-seven Encompass hospitals are joint ventures, mostly with nonprofit hospitals as investors, according to the company’s June financial filing, the most recent available.

Darby said the company’s profits allow it to build hospitals in areas that lack intensive inpatient rehabilitation and improve existing hospitals. “High-quality patient care is not only consistent with shareholder return, but quality and shareholder return are in fact critical to one another,” he said.

The success of Encompass is particularly notable given that it barely survived what experts said was one of the largest modern accounting scandals in 2003.

The Securities and Exchange Commission charged that the company, then known as HealthSouth, overstated earnings by $2.7 billion to meet Wall Street analyst quarterly expectations, leading to the ouster of its founder and directors. In 2004, the company agreed to pay the government $325 million to settle Medicare fraud allegations without admitting wrongdoing. Darby credited the company’s new leaders for obtaining a $2.9 billion judgment on behalf of shareholders against the company’s founder.

The company changed its name to Encompass in 2018 after acquiring Encompass Home Health and Hospice. In 2019, the Justice Department announced the company had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed patients to get higher Medicare reimbursements, and admitted patients who were too sick to benefit from therapy. The company denied any wrongdoing, blaming independent physicians who worked at its hospitals. Darby said Encompass settled the case only to “avoid more years of expense and disruption.” He said the Justice Department never filed a lawsuit despite years of investigation.

Medication Harms

Rehab hospital inspection reports are not posted on Care Compare, Medicare’s online search tool for consumers. KFF Health News had to sue CMS under the Freedom of Information Act to obtain all its inspection reports for rehab hospitals. In contrast, Care Compare publishes all nursing home inspection reports and assigns each facility a star rating for its adherence to health and safety rules.

So people now choosing a rehab hospital would not know that at the Encompass hospital in Sioux Falls, South Dakota, in 2021, a nurse accidentally gave Roufs a blood pressure drug called hydralazine instead of hydroxyzine, his prescribed anti-anxiety medication, according to an inspection report. Roufs went into cardiac arrest. This type of error, called a “look-alike/sound-alike,” is one hospitals and staff members are supposed to be especially alert to.

Months before, an internal safety committee had identified a trend of medication errors, including when a nurse accidentally gave a patient 10 times the prescribed amount of insulin, sending him to the hospital, the inspection report said. The nurse had misread four units as 40. Since Roufs’s death, inspectors have faulted the hospital six times for various lapses, most recently in April 2024 for improper wound care.

An Encompass hospital in Texarkana, Texas, misused antipsychotic medications to pacify patients, resulting in an immediate jeopardy finding from CMS, the report said. And the company’s hospital in Erie, Pennsylvania, was issued an immediate jeopardy violation for not keeping track of medication orders in 2023, when a patient had a cardiac arrest after not receiving all of his drugs, according to the inspection report.

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues.

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities, according to a CMS spokesperson.

Deadly Bedsores

The family of Paul Webb Jr., 74, claimed in a lawsuit that the Encompass hospital in Erie left Webb unattended in a wheelchair for hours at a time, putting pressure on his tailbone, in 2021. His medical records, provided to reporters by the family, list a sitting tolerance of one hour.

Webb — who had been originally hospitalized after a brain bleed, a type of stroke — developed skin damage known as a pressure sore, or bedsore, on his bottom, the lawsuit said. The suit said the sore worsened after he was sent to a nursing home, which the family is also suing, then home, and he died later that year. In his final weeks, Webb was unable to stand, sit, or move much because of the injury, the lawsuit said.

In court papers, Encompass and the nursing home denied negligence, as Encompass has in some other pending and closed lawsuits that accused it of failing to prevent pressure sores because nurses and aides failed to regularly reposition patients, or notice and treat emerging sores. Darby said Webb’s death occurred three months after his Encompass stay and was not related to his care at Encompass. He said no hospital with long-term patients could prevent every new or worsening pressure sore, but that Encompass’ rates were similar to the 1% national average.

One of Webb’s sons, Darel Webb, recalled a warning given to the family as they left an appointment their father had with wound specialists: A doctor brought up Christopher Reeve, the actor who played Superman in movies in the 1970s and 1980s.

“He goes, ‘Remember, Superman was paralyzed from falling off the horse, but he died from a bedsore,’” he said.

Jordan Rau has been writing about hospital safety since 2008. Irena Hwang is a New York Times data reporter who uses computational tools to uncover hidden stories and illuminate the news.

METHODOLOGY

To examine the medical rehabilitation hospital industry, we obtained and analyzed a database of inspection reports of freestanding rehabilitation hospitals from the federal Centers for Medicare & Medicaid Services, or CMS. We also obtained inspection reports from several states through public records requests.

We analyzed inpatient rehabilitation facility characteristics and patient volume data contained in hospital data files from the Rand Corp., a nonprofit research organization. This dataset compiles cost reports all hospitals submit each year to CMS. For each facility for the years 2012 to 2023, we categorized annual discharges by facility type (freestanding rehabilitation hospital or unit within an acute care hospital); facility ownership status (for-profit, nonprofit, or government); and which hospitals were owned by Encompass Health under its current or prior name, HealthSouth.

Financial information about Encompass Health was obtained from the company’s Securities and Exchange Commission disclosure filings.

We examined the readmission rates for all inpatient rehabilitation facilities that CMS publishes in its quality data. CMS evaluates the frequency with which Medicare patients were readmitted for potentially preventable reasons to an acute care hospital during their rehab stay. Separately, CMS also evaluates the frequency of potentially preventable readmissions to an acute care hospital within 30 days of discharge from rehab. We also examined the rate of successful return to home or community. Figures for all three metrics were available for about 1,100 of the roughly 1,200 rehab facilities in the CMS data. The most recent readmission data covered Medicare discharges from October 2021 through September 2023.

We examined nursing home penalties from the last three years from CMS’ data on nursing homes.

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

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Rehabilitation therapy can be a godsend after hospitalization for a stroke, a fall, an accident, a joint replacement, a severe burn, or a spinal cord injury, among other conditions. Physical, occupational, and speech therapy are offered in a variety of settings, including at hospitals, nursing homes, clinics, and at home. It’s crucial to identify a high-quality, safe option with professionals experienced in treating your condition.

What kinds of rehab therapy might I need?

Physical therapy helps patients improve their strength, stability, and movement and reduce pain, usually through targeted exercises. Some physical therapists specialize in neurological, cardiovascular, or orthopedic issues. There are also geriatric and pediatric specialists. Occupational therapy focuses on specific activities (referred to as “occupations”), often ones that require fine motor skills, like brushing teeth, cutting food with a knife, and getting dressed. Speech and language therapy help people communicate. Some patients may need respiratory therapy if they have trouble breathing or need to be weaned from a ventilator.

Will insurance cover rehab?

Medicare, health insurers, workers’ compensation, and Medicaid plans in some states cover rehab therapy, but plans may refuse to pay for certain settings and may limit the amount of therapy you receive. Some insurers may require preauthorization, and some may terminate coverage if you’re not improving. Private insurers often place annual limits on outpatient therapy. Traditional Medicare is generally the least restrictive, while private Medicare Advantage plans may monitor progress closely and limit where patients can obtain therapy.

Should I seek inpatient rehabilitation?

Patients who still need nursing or a doctor’s care but can tolerate three hours of therapy five days a week may qualify for admission to a specialized rehab hospital or to a unit within a general hospital. Patients usually need at least two of the main types of rehab therapy: physical, occupational, or speech. Stays average around 12 days.

How do I choose?

Look for a place that is skilled in treating people with your diagnosis; many inpatient hospitals list specialties on their websites. People with complex or severe medical conditions may want a rehab hospital connected to an academic medical center at the vanguard of new treatments, even if it’s a plane ride away.

“You’ll see youngish patients with these life-changing, fairly catastrophic injuries,” like spinal cord damage, travel to another state for treatment, said Cheri Blauwet, chief medical officer of Spaulding Rehabilitation in Boston, one of 15 hospitals the federal government has praised for cutting-edge work.

But there are advantages in selecting a hospital close to family and friends who can help after you are discharged. Therapists can help train at-home caregivers.

How do I find rehab hospitals?

The discharge planner or caseworker at the acute care hospital should provide options. You can search for inpatient rehabilitation facilities by location or name through Medicare’s Care Compare website. There you can see how many patients the rehab hospital has treated with your condition — the more the better. You can search by specialty through the American Medical Rehabilitation Providers Association, a trade group that lists its members.

Find out what specialized technologies a hospital has, like driving simulators — a car or truck that enable a patient to practice getting in and out of a vehicle — or a kitchen table with utensils to practice making a meal.

How can I be confident a rehab hospital is reliable?

It’s not easy: Medicare doesn’t analyze staffing levels or post on its website results of safety inspections as it does for nursing homes. You can ask your state public health agency or the hospital to provide inspection reports for the last three years. Such reports can be technical, but you should get the gist. If the report says an “immediate jeopardy” was called, that means inspectors identified safety problems that put patients in danger.

The rate of patients readmitted to a general hospital for a potentially preventable reason is a key safety measure. Overall, for-profit rehabs have higher readmission rates than nonprofits do, but there are some with lower readmission rates and some with higher ones. You may not have a nearby choice: There are fewer than 400 rehab hospitals, and most general hospitals don’t have a rehab unit.

You can find a hospital’s readmission rates under Care Compare’s quality section. Rates lower than the national average are better.

Another measure of quality is how often patients are functional enough to go home after finishing rehab rather than to a nursing home, hospital, or health care institution. That measure is called “discharge to community” and is listed under Care Compare’s quality section. Rates higher than the national average are better.

Look for reviews of the hospital on Yelp and other sites. Ask if the patient will see the same therapist most days or a rotating cast of characters. Ask if the therapists have board certifications earned after intensive training to treat a patient’s particular condition.

Visit if possible, and don’t look only at the rooms in the hospital where therapy exercises take place. Injuries often occur in the 21 hours when a patient is not in therapy, but in his or her room or another part of the building. Infections, falls, bedsores, and medication errors are risks. If possible, observe whether nurses promptly respond to call lights, seem overloaded with too many patients, or are apathetically playing on their phones. Ask current patients and their family members if they are satisfied with the care.

What if I can’t handle three hours of therapy a day?

A nursing home that provides rehab might be appropriate for patients who don’t need the supervision of a doctor but aren’t ready to go home. The facilities generally provide round-the-clock nursing care. The amount of rehab varies based on the patient. There are more than 14,500 skilled nursing facilities in the United States, 12 times as many as hospitals offering rehab, so a nursing home may be the only option near you.

You can look for them through Medicare’s Care Compare website. (Read our previous guide to finding a good, well-staffed home to know how to assess the overall staffing.)

What if patients are too frail even for a nursing home?

They might need a long-term care hospital. Those specialize in patients who are in comas, on ventilators, and have acute medical conditions that require the presence of a physician. Patients stay at least four weeks, and some are there for months. Care Compare helps you search. There are fewer than 350 such hospitals.

I’m strong enough to go home. How do I receive therapy?

Many rehab hospitals offer outpatient therapy. You also can go to a clinic, or a therapist can come to you. You can hire a home health agency or find a therapist who takes your insurance and makes house calls. Your doctor or hospital may give you referrals. On Care Compare, home health agencies list whether they offer physical, occupational, or speech therapy. You can search for board-certified therapists on the American Physical Therapy Association’s website.

While undergoing rehab, patients sometimes move from hospital to nursing facility to home, often at the insistence of their insurers. Alice Bell, a senior specialist at the APTA, said patients should try to limit the number of transitions, for their own safety.

