HHS Secretary Kennedy released the fourth episode of the Real Food Show with celebrity chef Andre Rush.

SAMAHSA announced it awarded $42.3 million in new funding through two federal block grants to advance a “Treatment First” model.

HHS announced a new Department-wide policy establishing the HHS Personal Protective Equipment (PPE) Forecast.

On a weekday morning in a quiet Boston neighborhood, a kitchen bustled with activity. Volunteers sliced chicken breasts, stuffed bell peppers, filled trays, and carefully labeled each item. It was part of an experiment to offer nutritious and medically tailored meals to Medicaid patients who are unable to shop for groceries and cook for themselves.

“Once I started to eat these meals that were geared toward my illness, I built up my muscle mass again, built up my strength, built up my confidence in myself,” said Vanessa Georges, who is in remission from throat cancer and said she would struggle to consume enough calories without the deliveries. “These meals have given me a second chance.”

Georges said she noticed another benefit from the meals: She spends less time at the doctor’s office.

Researchers have found evidence backing her observation. About 1,900 Massachusetts residents who, like Georges, received medically tailored meals for at least three months needed less medical care, according to a study published in the journal Nature Medicine. They had 20% fewer emergency department visits and 31% fewer hospitalizations than similar patients who did not receive meals.

“It actually saves the healthcare system money,” said Dariush Mozaffarian, a cardiologist and professor at Tufts University who led the study. “That’s a really big deal, because most things in healthcare don’t.”

The research from Massachusetts adds to evidence that medically tailored meals could save states money — in addition to improving health. Yet such programs could land on the chopping block as states look to tighten spending under Trump administration budget cuts, even as federal officials argue that food is a critical component of health.

Medicaid Budget Cuts Loom

The 2025 law known as the One Big Beautiful Bill Act slashed projected Medicaid funding by more than $900 billion. Many Republicans who backed the bill believe federal health spending is too high and riddled with fraud. Sen. John Kennedy, a Louisiana Republican, for example, has accused California of “outrageous fraud” for using Medicaid dollars to fund housing and nutrition programs.

Amaya Diana, a policy analyst at KFF, said states will have to make tough choices in the next few years as they figure out how to fill funding gaps. “If states are not able to offset the loss of federal funds with new taxes or reductions in other state spending, they may have to make program cuts,” she said. (KFF is a health information nonprofit that includes KFF Health News.)

Thirteen states have received federal waivers to use Medicaid dollars to pay for meals — part of an approach known as “food is medicine.” Three other programs are awaiting federal approval.

President Donald Trump’s support for social services has wavered. While the first Trump administration allowed states to pursue medically tailored meals and other social supports, the second Trump administration rescinded Biden-era guidance for Medicaid initiatives that address social needs. It hasn’t detailed a new policy. Administration officials have warned that they will be more focused on the budget impacts of such initiatives.

“They signaled they’re going to be a lot more skeptical,” said Kurt Hager, an assistant professor at the University of Massachusetts Chan Medical School who studies nutrition programs and helped lead the Massachusetts study. “Instead of using a broad-based approach nationwide, they’re going to make decisions on a state-by-state basis.”

At the same time, health leaders in Trump’s administration have made nutrition a major focus, including by promoting less-processed foods. Robert F. Kennedy Jr., who leads the Department of Health and Human Services, and Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, have pushed hospitals to serve healthier foods to boost patient outcomes.

Trays of stuffed peppers and carrots from Community Servings are ready to be sealed and delivered to Boston-area residents who receive medically tailored meals. (Robin Lubbock/WBUR)

The healthcare system is often willing to pay for surgeries, Oz said in a social media video in June, “but not always willing to pay for the nutrition that might help prevent those outcomes in the first place. That’s bothered me my whole career.” He added that the agency is evaluating several strategies, including medically tailored meals, to prevent illness and hospitalization. CMS officials did not respond to several emailed requests for comment for this article.

Katie Garfield, who studies social determinants of health at Harvard Law School’s Center for Health Law and Policy Innovation, said the lack of federal guidance is stirring uncertainty for states that want to pursue nutrition programs in Medicaid. “We’re still waiting to see that big step forward around ‘food is medicine’ interventions,” she said. “We need to see that step forward to resolve some of the uncertainty.”

Lawmakers have had a hard time engaging administration officials on medically tailored meals, said U.S. Rep. Jim McGovern, a Massachusetts Democrat who sponsored a bill that would pilot meal deliveries for some chronically ill seniors on Medicare. The legislation has yet to come up for a vote.

“I had thought, based on some of his rhetoric before he entered the Trump administration, that RFK Jr. would be a natural ally on this,” McGovern said. “But we can’t seem to get his attention.”

The Costs of Poor Nutrition

Some companies have been accused of billing Medicaid for meals that were neither healthy nor nutritious, raising concerns about lax regulation of these programs.

But at Community Servings in Boston, the food is prepared with specific attention to sugar, salt, fat, vitamins, and minerals and is based on a person’s health needs, said David Waters, chief executive of the nonprofit. Many recipients require food that is mild or low in fiber, for example.

“What we’re able to do is to work with your healthcare provider to understand your health realities — what your diagnoses are, what your medications are, side effects, food allergies, cultural norms — and then prescribe a diet for you that is scratch-made,” Waters said.

The Massachusetts researchers found that the meals — at a cost of $125 per person per week — essentially paid for themselves. Patients with heart disease used about $10,000 less in healthcare services over six months, and patients with kidney disease used $12,000 less in healthcare. There were also savings for people with diabetes, depression, and anxiety.

“Those are pretty big numbers when you think of how expensive those diseases can be and the prevalence in the population,” Waters said.

Nationally, researchers estimate, 10 million Americans would benefit from medically tailored meals, though only a small fraction are enrolled.

“Poor nutrition is the top cause of poor health in this country. It’s the top cause of preventable healthcare spending,” said Mozaffarian, director of the Food is Medicine Institute at Tufts. He has estimated that medically tailored meals could help patients avoid 1.6 million hospitalizations and save the U.S. $13.6 billion in healthcare costs each year.

A Weekly Delivery That Makes a Difference

Steve Honyotski receives 10 meals at his Boston home each week, cooked fresh and delivered cold or flash-frozen. They’re ready to eat after just a couple of minutes in the microwave.

“The carrot ginger soup is my favorite,” Honyotski said.

Honyotski, 71, lives with several chronic conditions, including diabetes, obesity, and high blood pressure. He said he’s noticed improvements in his health since he started eating medically tailored meals. He needs less insulin to control his diabetes, and he’s lost enough weight to delay a knee replacement surgery.

Community Servings is a nonprofit that provides medically tailored meals in the Jamaica Plain neighborhood of Boston. (Robin Lubbock/WBUR)

For now, those meals will keep coming. And Massachusetts’ Medicaid director, Ryan Schwarz, said the state will seek federal approval to continue medically tailored meals in the coming years. “We feel very strongly committed to continuing these services,” he said.

In North Carolina, researchers found that food and housing supports lowered Medicaid spending over time. Yet even with federal approval for medically tailored meals, and evidence that the meals — along with housing and transportation support — were helping people, North Carolina state lawmakers suspended the services in 2025 over budget worries. After budget deliberations this summer, state legislators changed course and decided to partially fund the program.

“To me, that’s a signal of what might occur in other states as these Medicaid cuts hit,” said Hager, the UMass researcher. “Even though they have the authority to run these programs, it might be a lot harder for the states to actually implement them.”

This article is from a partnership that includes WBUR, NPR, 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.

When the FDA was deciding whether to approve the drug Tavneos several years ago to treat a set of rare autoimmune diseases, agency experts argued that would be a mistake, according to FDA records.

One problem cited: The manufacturer had provided only “limited safety data.”

As it often does, the FDA in 2021 approved the drug with a proviso: It required the manufacturer to conduct an additional years-long safety study once the drug was on the market.

Today, like many similar “postmarket” studies mandated by the FDA, that additional study is delayed, according to a federal database. As of last fall, only 21 of the planned 300 patients had been enrolled, the FDA said in an April letter and regulatory posting.

Meanwhile, the FDA has identified dozens of cases of liver damage “possibly” or “probably causally associated” with the drug. That was one of the potential side effects the postmarket study was meant to evaluate.

Tavneos illustrates the perils of the FDA’s approach to many drugs and medical devices — and the frequent lapses in follow-through.

A KFF Health News analysis of Food and Drug Administration data found hundreds of postmarket studies listed as delayed. In some cases, the work was delayed by more than a decade or the manufacturer was still developing a plan for the study.

As a result of delays, patients, doctors, and others could be left in a fog about the risks and benefits of the drugs or devices, even as they stake their money, their health, or their lives on the products.

Postmarket study requirements “have often proven toothless,” said cardiologist Sanket Dhruva, an associate professor of medicine at the University of California-San Francisco who has published related research.

The FDA’s reliance on postmarket studies reflects a balancing act.

Making new treatments available faster can save or improve lives, especially when patients with grim prognoses and no good options have little to lose. The full risks and benefits may be revealed only over the long term, and when therapies are used by far more people than even large clinical trials enroll.

But relying on post-approval studies to resolve questions risks exposing patients to products that do more harm than good. Whoever is paying the bills — patients, insurance companies, employers, or government health programs such as Medicare and Medicaid — can end up wasting money and rewarding manufacturers for useless or risky products.

“Doctors rely on this evidence, patients rely on this evidence, and if that evidence is not there, it’s going to lead to a lot of uncertainty,” Dhruva said.

Trump administration policy changes designed to hasten drugs through FDA review could leave more riding on postmarket studies, medical researchers say.

For example, in February, FDA leaders announced that “the default requirement” for agency approvals will be one clinical trial instead of two.

Reducing pre-approval testing “will inevitably put a lot of pressure on the post-approval system,” said Aaron Kesselheim, a professor at Harvard Medical School who has analyzed postmarket studies.

FDA officials said the new policy would “substantially reduce costs” for manufacturers and “speed drugs to market.” Writing in The New England Journal of Medicine, they denied the change would compromise safety or efficacy, saying that “erroneous conclusions may be reached even with two, three, or four studies.”

In response to questions for this article, a spokesperson for the Department of Health and Human Services, which includes the FDA, said postmarket studies can experience delays for legitimate reasons. “Assessing the significance of any delay requires a case-specific review,” said the spokesperson, Emily Hilliard.

The fact that a study is delayed “should not be treated as evidence that a product has an unresolved safety or effectiveness issue,” Hilliard said.

Amgen, the company that makes Tavneos, is still working on the postmarket research the FDA mandated, company spokesperson Alison Chartan said, adding, “We remain committed to completing this important study.”

Amgen’s headquarters in Thousand Oaks, California, in May 2023. (Mario Tama/Getty Images)

Behind Schedule

An FDA database downloaded by KFF Health News in August tracks the progress of postmarket studies that makers of drugs or biologics — such as vaccines and gene therapies — were required to perform or promised to perform.

The database showed almost 600 were running behind schedule.

Of those, more than 250 originally had final reports due before July 31, 2026 — the date that, according to an FDA webpage, the database last had been updated.

About a third of ongoing studies were listed as delayed.

In some cases, the FDA has granted extensions. In others, it has denied them. And in rare instances, the products were discontinued before the studies ran their course.

Postmarket studies can involve clinical trials or other analyses of patient data. They can look at safety or efficacy. A product can be the subject of more than one postmarket study.

The nearly 600 delayed studies involved almost 350 products, KFF Health News found.

The FDA has defined delayed as behind the original schedule. That can mean off track or overdue.

As of August, other FDA databases tracking medical devices listed dozens of postmarket studies as behind schedule.

Products included:

The CustomFlex Artificial Iris, a prosthesis implanted in the eye in place of damaged, defective, or congenitally missing irises. The protocol for a study in children was accepted in 2019, the database said. The study was meant to follow patients for five years. According to an FDA page downloaded in August, zero patients were enrolled.

Barbara Fant of Clinical Research Consultants, to whom the FDA’s 2018 letter approving the product was addressed, said the rarity of an eye disease called aniridia poses challenges for post-approval studies. The German manufacturer, the U.S. distributor, and Clinical Research Consultants are working with the FDA to identify alternative ways to fulfill the postmarket requirements, Fant said.

