One year into its creation, a $50 billion federal program aimed at improving rural healthcare lacks transparency, which could make it difficult to protect against fraud, identify successful projects, and ensure the program delivers on its promise to transform the system.

Transparency “is really important to help protect the integrity of the program, ensure funds are reaching the communities they’re meant to serve,” said Maya Sandalow, director of health policy for the Bipartisan Policy Center, a nonprofit think tank.

The federal government and states are compelled by public records laws to share documents when requested. But those requests can take months to fulfill, making their release too late for meaningful oversight as states rush to spend their allotments under tight federal deadlines.

In the meantime, the Centers for Medicare & Medicaid Services — which oversees the Rural Health Transformation Program — and some states aren’t proactively sharing information about where the funding is going and how it will be used.

CMS spokesperson Timothy Foster said the agency “will publish an annual report on state progress.”

States’ individual reports to CMS are “intended to be” shared upon request, but the agency won’t be proactively publishing the individual state reports, according to a CMS document.

Foster didn’t respond to questions about whether the agency will share examples of projects that are and aren’t working or create a tracker of funding recipients, award amounts, and what organizations plan to do with their funding — ideas that health and government transparency advocates have requested.

Instead, much of the program’s transparency thus far has been up to state governments, and “the level of details that states have publicized really varies,” said Sandalow, who co-wrote a recent paper on how the federal government can strengthen the rural health program, including through transparency.

Some states are sharing information with lawmakers, holding public meetings, and explaining where organizations plan to invest their money.

Others are more secretive, with multiple states declining to release public records in response to KFF Health News’ requests. Mississippi’s governor vetoed a transparency-related bill, West Virginia holds closed-door advisory meetings, and a South Dakota official wrote that he hoped CMS would keep its application from public view.

“I just don’t believe in all this secrecy,” said Mississippi state Sen. Hob Bryan, who chairs his chamber’s public health committee. “If they’re not up to something nefarious, why do they have to do it all in secret?”

Bryan, a Democrat, said there’s bipartisan concern about the lack of transparency in his state.

Reaching Rural Patients

Congressional Republicans created the five-year Rural Health Transformation Program last summer as an eleventh-hour sweetener to President Donald Trump’s signature One Big Beautiful Bill Act. The money was intended to offset concerns about the outsize fallout anticipated in rural communities from the law, which is expected to reduce overall Medicaid spending by more than $900 billion over a decade.

Sandalow said some states may be struggling to share information since they’re busy rushing to hire staff and meet the program’s tight deadlines, including an annual report due Aug. 31.

In the meantime, a slew of media outlets, nonprofits, and businesses are stepping in to make it easier for the public to track the rural health program.

KFF Health News is collecting states’ applications and approved plans and budgets, not all of which have been posted on state websites.

Rural Health Payout Tracking Applications for Rural Health Transformation Funds

KFF Health News is working to collect and post complete application materials, by state, here and will update this repository as new materials, released in response to public records requests, arrive.

Dec. 4, 2025 Rural Health Payout Tracking State Rural Health Transformation Plans

KFF Health News is working to collect and post approved plans as more states respond to emails and public records requests for their documents.

July 27, 2026

And several health nonprofits and companies have created trackers that describe states’ rural health initiatives, post funding opportunities, or list award recipients. But some resources are available only through paid services, aimed at helping businesses interested in applying for money.

Sandalow said previous federal programs “tend to draw attention for gaps in transparency and oversight rather than for doing it well.”

As an example, she pointed to the lack of oversight and transparency with the CARES Act and other covid relief programs, which saw fraud and improper payments.

In March, CMS published proposed quarterly and annual state reporting requirements for the rural health program, and a notice seeking comments. At least three groups replied with letters expressing concerns about transparency.

CMS should share states’ progress reports, funding recipients, and what organizations plan to do with their awards, wrote Zachary Gaumer, the Bipartisan Policy Center’s vice president for health policy.

Sharing this information would make it easier to track progress, identify successful programs that other states may want to replicate, and “ensure funds reach the rural communities they are intended to serve,” he wrote.