“Every time a patient moves from one setting to another,” she said, “they’re in a higher risk zone.”

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

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International Dairy Foods Association (IDFA) announcement on the dairy industry’s commitment to eliminate artificial food dyes from their ice creams.

On his way to an Ultimate Fighting Championship event, Health and Human Services Secretary Robert F. Kennedy Jr. stopped by the home of podcaster Gary Brecka. The two spent time in a hyperbaric oxygen chamber and tried some intravenous nutrition drips that Brecka, a self-avowed longevity and wellness maven, sells and promotes on his show, “The Ultimate Human.”

Then the podcast taping started, and Kennedy — who was also on the mic — took aim at Big Pharma’s influence on federal health policy.

“We have a sick-care system in our country, and the etiology ultimately of all that disease is corruption,” Kennedy said before the show cut away to an ad for vitamin chips. “And it’s the capture of these agencies by the industries they are supposed to regulate.”

While Kennedy lambastes federal agencies he says are overly influenced by the pharmaceutical industry, he and some other figures of the “Make America Healthy Again,” or MAHA, movement — such as siblings Calley and Casey Means, Robert Malone, and Peter McCullough — have their own financial ties to a vast and largely unregulated $6.3 trillion global wellness industry they also support and promote.

Kennedy and those four advisers — three of whom have been tapped for official government roles — earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a KFF Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS.

The total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data isn’t publicly available.

The Means siblings have launched wellness companies that have raised more than $99 million from investors, according to company news releases as well as information from Clay, a customer research data company, and Tracxn, an information technology firm that provides access to a database of companies, funding rounds, and investor information.

“Secretary Kennedy, and all HHS officials, fully comply with all ethics and financial disclosure laws,” agency spokesperson Emily Hilliard said in an email. “Any attempt to suggest impropriety is reckless and politically motivated.”

Some public health leaders and ethicists say the financial ties raise red flags, with the potential for personal profits to shape decision-making at the highest levels of federal health agencies.

“It’s becoming completely corrupted,” said Arthur Caplan, founding head of the medical ethics division at New York University’s Grossman School of Medicine. “You shouldn’t have a vested interest in making recommendations on wellness or supplements or health. It opens the door to all kinds of shenanigans. Big Wellness is no different than Big Pharma. They’re a well-organized political force.”

Unlike any other previous administration, President Donald Trump’s administration has elevated anti-vaccine and wellness leaders to positions at HHS from which they can steer federal policy. Adherents to the MAHA movement say the change is long overdue, arguing that previous administrations haven’t devoted sufficient attention to the potential harms of traditional medical approaches.

Critics including health policy leaders and physicians say they worry the revamped HHS and its agencies are now harming public health. For example, they point to a recent Kennedy decision to remove and replace all the members of a vaccine advisory group, a move the American Medical Association criticized as lacking transparency and proper vetting. Two of Kennedy’s newly named panel members — Malone and Martin Kulldorff — previously earned money as paid experts in vaccine lawsuits against Merck, as first reported by Reuters and the life-sciences news outlet BioSpace.

Calley Means, who has criticized the recommended U.S. vaccine schedule for youths and has no medical training, is a special government employee and a top health adviser to Kennedy. He also co-founded the wellness company Truemed.

The company enables people to spend pretax dollars from Flexible Spending Accounts and Health Savings Accounts to pay for wellness products, health food, and SoulCycle classes.

Truemed’s website says it can provide customers with a “Letter of Medical Necessity” for the items.

The IRS has warned consumers about companies that misrepresent wellness items like food as FSA-eligible when they are not, in fact, permitted medical expenses.

The IRS did not respond to questions about the status of that policy under the Trump administration.

In 2024, when Kennedy was running for president as an independent, he promoted Means’ company on his own podcast. Means also promoted his close connection with Kennedy last year on podcasts and on Instagram while also using social media to advance Truemed. And while working for the public as a special government employee since March, Means has used social and new media to promote podcasters who make money selling wellness products, to criticize specific pharmaceutical drugs, and to tout the wellness book he co-wrote, “Good Energy,” according to a KFF Health News review of social media posts and podcasts.

Means has also used podcasts and social media to rail against new injectable weight loss drugs. The Trump administration in April decided not to finalize a rule that would have allowed Medicaid and Medicare to cover the injectable drugs, putting them out of reach for millions of potential users.

Hilliard, the HHS spokesperson, didn’t respond to questions about whether Means, as a Kennedy adviser, has recused himself from decisions that could affect his business. Neither HHS nor the White House responded to requests to speak with him.

His sister, Casey Means, is Trump’s pick for surgeon general and was also an adviser to Kennedy during his 2024 presidential run. She co-founded Levels, a company valued at $300 million in 2022 that promotes glucose monitoring for nondiabetic, healthy individuals. Consumers pay $199 for a one-month supply of continuous glucose monitors.

She has used social media to call for public policy that would encourage blood sugar monitoring for healthy individuals, saying “tips to stabilize glucose should be on every billboard in America.” Research has found little evidence that such monitoring provides health benefits for people without diabetes.

Her company stands to benefit under the Trump administration. Kennedy said in April that he was considering a regulatory framework for federal health programs’ coverage of injectable weight loss drugs that would first require patients to try glucose monitoring or other options.

“And if they don’t work, then you would be entitled to the drug,” he told CBS News.

Casey Means isn’t a practicing doctor and doesn’t hold an active medical license, according to records from the Oregon Medical Board. And, as an online influencer, she “failed to disclose that she could profit” from sales of products she recommends, according to The Associated Press.

HHS spokesperson Hilliard didn’t answer questions about whether Casey Means would recuse herself from working on anything that would directly benefit her company, or why she didn’t disclose that she could profit from sales of products she recommends. HHS didn’t respond to questions about Means’ ties to Kennedy or agency support for glucose monitoring, nor did the agency respond to a request to speak directly to the Trump surgeon general pick.

Outside Advisers

McCullough, a former cardiac doctor who has financial ties to the wellness industry, has been part of Kennedy’s circle of informal advisers, according to people close to the secretary. He also has enough sway with some GOP lawmakers that they’ve had him testify before Congress. In May, he told a Senate subcommittee that mRNA covid-19 vaccines can lead to deaths that have been underreported. But the FDA says the covid vaccines are safe, with fewer than 1 in 200,000 vaccinated individuals experiencing a severe allergic reaction or heart problems like myocarditis or pericarditis.

He profits from his anti-covid-vaccine message. McCullough devised a protocol he says helps people detox from covid mRNA shots, selling the products through The Wellness Co. McCullough is the company’s chief scientific officer, draws a partial salary, and holds an equity stake.

For $89.99, consumers can purchase Ultimate Spike Detox supplements containing nattokinase, an enzyme from fermented soybeans. A two-month supply of Spike Support supplements sells on Amazon for about $62. More than 900 bottles have sold in the past month.

McCullough didn’t respond to an email seeking comment. HHS also didn’t respond to questions about his relationship with Kennedy.

Some health policy leaders and doctors say the financial connections federal health officials and advisers have to the wellness industry raise concerns.

“It’s exactly the problem RFK has taken up with the FDA, saying it’s too beholden to pharma,” said Pieter Cohen, an associate professor of medicine at Harvard University.

“When you’re in bed with supplement manufacturers, you are creating the same kinds of conflicts of interest, whether or not you directly profit,” he said. “You should be independently advocating for public health, not cheerleading for any particular industry.”

The wellness sector includes personal care, weight loss, health, nutrition, and wellness tourism.

Its lobbying influence is markedly smaller than the lobbying reach of pharmaceutical companies, according to OpenSecrets, a research organization that tracks money in U.S. politics. The nutritional and dietary supplements industry spent about $3.7 million on lobbying in 2024, for example, compared with the $387 million the pharmaceutical industry spent the same year.

It’s also gotten far less scrutiny. The industry is a growing political force with its own lobbyists, celebrities, and industry-backed advocacy groups, and research shows that public interest in wellness has grown since the pandemic. Eighty-four percent of U.S. consumers say wellness is a “top” or “important” priority, according to a survey released this year by McKinsey & Co.

Unlike with Big Pharma, there’s scant regulation of the industry. Companies can sell supplements and other products without notifying the FDA, and there’s little oversight by the Federal Trade Commission of their product claims.

“The wellness industry profiteers by undermining and creating distrust in science and regulated products,” said Andrea Love, an immunologist and microbiologist who founded ImmunoLogic, a science and health education organization. “They are messaging that the government and Big Pharma are hiding information and treatments or cures to keep us weak and vulnerable.”

Ethics and Disclosures

People on both sides of the issue say the industry has found its captain in Kennedy, an anti-vaccine activist with deep ties to the MAHA and wellness movements.

He has profited by referring people to law firms that are suing over alleged vaccine injury. For example, he gets a fee for referring potential clients to a Los Angeles personal injury firm, according to a January ethics statement to HHS and his financial disclosures. One of his adult sons works at the personal injury law firm.

When his nomination to the HHS secretary post was under consideration, Kennedy indicated in his ethics disclosure that he intended to continue profiting from lawsuits over Gardasil, a Merck vaccine that protects against HPV. After Democrats raised concerns with the financial relationship, he told Congress he would divest his interest and sign over the financial stake to one of his adult sons.

Federal ethics rules bar government employees from participating in matters in which they, their spouse, or their minor child has a financial stake. It doesn’t include adult children such as Kennedy’s sons.

“There are a lot of loopholes, and that is one of them,” said Cynthia Brown, senior ethics counsel at the Citizens for Responsibility and Ethics in Washington, a watchdog organization focused on U.S. government ethics and accountability. “It certainly is an appearance problem. Even if it’s not a technical violation, it is an ethical problem in terms of influence.”

Some lawmakers and ethics leaders weren’t mollified by Kennedy’s planned divestiture. Sen. Elizabeth Warren (D-Mass.) called on Kennedy to agree to a four-year, post-employment ban on accepting any compensation from lawsuits involving any entity regulated by HHS.

“It would be insufficient for RFK Jr. to only divest his interest in the Gardasil case while leaving the window open to profit from other anti-vax lawsuits, including future cases he could bring after leaving office,” she said in a statement.

Kennedy also made money on the MAHA name by applying in September to register it as a trademark. He transferred trademark ownership to a limited liability company led by friend and MAHA ally Del Bigtree after making about $100,000 off the phrase, according to his financial disclosure.

HHS’ Hilliard didn’t answer questions about whether Kennedy had signed over his interest in fees from legal referrals to his son, the money he made by registering MAHA as a trademark, or whether he agreed with Warren’s request that upon leaving office he accept a four-year ban on accepting money from lawsuits involving entities regulated by HHS.

Bigtree is executive director of the Informed Consent Action Network, or ICAN, an anti-vaccination group. He was communications director for Kennedy’s failed presidential campaign, and as an informal adviser to the secretary he helped vet candidates for HHS jobs. Bigtree’s salary at the nonprofit was $234,000 for the 2023 fiscal year, according to documents filed with the IRS. ICAN paid $6 million in legal fees to Siri & Glimstad in 2023. The firm’s managing partner, Aaron Siri, focuses on vaccine injury. He has been Kennedy’s personal lawyer and adviser, and also helped vet candidates for the secretary.

Brown, an ethics counselor, said the transfer and ongoing advisory relationship could raise questions about who is influencing Kennedy. Bigtree, at a Politico event in February, called on Kennedy to recruit scientists to HHS who believe vaccines cause autism, for example. One of Kennedy’s early actions at HHS was the launch of a study on the causes of autism.