“Confirming the long-term safety of the device remains a top priority for both the study team and FDA,” Fant said.

Paxlovid, a treatment for covid. A study to assess its safety in pregnant women was originally to be completed by the end of 2024, the FDA database said. “The trial completion and final report milestones were missed,” the database said.

Pfizer, the manufacturer, is working with the FDA and remains committed to “submitting results as soon as practicable,” Pfizer spokesperson Jerica Pitts said.

The Scandinavian Total Ankle Replacement system. The device and the original protocol for the clinical trial were approved in 2009. The study was meant to include a minimum of 500 subjects, the database said, but the actual number enrolled was 142. Almost half those patients had one or more adverse events, with dozens of “reoperations,” “revisions,” or “removals,” the database said.

Rachel Colloff and Cristina Pasquino — spokespeople for Enovis, which markets STAR Ankle — did not respond to multiple inquiries. Jenny Braga, a spokesperson for Stryker, which previously sold the product, did not answer questions about the postmarket study.

Oxaydo (originally named Oxecta), a form of the potentially addictive opioid painkiller oxycodone touted as designed to deter abuse. When the FDA approved it in 2011, it required the manufacturer, part of Pfizer, to conduct a postmarket study to assess whether it reduces “misuse and abuse, and their consequences: overdose, death and addiction.” The final report was originally scheduled to be submitted in 2016.

The FDA database listing the study as delayed said the agency “issued a failure to respond letter” in 2022.

Today the issue may be all but moot.  

Control of the product passed from company to company over the years until 2023, when Acura Pharmaceuticals said in a Securities and Exchange Commission filing that patents on Oxaydo would begin expiring that year and it didn’t intend to continue marketing the drug.

According to another FDA database, Oxaydo has been discontinued.

The FDA has enforcement powers and uses them “where appropriate,” HHS’ Hilliard said. She did not provide requested details, and she did not answer questions about the studies listed above.

Delay Can Pay

For manufacturers, delay can pay, Harvard’s Kesselheim said. While postmarket studies are ongoing, companies can continue to sell the products.

“Medicare and Medicaid spent more than $18 billion from 2018 to 2021 for accelerated approval drugs with incomplete confirmatory trials past their original planned completion dates,” the HHS Office of Inspector General estimated in 2022.

The FDA can demand postmarket studies for a variety of reasons, including to address concerns that arise after a product has been approved. Some look at uses not covered by the original approval, and some are meant to shed light on serious risks that are already known.

In April, when it approved Foundayo, a weight loss drug made by Eli Lilly, the FDA required the company to conduct additional research to assess a variety of concerns, including “retained gastric contents,” “major adverse cardiovascular events,” and “drug-induced liver injury,” as well as effects of exposure during pregnancy, such as “major congenital malformations,” “spontaneous abortions,” and “stillbirths.”

The FDA said it approved the drug under the new Commissioner’s National Priority Voucher program, intended for products that “address critical national health priorities.” The program strives for an “ultra-fast” review, the FDA has said — one to two months, instead of six months or more with other expedited pathways.

“Postmarketing requirements and enhanced safety monitoring are a routine part of the FDA’s approach to evaluating newly approved medicines,” Eli Lilly spokesperson Kristiane Silva Bello said, “including ongoing monitoring in areas identified during clinical development.”

‘False Hope’

The FDA waded into a world of uncertainty in 2016 when it granted accelerated approval to a drug for Duchenne muscular dystrophy, a degenerative disease that primarily affects boys, disabling them at a young age and ultimately killing them.

Agency scientists had found that the drug, Exondys 51, was unproven and argued against greenlighting it.

Ellis Unger, then a senior drug evaluation official at the FDA, wrote in an internal memo that “thousands of patients and their families would be given false hope in exchange for hardship and risk.”

The manufacturer, Sarepta Therapeutics, conceded the uncertainty. “A clinical benefit of EXONDYS 51 has not been established,” it said when the drug, also known by the generic name eteplirsen, was approved.

The drug, the first FDA-approved treatment for Duchenne muscular dystrophy, targeted a subset of patients with the disease.

The FDA required Sarepta to conduct further studies and warned that it could withdraw approval if postmarket trials failed to verify a clinical benefit or were “not conducted with due diligence.”

Unger issued a warning of his own: “FDA has not succeeded in withdrawing the marketing of a single drug for lack of verification of clinical benefit following accelerated approval. The reality is that if eteplirsen is given accelerated approval, it is highly likely to remain on the market indefinitely, irrespective of whether or not efficacy is verified.”

Sarepta was originally required to submit a final report on a postmarket study by a May 2021 deadline, according to an FDA database and a 2016 FDA letter to the company.

Almost a decade after the drug was approved, and more than five years after that deadline, the study was listed in an FDA database as delayed.

“The final report milestone was missed, because the sponsor requested milestone extensions due to study delays,”  the database said.

Meanwhile, in 2022 the website Pharmaceutical Technology ranked Exondys 51 as the second-most expensive drug in the U.S., at an annual cost of $750,000 to $1.5 million.

Last year, the drug generated $538 million in sales for Sarepta, according to a company presentation to investors.

Sarepta found it difficult to recruit patients for the postmarket clinical trial, company spokesperson Tracy Sorrentino said. The target population is small, patients were hesitant to enroll, and Sarepta was competing with other clinical trials for participants, Sorrentino said.

The study has been fully enrolled since 2023, Sorrentino said, and the company plans to provide an initial look at the data late this year.

‘Manipulated’

Amgen is the maker of the drug Tavneos. (Hannah Yoon/Bloomberg via Getty Images)

Amgen has cited similar challenges, even as Tavneos generated $459 million in global sales last year.

When an approved treatment is available, patients may be reluctant to enroll in a study in which they could be given a placebo, Amgen’s Chartan said.

The clinical trial was originally supposed to be done by the end of 2030. As of July 24, just 49 patients had been enrolled, Chartan said.

The FDA has said the study was to include 300 patients, and each patient enrolled must be followed for five years, said Hilliard, the HHS spokesperson.

Tavneos was approved to treat severe cases of a group of diseases — known by the shorthand ANCA-associated vasculitis — in which, as the Cleveland Clinic explains, the immune system inflicts potentially fatal damage on blood vessels and organs. 

“As of January 2026, estimated real-world exposure” to Tavneos “exceeds 25,000 patient-years globally, consisting of over 6,500 in the United States and 19,000 abroad,” Amgen has said. (For context, one patient taking a drug for five years would amount to five “patient-years.”)

A clinical trial sponsored by ChemoCentryx to secure approval of Tavneos failed to prove it was effective, the FDA now alleges. Instead of disclosing that outcome to the FDA, company personnel “manipulated” the results, the FDA alleged in an April letter to Amgen.

Amgen, the parent company of ChemoCentryx, has denied the results were manipulated and has said the data “remain valid.”

Nonetheless, the European Union recently revoked its approval of Tavneos.

The FDA is trying to pull Tavneos from the market, and Amgen is fighting that effort.

The company has a lot riding on the outcome. Tavneos can cost more than $220,000 per year, according to the drug discount website GoodRx, and when Amgen acquired ChemoCentryx in 2022 for $3.7 billion, Tavneos was the only drug ChemoCentryx had brought to market.

In a June letter to the FDA, Amgen said the benefits of Tavneos outweigh the risks.

The FDA disagrees.

The FDA “can no longer conclude that there is, or has ever been, a valid demonstration of substantial evidence of effectiveness for TAVNEOS,” the agency wrote.

Citing 76 cases of DILI — drug-induced liver injury — the agency said it was “increasingly concerned about the safety profile of TAVNEOS.” Without proof of effectiveness, at least for its approved use, “the drug’s benefits cannot outweigh its known risks,” the FDA wrote.

Data reporter Maia Rosenfeld contributed to this report.

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.

The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) today announced a settlement with Ambry Genetics Corporation (Ambry).

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.

Reports from a top artificial intelligence company that it stopped several attempted uses of its product that could assist in manufacturing a bioweapon caught the attention of lawmakers in Washington this week. But it is still unclear whether or when Congress will act to regulate the fast-moving industry — and the House has left town until after Election Day.

Meanwhile, with many voters expressing anger over the rising cost of healthcare, President Donald Trump is proposing to send $500 checks to some people enrolled in Affordable Care Act insurance plans before the election. But even if those checks materialize, in most cases they will be smaller than the increases many policyholders have already seen.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Tami Luhby CNN @Luhby Read Tami's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• Anxieties about AI reached a fever pitch this week, with a few leading developers calling to slow the pace of innovation amid troubling reports about AI’s progress and use, including reported attempts to misuse AI for biological warfare. Meanwhile, the Trump administration is pressing to incorporate AI into healthcare.
• Federal lawmakers are exploring changes to the independent arbitration system created by the No Surprises Act, which took effect in 2022. While the law has cut down on patient exposure to surprise out-of-network medical bills in emergencies, the system has resulted in far larger paydays than anticipated for many doctors — which, in turn, has prompted a sizable increase in coverage costs, including for employers.
• Some cities and states are suing to block implementation of the latest public charge rules from the Trump administration, arguing they could have a chilling effect for some who are entitled to public benefits, such as the eligible children of immigrants. They allege that could leave cities and states on the hook and harm local economies.
• Abortion opponents are claiming victory as the Environmental Protection Agency moves to test water for remnants of abortion pills, among other chemicals and drugs. California’s attorney general is wrapping up a lawsuit against two nonprofits offering what they describe as abortion pill reversals, despite a lack of evidence the method works or is safe. And the family of a Texas woman who died after being denied an abortion is suing her doctors and the state’s attorney general, Ken Paxton.

Also this week, Rovner interviews Sabrina Corlette of the Georgetown University Center for Health Insurance Reforms, discussing some potential short-term fixes to the nation’s health system.

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

Julie Rovner: KJZZ Phoenix’s “Data Shows DES Failed To Complete Most SNAP Eligibility Interviews, Resulting in Massive Cuts,” by Camryn Sanchez.

Tami Luhby: The Washington Post’s “What ‘Ferritin Face’ Means — And How To Tell If You May Be Iron-Deficient,” by Erica Sloan.  

Anna Edney: Bloomberg News’ “Patients Who Fight Health Insurance Denials Often Win,” by John Tozzi, Tanaz Meghjani, and Ike Swetlitz.

Alice Miranda Ollstein: KFF Health News’ “Indigenous Groups Are Exempt From Medicaid Work Rules, but Native Hawaiians Aren’t,” by Ashley Mizuo.

Also mentioned in this week’s podcast:

• Science’s “‘Chilling’ Warning or Overreaction? AI Bioweapons Report Divides Experts,” by Jocelyn Kaiser.
• The New York Times’ “U.S. Health Officials Move Quickly To Deploy Medical A.I. Despite Concerns,” by Christina Jewett.
• Roll Call’s “Surprise Billing Dispute Process In ‘Crisis,’ Groups Say,” by Ariel Cohen.
• KFF Health News’ “A Generation of Kids Suffer as Trump Destabilizes Immigrant Families,” by Claudia Boyd-Barrett.
• Politico’s “Abortion Opponents Claim ‘Tremendous Victory’ as EPA Tests Water for Abortion Pills,” by Miranda Willson, Alice Miranda Ollstein, Ariel Wittenberg.
• Politico’s “Free Speech or False Advertising? California Judge To Rule on ‘Abortion Pill Reversal’ Claims,” by Rachel Bluth and Alice Miranda Ollstein.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

And subscribe to “What the Health? From KFF Health News” on Apple Podcasts, Spotify, the NPR app, YouTube, 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.

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

HHS issued an RFI seeking evidence and information from the public and experts on the potential health effects of electromagnetic fields.

HHS launched the new Systems for Phenotypic Evaluation, Clinical Trajectories, Response, and Agency (SPECTRA) program.

HHS Secretary Robert F. Kennedy, Jr., announced the addition of eight new members to the U.S. Preventive Services Task Force.

The scenario often unfolds like this: Medical researchers investigate a frequently used drug and report that it’s less effective for older patients than previously thought, or that its risks outweigh its benefits in older adults. More studies follow, confirming those findings.