Molly Smith, group vice president for public policy at the American Hospital Association, asked CMS “to be as detailed as possible” about the “final destinations of these funds, given the complexity of the grant funding process.”

In her letter, Charlene MacDonald, who leads the Federation of American Hospitals, noted that some funding recipients, such as large health systems and academic medical centers, will be distributing their awards to other entities.

CMS should collect those “downstream subrecipients,” wrote MacDonald, whose group represents for-profit hospitals and healthcare systems.

Without this information, she said, it will be difficult to know if “funding is reaching the rural hospitals, providers, and communities primarily intended to benefit from the program.”

It can also be difficult to know which for-profit companies are being paid with rural health money.

For example, Nevada and Kansas have listed hospitals and other health facilities that received funding to purchase telehealth, scanning devices, and other health technology. But the states list only some of the companies from which recipients will buy those products.

States won’t have to report “downstream” funding in their August reports to CMS but will have to do so for all future reports, according to the agency’s recently finalized reporting requirements.

The CMS documents say states must list subrecipients that receive subawards as well as vendors or contractors paid by an organization using rural health funding. Although states must report how much money these downstream recipients receive, they don’t have to describe which specific services or products the recipient is providing.

DIY Dashboards

As groups ask CMS to share more information, some states have created their own rural health spending dashboards or recipient lists, with varying levels of detail.

Alaska, Kansas, Oklahoma, and other states list which organizations receive funding, their award amounts, and detailed descriptions of how recipients will spend the money.

Florida and Nebraska, however, are among the states that don’t share what awardees plan to do with their funding.

New Hampshire is posting recipient contracts that detail projects and their budgets on its Rural Health Transformation Program website. Some other states have uploaded contracts and grants on general procurement or award databases, which can be difficult to navigate.

Ohio, Virginia, and New Jersey have used press releases to announce awards. But the announcements aren’t posted on their Rural Health Transformation Program websites, which could make it difficult to find this information.

Many states created advisory groups to provide transparency and accountability for their programs. Most committees host public meetings and upload minutes, recordings, or other materials from the discussions.

But the West Virginia Department of Health won’t share what’s discussed in its rural health advisory panel’s closed-door meetings, according to spokesperson Gailyn Markham.

“The panel is intended to serve as an informal forum for discussion and feedback among invited participants and program staff,” Markham said.

South Dakota, North Dakota, and Mississippi are among the states without advisory committees.

In response to public records requests, South Dakota released a nearly completely redacted version of its budget for the rural health program while Mississippi declined to release its budget.

Mississippi’s governor said he vetoed a transparency-related bill because it would “create an unnecessary layer of bureaucracy” that would have slowed the award process, which could cause the state to lose out on future funds. Mississippi is “an incredible outlier in all this secrecy,” Bryan, the state lawmaker, told KFF Health News.

Sandalow said it’s important for states to publish the impact of their rural health projects, adding that CMS should share which rural health projects are and aren’t working.

She said national and state health organizations are creating networks and holding conferences to help spread this information. States should “be able to learn from each other, get a sense of lessons learned and best practices, and then be able to pivot their initiatives accordingly,” Sandalow said.

Michael Cannon, who oversees health policy studies at the libertarian Cato Institute, said people should know how their $50 billion in taxes is being spent on the rural health program, and whether state projects are making rural patients healthier.

If investors put that much money into a project, there is “no way” they “would let the recipients of those funds get away with the shoddy approach to transparency and accountability that the states are taking,” he said.

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

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

HHS announced a $32.5M initiative to replace processed foods with nutrient‑dense, real food and identify scalable strategies to improve school meals.

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BAKERSFIELD, Calif. — Carlos A. grew up in a family on Medicaid, which made healthcare an afterthought since the public insurance is free for low-income enrollees. But when he received a raise two years ago, he found himself earning too much to qualify for the safety net program. And when he browsed Covered California plans, he found that marketplace prices were still too steep for his comfort.

“It was a panic at first,” Carlos said.