ICAN didn’t respond to an email seeking comment. HHS also didn’t respond to questions about Kennedy’s transfer of the MAHA trademark to Bigtree.

“This is the type of Washington wheeling and dealing that raises questions about integrity in government,” Brown said. “If it was trademarked before he became a public official, there may be no law broken. But by transferring it to someone he knows, it illustrates the constant trickle of influence among those in power.”

Past administrations have faced similar criticism over health regulators’ ties to Big Pharma. Alex Azar, who led HHS during the previous Trump administration, worked for drugmaker Eli Lilly before entering public office. Robert Califf, FDA commissioner during the Biden administration, was a consultant to drug companies.

Scott Gottlieb, who was FDA commissioner from 2017 to 2019 and an adviser to Trump’s presidential campaign, stepped down to join the board of the drugmaker Pfizer.

“Big Pharma is well off. But, in general, financial conflicts don’t depend on how much the organizations are spending,” said Zeke Emanuel, a bioethicist who served on a covid advisory board under President Joe Biden. “The question is, is there a reasonable concern that financial or other concerns are affecting their judgment?”

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Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, the industry often also warns of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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Céline Gounder, KFF Health News’ editor-at-large for public health, discussed measles cases on CBS News’ “CBS News 24/7” on July 9. Gounder also discussed the presence of Immigration and Customs Enforcement in medical facilities on CBS News’ “CBS Mornings Plus” on July 8.

• Click here to watch Gounder on “CBS News 24/7.”
• Click here to watch Gounder on “CBS Mornings Plus.”

KFF Health News contributor Sarah Kwon discussed a delay in implementing California’s law mandating that some insurance plans cover in vitro fertilization on KVPR’s “Central Valley Daily” podcast on July 9.

• Click here to hear Kwon on “Central Valley Daily.”
• Read Kwon’s “California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch.”

KFF Health News senior correspondent Angela Hart discussed how health care cuts in President Donald Trump’s megabill will affect Californians on KQED’s “Political Breakdown” podcast on July 8.

• Click here to hear Hart on “Political Breakdown.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson.

KFF Health News chief rural correspondent Sarah Jane Tribble discussed possible effects of the megabill on rural hospitals on CNN’s “CNN This Morning” on July 4.

• Click here to watch Tribble on “CNN This Morning.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson.

KFF Health News senior correspondent Renuka Rayasam discussed the megabill and its impacts on health care in Texas on KXAN’s “KXAN Midday” on July 3.

• Click here to hear Rayasam on “KXAN Midday.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Rayasam, and Bernard J. Wolfson.

KFF Health News Southern correspondent Sam Whitehead discussed enrollment in Affordable Care Act marketplace plans on WUGA’s “The Georgia Health Report” on June 27.

• Click here to hear Whitehead on “The Georgia Health Report.”
• Read “In a First, Trump and GOP-Led Congress Prepare To Swell Ranks of US Uninsured,” by Renuka Rayasam and Whitehead.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Elliott Hinkle experienced depression and suicidal thoughts even before entering the foster care system in Casper, Wyoming, at age 15.

At the time, Hinkle, who is transgender, struggled with their sexual identity and gender issues, and their difficulties continued in foster care. They felt like they had no one to confide in — not their foster parents, not church leaders, not their caseworker.

“To my knowledge, I don’t remember ever taking a suicide screening,” Hinkle said. “No one ever said: ‘Are you having thoughts of taking your life? Do you feel hopeless?’”

With their psychological and behavioral health needs left unaddressed, Hinkle’s depression and suicidal thoughts worsened.

“Do I stay in the closet and feel terrible and want to end my life?” Hinkle said. “Or do I come out and lose all my supports, which also feels dangerous?”

Children in foster care are significantly more likely to have mental health issues, researchers say. They attempt or complete suicide at rates three to four times that of youths in the general population, according to several studies.

LGBTQ+ people in foster care, like Hinkle, are at an even higher risk of having suicidal thoughts.

Yet despite the concentration of young people at risk of serious mental illness and suicide, proactive efforts to screen foster children and get them the treatment they need have been widely absent from the system. And now, efforts underway to provide widespread screening, diagnosis, and treatment are threatened by sweeping funding cuts the Trump administration is using to reshape health care programs nationwide.

In June, federal officials announced they would shut down a suicide hotline serving LGBTQ+ youths as part of those cuts.

Children in foster care use a disproportionate amount of Medicaid-funded mental health services. Meanwhile, President Donald Trump’s massive budget package, passed this month by Congress, contains substantial shifts in Medicaid funding and policies that are projected to drastically reduce services in many states.

“I think anybody who cares about kids’ well-being and mental health is concerned about the possibility of reduced Medicaid funding,” said Cynthia Ewell Foster, a child psychologist and clinical associate professor in the University of Michigan psychiatry department. “The most vulnerable children, including those in foster care, are already having trouble getting the services they need.”

A lack of federal standards and other system-level issues create barriers to psychological and behavioral care in the child welfare system, said Colleen Katz, a professor at Hunter College’s Silberman School of Social Work in New York.

“When you’re talking about anyone getting screened for suicide ideation upon entrance into the system, it’s inconsistent at best,” she said.

Katz said all children entering foster care should have a brief, standardized suicide screening embedded into their initial medical assessment. And more screenings need to be conducted throughout a foster care stay, she said, because youths getting ready to transition out of the system are also vulnerable. 

Hinkle, now 31, said the summer before they aged out of the system was “one of the darkest periods, because I was coming to terms with the church not wanting me to be gay and I was about to lose stable housing and whatever foster care support there was.”

Katz studied transition-age youths in foster care in California, which has the highest numbers of placements in foster care nationwide. According to her analysis, 42% of study participants had thoughts of taking their life and 24% had attempted suicide, and she expects findings would be similar in other states.

Katz also examined suicide screening tools and found many that already exist could work and be easily administered by trained child welfare workers or alternative frontline service providers, or embedded in existing mental health services.

Still, the quality of services varies by state and locality and can hinder attempts to curb suicides.

Julie Collins, vice president of practice excellence at the Child Welfare League of America, which advocates for improvements to the child welfare system, said the gap in suicide prevention in foster care mirrors the overall nationwide void of behavioral health services for children and adolescents. “The preparation of people coming into the field isn’t what it needs to be,” Collins said of the lack of training for caseworkers.

Ewell Foster is trying to change that.

She worked with the state of Michigan to redefine and update the competencies required to earn an undergraduate certificate in child welfare in the state. Eighteen colleges and universities that offer certificate programs in child welfare in Michigan now teach about suicide prevention.

“It’s something the workforce has asked for,” Ewell Foster said. “They need real clear guidance on what to do when they are worried about someone.”

So far, Ewell Foster’s effort to change the wider system has not run into any roadblocks. Her work with Michigan’s child welfare agency is still being funded under a grant administered by the Substance Abuse and Mental Health Services Administration.

Agency spokesperson Danielle Bennett said such grants will continue for up to three years.

However, the future of the federal agency has been in question for months. The Trump administration has laid off hundreds of its employees and has proposed folding its functions into another agency.

Some states have made changes to address the foster care gaps on their own, but often it has taken legal action to spark changes in suicide prevention efforts.

In Kansas, officials made several changes after the state settled the McIntyre v. Howard class action lawsuit in 2021 on behalf of foster children who the suit alleged were subjected to inadequate access to mental health resources and moved from home to home frequently.

The state increased salaries for social workers in the child welfare system and reduced their caseloads, among other things.

Other states, including Texas, have implemented similar changes after facing lawsuits.

Still, experts caution that the changes taking place in foster care systems are not enough to steer outcomes.

Lily Brown, an assistant professor of psychology and director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine, said moving the needle in suicide prevention will require implementing a universal risk assessment for children in state care.

Brown recently sought a grant to fund and implement free, universal suicide risk screening in foster care throughout Pennsylvania. She had several counties agree to the project, but not enough to support her application — the study wouldn’t have had enough participants to work statistically, she said.

Without such studies, foster care systems nationwide can’t meet the needs of children, she said.

April Miller, 27, entered the system in Minnesota at age 3. As a Native American, she is part of a group that is overrepresented in foster care.

“The child welfare system as a whole neglected me,” said Miller, who said she endured several traumatic events in her early life, including witnessing a murder.

“I did a lot of self-harm and had thoughts of suicide but didn’t have access to means, which is why I am still alive,” she said.

Today, Miller is a social worker and suicide prevention coordinator in Bemidji, Minnesota.

Similarly, Hinkle’s experience in the system made them driven to change the trajectory of other young people.

Hinkle provides training, consultation, and policy development services at Unicorn Solutions in Oregon in support of youths and young adults affected by systems such as child welfare, with a particular focus on the LGBTQ+ community.

They said they are committed to making sure that sexual identity and gender topics are not avoided in the system.

“I think every young person should feel loved and cared for,” Hinkle said.

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After years of legal battles, state attorneys general won billions of dollars in opioid settlements from drug companies accused of fueling the addiction crisis. They declared victory at press conferences, and some touted the deals during their gubernatorial campaigns.

But now that the windfall is being spent, are attorneys general doing enough to ensure it’s used for the intended purposes?

No, say many families affected by the overdose crisis, recovery and harm reduction advocates, policy experts, and researchers following the cash.

“This is blood money,” said Toni Torsch, a Maryland resident whose son Dan died of an overdose at age 24. It can’t make up for the lives lost, but “we do want to make sure that it’s going to count.”

Torsch and others affected by the crisis are increasingly worried that no one seems to be guarding the opioid settlement cash while elected officials eye it hungrily. With the Trump administration slashing federal funding for addiction and Congress approving massive reductions to Medicaid — the largest payer for addiction care nationwide — people fear state legislators will use the settlements as a grab bag to fill budget shortfalls.

In the face of these concerns, two research and advocacy organizations are proposing a solution: a crowdsourced database to identify potential examples of misuse and prompt attorneys general to investigate.

The Opioid Policy Institute and Popular Democracy launched a website that allows members of the public to submit alleged cases of waste, fraud, abuse, and mismanagement of opioid settlement funds. Submissions are reviewed by Jonathan Stoltman, director of the Opioid Policy Institute, and then posted with details such as how much money was spent, what was purchased, who made the decision, and links to relevant news articles or budget documents.

The database, shared first with KFF Health News, includes about 150 examples to start, including $2,362 awarded by a Missouri county to its roads and bridge department and $375,600 spent on a body scanner for a Michigan county jail. The initial examples were sourced from people in recovery, advocates, and others Stoltman and his team asked to test the project. Stoltman acknowledged he’ll face criticism as the primary arbiter of what qualifies as misuse for the database, but said he’ll use research studies to defend his decisions.

The website also shows people how to file complaints with their state attorney general and ask the office to develop a formal process for receiving and investigating such complaints.

“I hope this is a wake-up call for state AGs that their work on this project is not done,” said Frank Kearl, who co-led the effort with Stoltman and is working as an attorney at Popular Democracy until July 14. “We still have time” to make changes to ensure we “spend this money in a way that actually responds to the harm that was caused.”

The website’s launch comes just over a week after New Jersey lawmakers passed a budget that gave health systems $45 million in settlement funds despite the state attorney general’s opposition. Legislators said it would shield hospitals from the blow of federal Medicaid cuts, but harm-reduction advocates said it gives short shrift to people with substance use disorders, whom the money was meant to serve.

Lawmakers in North Carolina and Washington, D.C., are also considering using settlement funds to plug gaps, and Connecticut and Nevada have discussed it too.

“That’s not what it’s there for,” said Torsch, who runs a nonprofit dedicated to addiction recovery in her son’s honor. “We want to make sure that money is being spent in the most responsible and effective way to help people that are still struggling.”