After a few years, medical associations revise their guidelines, warning that the drug in question should be avoided or at least prescribed more selectively. It might be added to the Beers Criteria, an influential list of potentially inappropriate medications for older patients, published by the American Geriatrics Society.

If the drug’s role is preventive, the U.S. Preventive Services Task Force, an independent expert panel, may weigh in with cautions. The FDA may issue “black box” warnings about concerning side effects.

After a few more years, researchers look at broad national data to see whether use of this drug declined. Often, the answer is: Yes, but not enough. Sometimes, though, use didn’t decline much at all or actually increased.

“Medications are like barnacles,” said Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the U.S. Deprescribing Research Network. “They’re easy to start, but they can be hard to stop.”

This medical inertia partly reflects the time lag involved in disseminating findings. “Clinicians have a million things they need to know and attend to, and information may take a while to get to them,” Steinman said.

But it also reflects the way “clinicians and patients get used to treating conditions in certain ways,” he said. “They become ingrained habits.” Finding alternative approaches is challenging, so “it’s easy to go with what you know.”

Recent studies of three medications or classes of drugs widely used among older Americans illustrate the problem.

The Drawbacks of Benzodiazepines

Scientists began raising alarms about benzodiazepines more than 20 years ago. Prescribed for insomnia and anxiety, “they offer prompt relief,” said Mark Olfson, a psychiatrist and epidemiologist at Columbia University.

The problem? Benzodiazepines (including Valium, Xanax, and Ativan) and the related “Z” drugs (Ambien, Lunesta) “may impair balance, coordination, and cognition that can translate into falls and fractures and motor vehicle accidents,” Olfson said. In patients also taking opioids for pain, benzodiazepines can cause overdoses.

Moreover, “once you’ve taken them for a period of time, you develop a dependence,” Olfson added. “When you come off them, you may develop withdrawal symptoms.”

So what’s happened to benzo use among older adults, who are more sensitive to these effects? In a recent examination of prescribing trends, published in the Annals of Internal Medicine, Olfson and his team reported progress. Among people 65 and older, the rate of patients filling prescriptions for benzos dropped to 11.5% in 2024, from about 14% in 2015.

But that decline has stalled since 2020, perhaps related to the covid-19 pandemic. Moreover, prescribed use actually rose among those over 75, from 12% in 2020 to about 13% four years later. Dispensing through pharmacies in long-term care facilities more than doubled. And about a third of users were taking the drug for longer than six months, increasing the likelihood of dependence. “It’s worrisome,” Olfson said.

But he cautioned that patients shouldn’t stop benzodiazepines suddenly or on their own, which can provoke withdrawal. “It requires supervised tapering” with a medical professional, he said. “It takes many weeks.”

Overprescribing Antibiotics

For years, the standard treatment for diverticulitis, the inflammation or infection of small pouches that form in the colon, was antibiotics, primarily fluoroquinolones (like Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin).

“It was unquestioned,” said Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system. “Antibiotics are safe and effective, great, lifesaving drugs, so the mindset was: When in doubt, use them.”

But in 2015, the American Gastroenterological Association recommended against routinely prescribing antibiotics for “uncomplicated” diverticulitis, which represents a great majority of cases. Other medical groups followed suit.

Clinical trials had shown that, for this condition, antibiotics had little or no effect on mortality, the need for surgery, complications, or recurrences. “They hadn’t improved anything,” Sutton said.

And as with any drug, “there are downsides, unintended consequences,” he said. “Side effects from antibiotics account for a substantial amount of emergency room visits” for symptoms like nausea, vomiting, and diarrhea. Antibiotics heighten the risk of the virulent C. difficile infection, too.

Plus, “the more you use antibiotics, the less they work in the future,” Sutton said. The World Health Organization has deemed antimicrobial resistance “a major global health threat.”

So Sutton and his colleagues, studying treatment in 70,000 visits to 120 VA facilities, expected to see antibiotic use for uncomplicated diverticulitis decline over 10 years.

Instead, they reported recently in the Annals of Internal Medicine that antibiotic prescriptions remained nearly universal at 97% of visits, guidelines or no guidelines. The patients would most likely have done as well with a few days of Tylenol and a clear liquid diet.

Antibiotic overuse remains common for other conditions of later life, too, including the kind of urinary tract infections that cause no troublesome symptoms and upper respiratory infections that are typically viral, not bacterial.

In such cases, when a doctor prescribes an antibiotic, “I’d encourage patients to say, ‘Please explain the rationale for doing this,’” Sutton said. “If they don’t, it’s OK to press pause.”

When Aspirin Isn’t the Answer

Aspirin is different. Because it’s cheap and sold over the counter, anybody can start taking it on their own — and millions of older Americans do, thinking it will help prevent cardiac problems.

For people who’ve already had a heart attack, stroke, or cardiac intervention like a stent or bypass surgery, daily low-dose aspirin for “secondary prevention” does lower the odds of another event, studies have demonstrated.

But for “primary prevention” in people who haven’t had one, the guidelines changed in 2019, when the American College of Cardiology and the American Heart Association recommended against aspirin for this purpose in those 70 or older. The U.S. Preventive Services Task Force went further, warning against aspirin for primary prevention starting at age 60.

Large clinical trials had shown scant benefit for aspirin as a primary prevention measure, but there were harms, notably gastrointestinal bleeding. “As we age, the risks of bleeding go up,” said Timothy Anderson, an internist at the University of Pittsburgh who co-directs its Prescribing Wisely Lab. More rarely, but more seriously, aspirin can cause bleeding in the brain.

In a JAMA study published last year, Anderson and his co-author found the message was getting through: Aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had dropped substantially from 2011 to 2023. But more than a third of those 70 or older were still taking it.

Some caveats: A subgroup of older adults with high risk factors for cardiovascular disease may benefit from aspirin for primary prevention. And, confusingly, some evidence suggests that older patients already taking aspirin face a higher risk of cardiovascular disease if they discontinue it.

“Step 1 is a conversation with your primary care physician” about aspirin, Anderson said. “‘Is this still right for me as I get older?’”

Older patients taking aspirin, many without any medical guidance, “are interested in reducing their risk of heart attack and stroke,” he said. “They’re trying to be proactive and healthy.” But with blood pressure medications and statins for cholesterol, “we have better strategies than aspirin for that.”

The New Old Age is produced through a partnership with The New York Times.

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.

A long-running lawsuit challenging what it means to be an employee and therefore have access to work-based health plans is being closely watched by health policy analysts. Its outcome could spur the availability of lower-cost but potentially skimpier health coverage that skirts some consumer protections.

Court papers indicate a settlement in the case against the Department of Labor may be in the works, although the parameters of any such deal are unknown.

It would come amid premium surges on Affordable Care Act marketplaces that have led millions to drop coverage this year. The Trump administration has also been sharply focused on expanding access to alternative coverage, such as short-term plans that avoid ACA rules on preexisting conditions and benefit requirements.

“Depending on what happens with the settlement, this could be an even bigger expansion,” said Katie Keith, director of the Center for Health Policy and the Law at the Georgetown University Law Center. “People are worried that it is the opening salvo into promoting junk plans that don’t meet the ACA requirements.”

The plaintiff, Data Marketing Partnership, filed its case against the Department of Labor in 2019, during the first Trump administration. It wants official recognition as an employer so it can continue to allow its limited partners to buy into a type of job-based health insurance that doesn’t have to comply with state insurance rules or offer coverage as robust as required under the ACA.

But to grasp the claim, one also has to understand how the coverage works.

A consumer shopping for health insurance may come across information online or from a marketer about this concept, sometimes called “limited partnership” coverage. The pitch? Buy insurance offered through Data Marketing Partnership and handled by LP Management Services. To qualify, the consumer must download an app that tracks their internet searches. The company could then sell that data.

Some potential consumers may be turned off by the thought of their internet searches being tracked, but others may find it appealing because it allows them to become a limited partner eligible to buy into the company’s employee health insurance plans. But can these partners be considered employees?

The court’s answer has potential implications for regulators and consumers. Some health policy and market experts warn that a green light could lead to a proliferation of aggressively marketed and potentially questionable insurance with limited recourse for consumers because the plans would be exempt from state oversight.

“If this took off, you logically could see the rise of a whole bunch of what, functionally, would be unregulated insurance companies,” said Ali Khawar, who was the principal deputy assistant secretary of the Department of Labor’s Employee Benefits Security Administration during Joe Biden’s presidency and now runs his own consulting outfit.

No one knows if the department is going to change its long-running stance defending the case. But any settlement could add more uncertainty to insurance markets.

Already insurers are requesting double-digit increases in ACA premiums again next year, partly because declining enrollment often means that the healthiest policyholders are leaving. That trend could accelerate in coming years as more people are drawn into alternatives such as limited-partnership policies.

States Act as Federal Case Plays Out

The Department of Labor defended the case throughout the first Trump administration and the Biden era, issuing a sharply worded advisory opinion in early 2020 stating that people who simply download software to “capture data as they browse the Internet” are not “employees or bona fide partners.”

A district court judge in Texas, who had previously ruled the ACA unconstitutional in a decision ultimately rejected by the Supreme Court, called the advisory opinion “arbitrary and capricious” in a 2020 ruling in favor of the data marketer. The U.S. Court of Appeals for the 5th Circuit largely upheld the lower court’s decision but ordered it to reconsider whether someone who downloads software is either a “working owner” or a “bona fide partner.”

The employer-employee relationship is at the heart of the case because of a 1974 federal law designed to help large, self-insured employers offer retirement and health benefits to workers without having to meet varying rules from multiple states.

That law — the Employee Retirement Income Security Act — allows such plans to avoid most rules set by the states, which generally regulate most other types of insurance and assist consumers who report problems with their policies. As self-insured employer plans, the policies also don’t have to comply with some ACA rules, such as the requirement to cover 10 broad categories of “essential health benefits.”

“If the case goes the wrong way, it could impact consumers or hamstring the states,” said Marie Grant, Maryland’s insurance commissioner.

Arguments over what constitutes an employer plan are not new, and other organizations have tried offering such coverage. Some states have taken action against purveyors of limited-partner policies.

Maryland in 2024 fined a company, The Vitamin Patch, for offering limited-partnership insurance after investigating complaints and determining it was not licensed to sell coverage in the state.

Washington in 2021 ordered another company to stop offering its plans in the state and fined it $25,000.

Maine and Connecticut in 2024 warned consumers about this type of coverage.

“These plans do not provide comprehensive medical coverage and can leave consumers with large, unpaid medical bills,” according to Connecticut’s notice.

Maine’s announcement noted that entities offering these types of health insurance included The Vitamin Patch as well as Affiliated Workers Alliance, Consumer Data Partners, Employers Business Alliance, Socios Buenos, and Strategic Limited Partners.

State insurance commissioners filed legal arguments in the Department of Labor case citing their concerns about losing the ability to enforce consumer protections.

“This is not a Republican-Democrat thing,” Khawar said. “It’s really a story about state authority, the way such authority would be significantly undermined in insurance markets.”

What’s the Risk?

Still, these limited-partnership plans are viewed by proponents as a needed additional choice for consumers, at potentially lower cost than ACA plans.

When the case was filed, attorneys general from seven right-leaning states, for example, urged the Department of Labor to back Data Marketing’s request to designate its limited partners as employees. That would provide an option for people who “earn too much to qualify” for ACA subsidies and be an interim solution until the ACA could be repealed and replaced, they wrote. They argued that states would retain some regulatory authority and added that the Department of Labor, which oversees self-insured employer plans, could set requirements to “encourage” stable companies to enter the market.

Critics, the attorneys general wrote, might fear that ACA alternatives will draw away younger or healthier people, thus affecting those who remain, but they argued that had already happened.

Data Marketing’s attorneys emailed KFF Health News that they could not provide a comment for this article because the case is in active litigation. Neither the White House nor the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, responded to questions from KFF Health News about whether the Department of Labor has changed its stance and how the administration views limited-partnership health plans.

In court filings, however, Data Marketing said that without an employer designation, it would have to end the insurance coverage, affecting about 50,000 policyholders. That would also hurt its ability to generate revenue, it argued, because offering insurance is “a significant attractor” to get people to join its partnership and let it access their electronic data.