He has a chronic immune condition that needs to be managed by regular medication. KVPR and KFF Health News agreed to withhold his diagnosis and last name to protect him from repercussions related to his health.

“I have to be able to afford my health insurance to go to the doctor, because if not, then there’s no peace of mind,” he added.

Now in his late 20s, he receives employer-based coverage through his job at an Amazon warehouse. In addition to adjusting to monthly premiums and copays for medical visits and prescriptions, he also learned he needs prior authorization for that medication he had been on for a decade. Without it, he could get only the generic version, which he’s nervous to try. He felt his insurer failed to justify the switch.

“I felt that this was a slap in the face because I’m paying for my premiums,” he said. “It’s a contract. I’m going to pay my premiums, you cover my insurance, and if there’s a copay to my medicine, I’ll pay it. So why are you playing funny business with my medication?”

Carlos is one of many voters weighing healthcare costs in California’s 22nd Congressional District, which stretches from Bakersfield up to parts of western Fresno County. It’s newly redrawn to improve Democrats’ chances, but it remains among the nation’s most competitive this cycle and could determine control of the U.S. House. It’s long been held by Republican Rep. David Valadao, who’s been voted into the seat in almost every election since 2012.

Rep. David Valadao (R-Calif.) at the U.S. Capitol on March 25, 2025. (Bill Clark/CQ-Roll Call, Inc via Getty Images)

Carlos was among dozens of people who attended a rally in Bakersfield this month in support of Democratic challenger Randy Villegas. Carlos said healthcare costs will be among the key considerations in his vote in this fall’s midterm election, calling it an issue that both candidates need to address.

“I do expect them to campaign on healthcare,” Carlos said. “They’d be very foolish not to.”

Democrats are calling out Valadao’s vote for HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, which cut billions in healthcare for poor people. The last time healthcare was on the ballot to this extent, Valadao lost his Central Valley seat in 2018 during a “blue wave” after the Republican lawmaker voted to repeal the Affordable Care Act. He retook his seat in 2020 by just 1,522 votes.

Valadao has said he voted for HR 1 because it protected Medicaid, known as Medi-Cal in California, for the most vulnerable, including children, pregnant women, disabled people, and seniors. He supported a rural health fund for hospitals in underserved areas. At the same time, he said the legislation’s work requirements for nondisabled adults were reasonable and would help maintain the program.

“Polling shows that the majority of Americans want us to have our programs to be sustainable,” Valadao told TV channel KERO in Bakersfield before the vote. “Sustainable means taking care of those who need it most, and those who should be working in part of society and being productive should be. And it’s not an unfair ask.”

The work requirement’s documentation mandate will take effect in 2027 for Medi-Cal enrollees. According to the California Health Care Foundation, an estimated 1.1 million people are expected to lose coverage by 2030 due to the eligibility and administrative changes.

Villegas, a populist who favors universal healthcare and is backed by Sen. Bernie Sanders (I-Vt.), has highlighted how Valadao’s HR 1 vote will be felt by low-income residents across the district. The Visalia school board member said he grew up as a Medi-Cal recipient. As of 2024, the current 22nd District, which has some overlap with its redistricted replacement, had the highest Medicaid enrollment rate — 64% — of any Republican-held seat in the nation, according to KFF, a health information nonprofit that includes KFF Health News.

Randy Villegas, a Democrat running for California’s 22nd Congressional District, campaigns in Bakersfield on May 23. (Myung J. Chun/Los Angeles Times via Getty Images)

“David Valadao voted to cut healthcare for nearly 70,000 people in the Valley to give tax breaks to billionaires and his wealthy donors,” Villegas said in a statement. “In Congress, I’ll fight to reverse those cuts and lower healthcare costs.”

Valadao’s office didn’t return requests for comment. His campaign touts his support for quality, affordable health coverage and maintaining access for the most vulnerable. Polling also finds that the Trump administration’s recent withholding of Medicaid funds from states is resonating with Republicans, with 55% saying it’s important for candidates to discuss fraud in government health programs. Republicans in swing districts, including Valadao, have begun airing ads emphasizing reform.