Last year, when Torsch heard that a western Maryland county spent some of its settlement money on guns, she reached out to her state attorney general to complain. The office said it wasn’t its responsibility, Torsch said, and told her to contact the health department.

She was confused.

The attorney general’s office is supposed to represent “the top cops,” Torsch told KFF Health News.

The Maryland attorney general’s office declined to answer KFF Health News’ questions about how it handles opioid settlement complaints.

About a dozen companies are expected to pay state and local governments more than $50 billion in opioid settlements over nearly two decades. Purdue Pharma’s case, the most well known, is still wending its way through court. But other companies, including Johnson & Johnson, CVS Health, and Walgreens, have begun paying.

Although the specifics of each settlement deal vary, most require states to use at least 85% of the money on efforts related to the opioid crisis. But enforcement is left to the companies that paid out the money. And legal experts are skeptical that the companies are monitoring state spending.

Attorneys general should be enforcing that standard too, said Stoltman, of the Opioid Policy Institute. “If you’re going to bang your chest about how much money you got for your state for opioids,” he said, “what are you doing to make sure that it’s actually being spent well?”

Stoltman’s and Kearl’s teams surveyed attorneys general offices in 56 states and territories to see if each office had a complaint form specific to this pot of money, explained the details needed to report misuse, and allowed submitters to track their complaints. They also searched websites of state auditors, comptrollers, and similar entities for complaint forms or procedures.

Their findings? Only three states mentioned specific processes for reporting misuse of opioid settlement money.

South Carolina and New Jersey had links on settlement-related websites that directed people to general complaint forms. Oklahoma was the only state to have an opioid settlement-specific form.

Jill Nichols, opioid response and grant coordinator in the Oklahoma Office of Attorney General, said it was created in April in response to the researchers’ inquiry. As of late June, she’d received one complaint, which was found to be without merit.

Stoltman and Kearl said they hope the crowdsourced database will encourage more attorneys general to take an active oversight role by illustrating how much potential misuse is occurring.

The Michigan attorney general’s office said it plans to publish a settlement-specific complaint form this year.

But some attorneys general told KFF Health News it wasn’t their job to track how the money is spent.

Brett Hambright, a spokesperson for Pennsylvania Attorney General David Sunday, said the state created an opioid settlement council to take on that responsibility.

In North Carolina, Attorney General Jeff Jackson’s office said, settlement funds are controlled by the state legislature and local governments. “Our office does not administer the funds nor do we have the power to withhold them,” spokesperson Ben Conroy said.

Even when attorneys general watch the money closely, their power may be limited. For example, Arizona Attorney General Kris Mayes went to court last year to stop the state legislature from giving $115 million in settlement funds to the Department of Corrections. But a judge ruled against her.

Maryland Attorney General Anthony Brown’s office directed KFF Health News’ questions to other state agencies.

Michael Coury, a spokesperson for Maryland’s Office of Overdose Response, said members of the public can email the office with complaints. If the office agrees misuse has occurred, it will bring the complaint to the attorney general, who — per the state’s agreement with local governments — “may” take action.

As of this year, the attorney general’s office will receive $1.5 million of Maryland’s opioid settlement funds annually to cover personnel and administration costs related to opioid-related lawsuits. This may involve suing more companies for future settlement deals.

Torsch, the Maryland mom, said she wishes the focus wasn’t just on winning more money but also ensuring that existing settlement dollars are spent well.

“We owe it to all the families that have been destroyed and suffered great losses,” she said.

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The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

As he had wanted, President Donald Trump signed his big budget bill into a big budget law in a White House ceremony on July 4, cementing, among other things, billions of dollars in cuts to health programs such as Medicaid. The new law will also reshape rules for the Affordable Care Act, Medicare, and other health programs. 

Meanwhile, the threat of layoffs continues to hang over the heads of employees at the Department of Health and Human Services, and funding for health-related contracts and grants remains stalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Rachel Roubein of The Washington Post, and Tami Luhby of CNN.

Panelists Rachel Cohrs Zhang Bloomberg News @rachelcohrs Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories. Tami Luhby CNN @Luhby Read Tami's stories.

Among the takeaways from this week’s episode:

• As details of Trump’s tax and domestic policy law come into focus, it’s clear that many immigrants in the country legally stand to lose government benefits, especially health coverage. While the GOP described the legislation as targeting “illegal immigrants,” the law as written bars many individuals living here with the government’s permission — including refugees and victims of domestic abuse and trafficking — from signing up for Medicaid, receiving Affordable Care Act marketplace subsidies, and more.
• Other aspects of Trump’s priority-laden law received extra attention following its hastened passage. In an unusually political move, the Social Security Administration touted to beneficiaries the law’s cuts to taxes on Social Security benefits — which is neither what the law does nor what a federal agency traditionally does when Congress passes a law.
• This week, the Supreme Court issued a decision from its shadow docket supporting the Trump administration’s ability to lay off federal workers using only his executive authority. That opinion is the latest curve on this year’s employment roller coaster for government employees, suggesting many people could soon lose their jobs.
• In health agency news, public health groups are suing the Trump administration over the withdrawn recommendations on covid-19 vaccines — as insurers and others in the health industry sort out how to handle a federal shift in immunization recommendations. And HHS Secretary Robert F. Kennedy Jr. canceled a meeting of the U.S. Preventive Services Task Force. The abrupt cancellation suggests Kennedy could soon remake the panel, as he did last month with the panel on vaccines.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, who reported the latest KFF Health News’ “Bill of the Month” feature, about some very expensive childhood immunizations. If you have a medical bill that’s exorbitant, baffling, or confusing, send it to us here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New England Journal of Medicine’s “The Corporatization of U.S. Health Care — A New Perspective Series,” by Debra Malina, et al.

Rachel Roubein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and JoNel Aleccia.

Rachel Cohrs Zhang: The Wall Street Journal’s “Prosecutors Question Doctors About UnitedHealth’s Medicare Billing Practices,” by Christopher Weaver and Anna Wilde Mathews.

Tami Luhby: The Washington Post’s “A New D.C. Hospital Grapples With Too Many Patients and Too Few Nurses,” by Jenna Portnoy.

Also mentioned in this week’s podcast:

• The Washington Post’s “Inside Operation Gold Rush, Largest Health Care Fraud Bust in U.S. History,” by Dan Diamond and Lauren Weber.
• KFF Health News’ “World’s Premier Cancer Institute Faces Crippling Cuts and Chaos,” by Rachana Pradhan and Arthur Allen.
• Stat’s “Inside the Staff Exodus and Tanking Morale That Threaten Makary’s FDA,” by Lizzy Lawrence.
• The New York Times Magazine’s “Inside the Collapse of the F.D.A.,” by Jeneen Interlandi.
• CNN’s “Social Security Administration Praises Trump’s Agenda Bill in Widely Sent Out Statement,” by Shania Shelton and Tami Luhby.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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The Advanced Research Projects Agency for Health (ARPA-H), an agency HHS, today unveiled its groundbreaking Functional Repair of Neocortical Tissue

HHS announced a significant policy shift to restore compliance with federal law and ensure that taxpayer-funded program benefits intended for the American people are not diverted.

As a postpartum doula, Dawn Oliver does her best work in the middle of the night.

During a typical shift, she shows up at her clients’ home at 10 p.m. She answers questions they may have about basic infant care and keeps an eye out for signs of postpartum depression.

After bedtime, she may feed the baby a bottle or wake the mother to breastfeed. She soothes the infant back to sleep. Sometimes, she prepares meals for the family in a Crock-Pot or empties the dishwasher.

She leaves the following morning and returns, often nightly, for two or three weeks in a row.

“I’m certified to do all of it,” said Oliver, of Hardeeville, South Carolina, who runs Compassionate Care Doula Services. It takes a village to raise a child, as the adage goes, but “the village is not what it used to be,” Oliver said.

Doulas are trained to offer critical support for families — before delivery, during childbirth, and in those daunting early days when parents are desperate for sleep and infants still wake up around the clock. While doulas typically don’t hold a medical or nursing degree, research shows they can improve health outcomes and reduce racial health disparities.

Yet their services remain out of reach for many families. Oliver charges $45 an hour overnight, and health insurance plans often don’t cover her fees. That’s partly why business “ebbs and flows,” Oliver said. Sometimes, she’s fully booked for months. Other times, she goes several weeks without a client.

That may soon change.

Two bipartisan bills, introduced in separate chambers of the South Carolina General Assembly, would require both Medicaid, which pays for more than half of all births in the state, and private insurers to cover the cost of doula services for patients who choose to use one.

South Carolina isn’t an outlier. Even as states brace for significant reductions in federal Medicaid funding over the next decade, legislatures across the country continue to pass laws that grant doula access to Medicaid beneficiaries. Some state laws already require private health insurers to do the same. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana, and Montana, have passed laws to facilitate Medicaid coverage of doula services.

All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so.

Notably, these coverage requirements align with one of the goals of Project 2025, whose “Mandate for Leadership” report, published in 2023 by the conservative Heritage Foundation, offered a blueprint for President Donald Trump’s second term. The document calls for increasing access to doulas “for all women whether they are giving birth in a traditional hospital, through midwifery, or at home,” citing concerns about maternal mortality and postpartum depression, which may be “worsened by poor birth experiences.” The report also recommends that federal money not be used to train doctors, nurses, or doulas to perform abortions.

The Heritage Foundation did not respond to an interview request.

Meanwhile, the idea that doulas can benefit babies, parents, and state Medicaid budgets by reducing costly cesarean sections and preterm birth complications is supported by a growing body of research and is gaining traction among conservatives.

A study published last year in the American Journal of Public Health found that women enrolled in Medicaid who used a doula faced a 47% lower risk of delivering by C-section and a 29% lower risk of preterm birth. They were also 46% more likely to attend a postpartum checkup.

“Why wouldn’t you want somebody to avail themselves of that type of care?” said Republican state Rep. Tommy Pope, who co-sponsored the doula reimbursement bill in the South Carolina House of Representatives. “I don’t see any reason we shouldn’t be doing that.”

Pope said his daughter-in-law gave birth with the assistance of a doula. “It opened my eyes to the positive aspects,” he said.

Amy Chen, a senior attorney with the National Health Law Program, which tracks doula reimbursement legislation around the country as part of its Doula Medicaid Project, said lawmakers tend to support these efforts when they have a personal connection to the issue.

“It’s something that a lot of people resonate with,” Chen said, “even if they, themselves, have never been pregnant.”

Conservative lawmakers who endorse state-level abortion bans, she said, often vote in favor of measures that support pregnancy, motherhood, and infant health, all of which these doula reimbursement bills are intended to do.

Some Republicans feel as if “they have to come out in favor of that,” Chen said.

Health care research also suggests that Black patients, who suffer significantly higher maternal and infant mortality rates than white patients, may particularly benefit from doula care. In 2022, Black infants in South Carolina were more than twice as likely to die from all causes before their 1st birthday as white infants.

That holds true for women in rural parts of the country where labor and delivery services have either closed or never existed.

That’s why Montana lawmakers passed a doula reimbursement bill this year — to narrow health care gaps for rural and Indigenous communities. To that end, in 2023, the state enacted a bill that requires Medicaid to reimburse midwives for home births.

Montana state Sen. Mike Yakawich, a Republican who backed the Democratic-sponsored doula reimbursement bill, said pregnant women should have someone to call outside of a hospital, where health care services can be costly and intimidating.

“What help can we provide for moms who are expecting? My feeling is, it’s never enough,” Yakawich said.