Ellen Montz, who helped oversee ACA implementation in the Biden administration and is now a managing director at consultancy Manatt Health, had a different take. “The only reason why these sorts of products exist is because they aren’t beholden to consumer protection rules of the ACA and can essentially make money by attracting good risk, people who are healthy,” she said.

Maryland’s Grant echoed this warning, saying that proliferation of such plans could lead to even higher premiums in the ACA markets, if those who remain are older or sicker than those who leave.

Nineteen patient advocacy groups sent a letter to the Department of Labor Aug. 11 urging it to continue its defense in the case, warning that a settlement that says such arrangements create an employer-employee relationship could “significantly” undermine “both state regulatory authority and decades of bipartisan efforts to promote stable, well-functioning health insurance markets.” Some of those groups had filed a legal brief in support of the department in 2021.

Days after the August letter, U.S. Rep. Bobby Scott (D-Va.), the ranking member of the House education and workforce committee, warned the department against increasing the availability of “questionable employment relationships” and the insurance they offer.

He cited reports of call centers’ misleading consumers “who think they are enrolling in comprehensive health insurance but instead sign up for junk coverage under the guise of creating an employment relationship with what the consumer believed to be a traditional health insurer.”

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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When Josh Fleig, Louisiana’s chief innovation officer, learned his state had set aside $20 million a year, for five years, to invest in startup rural health companies, his reaction was not surprising: “Wow!”

In rural America, where people are often reported to be sicker with poor access to healthcare, the cash influx is a relief. In the economic development space where Fleig operates, it’s an opportunity.

“Look, that’s a lot of money for what we do,” said Fleig, whose state-funded economic development office invests in corporate launches, ranging from software startups to shipbuilders.

Josh Fleig, chief innovation officer for the Louisiana Economic Development agency, says he’s excited to help fund startup technology companies that could improve the health of rural residents in the state. (Margot McNeely/Louisiana Innovation)

Louisiana and a handful of other states set aside money from their share of the $50 billion federal Rural Health Transformation Program to quickly invest in new technologies, mirroring private industry moves. Lawmakers added the rural health program to offset more than $900 billion in reduced Medicaid spending expected over 10 years from Republicans’ sweeping 2025 tax and spending law.

But rather than filling the budget hole, the rural program’s assignment is to find new approaches for revitalizing rural communities where doctors are in short supply and hospitals have been downsizing and closing for decades. The federal government doled out the first-year rural health program awards to states this year, with pots ranging from $147 million in New Jersey to $281 million in Texas.

Modernizing technology infrastructure is a key pillar of the federal rural health program, and the catalyst money epitomizes the administration’s strategy to move fast and experiment with untested technology — much like the “move fast and break things” mantra during the heyday of Silicon Valley.

Instead of breaking things, though, the goal is to “move fast, fast-fail, innovate quickly, and move to sustainability,” said Aaron Bujnowski, a managing director with the healthcare industry group at the consultancy Alvarez & Marsal. “This is a transformation that is still meant to serve the people.”

Rigorous Rules and Tight Deadlines

Beyond Louisiana, Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, confirmed that Delaware, Georgia, Massachusetts, Nebraska, South Carolina, Virginia, and West Virginia are also creating rural health tech catalyst funds.

Every year, states must compete for rural funding in the five-year federal program. Federal regulators will take money away from states that do not meet the goals promised in their applications, including whether they designated money to companies for tech innovations.

CMS, which is overseeing the program, released a seven-step guidance document for states to follow when creating the tech catalyst operations. No more than 10% of each state’s award can be spent on a rural tech catalyst fund.

States’ initial annual progress reports for the rural fund were due at the end of August. CMS has declined to publicly post those reports; it plans to publish an annual report on state progress. States must show that first-year funds will be obligated — but not necessarily spent — by Oct. 30, according to the CMS guidance document.

Daniel X. O’Neil, a technology consultant who advocates for open data and open government, created a state tracker and parsed the original state applications to find dozens that mention catalyst awards and technology funds.

O’Neil said he is “looking forward to the clawbacks and the craziness of October because, you know, that’s serious stuff.”

For the rural health catalyst funds, CMS requires states to submit the list of finalists “at least 15 business days” before announcing winners, along with “sufficient information” for the agency to “assess each proposed project,” according to the guidance document.

The document outlines intellectual property and federal rights but does not provide guidance or standards for patient rights or protections. CMS spokesperson Foster stated in an email that the technology investments must comply with federal “privacy, security, interoperability, and patient safety” requirements.

Protecting Patients

Maya Sandalow, director of the health program at the Bipartisan Policy Center and one of the leading analysts watching the rural fund, said the catalyst funds are “public dollars” and has called for more transparency in the overall rural health program. The center is a nonprofit think tank in Washington, D.C.

Accurate and timely reporting must be done to ensure “the necessary guardrails are in place” to protect patients, she said, adding that the innovation needs to be “tested in a way that’s safe for the patients that they are going to be used on.”

To apply, startups must be less than 10 years old and have raised less than $50 million in early funding. Companies that win a portion of state catalyst funds must meet predetermined milestones before being paid — and federal officials will make “targeted reviews as needed,” according to the guidance document.

Louisiana officials announced the state’s tech catalyst fund with an event in rural Natchitoches, known as the filming location of the 1989 film Steel Magnolias. The fund quickly drew more than 200 companies competing for between $250,000 and $3 million in seed money.

Tiny startup Greens Health was invited to the event. The 2-year-old company analyzes Medicare claims to identify patients with chronic diseases, such as diabetes, and works with local home health nurses and senior facilities to improve care.

“We’ve been looking for a way to launch in Louisiana,” said Kehlin Swain, co-founder and chief executive of Greens Health. The company serves about 100 patients across Texas, Alabama, and Florida and hopes to get a $250,000 investment from Louisiana.

Louisiana’s Fleig said his state is “at a really interesting turning point.” The state secured $208.4 million for the first year of the rural health program and quickly created its catalyst fund using the state’s already established innovation department.

At the same time, nearly 1.1 million people live in Louisiana’s rural parishes and the state ranks as the “least healthy” in the nation, according to its own application. State rates of diabetes, obesity, and cardiovascular disease are among the highest in the nation.

Fleig believes Louisiana is an ideal place to test technology solutions. So, while Silicon Valley has “not needed much of what Louisiana has had to offer” for much of its existence, it does now, he said.

Caret Health is one of those companies. Co-founders Riya Pulicharam, who is a physician-researcher, and Kevin Zhao, an engineer, met in Silicon Valley. Together, they created a technology platform that identifies patients who need help getting to their appointments, having scans done, or picking up prescriptions. That technology flags a human, who then contacts the patient with a call or text.

Zhao said Caret had successful pilots at large health systems, but those places also had other vendors and “it was a pretty big uphill battle” to get in and scale. Then, in 2024, the company began paying attention to rural places.

“There wasn’t a lot of existing infrastructure. And that was really good for us because we were able to come in very quickly,” Zhao said. “A lot of the hospitals really needed this kind of service.”

Fast-forward to 2026: Caret Health is about 4 years old and has contracted with about 60 hospitals in 16 states. Pulicharam and Zhao hope to win $3 million to expand into Louisiana.

Louisiana’s Fleig said the state will take an equity stake in each company it invests in. “The dream” is that selected startup companies will also help the state make money to reinvest. If some companies fail — or fail fast — that’s to be expected, but the state should still make money because of “the law of averages,” he said.

“If we are good, we’ll make more money than we spent,” Fleig said. “Either way, it’s going to go back into improving healthcare outcomes.”

Rural Tech-Catalyst Funds: Fast-Moving, High-Pressure

First-year progress reports were due at the end of August. Using the annual report, federal officials will recalculate and potentially claw back money from underperforming states, according to reporting requirements created by the Centers for Medicare & Medicaid Services, which oversees the program.

States will be scored on a multitude of initiatives and plans, plus whether they earmark their first-year spending by Oct. 30. Year 2 funding will be determined by the end of October.

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 supplemental funding to three states to strengthen the role of faith-based organizations and leaders in substance use.

HHS Office for Civil Rights Announces Settlement Ending Discrimination Against Jewish Students at Lincoln Memorial University

Taya Hailstone has been in remission from childhood Hodgkin lymphoma for five years. But the cancer’s lasting damage to her organs and nerves can make basic tasks, like loading a dishwasher, hard.

Still, Montana’s health department decided last year that Hailstone is no longer eligible for low-cost disability health coverage through Medicaid. The department switched her coverage to the state’s Children’s Health Insurance Program, another Medicaid program — three months before she aged out.

Before making the decision, the state didn’t seek records from the medical team treating Hailstone, according to letters from those doctors reviewed by KFF Health News. Rather, the administrative ruling came after state officials learned the now-19-year-old had stopped receiving Social Security disability payments. She said she did that because she hoped to get healthy enough to work and save some money — beyond what’s allowed under the strict income caps tethered to those payments. But her health changes day to day, and she said for now she’s still too sick to consistently work.

Hailstone, who lives with her mom, has been able to keep Medicaid coverage while they appeal the case. She said that without Medicaid she can’t afford the treatment to manage the aftermath of her cancer.

“It feels like this process was made to make you give up,” Hailstone said.

Patients with disabilities have long struggled with administrative hoops, blunders, and confusion when trying to qualify for federally subsidized health coverage because of their illness. Now, new federal Medicaid work requirements mean states face the additional task of deciding who qualifies for a medical exemption. That means reviewing medical cases for an even larger swath of Medicaid enrollees.

Attorneys, researchers, and advocates who specialize in public aid said disability cases like Hailstone’s — though separate from the incoming work requirements — are an indication that states aren’t ready. As a result, they said, more people will be denied coverage in an opaque process.

“This will be the story of millions of people,” said Anthony Wright, who heads Families USA, a national nonprofit that advocates for ways to make healthcare more accessible.

Jon Ebelt, a spokesperson with the Montana Department of Public Health and Human Services, said the state doesn’t comment on individual Medicaid cases.

An estimated 18.5 million people will have to meet the new rules requiring them to prove they’re working, going to school, or volunteering to keep their Medicaid coverage, according to the Congressional Budget Office. More than 40% of those enrollees live with a chronic health condition, according to KFF. Some will be excused from those rules if they can prove they’re too sick to work.

More than 5 million people are expected to lose Medicaid coverage by 2034 because of the work requirements, according to the CBO.

Work Requirements Become Law

Many Republican policymakers and the Trump administration have touted Medicaid work requirements to preserve coverage for the neediest. Congress made that national policy through last year’s One Big Beautiful Bill Act and gave states until January 2027 to implement work-for-coverage rules.

Some states are starting those checks early. Montana began in July. Nebraska initiated work requirements in May.

In the federal law creating the work requirements, Congress allowed states to exempt people who have an illness that qualifies them as “medically frail.” Many states created plans for those judgment calls, only to be surprised when federal officials released rules for the requirements that went beyond what Congress outlined, by also requiring enrollees to prove their illness makes it too hard to work.

Families USA and other organizations have argued the new rules force states to set up a patchwork of systems that, together, would be larger and more complicated than the Social Security Administration’s own disability review system. Last year, that federal program cost more than $5 billion to administer to roughly 7 million people nationally. For comparison, Wright said, the federal law provided $200 million for states to share as they implement the work requirements. States are paying contractors millions of dollars to prepare often already flawed public aid systems to meet the new standards.

In June, 25 states sued the Trump administration over the medical frailty rules, arguing they’re too hard for patients to meet and for states to assess. That case is ongoing.

Hailstone was diagnosed with blood cancer at age 10. Her intestines tore, which led to their partial removal. As a result, her body struggles to process food and she can face severe dehydration. She said lingering side effects from her cancer treatment can leave her mind foggy and cause her hands and feet to swell enough that it’s hard to grip a fork or walk across a room.

Cancer dominated nearly half her life. It left mental scars, too.

“Some days you feel fine and then you suddenly crash,” Hailstone said.