But many in the electorate remain undecided in this district where nearly a quarter of voter registrations are nonpartisan. Some said they haven’t heard enough from candidates about affordability solutions, which they hope will change because healthcare costs top the list of their economic anxieties.

Matthew Depue, who lives in Hanford and has private health insurance through his employer, said he has been fortunate to have reliable coverage. His healthcare premiums affect his monthly budget, but he said he hasn’t had to delay care or choose between paying medical bills and other necessities.

Still, Depue said, rising healthcare costs are quickly becoming harder to ignore. Last year, federal lawmakers declined to extend enhanced tax credits, which state officials say contributed to an average 10% premium increase for Covered California plans.

He also sees how affordability is pushing people across borders to find cheaper treatments and medications.

“People go from here to Mexico to get stuff done because it’s so much cheaper,” Depue said.

Even though healthcare is important to him, it isn’t the only issue driving his vote. Depue, who doesn’t know whom he’ll vote for, said he would evaluate candidates based on everything they stand for, including their positions on things like taxes and the difficult job market. District 22’s voter registration is 42% Democratic, 26% Republican, and 24% no party preference, according to the California secretary of state’s May report, the latest available.

Hanford, with a population of roughly 62,000, is the seat of Kings County. (Cresencio Rodriguez-Delgado/KVPR)

For Hanford resident Patreza Newton, affording healthcare has become deeply cumbersome. She hopes that whoever wins the election will work to prioritize healthcare, saying the current health system is unaffordable.

She used to purchase her own plan under Obamacare and is now covered by her church’s insurance. But to keep monthly premiums affordable, she chose a high-deductible plan, which means she has to pay out-of-pocket for some prescriptions and specialist visits.

Newton said she falls into what she calls “the in-between,” people who earn too much to qualify for Medicaid but still struggle to afford coverage.

Years ago, Newton was hit with a hospital bill of roughly $65,000 after surgery and had to apply for financial hardship assistance because she couldn’t afford to pay the bill.

As she considers how to vote this fall, she said she isn’t looking for overwhelming promises but rather a leader who understands what families are experiencing. She’s undecided on a candidate, saying none has shown the initiative she is looking for.

“I do think there should be a way that people can afford it,” she said, “no matter who they are.”

This article is from a partnership that includes KVPR, an NPR affiliate in central California, and KFF Health News.

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Last year, Stephanie Halver’s primary care doctor consulted a risk assessment tool to calculate her chances of one day developing breast cancer. Halver, now 43, remembered the likelihood “popped up really high.”

That’s partly because Halver’s mother and aunt have had breast cancer. Her age and dense breast tissue also put her at higher risk.

Halver, who lives in Vancouver, Washington, said her doctor recommended she get an annual breast MRI, six months after her yearly mammogram. The scan would serve as an additional safeguard, since breast MRIs can detect abnormalities that mammograms miss.

Case in point, actress Olivia Munn had a breast MRI in 2023 that detected an aggressive form of cancer in both breasts, even though a recent mammogram had been clear, she told People magazine. Like Halver, Munn said her doctor recommended the MRI after a risk assessment score showed she faced a greater-than-normal chance of developing breast cancer.

Catching breast cancer early, before it spreads, improves survival rates, according to the National Cancer Institute. After Halver’s insurer preapproved the scan, she scheduled the MRI for September.

“Luckily, they find nothing,” Halver recalled.

Then the bill came.

The Medical Service

A breast MRI — short for magnetic resonance imaging — is a preventive and diagnostic tool that captures pictures of breast tissue in higher detail than a mammogram. MRIs may be recommended for patients at an increased risk for breast cancer, including those with dense tissue, a family history of breast cancer, or certain genetic markers.

But the scans are generally not recommended for women considered at average risk, according to the American Cancer Society, because they can also yield false positives, subjecting patients to unnecessary follow-up tests and procedures.