Britney WolfVoice lives on the Northern Cheyenne Indian Reservation in southeastern Montana, about two hours from the closest birthing hospital. In early July, she was seven months pregnant with her fourth child, a son, and said she planned to have a doula by her side for the second time in the delivery room. During WolfVoice’s previous pregnancy, an Indigenous doula named Misty Pipe brought cedar oil and spray into the delivery room, rubbed WolfVoice’s back through contractions, and helped ensure WolfVoice’s husband was the first person their daughter saw.

“Being in a hospital, I felt heard for the very first time,” WolfVoice said. “I just can’t explain it any better than I felt at home. She was my safe place.”

Pipe said hospitals are still associated with the government forcibly removing children from Native American homes as a consequence of colonization. Her goal is to help give people a voice during their pregnancy and delivery.

Most of her clients can’t afford to pay for doula services out-of-pocket, Pipe said, so she doesn’t charge anything for her birth services, balancing her role as a doula with her day job at a post office.

“If a mom is vulnerable, she could miss a prenatal appointment or go alone, or I can take time off of work and take her myself,” Pipe said. “No mom should have to birth in fear.”

The new state law will allow her to get paid for her work as a doula for the first time.

In some states that have enacted such laws, initial participation by doulas was low because Medicaid reimbursement rates weren’t high enough. Nationally, doula reimbursement rates are improving, Chen said.

For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client.

But Chen said it is unclear how federal Medicaid cuts might affect the fate of these state laws.

Some states that haven’t passed doula reimbursement bills, including South Carolina, might be hesitant to do so in this environment, she said. “It’s just a really uncertain time.”

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

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Kelli Reardon undergoes an MRI twice a year to screen for breast cancer, a measure she said she must take to protect her health. Her mother died of the disease at age 48, putting Reardon at higher risk, and Reardon has dense breast tissue, which makes it harder to detect a growth through a mammogram.

When Reardon moved from Alabama to North Carolina, she had little choice but to switch from having the screening done at an imaging center to having it done at a hospital.

Then she saw how much higher the charges were. At first, Reardon thought it was an error: “They made a mistake with billing,” she said. “They accidentally added a zero.”

It wasn’t a mistake.

In this installment of InvestigateTV and KFF Health News’ “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, and Jamie Grey, director of investigations, explore how the type of medical facility where a patient seeks care can affect the cost of that care — particularly when that facility is a hospital.

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

USE OUR CONTENT

This story can be republished for free (details).

HHS notified the New England Commission of Higher Education that Harvard University, is in violation of federal antidiscrimination laws

In response to the high price of prescription drugs, “An Arm and a Leg” asked listeners to share their strategies for getting the medicine they need at prices they can manage.

Host Dan Weissmann and producers Emily Pisacreta and Claire Davenport share tips from a retired hospital manager who now helps seniors find the right Medicare plans, a pharmaceutical sales rep, an employee benefits adviser, and a battle-worn hospital caseworker. Each brings surprising, maybe even lifesaving, information to the table.

Explore the full crowdsourced series, including five installments of the “First Aid Kit” newsletter: The Prescription Drug Playbook.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: The Prescription Drug Playbook, Part II

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. Let’s meet Jeanne Chamberlin from North Carolina. She regularly talks with folks who take like 15 different meds every day. 

Jeanne Chamberlin: You are like, oh my gosh. And literally the retail costs are $20,000 a month. 

Dan: Jeanne’s an expert, twice over. Since retiring from a career managing hospitals and medical groups, she’s been helping her fellow seniors figure out how to manage what they pay for health care — as a county-level volunteer coordinator for a program called SHIP. 

Jeanne: And SHIP stands for Seniors Health Insurance Information Program. 

Dan: Actually in some cases it stands for State Health Insurance Assistance Program. 

Whatever you wanna call it — It’s a federally funded program that helps seniors with all things Medicare. Every state has its own version of SHIP. 

During the busy season — that’s in the fall, when people can pick new insurance for the coming year– Jeanne says she and her team speak to more than a hundred people a week. 

And one thing that comes up in basically ALL of those conversations: Can I change things to get my meds for less next year? 

She says one year, her team added up the impact of those conversations. Half of the people changed plans, and on average, they saved 300 dollars. Not bad… 

Jeanne: But there were many, many people who saved a thousand, 2000, even $10,000 by changing from one Medicare plan to another based entirely on the cost of their drugs. 

Dan: Jeanne’s gonna tell us how she helps people get those kinds of savings– with strategies that aren’t just for people on Medicare. 

And Jeanne is just one person who wrote to us when we asked for you, our listeners, to tell us about your tactics and tricks for dealing with the high cost of prescription drugs.

The result: two podcast episodes– this is number two — and four installments of our First Aid Kit newsletter. 

In this episode, we’re gonna hear from Jeanne and three other *incredible* sources who came to us with crucial insider knowledge. Knowledge that — now they we have it– we have to share with you. 

Jeanne’s gonna help us get set up. She’s gonna share what she tells those seniors, and how it can apply to anyone, at any age. 

… Then, a pharma insider is gonna air an open secret. 

An employee benefits advisor — a kind of scout for deals — will tell us where she’d send someone struggling to pay for meds. 

Finally, we’ll meet a battle-worn hospital caseworker. And beyond the specific tip she wrote in with, her work – and life story – are gonna bring us some deeper perspective. 

These people kick ass. 

And for all their advice, there is, of course, a BIG caveat: 

like we said last episode — your mileage will vary. There is no one solution for everyone. This is a set of patches, workarounds, bandaids. 

To be honest, a lot of them are actually weird byproducts of the profit-making machine. Which is a big reason they’re so patchy and unreliable. 

We deserve SO much better. But in the meantime, we can help each other. That’s what this project is about. Including the four newsletter installments I mentioned. And we’ll link to those from wherever you’re listening — so: you don’t need a pencil and paper here. We’ve got you. 

Our hope is that you walk away from all of this armed with a *little* more knowledge that could help you or someone you care about get the meds they need. A kind of leg up. An Arm and a Leg-leg-up. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann– I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the

most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. 

So, first: Jeanne wrote to us about what she knows from helping people enroll in Medicare. But she also had an instructive personal story to share. Because even experts have to scramble sometimes. 

A while ago, when Jeanne’s husband had a gut infection, he got prescribed two antibiotics. His insurance coverage meant one was gonna cost him thirty bucks. But the other one? His plan didn’t cover it And… . 

Jeanne: It was $1,200. For a 14 day supply it was just obscenely expensive. 

Dan: So immediately, Jeanne says she went into problem solving mode. And her order of operations provides a great template for any of us. 

Step one: Google for discounts. Just taking a quick first pass at the kind of thing we talked about in our last episode. Maybe that’s GoodRx. Maybe that’s a coupon from the drug maker. Results for Jeanne: Not great. 

Jeanne: I could get it down to $800. It’s like, still, you’re like $800. Really? 

Dan: So, on to step two: Tell your provider there’s a problem and ask for advice. 

Jeanne: We went back to the doctor and said, is there something else that you know you can do? 

Dan: Jeanne was thinking: Maybe the doc could recommend another antibiotic — one that insurance would cover. Or help them fight her husband’s insurance to get this drug covered. 

But actually, the doc’s proposal was much simpler. 

Jeanne: She said just take the other one. 

Dan: Just take the one Jeanne’s husband could get for thirty bucks. Skip the second drug. 

Jeanne: So he did, and he was fine!

Dan: END OF STORY. In this case. It’s not always that easy. But the moral is: ASK. If your insurance covers a different drug, your doc can tell you if it’s a good bet for you. If not… well… we’ll come back to other ways your doc could help. 

But right now let’s move on to the biggest, most valuable advice Jeanne gives to seniors– and that applies to everybody. 

Especially anybody with meds they’re taking long term, like blood pressure or cholesterol meds, or whatever. 

And the advice is this: Look ahead, every year. 

In the fall, when it’s time to sign up for next year’s insurance plan: Get a look at the list of which drugs your insurance will cover, and how much they expect you to pay for them. It’s called the formulary. 

Because even if you don’t change anything about your insurance, your insurance could change the formulary. That can happen to anybody. 

Jeanne sees it all the time with seniors, when their plans reboot at New Year’s. 

Jeanne: People come in in January and this happens every year, and say, I just went to the pharmacy and. They want $300 for my medicine. And last year, or last month in December, it was $30. 

Dan: These folks didn’t plan to change anything about their insurance — but their insurance plan changed on them– and stopped covering a drug they’ve been taking. Now they’re getting charged sticker price. 

And Jeanne’s like, ‘Man, I wish you’d have come to see us during the fall sign-up– open enrollment.’ 

Jeanne: We could have probably found a plan that covered that drug still.. 

Dan: Now, it’s true that folks on Medicare tend to have more choices than the rest of us here. In Medicare, drug coverage is its own separate plan — called Part D — and seniors in Jeanne’s county have more than a dozen to pick from. 

If you get insurance from work — and maybe there’s just one plan — this thing of looking ahead is maybe even more important.

At some point, maybe a couple months before the new year, you should get a chance to see that next year’s formulary 

And it could say, “Hey, your drug is gonna be more expensive for you next year” 

That’s your cue to start problem-solving right away. Get a plan in place before that new price kicks in. 

Step one: Check: Can you find discounts online that make this drug affordable? Cool. 

No? Time to get in touch with your provider’s office: start tapping their expertise. 

Jeanne: The provider normally has a lot of people with your condition and probably prescribes this medication a lot. 

Dan: And so, if your insurance company says they’ve got some other drug you could take, one they’ll pay for– your provider will know: could that drug work for you? 

And if you’ve got a choice of plans — but they all require a special approval process now for your drug — your provider will know: Is one of them more likely to actually issue that approval? 

Jeanne: Ask them about a plan where they have an easy time getting it approved for somebody with your condition where it always goes through. 

Dan: And that’s the plan you want to pick. And, speaking of getting your insurance company’s approval: 

We’re about to move from Jeanne’s advice– plan ahead, get your provider to help — to the next step. Because you can’t plan everything. Sometimes you get sick, with something new. No planning for that. 

And sometimes, your insurance is definitely not gonna say yes right away to the drug your doc thinks you need. And your doc thinks you need this particular drug. So, how ELSE can your provider help?

John: I work, uh — work for an industry with an approval rating below Congress. 

Dan: He’s a pharmaceutical sales rep! He asked us to keep his full name and employer confidential. 

He’s also an Arm and a Leg fan. 

John: I love it when, uh, I hear stories of average people just sticking it to the insurance company. It’s nice when the patient wins, cause they don’t get a lot of wins. 

Dan: We reached John in his primary office — also known as his car. 

When we asked listeners a few months ago to share lessons about getting prescription meds without paying an arm and a leg, he wrote right in with tips. 

And one, I love just for the attitude. Here’s John reading from the email he sent us: 

John: Step therapies. Uh, denials and price at pharmacy should be viewed as suggestions. 

Dan: Suggestions. Perfect. The other is much more specific. As a salesman, a big part of John’s job is prepping doctors for the fights they’re gonna have with insurance companies, to get approvals for drugs. He does that because approvals for them mean sales for John. 

Of course, approvals take time. 

John: But one thing that you know doesn’t care about time is diseases. 

The disease of Crohn’s or Bipolar disorder, whatever, isn’t like, look, I’ll hold off on affecting you until this prior authorization is done. 

Dan: So here’s John’s advice: while you’re fighting for that approval– pushing back on the insurance company’s “suggestion” that you try something else– Ask your provider if they can get free samples from the pharma company — from a rep like him.