Hailstone during her treatment for Hodgkin lymphoma. Though she has been in remission for five years, she deals with lasting effects from the disease. Now she is trying to convince the state of Montana that she should still qualify for Medicaid’s disability coverage. (Kyla Hailstone)

Hailstone and her mom live in Roundup, a central Montana town of roughly 2,000 people. They regularly make the nearly two-hour round-trip drive to Billings for specialized care. She typically has three medical appointments a week to see her physical and occupational therapists and a mental health counselor.

Hailstone said she’s lucky she has her mother’s help navigating Medicaid. Her mom, Kyla Hailstone, said that the state hasn’t clearly defined how it determined her daughter’s disability status and that its appeal process has been slow and dysfunctional.

Taya Hailstone would qualify for Medicaid based on her income if she can’t prove her eligibility for disability coverage. But that would mean proving she’s too sick to meet the work requirement — putting her in the same position of having to rely on a state review of her illness.

“If I lose this, this is life-changing,” Hailstone said.

‘Things Fall Through the Cracks’

Hailstone qualified as disabled through the federal government as recently as 2024, about a year before the state said it was dropping her coverage. State officials can do their own medical review to determine whether someone meets the federal definition of a disability to access Medicaid.

“Whether that happens is always a bit of a crapshoot just based on state capacity,” said Megan Dishong, deputy director of the Montana Legal Services Association, which helps low-income people navigate public programs. “Things fall through the cracks.”

Ebelt said the state health department accepts disability decisions from the Social Security Administration. The state agency can conduct an internal disability determination if a person doesn’t have one from the SSA, but Ebelt said it doesn’t have to if a person qualifies for coverage another way.

“We are committed to treating every client with respect and helping those who are eligible receive appropriate Medicaid coverage,” Ebelt said.

Montana instituted a three-month grace period for the work requirements. State officials won’t begin disenrolling people for noncompliance until October.

Pamela Herd, a University of Michigan social policy professor who has studied bureaucratic obstacles to public benefits, said convoluted disability cases are common enough for attorneys to specialize in accessing aid.

“When we’ve designed public programs in ways that people can’t figure out whether they’re eligible without consulting lawyers, we’ve done something wrong,” Herd said. “That has huge, huge implications for what’s to come.”

Montana officials have said they’ll automatically review medical records that could help patients qualify for an exemption. Even so, the federal guidelines released in June mean patients will probably still face additional steps to guarantee an exemption.

Meanwhile, already overstretched doctors worry they’ll face the burden of judging whether someone’s illness qualifies them for a work exemption.

Dishong said that between now and October, Montana officials could offer more clarity on how the process will work. She said she’s worried the state will end up “with a slow-roll mess” instead.

“This is a problem that’s just starting,” Dishong said.

As for Hailstone, she’s now reapplying for Social Security disability payments. That aid would limit how much she can work. But it would also guarantee access to Medicaid.

Have you tried to prove your eligibility for Medicaid under new rules that require people to show they are working, going to school, or participating in another qualifying activity? Click here to contact 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.

Employer-sponsored health insurance covers more than 165 million Americans. It can entice someone to work at one company over another, or be a set of golden handcuffs that keeps them locked into a job they may not enjoy.

But rising costs are straining that system like never before. As premiums balloon, employers have started to pass on more costs to their workers, and the percentage of small businesses offering employees health insurance has dropped significantly.

Stat reporter Bob Herman has been covering this in his series “Out of Pocket, Out of Reach.” An Arm and a Leg host Dan Weissmann and Herman break down how businesses big and small handle the skyrocketing cost of providing health insurance and what it means for workers.

Dan Weissmann @danweissmann @danweissmann.bsky.social 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% 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: System meltdown: employer-sponsored health insurance

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. Rachel Bernier-Green runs Thrive-O Financial Advisory on Chicago’s South Side. She describes herself as a fractional CFO for small businesses, offering strategic financial advice along with accounting services. And she says employee health insurance was part of her business plan from the beginning.

Before she even had employees, she built extra money into her prices, and at first, she put that extra money into a rainy day fund. But by late 2024, she thought the time had come. 

Rachel Bernier-Green: I’d been in business for a while. I had a few team members, and things were moving along. 

Dan: She wanted to keep those team members around, and she knew health insurance would help do that

Rachel Bernier-Green: And so that’s when I actually started to think, “How do we actually get this in place?”

Dan: She says she moved quickly– and by January 2025, her six-person team had health insurance.  Then things got wobbly.

Early in the year, a major client left. Income took a hit, and by spring she could see big trouble coming toward her. Insurance for 2026 was going to be way more expensive. And she could tell because some of her clients were already seeing rate hikes from their health insurance companies.

They had policies that renewed early in the year, . And these were much steeper increases than they’d been expecting, so they came to Rachel, their fractional CFO, to help them figure out how to adjust, and Rachel knew she would have to do the same.

Rachel Bernier-Green: It was almost like standing on a train tracks and you’re just kind of staring down the impending doom because you know you’re going to be in the exact same situation in a couple of months.

Dan: She says she shared the bad tidings with her team as data came in right from the start, and she said she makes a practice of sharing the company’s finances, details and all, with her colleagues. She calls it open book accounting.

Rachel Bernier-Green: We have regular team meetings where we’re discussing these things and we could all look at the numbers and the writing was on the wall. So when we kind of got to the end of the road, it wasn’t me saying, “Surprise, here’s what’s going on with the health insurance.” It was more, okay, we’ve reached the point where we have to make a decision and call it.

Dan: They made the call at a regular team meeting, which doesn’t mean the meeting was routine.

Rachel Bernier-Green: My heart was just in my stomach. Um, Because like I knew what we needed to do and I just didn’t want to, want to do it. 

Dan: But they’d gotten their renewal notice for 2026. Health insurance was gonna go up by more than 10%. Rachel says everybody agreed the business couldn’t afford it. 

Rachel Bernier-Green: The numbers were pretty clear in black and white. the entire team was on the same page that what was most important was that the business continues to survive so that we could bring back those benefits in the future. 

The thing I remember the most is that another team member who relied on the insurance reassuring me that that was the right thing to do.

Dan: Even with that kind of consensus, and even with a plan in place to bring back those benefits for 2027, Rachel describes the whole episode as devastating. She’s gone on a plan from her husband’s employer. Some other colleagues have done the same, one has left the firm, and two are uninsured. Rachel and her colleagues aren’t alone.

They’re a case study. A reporter named Bob Herman featured them recently in a story for STAT — a news outlet dedicated to health and medicine.  The headline for Bob’s story: America’s Small Businesses are Giving Up on Health Insurance. And the crisis Bob is reporting on goes beyond small employers. That story kicked off an eight-part series called Out of Pocket, Out of Reach, with a subtitle that tells you how big and how deep this crisis goes.

It’s “How America’s Employer-Based Healthcare System Continues to Crumble in Slow Motion,” which sounds scary and absolutely sucks, but it’s the kind of big picture look we really need, and Bob is exactly the person to break it down. He’s the Business of Healthcare Reporter at Stat. He has done the most comprehensive reporting on the giant UnitedHealth Group.

And for years, he’s published a list of the top paid CEOs in healthcare. These compensation packages go to the hundreds of millions of dollars a year in some cases. It’s completely wild. And he knows how to bring a huge story down to earth. He’s coming right up. This is An Arm and a Leg, a show about why healthcare costs so freaking much and what we can maybe do about it.

I’m Dan Weissmann, I’m a reporter. I like a challenge, so the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering, and useful. Bob Herman joined me from a closet. One of his kids had a friend over, it was the quietest place in his house.

He was sitting on the floor. I should’ve been recording the whole time. But we did have the recorder on when I asked him, “How did you come to the conclusion that employer health insurance doesn’t just suck, it’s crumbling?”

Bob Herman: Well, here, maybe it’ll help if I explain kind of the origins of why we even started it. Um, so I’d gotten back from parental leave last year around November. My wife and I just had our second kid, and literally the first thing I have to do, both of us, we both have to do when we get back, is we have to figure out what health insurance plans we’re gonna enroll for the next year, which, as I’m sure you and every one of your listeners knows, is a miserable experience. Um, and I… And we cover healthcare, and it’s still miserable. It’s tedious but also it’s, it, it is high stakes. And at that time, we had seen all the headlines that employer-sponsored health insurance was experiencing double-digit increases ac- everywhere. It is one of the primary ways that Americans are covered, and we’re all getting slammed in the face with historically high premium increases. It turned into, like, this needs to be a project at Stat. Let’s go after it. Let’s figure out what’s going on. And I think it just became very clear that employer-sponsored health insurance is not, you know, the robust product that I think a lot of people think it is.

Dan: And your conclusion here is, like, there’s a structural problem here, starting with how fast the cost of employer-sponsored insurance is going up. 

There’s a, there’s a really big number in your story where you kind of compare how much more health insurance costs now than it did 40 years ago comparing it to the rate of inflation. And basically, health insurance prices have risen almost four times as much as inflation in general. 

Bob: ?Right. And like, you know, we’re talking over the past several decades, almost 1,000% increase versus wages that were much, much lower than that., 

Dan:  So, one takeaway there is:  This huge increase amounts to something like a hidden pay cut for all of us. 

Bob Herman: Hopefully that’s one thing that this series can accomplish is for all workers out there, when you enroll in your health plan every year, how your employer’s paying for it, how much is getting taken out of your own paycheck. These are things that ultimately affect how someone can pay for their day-to-day things, like groceries feel expensive, rent feels expensive. Why? I think part of it is because your employer health plan, it’s become such a financial burden for everybody

Dan: Yeah. Yeah. That is, I, yes. I mean, you, you’ve said to me, I, I think about all the time, which is like, even if your employer covers your health insurance, , like every dollar that your employer is putting toward health insurance is a dollar they could be paying you. It’s a dollar that’s on the budget line for your position

Bob Herman: It’s exactly right, Dan, and this is like, you know, it’s like an iceberg. I think a lot of people see, like, what’s, what gets taken out of their paycheck every month. Like, okay, I’m paying, you know, a couple hundred dollars toward my health- health insurance premium. That is only, like, 20 to 25% of what your actual premium is.

Your employer’s paying most of it. You just don’t see it. But, like, there is so, like, this big block of compensation that you get, a big and growing chunk of it is for the h- for your health plan, and it’s so hidden, and I think that’s what kind of makes the whole p- the, the whole thing so difficult, uh, for Americans to afford.

Dan: I mean the amounts are really striking. The average employer plan for a family now costs 27 thousand dollars a year. That’s average, not the most expensive. And that’s like? It’s a new car, right? These days it’s y- and not, I mean, not a top-of-the-line car, but a Toyota Corolla is, you know, a car yeah 

Bob Herman: Yeah, it, it’s that new, it’s that new car every year, but the employer’s paying the tens of thousands that makes up most of the car. That’s the part that is hidden and that’s what, you know, I think makes the healthcare system, you know, really take advantage of everything

Dan: And, um, you know I notice you’re saying that the fact that it’s hidden helps the health care SYSTEM take advantage of everything.  Not just the health insurance companies. Because they make profits, band they’re the conduit through which everyone else also gets paid.

Bob: You’re right, like it is the health, the health insurance company often takes some for itself, yes, but majority of that money is, it goes out the door to hospitals, to drug companies, to doctors, to device makers, drug distributors, whoever else. Like, all those different companies know that the employer-sponsored system is like their golden goose. 

Dan: So that wild inflation in health insurance premiums — it’s driven by how much more everything in health care costs. How much prices keep going up.  You’ve said — I mean, everybody knows — we pay more for health care in the US than anywhere in the world. Knee replacement, MRI, any meds you can name, we pay a lot more. And I hear you saying: The fact that some of these costs are hidden — they’re bundled into employer health plans — that actually creates opportunities for price gouging, for all kinds of gaming the system. 

Bob Herman: there’s all this money that employers are dumping into these, you know, health insurance premiums for their workers, and it is, it’s like a feeding frenzy. Uh, you know, years ago I remember going to JP, the JP Morgan conference, uh, out in San Francisco. It’s just like the confab where all the big healthcare industry players, you know, gush about how much money they’re making. And commercial insurance, the employer-based insurance is their golden goose, and they know it. And, I, I went around talking to people, and it’s not like they were dismissing that idea. They know that the commercial insurance market, the, what we get, what we all pay for and through our employers, that’s where they make hay. They could charge whatever they want, they being hospitals, doctors, drugs, doesn’t matter. They know that there’s that massive pool of money there. It is, you know, just imagine, like, Scrooge McDuck, right, where there’s this massive pile of coins, and he’s kinda swimming through it. And

Dan: That image has come up before on this show. 