Breast MRIs are also used to diagnose cancer when an abnormality is detected during a mammogram, and they can determine the cancer’s stage after diagnosis.

The Bill

$1,205: After an insurance payment of $13.90, the patient was responsible for $1,191.10. The clinic also charged $65.60 for “Injectable/Oral Med,” often used to keep patients still or less anxious during the scan. Halver’s insurance covered about half of that charge.

The Billing Problem: Not Always Preventive

When Halver received the bill from Vancouver Clinic, where the MRI was conducted on Sept. 26, she was confused.

She knew that the Affordable Care Act requires health plans to cover preventive care, such as Pap smears and mammograms, at no cost to patients.

What’s more, Halver’s breast MRI had been recommended by her doctor and preapproved by Blue Cross Blue Shield of Texas, of which she is a beneficiary through her employer-sponsored plan. The whole point of it was preventive. That’s why she assumed it would cost her nothing.

To make things more confusing, a state law in Washington requires many health insurers to cover breast MRIs.

“I’ve had many phone calls trying to understand” the bill, Halver said.

Halver thought her health insurance plan would pay for a breast MRI recommended by her doctor in 2025. Even though the scan had been preapproved, she ended up with a $1,200 bill. (Kristina Barker for KFF Health News)

It came down to this: The U.S. Preventive Services Task Force, a panel of outside experts that advises the federal government, is charged with recommending which screenings health insurers are required to cover at no cost to patients, and preventive breast MRIs don’t fall into that category.

The task force has determined “the current evidence is insufficient to assess the balance of benefits and harms” of breast MRIs for women with dense breast tissue “on an otherwise negative screening mammogram.”

The federal guidelines are different for patients whose mammograms detect an abnormality, said Cathy Peters, senior director of state and local campaigns at the American Cancer Society Cancer Action Network.

In these cases, Peters said, guidelines published by the federal Health Resources and Services Administration specify that additional imaging, such as ultrasounds and MRIs, are preventive.

After an abnormal mammogram, these services are recommended “to address findings on the initial screening mammography” and to “complete the screening process for malignancies,” according to HRSA.

Those guidelines are a step in the right direction, but women who have not had an abnormal mammogram may end up “running into a big bill,” Peters said. This can be a deterrent when it comes to future screenings, she said, because when “you get hit with that once, you’re going to be very careful the next time you go.”

Some states have enacted laws that require insurers to cover breast MRIs, Peters said, but they generally don’t benefit patients like Halver who are enrolled in large, employer-sponsored insurance plans. These “self-insured” plans are regulated by the federal government, not by state lawmakers.

“Sadly, these state-by-state laws,” Peters said, don’t “fix the federal problem.”

The Resolution

Blue Cross Blue Shield of Texas declined to answer questions about Halver’s benefits or bill.

Halver appealed the insurer’s coverage determination, and in July she received a letter indicating that her appeal was denied.

Halver said she contacted her employer’s human resources department earlier this year and learned that mammograms are covered as a preventive screening under her health plan but breast MRIs are not. That means her annual breast MRI will be subject to deductibles, coinsurance, and other cost-sharing requirements.

In this case, the cost of Halver’s breast MRI was applied to her $3,300 annual deductible, an explanation of benefits from her insurer showed.

“I think I’m on the hook for this bill,” she said.

And because her risk of breast cancer is high, she said, “that’s a guaranteed bill every year.”

Halver learned that mammograms are covered as a preventive screening under her health plan but breast MRIs are not. (Kristina Barker for KFF Health News)

The Takeaway

If your doctor or medical provider recommends an annual breast MRI in addition to an annual mammogram, consider researching your state’s coverage rules on the DenseBreast-Info website. The nonprofit organization maintains a map with up-to-date information on state laws about breast cancer screenings. Depending on where you live and what type of health plan you have, preventive breast MRIs might be covered at no cost.

If it turns out you could be on the hook for a future bill, there are a few things you can do beforehand to potentially lower your out-of-pocket costs.

Ricki Fairley, co-founder of Touch, the Black Breast Cancer Alliance, recommended first finding a patient navigator at the hospital or cancer center to assist you.