John: And the provider hopefully will say, yeah, let me call the rep and we’ll leave some at front for you. 

Dan: Actually, your provider may already have some on hand. A study from a few years ago found that TWO THIRDS of primary-care practices had CLOSETS of pharmaceutical samples. Which, wow. 

So, let’s address something big: Like John joked about as we introduced him, pharma sales reps are NOT generally looked upon as model citizens. 

The rap is: Some of them use less-than-scrupulous tactics to encourage doctors to prescribe expensive drugs… even to patients who might not get extra benefit from a specific drug. Or, in the case of opioids — which got pushed really hard — might cause harm. And free samples are part of that process. 

So, some providers won’t meet with sales reps at all. Some health systems don’t allow any of their staff to meet with them. 

But you don’t have to approve of how pharmaceutical companies do their business to take advantage of John’s suggestion. And neither does your doctor. 

John says, to get free samples, your doctor might not even need to talk to anyone. 

They can just make a request online, at the manufacturer’s website. John says it definitely happens. 

John: So even with providers or doctors that I’ve never seen in my nine years, I know that they’ve gotten samples before. 

Dan: But here too, there will be limits. 

John: Some manufacturers don’t even do samples. So it really varies a lot. Dan: But a lot of these samples do exist — 

And the idea of using them as a stopgap while you fight to get your insurance to pay for the meds you need — I had never thought of it until we asked you, our listeners, for your tips.

And you also sent us this: Could a local clinic supply the meds you need for a price you can actually afford? That’s next.. 

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues. 

OK, a whole new kind of expert here. Like Jeanne, who we heard from earlier. Cristy Gupton also lives in North Carolina. She works as an independent employee benefits designer. You’re probably like, what the hell is that? Here’s how she describes her work. 

Cristy Gupton: Imagine you’re a kid in high school, in shop class, and your teacher puts an old engine on the table, and says, take it apart and put it back together again and make sure it works. 

Dan: Except, the machine is a health benefit program for workers. And– back to the shop-class metaphor — Cristy says she’s the real gear-head in the room . 

Cristy Gupton: By the time I put the engine back together, it works twice as good, but at half the cost. 

Dan: Cristy says she does it by ditching expensive, off-the-shelf parts — standard insurance policies from big companies — for custom solutions. It’s a WHOLE THING, and super-interesting, and worth going into. 

For now, she’s got one big tip that *some* of us could use to get access to meds at super-low prices. Basically it’s this: Look for a community health center that offers a sliding scale. They can get drugs at extremely low prices, through a federal program called 340B. 

How low? 

Cristy Gupton: The drug Humira is one of the most prescribed drugs in America. And the list price is probably somewhere in the neighborhood of 5,000 a month. But a 340B covered entity could purchase it for a penny. 

Dan: So we checked, and actually: Humira’s list price isn’t 5,000 dollars. It’s 7,000 dollars. But YES, a 340B clinic can get it for a penny. Now, they don’t get every drug that cheap, but..

And look: although this is all very much worth knowing about, it’s not guaranteed to work for you. 

340B is complicated in all kinds of ways. Here’s my colleague Emily Pisacreta asking Christy about it. 

Emily: Help me understand what 340B is. 

Cristy Gupton: I’ll give you my best, um, like only know enough to be dangerous answer. 

Dan: After checking some actual experts, here’s what we think you need to know: 

A federal law from the 1990s — section 340B of that law — basically requires drug-makers to give some hospitals and health centers that serve low-income folks super-duper discounts on meds. 

Those discounts don’t always get passed along to patients. The feds say hospitals and clinics can take a profit, to subsidize their other work . 

But the rules say: community health centers DO need to make drugs affordable to people with lower incomes. Specifically, to people who make less than two times the federal poverty level. 

For 2025, that’s just over 64 thousand dollars for a family of four. Not a lot. 

But it’s a lot of people: More than 28 percent of Americans qualify. And some clinics may have sliding scales for people with higher incomes than that. 

So: There’s a search tool. We’ve got a link wherever you’re listening to this. Find a clinic in your area, call them, and see what the deal is. 

One last thing to know: You’ve gotta actually be a patient at the clinic in order to use this program. And actually, if you meet the income requirements, all the clinic’s services are gonna be super-subidized. 

But if you don’t want to engage too deeply with the clinic– don’t want to switch over all your care to a new team — Cristy says, in her experience, you may not have to.

Cristy Gupton: It can be as loose as they just have a virtual visit. I mean, that’s pretty simple. 

Dan: Again, we’ve got a link to the search tool for finding a health center near you. Which of course…near you… not everybody is gonna have. Your mileage may vary, literally. But is it worth checking? Yeah, I think so. 

OK we’ve thrown a LOT at you. I know, I know. And we do have one more set of expert tips. From someone we are really glad to have met. So here’s Erika — and her expertise is part of a lifelong project. 

Erika: You know, as a child with Type one diabetes, I had a very dysfunctional household and I had to take care of myself from a very young age. I have learned that the skills that I developed as a child with a chronic illness are transferable into a career to help people be taken care of. 

Dan: So now, she works as a patient navigator– a kind of case worker, at a hospital in rural Oregon. 

When my colleague Emily talked with Erika, they bonded a little. 

Emily: I live with Type One Diabetes and I really wish that I had had a patient navigator, um, when I was diagnosed. 

Erika: Yeah, I wish I had me as a patient navigator too. 

Dan: Most of the patients Erika does work with are managing chronic conditions and other serious health problems, under tough circumstances. 

Erika: For example, let’s say a patient has an amputation and they’re told on discharge to keep it elevated and keep it clean. Well if they’re living in their car, that can be a challenge. So in that case, case management would try to find them a hotel for a couple weeks. 

Dan: And of course, one of the most common problems she tackles: helping people get their meds at prices they can afford. 

Erika: There are weeks where that’s all I’ll do.

Dan: For insured patients, Erika he starts with drugs-and-insurance 101: Helping them figure out which drugs their insurance covers, at what price to them, and coaching them before they call their insurance company. 

Erika:I offer to be on the call with them if they want. And I will tell you right now that we’re gonna be on hold with that insurance company for 30 minutes 

Dan: Yeah, that sounds familiar. Also, for some patients on Medicaid, Erika runs interference with bureaucracies. 

And, when there’s no way that insurance will make the right drugs affordable for her patients– including folks with no insurance at all– Erika helps them explore one of the options she wrote in to us about. 

“Patient Assistance Programs” based on income. Some are from manufacturers, others come from private foundations. 

Erika: It’s such a matter of somebody knowing who to ask and where to get the stuff. 

Dan: And there are websites to find this kind of thing — we’ve got links and guides for you — and she says the applications aren’t complicated. 

But the people she works with, they need extra help. 

Erika: A lot of my patients don’t even know how to use a computer or to get onto the internet, or they don’t have smart phones, they just have cell phones. So a lot of them, I meet with them. I take my laptop, and we do an online application. I help them fill it out. 

Dan: And then hope it works. Some programs only give out so much assistance per year, so not everybody gets help. 

Erika: It’s a frustrating fight. I feel bad that people have to wage this, you know, to get what they need to be healthy. It’s, it’s not like people are asking for BMW or new clothing. People are asking for, oftentimes medications they need to keep themselves alive. It’s, it’s like asking for oxygen. Like what if you were told you you couldn’t afford oxygen? That’s the way people feel sometimes.

Dan: And that’s why, even though Erika wrote to us about practical specifics, it’s her approach, her presence that we especially wanted to share with you. 

Erika: I advised all my patients to get a tattoo that says, be persistent. I mean, seriously, I don’t expect them to get tattoos. But as a patient who manages a chronic condition, you just have to be. 

Dan: Oh yeah. The ongoing burden of dealing with all this, it’s a bear. And it came up again and again when you wrote in to us. 

Erika: Yeah. Stress management, whew. 

Dan: For Erika’s patients, and for herself too. 

Erika: I have to remember to like, stop, step away, do some breathing. And these are things I teach to my patients a little bit too. Like, okay, let’s stop and do some breathing together on the phone. Okay. 

Dan: She calls her strategy “self compassion.” It’s about helping people see how much they’re already doing. 

Erika: I encourage people to take a moment and appreciate that about yourself. Okay? you’ve been on the phone with your insurance company for 30 minutes. 

You’re trying to get this done. You really need to appreciate that you’re doing that for your health. For your health. Feel good about that, at least. 

Dan: You are taking time to listen to this podcast. We are here, right now, together, doing our best. 

For the practical lessons — all the things to try, that may or may not work — we’ve done our best to write them down for you, and organize them so they’re useful, in our First Aid Kit newsletter. Four installments. 

You can find those newsletters — and these episodes — at Arm and a Leg show, dot com, slash, drugs. 

That’s the address where we first asked you to share what you’d learned by walking through this maze. Now we’re inviting you to come and see what we’ve learned from you.

Arm and a Leg show dot com, slash drugs. There’ll be a link wherever you’re listening to this. 

And you’ll find one more thing there, too. 

To honor the endless and ridiculous process that we sometimes have to go through to get our medicines… my colleague Claire Davenport, who has led the reporting for so much of this series, made an endless and ridiculous song. Well, with the help of an AI. Stay tuned after the credits for a little taste of that. 

We’ll be back with a new episode in a few weeks. 

Till next time, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta and Claire Davenport with help from me, Dan Weissmann, and Lauren Gould. 

And edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Weiner and Blue Dot Sessions. 

Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show. 

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. 

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support. 

And NOW….a little treat. 

So: At one point, we were like, “What if we could make like a jingle to help people remember all the tactics we’re talking about?” 

But when our producer Claire tried actually writing one, with AI supplying the melody and the band — it just kinda showed us how endless and ridiculous the list actually is. 

And we found that just adorable. Here’s how it starts… 

AI Song: I am a prescription – medication. And as you might know, I’m Expensive in this nation. Getting me can be confusing. And often quite scary. Since when it comes to meds. The prices can vary. Luckily, there’s some tricks you can try. When you’re in this situation and the price is high… 

Dan: Alright, I think you get the idea — and if you want more, it’s all at Arm and a Leg show dot com, slash, drugs. Along with these podcast episodes and First Aid Kit newsletter installments, and everything we hope you’ll actually find useful. Thanks.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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Nicole Silva’s 4-year-old daughter was headed to a relative’s house near the southern Colorado town of La Jara when a vehicle T-boned the car she was riding in. A cascade of ambulance rides ensued — a ground ambulance to a local hospital, an air ambulance to Denver, and another ground ambulance to Children’s Hospital Colorado.

Silva’s daughter was on Medicaid, which was supposed to cover the cost of the ambulances. But one of the three ambulance companies, Northglenn Ambulance, a public company since acquired by a private one, sent Silva’s bill to a debt collector. It was for $2,181.60, which grew to more than $3,000 with court fees and interest, court records show. The preschool teacher couldn’t pay, and the collector garnished Silva’s wages.

“It put us so behind on bills — our house payment, electric, phone bills, food for the kids,” said Silva, whose daughter recovered fully from the 2015 crash. “It took away from everything.”

Some state legislators are looking to curb bills like the one she received — surprise bills for ground ambulance rides.

When an ambulance company charges more than an insurer is willing to pay, patients can be left with a big bill they probably had no choice in.

States are trying to fill a gap left by the federal No Surprises Act, which covers air ambulances but not ground services, including ambulances that travel by road and water. This year, Utah and North Dakota joined 18 other states that have passed protections against surprise billing for such rides.