Bob Herman: Yeah, it, it’s just that is, that is the employer market. And, you know, it’s, it’s a lot easier to make money when, you know, the people who are paying into it don’t understand how much they’re paying into it

Dan: Yeah. So you came into this project ’cause you cover the whole business of healthcare. You were already thinking like, “This is a huge story people need to know about. It’s a hidden pay cut. It keeps making insurance and healthcare more expensive every year. Keeps getting worse.” But it, it sounds like you didn’t realize at first the kind of trouble that small businesses were in

Bob Herman: As I was just doing research and talking with people and reading up, you know, there was a KFF employer health benefits survey, I and just buried deep th- within this, very detailed report, there was this chart showing for companies with 200 or fewer employees, you know, a little bit less than 60% of these small companies were offering health insurance now. Historic low, it’s the lowest it, it had ever been . And I was like, And I was like, oh my God, like, that is a shift. It’s this idea that small companies are giving up on this grand American idea of offering health insurance. It’s actually unraveling right now. 

Dan: and so, you concluded small businesses are giving up on health insurance what does that mean they’re actually doing?

Bob Herman: Yeah. I think when we think about employer-sponsored health insurance, companies do it because it’s a retention tool. And , it could be a deciding factor for an employee to come work for you, right?

Like, “Oh, my gosh,” like, “this health plan looks pretty good. Sign me up.” but if, if it’s actually eating into your bottom line, especially as a small business where you don’t have a whole lot of margin to begin with, like that is, that is huge.

 Small companies, they already kind of live on the bleeding edge, right? They just, you know, if you’re at a Fortune 100 company, you have more money than you know what to do with. If you’re a small company, just by your nature, you don’t, you know, your business is small. And it means that the cost of health insurance eat into your expenses so much more.

 And, you know, if you’re just a company of like, for example, 25 people, and you have one really big medical claim, your insurance company can, could come back to you next year and say, “We gotta raise rates 20% because of that one medical claim.”  and, and you know what the crazy thing is? It’s like a 20% is a, a g- gigantic amount, and it’s not, like, that uncommon for a small business to get slapped with that. Like, I, I spoke with, a business in Pennsylvania, and they were staring down the barrel of, like, a 50% increase.

 It’s not uncommon for premiums to, like, double, which, what are you gonna do then? You have to look for other options.

Dan: A-and what you knew when you started was things are getting bad, like rates have been going up even faster than we’re used to, right?

Bob Herman: And the, the past two years in particular have been really bad because, you know, insurers, like they endured a lot of losses. Not a lot of losses, but like they, this … The, the losses were more than they had expected over the past couple years, and so they’re making up for it now. They made up for it in 2026, and they’re making up for it again in 2027, and that’s exactly what you and others are feeling right now

Dan: C- I mean, they’re the house. It’s a casino and they set the odds, and the house never loses. Like, it’s, it’s made that way. Like, you can’t… Like, the, the bookmaker never loses. Like, , they employ a lot of actuaries, and actuaries are just bookmakers, right?

Bob Herman: Yeah. The actuaries, they are the, the very smart people that analyze, like, how much care everyone’s getting and how much they can predict that that will go up next year. , and they’re pretty good at it. And, you know, obviously the past couple years they were less good at it, but They know if there is a bad year, they can easily adjust the premiums to make up for that bad year. There is no, there’s no multiple years of losing money in health insurance. That, that just doesn’t happen

Dan: Unlike, unlike the rest of us. Yeah. So, if you’re really big, you’re spreading the risk out across a whole bunch of people, and you have reserves, and you have long-term plans.

 And if you’re a tiny little business you don’t have all of the tools to kind of sock money away for something or pull money out of your budget someplace else. Is that, is that basically the, the deal?

Bob Herman: I thi- yeah, I think you have it spot on. If you’re a big company, you can weather these things better.The more people you have, the more money you have to pay out when someone does have to file some kind of claim.

Dan: So but so what did your reporting show you about what small businesses are doing instead and what workers are doing instead?

Bob Herman: Yeah. I mean, none of it is ideal, right? ‘Cause, like, m- a lot of small businesses, they… The ones that I spoke with, and I think this is generally true, like, they wanna offer health insurance. And when they can’t do that, some are just saying, like, “You’re just gonna have to figure it out yourself,” which is, like, it’s a great way to lose an employee, right? Like, “Oh my God, I don’t have the safety net anymore.”

Others are doing, you know, maybe giving their employees extra cash that they can say, “Hey, go buy a health plan on the ACA marketplace.” And you know, it’s not ideal because if you think, you know, when, if you have a employer plan, usually it’s, you know, there’s a, a pretty big network or there’s, like, lower out-of-pocket costs, and when you go to the exchanges, it is a world of difference.

 Like, your doctor may or may not be in-network. Out-of-pocket costs and deductibles are generally much higher, and it’s just, it’s a completely different product. 

Dan: It’s worse. That what you find on the exchanges as an individual is worse than what you’d

Bob Herman: It is. 

Dan: I, I have, I, I, I know this firsthand. Like, the first episode of our podcast, I’m shopping on the exchange. I’m like, “This is bad.”

Bob Herman: Yeah, and like, don’t get me wrong, the ACA provided some kind of baseline level of protection for people who would otherwise be uninsurable. Like b- like, it’s crazy to think about 20 years ago, if you had some kind of preexisting condition, you just couldn’t get insurance. Like, sorry. And, um, but, uh, like the ACA plans are, they’re rough.

Like, it, like it’s, it almost… Like, if you have a $9,000 deductible, is that even insurance at that point? I think that’s a fair question to ask

Dan: And, a- and just to zoom out from there, like that chart you found, the one that showed smaller employers are down to just like 60% offering health insurance, it, it also showed that for larger employers, that number hasn’t changed much, right? It’s like still like 97%.

Bob Herman: Yeah, it’s, um, I think this question’s important because, um, it, it does kind of help explain the economy in terms of haves and have-nots, right? Where the biggest companies are always gonna be able to offer health insurance if they really want to. They just, they have the money to do it. Small businesses, like, we’re living in the shift right now where small businesses are not thriving anymore in terms of offering health insurance, . Well, guess what? Like, I don’t s- foresee this reversing course anytime soon. Ask any small business, and more of them are gonna be like, “You know, my time is, like, up.”

 And, you know, is it, does this, does this spur companies to shut down? I don’t know. Like, it’s totally plausible. Um, it’s not good. It’s not good for the economy, and it, there was even a recent survey that shows that it’s not good for workers either. Like, a lot of people just stick in their jobs, jobs that they hate, because they’re just doing it for the health insurance.

 Like, what kind of economy is that where you’re doing something, you’re collecting a paycheck really to just also get health insurance? It’s not, doesn’t feel particularly productive. So, like, these are all problems that are happening right now

Dan: The, I, I saw that survey and you wrote about it. Like twenty four percent of people in that survey said, “I would leave my job except for the health insurance.” A quarter of people

Bob Herman: Yeah. And what a term, right? Job lock. Like it’s, it’s this well-known economic term, job lock. Like you’re s- you’re locked into your job not because you want to, because, but because you feel like you need to. It’s, 

Dan: And you dug into some of those numbers. You were like, “Yeah, and job lock does not hit all people equally,” right? That people are… Who’s, who’s more vulnerable to job lock?

Bob Herman: It’s, it’s oftentimes it’s people who have more chronic health conditions, right? It’s like, “Oh my God, I know I’m going to be a user of my health insurance.” So like, that makes more s- like especially women because, um, you know, especially if, if you’re planning on having a baby or if you just have any kind of chronic condition, it’s like you are… If you know you’re gonna be using your health plan, you can’t afford to leave your job even if you think it sucks

Dan: , you said at the top of our conversation that, you know, this system is collapsing and that, that health insurance isn’t, employer health insurance is not the kind of robust product we thought it was. And not just for small businesses, even though it’s more obvious for them. But you did report this spring briefly on a survey that said, like, some large number of CFOs were like, “Yeah, we didn’t hire people,” or, “We raised our prices,” uh, because of the cost of health insurance, right?

Bob Herman: Yeah, this is still affecting larger businesses, and it’s happening in all the usual ways that we’ve seen over the past, you know, two decades. It’s making deductibles higher for employees. It’s making them contribute more from their paychecks. It’s changing the health plans. And, you know, I, I just spoke with someone the other day. They said that their out-of-pocket max, it’s the term like after you reach this amount, you don’t have to pay any more for the rest of the year, like it doubled. Like that is a health benefit design change where it actually functions like a wage cut too, right? So th- big companies will always be able to do it, but they have been making changes, and most of the times it just means that the worker and their dependents are taking it on the chin somehow.

Dan: Making health insurance worse. So, I mean, there’s a big story that’s just coming out right now: Did you see the story that Disney is saying, “Actually, your spouse can’t be on your plan anymore if they have an offer from their employer”?

Bob Herman: Yeah, , Disney’s basically saying if your spouse has an offer of insurance through their own employer, they have to take that. They can’t join the Disney plan, which is just, honestly, it’s batshit crazy.

For a company that is, like, supposed to be very family-friendly, this is a very anti-family-friendly thing that they’re doing

Dan: The analysis that I saw was like, look, uh, who chooses our insurance when they have an offer from their insurance? It’s somebody who thinks our insurance is better and is, and thinks they’re likely to use it.

Bob Herman: Right. 

Dan: We think we’re gonna be paying out claims. 

Bob Herman: Right. Yeah, I mean, if you think about it, um, if, if you are sick and you know you’re gonna use insurance, you’re gonna choose the plan that, uh, that offers you more protection. Um, so I mean, like actuarily, like it makes sense. Like they’re, they, they have data showing that like when people join or when dependents join the plan, it is costing them more money, and now they’re going to actively stop it. Like if, if the entire social fabric of employer-based insurance is you, if you have a job, you can get an offer of insurance and your, you and your family can join it, even that is starting to unravel. Like what happens if every other employer did this?

Dan: Yeah, it sounds like the idea you started with — that big employers will keep offering health insurance — they’re not gonna walk away but it sounds like you’re reconsidering this?

Bob Herman: I am kind of reconsidering, and honestly, it’s the GLP-1s that have really started making me reconsider this. Like, Pepsi just this week said, “We’re not offering GLP-1 coverage for weight loss anymore for our employees.” Like, it’s not to say, like, that big… I still think big companies are always gonna offer health insurance, but e- but something like GLP-1 coverage, where it is o- so much money and so many people are using it, 

[00:29:46] Even for that, they’re saying, “No, we can’t do it anymore.” they’re still gonna offer coverage that will, that will try to attract people that they wanna attract. But stuff like this shows that, and, like, it is very clear the employer-sponsored health insurance system is unraveling more than perhaps I’ve ever seen.

Dan:  And yet: The experts Bob talked to all said, they don’t expect this system to change anytime soon.  And Bob ended up with some pretty clear ideas about just why that is. That’s coming right up.

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. That’s a nonprofit newsroom covering health issues in America. It’s a newsroom full of superstar reporters; we are honored to work with them.. 

Dan: The sense I got, you know, from your reporting is it, like, big employers aren’t happy about it. They’re, they’re mad. Um, they’re unhappy, but that this system is not likely to go away, So, if everybody’s like, “This sucks,” why doesn’t somebody do something? And you had, like, you had a kind of analysis of like, who’s getting things out of it. Who’s benefiting from, from the way things are?And who would get hurt if, if things changed?

Bob Herman: Getting rid of the employer sponsored health insurance system is just vehemently opposed by big business. They know, especially the largest businesses, if they offer an attractive health plan, they could get anybody they want.And then going back to the job lock, those people could also stay with them for a long time because they know that they have the health plan. Um, and the, the largest tax break in the entire code is employer sponsored health insurance, so it’s great for, you know, middle and upper class p- you know, people. It’s great for the businesses. They don’t… Like, nobody pays any taxes on it. 