She urged women to seek out resources in their communities or through national advocacy groups, including Touch, to find ways to lower screening costs. Programs funded by some states can help offset the cost of breast cancer screenings for low-income patients, Fairley said.

Beyond that, shop around for the best price. Freestanding imaging centers may charge less for a preventive breast MRI than a hospital. If possible, also consider scheduling the MRI at the end of your health plan’s deductible year. If you’ve already met your deductible, you could end up owing less out-of-pocket.

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

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

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

In January, Jeff La Marca got a prescription for the popular weight loss drug Zepbound. But he couldn’t afford the $750 monthly price tag.

Then Medicare launched an 18-month pilot program that offers GLP-1 medications to some enrollees for only $50 a month. La Marca thought he might finally be able to afford the drug.

“I thought, ‘Thank God, there’s a path,’” said La Marca, who lives in Basking Ridge, New Jersey, and has tried numerous diets and exercise regimes.

But the 68-year-old’s celebration was short-lived.

His application to the pilot program was denied.

La Marca has severe obstructive sleep apnea, one of several diagnoses that exclude patients from the Bridge program’s $50 monthly price. The notification didn’t say why he was rejected. He thinks that if he didn’t have that diagnosis, he would qualify due to his weight.

“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it. I’m livid,” he said.

Jeff La Marca uses a machine to treat his obstructive sleep apnea. It adjusts his breathing with every breath. (Erica S. Lee for KFF Health News) La Marca, a retired professor living in Basking Ridge, New Jersey, is among an estimated 5.9 million Medicare enrollees excluded from a GLP-1 discount program because they have a medical condition such as Type 2 diabetes or sleep apnea. (Erica S. Lee for KFF Health News)

A Temporary Patch for a Long-Standing Gap

About 1 in 5 American adults have taken a GLP-1 medication, and most of them, including those with health insurance, say the drugs are difficult to afford. Federal law has long barred Medicare from covering drugs prescribed solely for weight loss, which is why the Medicare GLP-1 Bridge program made a big splash when it launched in July.

It’s a short-term pilot program in which Medicare is offering coverage of three GLP-1s for weight loss and management, to see if that would save Medicare money later. Eligible patients must be enrolled in Medicare Part D, a prescription drug coverage add-on to Medicare. Even though people must have Part D insurance to qualify, the preauthorization request doesn’t go through the insurer; it’s instead submitted to a separate system run by a contractor for the Centers for Medicare & Medicaid Services.

The pilot includes Wegovy, the KwikPen formulation of Zepbound, and the oral medication Foundayo.

Under the pilot, many Medicare beneficiaries with a body mass index of 35 or higher — the upper range of obesity — qualify for coverage of one of those drugs, if prescribed. Those otherwise eligible who have a BMI of 27 to 34 can qualify if they also have certain health conditions, such as prediabetes or cardiovascular disease.

But buried in the fine print is a distinction that’s tripping up patients like La Marca: The $50 price under Bridge applies only to people using the drug solely for weight loss. Anyone who has a qualifying medical condition that the Food and Drug Administration has approved GLP-1s to treat, such as Type 2 diabetes or moderate to severe obstructive sleep apnea, is instead routed back to their Medicare Part D prescription drug plan, which can require copays of hundreds of dollars a month for GLP-1s.

“The Bridge program was designed to target those people who can’t get GLP-1 coverage through Part D but would benefit from taking one for weight loss,” said Juliette Cubanski, who directs the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

The cost to Medicare of subsidizing the drugs will depend largely on how many people use the program, and the federal government hasn’t released an estimate.

Cubanski has estimated that 3.8 million people qualify and that, if a quarter of them enroll in Bridge and remain on treatment for the program’s full 18 months, it will cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion.

If the government expanded the program to include the additional 5.9 million people who are overweight and already eligible for GLP-1 coverage through Medicare Part D, it would add billions more to the program’s cost.