Those protections often include setting a minimum for insurers to pay out if someone they cover needs a ride. But the sticking point is where to set that bar. Legislation in Colorado and Montana stalled this year because policymakers worried that forcing insurers to pay more would lead to higher health coverage costs for everyone.

Surprise ambulance bills are one piece of a health care system that systematically saddles Americans with medical debt, straining their finances, preventing them from accessing care, and increasing racial disparities, as KFF Health News has reported.

“If people are hesitating to call the ambulance because they’re worried about putting a huge financial burden on their family, it means we’re going to get stroke victims who don’t get to the hospital on time,” said Patricia Kelmar, who directs health care campaigns at PIRG, a national consumer advocacy group. “It means that person who’s worried it might be a heart attack won’t call.”

The No Surprises Act, signed into law by President Donald Trump in 2020, says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network. Like doctors or hospitals, ambulance companies can contract with insurers, making them in-network. Those that don’t remain out-of-network.

But unlike when making an appointment with a doctor or planning a surgery, a patient generally can’t choose the ambulance company that will respond to their 911 call. This means they can get hit with large out-of-network bills.

Federal lawmakers punted on including ground ambulances, in part because of the variety of business models — from private companies to volunteer fire departments — and a lack of data on how much rides cost.

Instead, Congress created an advisory committee that issued recommendations last year. Its overarching conclusion — that patients shouldn’t be stuck in the crossfire between providers and payers — was not controversial or partisan. In Colorado, a measure aimed at expanding protections from surprise ambulance bills got a unanimous thumbs-up in both legislative chambers.

Colorado had previously passed a law protecting people from surprise bills from private ambulance companies. This new measure was aimed at providing similar protections against bills from public ambulance services and for transfers between hospitals.

“We knew it had bipartisan support, but there are some people that vote no on everything,” said a pleasantly surprised Karen McCormick, a Democratic state representative.

A less pleasant surprise came later, when Gov. Jared Polis, who is also a Democrat, vetoed it, citing the fear of rising premiums.

States can do only so much on this issue, because state laws apply only to state-regulated health plans. That leaves out a lot of workers. According to a 2024 national survey by KFF, a health information nonprofit that includes KFF Health News, 63% of people who work for private employers and get health insurance through their jobs have self-funded plans, which aren’t state-regulated.

“It’s why we need a federal ambulance protection law, even if we passed 50 state laws,” Kelmar said.

According to data from the Colorado secretary of state’s office, the only lobbying groups registered as “opposing” the bill were Anthem and UnitedHealth Group, plus UnitedHealth subsidiaries Optum and UnitedHealthcare.

As soon as the legislative session ended in May, Kevin McFatridge, executive director of the Colorado Association of Health Plans, a trade group representing health insurance companies in the state, sent a letter to the governor requesting a veto, with an estimate that the legislation would result in premiums rising 0.4%.

The Colorado bill said local governments — such as cities, counties, or special districts — would set rates.

“We are in a much better place by not having local entities set their own rates,” McFatridge told KFF Health News. “That’s almost like the fox managing the henhouse.”

Jack Hoadley, an emeritus research professor with Georgetown University’s McCourt School of Public Policy, said it isn’t clear whether state laws approved elsewhere are raising premiums, or if so by how much. Hoadley said Washington state is expected to come out with an impact analysis of its law in a couple of years.

The national trade association for insurance companies declined to provide a comment for this article. Instead, AHIP forwarded letters that its leaders submitted to lawmakers in Ohio, West Virginia, and North Dakota this year opposing measures in each state to set base ambulance rates. AHIP leadership described the proposals as inflated, government-mandated pricing that would reduce insurers’ chance to negotiate fair prices. Ultimately, the association warned, the proposed minimums would increase health care costs.

In Montana, legislators were considering a minimum reimbursement for ground ambulances of 400% of what Medicare pays, or at a set local rate if one exists. The proposal was sponsored by two Republicans and backed by ambulance companies. Health insurers successfully lobbied against it, arguing that the price was too steep.

Sarah Clerget, a lobbyist representing AHIP, told Montana lawmakers in a legislative hearing that it’s already hard to get ambulance companies to go in-network with insurers, “because folks are going to need ambulance care regardless of whether their insurance company will cover it.” She said the state’s proposal would leave those paying for health coverage with the burden of the new price.

“None of us like our insurance rates to move,” Republican state Sen. Mark Noland said during a legislative meeting as a committee tabled the bill. He equated the proposed minimum to a mandate that could lead to people having to pay more for health coverage for an important but nonetheless niche service.

Colorado’s governor was similarly focused on premiums. Polis said in his veto letter that the legislation would have raised premiums between 73 cents and $2.15 per member per month.

“I agree that filling this gap in enforcement is crucial to saving people money on health care,” he wrote. “However, those cost savings are outweighed in my view by the premium increases.”

Isabel Cruz, policy director at the Colorado Consumer Health Initiative, which supported the bill, said that even if premiums did rise, Coloradans might be OK with the change. After all, she said, they’d be trading the threat of a big ambulance bill for the price of half a cup of coffee per month.

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

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LOS ANGELES — Inside a bright new building in the heart of Skid Row, homeless people hung out in a canopy-covered courtyard — some waiting to take a shower, do laundry, or get medication for addiction treatment. Others relaxed on shaded grass and charged their phones as an intake line for housing grew more crowded.

The Skid Row Care Campus officially opened this spring with ample offerings for people living on the streets of this historically downtrodden neighborhood. Pop-up fruit stands and tent encampments lined the sidewalks, as well as dealers peddling meth and fentanyl in open-air drug markets. Some people, sick or strung out, were passed out on sidewalks as pedestrians strolled by on a recent afternoon.

For those working toward sobriety, clinicians are on site to offer mental health and addiction treatment. Skid Row’s first methadone clinic is set to open here this year. For those not ready to quit drugs or alcohol, the campus provides clean syringes to more safely shoot up, glass pipes for smoking drugs, naloxone to prevent overdoses, and drug test strips to detect fentanyl contamination, among other supplies.

As many Americans have grown increasingly intolerant of street homelessness, cities and states have returned to tough-on-crime approaches that penalize people for living outside and for substance use disorders. But the Skid Row facility shows Los Angeles County leaders’ embrace of the principle of harm reduction, a range of more lenient strategies that can include helping people more safely use drugs, as they contend with a homeless population estimated around 75,000 — among the largest of any county in the nation. Evidence shows the approach can help individuals enter treatment, gain sobriety, and end their homelessness, while addiction experts and county health officials note it has the added benefit of improving public health.

“We get a really bad rap for this, but this is the safest way to use drugs,” said Darren Willett, director of the Center for Harm Reduction on the new Skid Row Care Campus. “It’s an overdose prevention strategy, and it prevents the spread of infectious disease.”

Despite a decline in overdose deaths, drug and alcohol use continues to be the leading cause of death among homeless people in the county. Living on the streets or in sordid encampments, homeless people saddle the health care system with high costs from uncompensated care, emergency room trips, inpatient hospitalizations, and, for many of them, their deaths. Harm reduction, its advocates say, allows homeless people the opportunity to obtain jobs, taxpayer-subsidized housing, health care, and other social services without being forced to give up drugs. Yet it’s hotly debated.

Politicians around the country, including Gov. Gavin Newsom in California, are reluctant to adopt harm reduction techniques, such as needle exchanges or supervised places to use drugs, in part because they can be seen by the public as condoning illicit behavior. Although Democrats are more supportive than Republicans, a national poll this year found lukewarm support across the political spectrum for such interventions.

Los Angeles is defying President Donald Trump’s agenda as he advocates for forced mental health and addiction treatment for homeless people — and locking up those who refuse. The city has also been the scene of large protests against Trump’s immigration crackdown, which the president has fought by deploying National Guard troops and Marines.

Trump’s most detailed remarks on homelessness and substance use disorder came during his campaign, when he attacked people who use drugs as criminals and said that homeless people “have no right to turn every park and sidewalk into a place for them to squat and do drugs.” Health and Human Services Secretary Robert F. Kennedy Jr. reinforced Trump’s focus on treatment.

“Secretary Kennedy stands with President Trump in prioritizing recovery-focused solutions to address addiction and homelessness,” said agency spokesperson Vianca Rodriguez Feliciano. “HHS remains focused on helping individuals recover, communities heal, and help make our cities clean, safe, and healthy once again.”

A comprehensive report led by Margot Kushel, a professor of medicine at the University of California-San Francisco, this year found that nearly half of California’s homeless population had a complex behavioral health need, defined as regular drug use, heavy drinking, hallucinations, or a recent psychiatric hospitalization.

The chaos of living outside, she said — marked by violence, sexual assault, sleeplessness, and lack of housing and health care — can make it nearly impossible to get sober.

Skid Row Care Campus

The new care campus is funded by about $26 million a year in local, state, and federal homelessness and health care money, and initial construction was completed by a Skid Row landlord, Matt Lee, who made site improvements on his own, according to Anna Gorman, chief operating officer for community programs at the Los Angeles County Department of Health Services. Operators say the campus should be able to withstand potential federal spending cuts because it is funded through a variety of sources.

Glass front doors lead to an atrium inside the yellow-and-orange complex. It was designed with input from homeless people, who advised the county not just on the layout but also on the services offered on-site. There are 22 recovery beds and 48 additional beds for mostly older homeless people, arts and wellness programs, a food pantry, and pet care. Even bunnies and snakes are allowed.

John Wright, 65, who goes by the nickname Slim, mingled with homeless visitors one afternoon in May, asking them what they needed to be safe and comfortable.

“Everyone thinks we’re criminals, like we’re out robbing everyone, but we aren’t,” said Wright, who is employed as a harm reduction specialist on the campus and is trying, at his own pace, to stop using fentanyl. “I’m homeless and I’m a drug addict, but I’m on methadone now so I’m working on it,” he said.

Nearby on Skid Row, Anthony Willis rested in his wheelchair while taking a toke from a crack pipe. He’d just learned about the new care campus, he said, explaining that he was homeless for roughly 20 years before getting into a taxpayer-subsidized apartment on Skid Row. He spends most of his days and nights on the streets, using drugs and alcohol.

The drugs, he said, help him stay awake so he can provide companionship and sometimes physical protection for homeless friends who don’t have housing. “It’s tough sometimes living down here; it’s pretty much why I keep relapsing,” said Willis, who at age 62 has asthma and arthritic knees. “But it’s also my community.”

Willis said the care campus could be a place to help him kick drugs, but he wasn’t sure he was ready.

Research shows harm reduction helps prevent death and can build long-term recovery for people who use substances, said Brian Hurley, an addiction psychiatrist and the medical director for the Bureau of Substance Abuse Prevention and Control at the Los Angeles County Department of Public Health. The techniques allow health care providers and social service workers to meet people when they’re ready to stop using drugs or enter treatment.

“Recovery is a learning activity, and the reality is relapse is part of recovery,” he said. “People go back and forth and sometimes get triggered or haven’t figured out how to cope with a stressor.”

Swaying Public Opinion

Under harm reduction principles, officials acknowledge that people will use drugs. Funded by taxpayers, the government provides services to use safely, rather than forcing people to quit or requiring abstinence in exchange for government-subsidized housing and treatment programs.

Los Angeles County is spending hundreds of millions to combat homelessness, while also launching a multiyear “By LA for LA” campaign to build public support, fight stigma, and encourage people to use services and seek treatment. Officials have hired a nonprofit, Vital Strategies, to conduct the campaign including social media advertising and billboards to promote the expansion of both treatment and harm reduction services for people who use drugs.