Dan: I was really struck by the note that it’s the biggest, it’s the biggest tax break in the entire tax code, , we’re talking hundreds of billions of dollars that otherwise would go into the federal kitty that don’t. Um, so businesses, they see all of these, things that are beneficial to them, and even though it costs them so much money, it is not worth giving that up. like, “We, we still have way too many advantages from it, even though it costs us an arm and a leg.” You had a specific example, but like the Affordable Care Act was, part of its design was like super suped up, workplace health plans would incur a tax, and that this did 

Bob Herman: Yes. I, I don’t know if you remember that debate, Dan, but it wa- it was called the Cadillac tax, and it was this idea that, you know, if it’s a really, really super generous plan, we’re gonna start to tax a little bit. Everyone lost their minds about it, and it was across the board. It was businesses, it was unions, who obviously fight very hard to, you know, to, to negotiate for their health plans. It was just universally reviled. But the idea was we need to start taxing these. It went terribly. It got killed, and that w- it was honestly, it was a pretty modest change, and look at, look what happened there

Dan: A- and so I think what, what that example shows is there are people with something to lose, and then of course there’s all the people who, uh, you know, make money in healthcare, not just insurance companies, right? 

Bob Herman: Yeah. The healthcare industry is very powerful. If you look at like, like lobbying dollars, like healthcare companies and their trade groups are always at the top. And like, yeah, they want inertia. As they, you know, vacuum up another, you know, $6 trillion this year and exponentially more next yearIt is a feeding frenzy. And again, this was, this is money that otherwise would be in your paycheck.

Dan: Yeah. I mean, it’s just one of the things I think about of like, we become aware of how much things cost, a lot of us, when, like, we get a giant bill, or people we know, and we’re like, “That’s wild.” But as what you’re reporting is showing, like, no, all of this wildness is paid by all of us , a lot of us get insurance from our jobs, that’s money that could be our wages. We’re paying it there. Um, in places where the government pays for healthcare and it, we are paying that through our taxes. Um, and that is a part that I don’t think, I get to enough on this show, is that like, we’re vulnerable individually, but we’re also each of us individually paying a collective price.

Bob Herman: I remember years ago I was interviewing Don Berwick. He used to be the CMS administrator, uh, during President Obama’s term for a short while, and he made the good point that was like, workers pay for every dime of healthcare in this country, either through your wages or through what is owed to you through compensation or through taxes. Um, and I think if you, if your listeners just think of it that way, it’s actually pretty simple. Like, we’re all paying for this. It just doesn’t, it might not seem like it, but that is the reality

Dan: Um, this is a little bit risky, uh, just for our emotional health, but like, as a parent, as you report on these things, do you think about your kids as adults navigating an economy that’s another 20 and change years along this path?

Bob Herman: It’s, oh yeah. I mean, I’ve, uh, I, I don’t know. Maybe a lot of parents are worriers. I’m one of them. , I think about, like, my kids when they eventually have to go off our health insurance, right? When they have to find their own, and, you know, maybe they have their own healthcare needs at that point and they have to find something. Like, is it gonna be affordable for them? Are they gonna be one of those people who gets job locked, where they’re, they find a job but they absolutely hate every minute of it because they’re just doing it for the health insurance? Um, yeah. I, I mean, 20 years from now is a long time. Like, costs aren’t going down, and how will it affect their, you know, basic, uh, standards of living?

I have no idea. I, I mean, it’s hard not to think about it. Um, but it is far in the future, and I think that’s what also prevents people from changing things. Like, we know it’s bad, it’s gonna get worse, but, like, you know, when it’s that far in the future you can’t really address it right now. But I think that’s the perfect time to address, is before it gets so bad that our own kids can’t even, you know, afford their rent or their groceries or whatever else

Dan: I’m, I’m reminded, right, of the saying like, “The best time to plant a tree is 30 years ago, and the second best time to plant a tree is today.”

Bob Herman: Today. Exactly right 

 

Rachel Bernier-Green: I’m a little anxious about what we’ll be paying, but it, you know, it’s not keeping me up at night.

Dan: Back on the South Side of Chicago, Rachel Bernier-Green tells me she’s on track to bring insurance back for her team in 2027. She says changes they made to their business strategy last year have been paying off, so she’s got the money lined up

Rachel Bernier-Green: I mean, we hope that there are not, you know, more sky-high increases because yes, they do drastically, impact, um, our ability to operate the business But, ?I know that we’ll be well positioned to absorb the cost

Dan: as I, I’m preparing for today’s reporting, I’m like, “Oh yeah, this would be a good time for me to email our insurance broker and be like, ‘Hey Kurt, so what are we looking at for next year? Uh, I think it’s gonna be bad.’” And he’s like, “It’s gonna be bad.” He thinks for the plan that we’re on, which because of our needs for networks and stuff, is we don’t have a whole lot of choices. He’s like, “Yeah, you’re looking at like 14 to 18%, I think, for the next year.” 

Rachel Bernier-Green: Yeah. Yep Yeah. And, and the crazy thing is, like, I’m… Which sounds obscene, but I’m thinking is between 20 and 25%, um, that we need to be prepared for jumps of that magnitude. And I hope that that is not the case, but that’s what we are building into our, um, our models moving forward

Dan: And are you advising clients the same way?

Rachel Bernier-Green: Yeah. Yeah

Dan: I’m curious about, um, what it was like reading Bob’s story. What was it like, I mean, whether it was surprising or not, like what was it like seeing all of that kind of put together?

Rachel Bernier-Green: Oh, I was, um, just like silently cheering, um, because those are the, uh, exact conclusions that I, you know, I can’t inform the conclusions that he reaches, but that is exactly where, um, where I am. That the system is fundamentally broken and it is harming people in re- irreparable ways and that we need a significant overhaul,

Dan: Amen to that. Which is the thing about a story like this. On the one hand, it’s full of terrible news. On the other hand: Most of us — maybe all of us — are already experiencing the effects of all this terrible news. And I think it’s helpful, it’s good, to see it all tied together. To know:  We’re not alone. We’re not imagining things.  The whole system truly is completely broken — and as bob says, continuing to actually crumble.  

Even if we don’t have a *solution*, it’s good to know what we’re up against, to peel back the curtain.  

Next time on An Arm and a Leg, we take another look at Medicare Advantage. And, um… it’s more broken than we thought. 

News anchor: Many health insurance providers are dropping their Medicare Advantage plans.

Female voice: I heard that — I was just in tears.

Female voice 2: I don’t know any way to describe it other than total chaos. 

Dan: I’m hoping that you’re right here with me when I say:  It is so much better to know.  We do not want to get taken by surprise.

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Amanda Boyd is our Operations Manager. Bea Bosco is our consulting director of operations. 

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 editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news 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.

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, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the healthcare system, the producers would love to hear from you.

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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.

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

Imbalance of Power — And Healthcare

Why can members of Congress remain on full taxpayer-funded salaries during prolonged medical absences while millions of working Americans cannot afford to get sick? (Kennedy, Oz Contend Fraud Crackdown, Not Skyrocketing Prices, Led Millions To Leave Obamacare, Aug. 3.) Sen. Mitch McConnell’s current extended medical absence brings that disparity into sharp focus. He has missed dozens of Senate votes while continuing to receive his $174,000 taxpayer-funded salary.

Meanwhile, I have a friend who works two jobs and still cannot afford her mortgage and utilities without a roommate. She does not even have basic medical insurance. She earns too much to qualify for government assistance but not enough to comfortably afford insurance along with the basic cost of living. What happens if she gets seriously ill?

She doesn’t have the luxury of taking months off to recover while her income continues. She could lose her income, her home, and everything she has worked for simply because she got sick. Yet she is one of the taxpayers providing that financial security to members of Congress.

McConnell’s situation is particularly striking because of his long legislative history of opposing or limiting federal family and medical leave protections.

If continuing someone’s income while they recover from a serious illness is reasonable and humane when that person is a member of Congress, why isn’t it reasonable and humane for the Americans paying their salaries?

Americans should not face financial ruin because they get sick while their elected representatives enjoy protections unavailable to the people they serve.

— Ruth Bower; Salem, Oregon

Hospice Saga Hits Home

I could really have used the information in the article “My Husband Was Kicked Out of Hospice for Dying Too Slowly” (Aug. 14) before it happened to me. I was notified on a Monday morning by my husband’s residential hospice agency that I needed to find a new place for him ASAP, and “here’s a list of places.” I asked what it would cost for him to stay a day or two — saying I would pay it myself, just tell me how much. They didn’t. So I got on the phone, and it was a hectic and horrifying day calling around for a new place.

My husband had been home twice between hospital stays, had fallen both times, requiring me to call 911, and then he was rehospitalized. I’m 64, and there was no way I could lift my 300-pound husband if he fell again. Even a half-dozen firefighters had trouble.

I spent most of his final day calling hospice agencies, and a representative from one even showed up to visit (uninvited and unexpected). It was scary how little oversight or medical professionalism there was. His life ended about 7 p.m. that evening. We had already stopped his pacemaker a few days before.

I will never forget or forgive that I wasted my last day with him because he was not dying quickly enough for the hospice. He never saw a doctor once he enrolled in hospice. There are great nurses in hospice — I’ve met a few — but there are a lot of places for which this is just an easy revenue stream, and they seem to be in it just for the money.

— Debbie Bond; Corpus Christi, Texas

On Improving the Hospice Experience

Thank you for publishing the article on hospice. As a hospice clinician and leader who has been providing hospice education for over 20 years, I, too, continue to see the need for increased awareness around hospice in our communities. This story is similar to many I have recently collected from families who are searching online, using AI tools that fall short of accuracy, and expressing they are overwhelmed.

As the article states, they were given a list of hospices to pick from; that is common and can be a major cause of panic for families. The article provides nice tips on choosing a hospice, but there is so much more to it. Picking a hospice that aligns with your values is a good first step, but we cannot overlook the idea that people and families need help walking this journey, help with exploring their care goals and wishes.

I recently took on a mission to enhance and make hospice education more accessible. In doing so, I launched an app, myHospice Companion, focused on helping people and families learn about hospice before they need it; what hospice is and how it works, when they are ready; and what to understand and expect, all the way to the end. Two important articles were posted this year: a recent one entitled “The Hospice Conversation Starts Too Late,” by Kurt Merkelz, and a staggering article published by Hospice News about how the Centers for Medicare & Medicaid Services could save $1.5 billion annually if hospice were elected just five days sooner.

The data supports that people and families are looking for reliable sources of education. However, the hospice industry as a whole has focused on providing that information once someone is admitted, which is too late.

Educational leaders in our communities need to work together to enhance end-of-life knowledge. Our mission is to give them a tool to make a meaningful impact.

— Jason Kimbrel; Columbus, Ohio

Common Ground: The Height of Folly?

Whoever is investigating common ground between the major political parties (KFF Health News’ series “Common Ground”) clearly isn’t interviewing or polling Republican members of Congress — although there are probably a few Democrats in Congress who’ve gone along with making cuts to Medicaid and the Supplemental Nutrition Assistance Program, who don’t want to tax the rich more to keep the Social Security trust funds solvent, and who would never, ever vote for national healthcare systems similar to any of those in Western Europe or the Scandinavian nations.

I’ve yet to read that any members of Congress have seriously analyzed how nations with “universal” healthcare coverage manage such a system, and how much it would cost to implement in the United States. That demonstrates that neither party is truly committed to finding a better way to provide healthcare for all of us.

Too many GOP members of Congress have, for many years, tried to privatize Medicare (with some success), cater to healthcare insurers, and in every way demonstrate that they do not share what’s supposedly a general concern: improving the healthcare system in the U.S. and improving access for anyone not superwealthy to good quality healthcare. They should not only be making it more affordable, but making pre-med training and obtaining a doctor or nurse practitioner degree far, far, far more affordable than good programs for obtaining those degrees currently are.

We also need to pay registered nurses better than what they are being paid now, and support the National Science Foundation, the Centers for Disease Control and Prevention, the National Institutes of Health, et al., so that the U.S. continues to conduct medical research and fund the FDA so it can actually regulate the drug industry. We need an affordable drug system, too. Again, too many people in the U.S. can’t afford drugs that are affordable in other nations.