The demonstration’s initial weeks have been positive, and most prior authorization requests have been completed in under 12 hours, CMS spokesperson Timothy Foster said.

“This has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide,” Foster said.

“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it. I’m livid,” La Marca says, referring to the popular weight loss drug Zepbound. (Erica S. Lee for KFF Health News)

GLP-1s Aren’t Covered

Patients like La Marca are left in a tough spot, qualifying for Part D coverage of a GLP-1 but facing much higher cost sharing.

“‘Coverage’ doesn’t always mean ‘affordable,’” said primary care physician Taylor Lacy, who describes herself as a “big proponent” of GLP-1s and practices at Sunflower Medical Group in Roeland Park, Kansas.

The Bridge program is leaving behind patients with the greatest medical need, she said. She noted that many Medicare patients already must navigate prior authorization and spend months trying alternate, often cheaper treatments, a process known as step therapy, before finally getting approval — only to arrive at the pharmacy counter and discover that their GLP-1 copays will run them $200 to $600 a month, if not more.

Researchers studying how Medicare insurers cover GLP-1s have found that recipients have faced increases in out-of-pocket costs and that almost all plans now require prior authorization, which can make getting the drugs more difficult.

Chris Bond, a spokesperson for insurance industry trade group AHIP, blamed drugmakers’ prices, “which they alone set and they alone can lower.”

La Marca’s insurer declined to answer specific questions about La Marca’s case.

Left Waiting

For now, La Marca’s GLP-1 prescription remains unfilled. The severe sleep apnea diagnosis that helps establish his medical need is also what excludes him from the discount program that would bring the cost within his reach.

As he reflected on his appeals and the dead ends, La Marca paused, his eyes filling with tears of frustration.

“This is now my quest, because it’s my only chance to improve my health,” he said. “It’s the only thing left. I’ve tried everything.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

HHS and USDA announced efforts to strengthen school meals by connecting American farmers with local schools, investing in school kitchens, and more.

California is weighing stiff penalties for hospitals and other healthcare entities that don’t stay under state spending limits, potentially levying hundreds of millions of dollars in fines if these providers don’t take steps to rein in rising healthcare costs.

If the state Office of Health Care Affordability adopts the fines next week, hospitals, medical groups, insurers, and others could face penalties that amount to as much as 125% of the total they spend above the state’s annual growth targets.

The penalty proposal comes after healthcare entities in California were asked to limit growth by 3.5% last year and ramp down to 3% by 2029. Seven hospitals that state officials consider particularly expensive face even smaller growth targets: 1.8% in 2026, dropping to 1.6% by 2029.

Consumer advocates argue that state financial deterrents are critical to bring relief to millions of Californians struggling with high insurance premiums and out-of-pocket expenses. Hospitals accounted for 40% of the increase in U.S. health spending from 2022 to 2024, compared with 11% from retail prescription drugs. But adding teeth to those targets sets up a fight with the powerful hospital industry, which has a pending lawsuit challenging the spending limits as unreasonable. Hospitals warned that they will cut back on vital services, including in emergency rooms, obstetrics, and behavioral health.

Healthcare industry representatives said the state affordability office hasn’t accounted for year-to-year volatility or other factors beyond the industry’s control, such as rising minimum wages, state earthquake retrofit requirements, and expensive new drugs.

“They’re building the plane while flying it,” said Ben Johnson, group vice president for financial policy at the California Hospital Association. “We know improvements in affordability are needed, but we have serious questions about how and about what the unintended consequences could be under OHCA’s rather stringent approaches.”

When calculating penalties, California regulators would consider various factors, including a healthcare entity’s financial situation, its market impact, and the gravity and number of offenses, according to a board presentation in June. And entities would first be given opportunities to implement performance improvement plans to bring their spending into line before penalties are imposed. For those that don’t comply, the board is considering penalties of $10,000 a day or a flat $500,000.