The organization led a national harm reduction campaign and is working on overdose prevention and public health campaigns in seven states using roughly $70 million donated by Michael Bloomberg, the former mayor of New York.

“We don’t believe people should die just because they use drugs, so we’re going to provide support any way that we can,” said Shoshanna Scholar, director of harm reduction at the Los Angeles County Department of Health Services. “Eventually, some people may come in for treatment but what we really want is to prevent overdose and save lives.”

Los Angeles also finds itself at odds with California’s Democratic governor. Newsom has spearheaded stricter laws targeting homelessness and addiction and has backed treatment requirements for people with mental illness or who use drugs. Last year, California voters approved Proposition 36, which allows felony charges for some drug crimes, requires courts to warn people they could be charged with murder for selling or providing illegal drugs that kill someone, and makes it easier to order treatment for people who use drugs.

Even San Francisco approved a measure last year that requires welfare recipients to participate in treatment to continue receiving cash aid. Mayor Daniel Lurie recently ordered city officials to stop handing out free drug supplies, including pipes and foil, and instead to require participation in drug treatment to receive services. Lurie signed a recovery-first ordinance, which prioritizes “long-term remission” from substance use, and the city is also expanding policing while funding new sober-living sites and treatment centers for people recovering from addiction.

‘Harm Encouragement’

State Sen. Roger Niello, a Republican who represents conservative suburbs outside Sacramento, says the state needs to improve the lives of homeless people through stricter drug policies. He argues that providing drug supplies or offering housing without a mandate to enter treatment enables homeless people to remain on the streets.

Proposition 36, he said, needs to be implemented forcefully, and homeless people should be required to enter treatment in exchange for housing.

“I think of it as tough love,” Niello said. “What Los Angeles is doing, I would call it harm encouragement. They’re encouraging harm by continuing to feed a habit that is, quite frankly, killing people.”

Keith Humphreys, who worked in the George W. Bush and Barack Obama administrations and pioneered harm reduction practices across the nation, said that communities should find a balance between leniency and law enforcement.

“Parents need to be able to walk their kids to the park without being traumatized. You should be able to own a business without being robbed,” he said. “Harm reduction and treatment both have a place, and we also need prevention and a focus on public safety.”

Just outside the Skid Row Care Campus, Cindy Ashley organized her belongings in a cart after recently leaving a local hospital ER for a deep skin infection on her hand and arm caused by shooting heroin. She also regularly smokes crack, she said.

She was frantically searching for a home so she could heal from two surgeries for the infection. She learned about the new care campus and rushed over to get her name on the waiting list for housing.

“I’m not going to make it out here,” she said, in tears.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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In Connecticut, construction workers in the Local 478 union who complete addiction treatment are connected with a recovery coach who checks in daily, attends recovery meetings with them, and helps them navigate the return to work for a year.

In Pennsylvania, doctors applying for credentials at Geisinger hospitals are not required to answer intrusive questions about mental health care they’ve received, reducing the stigma around clinicians seeking treatment.

The workplace is the new ground zero for addressing mental health. That means companies — employees and supervisors alike — must confront crises, from addiction to suicide. The two seemingly unrelated advances in Connecticut and Pennsylvania have one common factor: They grew out of the work of a little known federal agency called the National Institute for Occupational Safety and Health.

It’s one of the key federal agencies leading workplace mental health efforts, from decreasing alarmingly high rates of suicide among construction workers to addressing burnout and depression among health care workers.

But after gaining considerable traction during the covid-19 pandemic, that work is now imperiled. The Trump administration has fired a majority of NIOSH staffers and is proposing severe reductions to its budget.

Private industry and nonprofits may be able to fill some of the gap, but they can’t match the federal government’s resources. And some companies may not prioritize worker well-being above profits.

About 60% of employees worldwide say their job is the chief factor affecting their mental health. Research suggests workplace stress causes about 120,000 deaths and accounts for up to 8% of health costs in the U.S. each year.

“Workplace mental health is one of the most underappreciated yet critical areas we could intervene on,” said Thomas Cunningham, a former senior behavioral scientist at NIOSH who took a buyout this year. “We were just starting to get some strong support from all the players involved,” he said. “This administration has blown that apart.”

NIOSH, established in 1970 by the same law that created the better-known Occupational Safety and Health Administration, is charged with producing research that informs workplace safety regulations. It’s best known for monitoring black lung disease in coal miners and for testing masks, like the N95s used during the pandemic.

As part of the mass firing of federal workers this spring, NIOSH was slated to lose upward of 900 employees. After pushback from legislators — primarily over coal miner and first responder safety — the administration reinstated 328. It’s not clear if any rehired workers focus on mental health initiatives.

At least two lawsuits challenging the firings are winding through the courts. Meanwhile, hundreds of NIOSH employees remain on administrative leave, unable to work.

Emily Hilliard, a press secretary for the Department of Health and Human Services, asserted in a statement that “the nation’s critical public health functions remain intact and effective,” including support for coal miners and firefighters through NIOSH. “Improving the mental health of American workers remains a key priority for HHS, and that work is ongoing,” she wrote.

She did not answer specific questions from KFF Health News about whether any reinstated NIOSH employees lead mental health efforts or who is continuing such work.

Reducing Suicides and Addiction in Construction and Mining

Over 5,000 construction workers die by suicide annually — five times the number who die from work-related injuries. Miners suffer high rates too. And nearly a fifth of workers in both industries have a substance use disorder, double the rate among all U.S. workers.

Kyle Zimmer recognized these issues as early as 2010. That’s when he started a members’ assistance program for the International Union of Operating Engineers Local 478 in Connecticut. He hired a licensed clinician on retainer and developed partnerships with local treatment facilities.

At first, workers pushed back, said Zimmer, who recently retired after 25 years in the union, many as director of health and safety.

Their perception was, “If I speak up about this issue, I’m going to be blackballed from the industry,” he said.

But slowly, that changed — with NIOSH’s help, Zimmer said.

The agency developed an approach to worker safety called Total Worker Health, which identifies physical and mental health as critical to occupational safety. It also shifts the focus from how individuals can keep themselves safe to how policies and environments can be changed to keep them safe.

Over decades, the concept spread from research journals and universities to industry conferences, unions, and eventually workers, Zimmer said. People began accepting that mental health was an occupational safety issue, he said. That paved the way for NIOSH’s Miner Health Program to develop resources on addiction and for Zimmer to establish the recovery coaching program in Connecticut.

“We have beat that stigma down by a lot,” Zimmer said.

Other countries have made more progress on mental health at work, said Sally Spencer-Thomas, co-chair of the International Association for Suicide Prevention’s workplace special interest group. But with the growth of the Total Worker Health approach, a 2022 surgeon general report on the topic, and increasing research, the U.S. appeared to finally be catching up. The recent cuts to NIOSH suggest “we’re kind of losing our footing,” she said.

Last year, Natalie Schwatka, an assistant professor at the Colorado School of Public Health’s Center for Health, Work & Environment, received a five-year NIOSH grant to build a toolkit to help leaders in labor-intensive industries, such as construction and mining, strengthen worker safety and mental health.

While many companies connect people to treatment, few focus on preventing mental illness, Schwatka said. NIOSH funding “allows us to do innovative things that maybe industry wouldn’t necessarily start.”

Her team planned to test the toolkit with eight construction companies in the coming years. But with few NIOSH employees left to process annual renewals, the funds could stop flowing anytime.

The consequence of losing such research is not confined to academia, Zimmer said. “Workers’ health and safety is very much in jeopardy.”

Health Care Sector Braces for Fallout From NIOSH Cuts

For a long time, clinicians have had troubling rates of addiction and suicide risk. Just after the height of the pandemic, a NIOSH survey found nearly half of health workers reported feeling burned out and nearly half intended to look for a new job. The agency declared a mental health crisis in that workforce.

NIOSH received $20 million through the American Rescue Plan Act to create a national campaign to improve the mental health of health workers.

The results included a step-by-step guide for hospital leaders to improve systems to support their employees, as well as tips and suggested language for leaders to discuss well-being and for workers to advocate for better policies.

Cunningham, the behavioral scientist who left NIOSH this year, helped lead the effort. He said the goal was to move beyond asking health workers to be resilient or develop meditation skills.

“We’re not saying resilience is bad, but we’re trying to emphasize that’s not the first thing we need to focus on,” he said.

Instead, NIOSH suggested eliminating intrusive questions about mental health that weren’t relevant to keeping patients safe from hospital credentialing forms and offering workers more input on how their schedules are made.

The agency partnered on this work with the Dr. Lorna Breen Heroes’ Foundation, named after an emergency medicine doctor who died by suicide during the pandemic. The foundation extended the campaign by helping health systems in four states implement pieces of the guide and learn from one another.

Foundation leaders recently appeared on Capitol Hill with Noah Wyle, who plays an emergency physician on the TV series “The Pitt,” to advocate for renewed federal funding for this work.

Corey Feist, foundation CEO and co-founder, said renewing that funding to NIOSH is crucial to get this guide out to all hospitals.

Without those resources, “it’s just going to really delay this transformation of health care that needs to happen,” he said.

Who Can Fill the Gap?

TJ Lyons, a multidecade construction industry safety professional who has worked at big-name companies such as Gilbane, Turner, and DPR Construction, is confident that workplace mental health will remain a priority despite the NIOSH cuts.

General contractors and project owners have been incorporating budget lines for mental health support for years, he said, sharing an example of a $1 billion project that included a mental health clinician on call for four hours several days a week. Workers would make appointments to sit in their pickup trucks during lunch breaks and talk to her, he said.

Now when these big companies subcontract with smaller firms, they often ask if the subcontractors provide mental health support for workers, Lyons said.

But others are skeptical that industry can replace NIOSH efforts.

Several workplace safety experts said smaller companies lack the means to commission research studies and larger companies may not share the results publicly, as a federal agency would. Nor would they have the same credibility.

“Private industry is going to provide what the people paying them want to provide,” said a NIOSH employee and member of the American Federation of Government Employees union, currently on administrative leave, who was granted anonymity for fear of professional retaliation.

Without federal attention on workplace mental health, “people may leave the workforce,” she said. “Workers may die.”

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

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OCR and Deer Oaks Behavioral Health Solution reach a settlement to resolve potential HIPAA violations.

KFF Health News chief Washington correspondent Julie Rovner discussed how cuts to Medicaid in President Donald Trump’s megabill will affect Americans’ access to health care on NPR’s “Up First,” CNN’s “CNN This Morning” and WNYC’s “The Brian Lehrer Show” on July 2. Rovner also discussed U.S. domestic and global vaccine policy on WAMU’s “1A” on July 1.

• Click here to hear Rovner on “Up First”
• Click here to watch Rovner on “CNN This Morning”
• Click here to hear Rovner on “The Brian Lehrer Show”
• Click here to hear Rovner on “1A”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed a new study that found a link between a common type of hormone therapy and higher rates of breast cancer on CBS’ “CBS Mornings” on July 2. Gounder also discussed a breakthrough drug for HIV prevention on CBS’ “CBS Mornings Plus” on July 1.

• Click here to watch Gounder discuss the hormone therapy study on “CBS Mornings”
• Click here to watch Gounder discuss the new HIV prevention drug on “CBS Mornings Plus”

KFF Health News chief rural correspondent Sarah Jane Tribble discussed how Medicaid cuts in President Trump’s megabill could strain rural hospitals on CNN’s “CNN News Central” and on NPR’s “All Things Considered” on July 2 and July 1, respectively.

• Click here to watch Tribble on “CNN News Central”
• Click here to hear Tribble on “All Things Considered”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson

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

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This story can be republished for free (details).