There’s no way the GOP in Congress will fix this. Republican presidents, from Ronald Reagan to the present, could’ve done so and did not. That the GOP has managed to propagandize so many people on vaccines, and toleration of increasingly expensive and poor-quality healthcare (and less access), just goes to show how many in the U.S. seem willing to effectively sabotage their lives — and the lives of their children.

— Susan Hogg; Newport, Oregon

Monopolies Hurt Healthcare Providers, Too

I am a recently retired health executive. I just read the article “Same Knee Surgery, Twice the Price: Hospital Monopolies Push Up Healthcare Costs” (Aug. 10). I loved the article. Very well written. Based on my experience, it is completely accurate. Well done.

However, you omitted a critical factor. During my approximately 40-year healthcare career, I saw the competitive landscape among health insurance companies shrink incredibly. One cannot discuss “merger mania” among hospitals and other medical institutions without acknowledging the negative impact that consolidation of health insurance carriers has had on the industry.

While the article made great points, it failed to articulate the effect insurance carrier consolidation has on healthcare providers’ bottom lines and their ability to negotiate reasonable fees. Your readers deserve to hear a balanced story.

— Quinten Davis; Randallstown, Maryland

Healthcare Students Clutching at Straws

Benjamin Pinckney’s story about the new federal student loan caps upending his dream of becoming a physician assistant is one that many students and prospective students unfortunately know all too well (“He Dreamed of Becoming a Physician Assistant. New Loan Rules May Thwart Him,” June 30). I’m a nurse practitioner and educator myself, and federal student loans were instrumental in my own educational journey. I might not be where I am today without them.

There are many bright, aspiring individuals seeking to become nurses to serve our nation’s growing patient needs. Yet the new federal loan caps have the healthcare workforce clutching at straws, as many students question their ability to pursue higher education. While the goal of lowering the cost of education is worthwhile, the rule risks forcing nursing students to choose between drowning in private, high-interest loans and abandoning their educational goals entirely. Either way, it will weaken our healthcare workforce at a time when the United States is expected to face worsening shortages of advanced practice providers and nursing faculty.

Just consider a few key data points: Demand for advanced practice nurses is projected to grow by 36%, much faster than the 3% average growth for all occupations. Over 1 million nurses are expected to retire by 2030, far outpacing the projected number of new nurse graduates. And 7.2% of faculty seats across the nation currently sit vacant, with about 81% of open positions requiring advanced degrees.

Fewer students can afford nursing education. Combined with fewer opportunities for clinical educators to pursue the advanced training needed to prepare future professionals, that equals a reduced ability of the nation’s healthcare system to meet Americans’ demand for high-quality care.

For now, the healthcare workforce is relieved that the rule has been paused in the courts. Looking ahead, we must actively work not only to control graduate education costs but also expand educational opportunities by championing legislation that designates advanced nursing degrees as professional degrees. Students who wish to become nurse educators and advanced practice registered nurses should be able to secure the federal financial aid they need, which is why legislation like the Nursing Is a Professional Degree Act, the Clarity in Professional Degree Act, and the Professional Student Degree Act are all so important.

I urge Congress to listen to stories like Pinckney’s and to the countless aspiring nurses across the nation who want to pursue careers that will strengthen our healthcare system but are being held back by loan policies that stand between qualified students and the workforce our country urgently needs.

— Lorie Hacker; Bargersville, Indiana

Rural Healthcare Needs AI That Earns Its Place

Rural patients’ skepticism of artificial intelligence raises an important point (“Patients Wary of Governments, Companies Pushing AI as a Rural Healthcare Solution,” Aug. 11). At this point, there’s not a “should” around AI adoption. It’s more about whether the technology can demonstrate enough value to earn the trust of patients and clinicians.

AI can and will help rural health systems facing staffing shortages, financial pressure, and limited technology resources. But the most meaningful opportunities may initially be behind the scenes. Reducing documentation burden, streamlining referrals, improving scheduling, and automating repetitive administrative work can give clinicians something rural communities urgently need: more time to care for patients.

That’s very different from asking patients to replace a trusted relationship with an AI avatar or chatbot.

Healthcare leaders should resist measuring success by how many AI tools they deploy or how many people use them. Rural AI investments should be judged by outcomes. Did clinicians save time? Did patients get appointments sooner? Did the technology reduce costs, improve efficiency, improve access, or produce better clinical results?

Because many AI tools have been developed using data and infrastructure from large health systems, rural organizations also need rigorous evaluation, strong governance, and reliable data before scaling them.

Patient skepticism is not an obstacle to innovation. It reminds us that technology earns trust through results. If AI gives rural clinicians more capacity to deliver human care — and health systems can prove it does — it can become part of the solution without pretending to be the solution itself.

— Jason Griffin; Missouri City, Texas

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.

WAIANAE, Hawai‘i — Native Hawaiians will need to comply with new work requirements to qualify for Medicaid after being excluded from exemptions carved out for other Indigenous groups, an omission that clinicians fear will exacerbate the challenges the marginalized population already faces in getting healthcare.

In 43 states and the District of Columbia, President Donald Trump’s signature One Big Beautiful Bill Act will require most adults to work, go to school or enter a training program, or volunteer for at least 80 hours a month. Native Americans and Alaska Natives are exempt from the mandates, which take effect in January.

Of the nearly 700,000 Native Hawaiians in the U.S., around 47% live in Hawai‘i. Within the contiguous United States, California, Washington, Nevada, Texas, and Oregon have the largest populations of Native Hawaiians.

Hawaiʻi’s Medicaid administrator, Meredith Nichols, said the Centers for Medicare & Medicaid Services didn’t respond to the state’s request to include an exemption for Native Hawaiians but said she believes the decision came down to the population’s lack of recognition as a tribal nation. Hawai‘i has about 390,000 Medicaid enrollees, 15% of whom identify as Native Hawaiian, Nichols said.

“We know that when we’ve asked similar questions in the past, it all comes down to federal recognition,” she said.

Hawaiʻi health administrators met with Trump administration officials in June. Some unsuccessfully pushed to add an exemption to the new law, which would need congressional approval.

White House spokesperson Kush Desai did not respond to requests for comment. In a statement, CMS spokesperson Timothy Foster confirmed that the agency met with 16 health centers in Hawai‘i about Medicaid changes but didn’t respond to other questions.

Barriers to Care

Native Hawaiians face many of the same health disparities as Native Americans and Alaska Natives, including higher risks during pregnancy, higher infant mortality rates, and higher rates of being uninsured than the white population. And in Hawaiʻi, Native Hawaiians have the second-lowest life expectancy among ethnic groups after other Pacific Islanders.

Kapono Chong-Hanssen is the medical director of Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i that also serves the privately owned island of Ni‘ihau, whose 170 full-time residents are predominantly Native Hawaiian. Chong-Hanssen said he anticipates many of his patients will no longer receive the care they need once the new work requirements take effect.

Chong-Hanssen says new Medicaid work requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients. (Ashley Mizuo/KFF Health News) Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i, operates out of multiple locations, including its clinic in Waimea on the west side of the island. Kaua‘i and Ni‘ihau were impacted by Hurricane Lowell this week, forcing Ho‘ōla Lāhui to temporarily close facilities. (Ashley Mizuo/KFF Health News)

The new requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients, who, in response to historical disenfranchisement, are more likely to disengage and “throw the whole system out” when they run into barriers, Chong-Hanssen said. “It just flies in the face of everything that we’re trying to do.”

Beyond medical services, Medicaid covers transportation expenses when patients travel between islands for care. A round-trip ticket between Kaua‘i and O‘ahu, for example, can cost hundreds of dollars.

Congress placed over 200,000 acres of land in a trust for Hawaiian homesteads in 1921 to bring Hawaiians back to their native lands after the U.S. backed the 1893 illegal overthrow of the Hawaiian kingdom. Nearly 30,000 Native Hawaiians are still waiting for land, while, as of the 2020 census, more than 34,000 people lived on Hawaiian homelands. The homesteads are often far from Honolulu, where most health services are located.

Waianae Coast Comprehensive Health Center primarily serves the west side of O‘ahu, which is home to the island’s largest Native Hawaiian population, near four Hawaiian homesteads.

Waianae Coast Comprehensive Health Center CEO Rich Bettini (right) and Vice President Leinaala Kanana demonstrate how to use pods throughout the campus that connect patients via phone to an employee who will help them submit needed information and applications to the state’s Medicaid program. (Ashley Mizuo/KFF Health News)

The center’s vice president, Leinaala Kanana, said that many of its patients are geographically isolated and that few jobs are available in the area. Patients also have trouble securing transportation to get to work or finding affordable childcare.

The center’s CEO, Rich Bettini, said Hawai‘i’s high living costs and depressed wages have pushed many people into homelessness, creating another barrier to complying with the new Medicaid requirements. Native Hawaiian and Pacific Islanders make up about 60% of O‘ahu’s homeless population. The center estimated about 2,800 of its patients may be affected by the requirements, half of whom are Native Hawaiian.

The annual “cost of living for a family of four in Hawaiʻi on O‘ahu is $100,000-plus. The average income of our patients is under $30,000 a year,” he said. “That is an enormous gap.”

‘Bigger Fish To Fry’

Native Hawaiians face obstacles to being granted the same exemptions as other Indigenous groups. While several federal laws refer to Native Hawaiians as an Indigenous group, they are not among the 575 tribes recognized by the federal government. Federal recognition can be granted either by Congress or administratively through a process established by the Department of the Interior. Native Hawaiians remain divided about whether they would even want federal recognition, with some fearing it would jeopardize their ability to restore Hawaiian independence.

Laws governing Medicaid also don’t acknowledge Native Hawaiians, aside from the 2021 American Rescue Plan Act, signed by former President Joe Biden. In the covid-era law, the federal government fully reimbursed Native Hawaiian health centers for Medicaid services for two years. However, all the qualifying Native Hawaiian health centers were in Hawai‘i, where fewer than half of Native Hawaiians in the country now live.

The federal government fully reimburses Indian Health Service and tribal facilities for healthcare services provided to Native Americans and Alaska Natives. Native Hawaiian healthcare systems instead receive the same reimbursement rate as in the rest of Hawaiʻi.

Waianae Coast Comprehensive Health Center CEO Rich Bettini said Hawai‘i’s high cost of living and depressed wages have pushed many people into homelessness, creating another barrier for Native Hawaiians to comply with new Medicaid requirements. (Ashley Mizuo/KFF Health News)

Keolamaikalani Dean, the CEO of the King Lunalilo Trust, which provides services for Native Hawaiian elders, pointed to the new Medicaid requirements as just one of many federal policies limiting Native Hawaiians’ healthcare.

“It’s horrible as a policy, but there are bigger fish to fry,” he said.

Dean said he’d rather advocate for giving Native Hawaiian healthcare systems the same full Medicaid reimbursement that the Indian Health Service receives. The change would have greater impact on patients seeking care, he said.

Native Hawaiian advocates said they have been overextended as they work to guard against an onslaught of threats to revoke other federal funding by the Trump administration.

In Trump’s proposed 2027 budget, cuts to Native Hawaiian programs cited the group’s lack of federal recognition as a “tribal nation.” The proposed cuts coincide with lawsuits from conservative groups challenging Native Hawaiian education programs and long-standing legislation that provides homestead land to some Native Hawaiians at almost no cost, alleging the programs racially discriminate against other groups.

Papa Ola Lōkahi, a nonprofit that oversees the Native Hawaiian healthcare systems in the state, declined to comment for this article. The group is involved in a lawsuit filed by a conservative group aiming to stop a university scholarship for Native Hawaiians pursuing healthcare careers.

U.S. Rep. Jill Tokuda (D-Hawaiʻi) viewed the exclusion of Native Hawaiians from the exemptions to Medicaid work requirements as an attempt to further erode Native Hawaiians’ Indigenous status, pointing to recent challenges by the Trump administration and lawsuits.

“These are not one-offs,” Tokuda said. “This is a targeted, coordinated attack to undercut the Indigenous status of Native Hawaiians.”

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 awards to 132 hospitals totaling nearly $25 million.