The penalties, which the affordability office’s eight-member board is required by state law to adopt, are slated for discussion, and a potential vote, at the board’s Aug. 26 meeting. The soonest healthcare providers would be subject to penalties is 2028, because it’s expected it will take two years to collect and publicly report spending data to measure against the 2026 targets. The state is still collecting data on how entities performed against the 2025 targets, which aren’t enforceable, according to Andrew DiLuccia, a spokesperson for the California Department of Health Care Access and Information.

States Set Targets

California is one of at least eight states that have set spending targets as part of an expanding effort to curb soaring healthcare spending across the nation. Connecticut, Massachusetts, Oregon, and Rhode Island have also authorized the use of some type of financial penalty. The specifics of each vary widely, although so far no state has applied them.

A survey last year by the California Health Care Foundation found that 4 out of 10 state residents said they had medical debt, and 6 in 10 reported that they or a family member had skipped or delayed medical care in the previous 12 months because of cost. Nationwide, about half of adults say it is difficult to afford healthcare costs.

After Rosalyn Book got stiches on her chin, the elementary school teacher received a $15,000 ER bill from a local hospital, despite having insurance. Many teachers in her district leave because they can’t afford the cost of healthcare and insurance premiums, she said.

“The healthcare charges are just insanity, and what we get as patients for the care, it’s not the best either,” said Book, president of the Monterey Bay Teachers Association. “If you’re a working, regular individual in terms of how much you make, the cost of living and especially the healthcare is just not doable.”

Meanwhile, hospitals are warning there’s a risk of more closures. According to Yale University’s Health Care Affordability Lab, 17 hospitals have closed in the state since 2016, compared with only six openings.

Hospitals and other healthcare providers have said the proposed multimillion-dollar penalties are too steep and could destabilize their operations at a time when they’re facing funding challenges, including massive federal cuts to Medicaid, the end of enhanced federal subsidies for Affordable Care Act plans, and a sharp rise in uninsured patients. The One Big Beautiful Bill Act, passed by congressional Republicans and signed by President Donald Trump last summer, is expected to reduce federal Medicaid spending by more than $900 billion — including by $30 billion in California — and increase the rolls of the uninsured in the U.S. by 10 million people over a decade.

Johnson said hospitals raise prices on commercial payers to offset the expense of treating uninsured patients, as well as patients on Medicaid and Medicare, which can reimburse care providers at rates that fall short of treatment costs.

In addition, said Anete Millers, vice president of legal and regulatory affairs at the California Association of Health Plans, tax increases on managed-care plans recently approved by state legislators to offset federal Medicaid cuts will force plans to increase their prices for consumers.

“Some spending pressures originate outside of the control of health plans and are the result of public policy decisions rather than underlying changes in healthcare utilization or efficiency,” she told the affordability office’s board at the June meeting.

Kristof Stremikis, the director of market analysis and insight at the nonprofit California Health Care Foundation, acknowledged that external forces can drive costs but said that plenty of unnecessary spending is within the healthcare system’s control, such as administrative waste and duplicative tests and procedures. Almost 25% of U.S. healthcare spending is considered wasteful, according to research published in JAMA.

Elizabeth Mitchell, a former Office of Health Care Affordability board member whose term ended in May, agreed.

“Every business has external challenges,” she said. “The hospital industry has not taken accountability to actually manage costs. I have heard those excuses for decades, and at some point, they have to make changes.”

First Step To Bring Down Costs

An analysis of five states with cost growth benchmarks, published in June, found that some have succeeded in modestly slowing healthcare spending, particularly those with enforcement mechanisms. However, spending growth in most states has still exceeded the targets set. 

Jeremy Vandehey, a consultant with the Peterson-Milbank Program for Sustainable Health Care Costs, said setting benchmarks and collecting data to analyze which entities meet them is only a first step. Armed with information about what and who is driving up costs, states are more empowered to take additional action, such as imposing penalties or regulating prices, to bring down costs, he said.

“I don’t think anybody in any state is declaring victory on healthcare costs, but I wouldn’t say that that means the programs are a failure,” Vandehey said. “In all of these states, there’s much more robust conversations happening about, OK, we haven’t solved our cost crisis, so we need additional action.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.