As the Trump administration’s January deadline looms for states to enforce new Medicaid work requirements, some state lawmakers are turning the tables by pushing to publicly name the largest companies that have employees enrolled in the government program covering low-income and disabled people.

California lawmakers seek to revive an expired law that would require the state to identify companies that employ 100 or more people and have employees enrolled in Medi-Cal, the state’s Medicaid program. Nevada has had a similar law in place since 2017, though a proposal for one in Oregon stalled when its legislative session ended in March.

The California bill author, Democratic state Sen. Lola Smallwood-Cuevas, said she is deeply troubled by what is going to happen when work requirements kick in. According to the state, nearly 5 million out of more than 14 million residents on Medi-Cal will be subject to the rule.

“We think this is a bill that’s about fairness,” Smallwood-Cuevas said. “It’s a basic principle that taxpayers deserve transparency about which large employers are shifting their healthcare costs onto the public.”

Large employers that regularly top Nevada’s list, such as Walmart and Amazon, have said that the state included part-time and seasonal workers in their counts and that their full-time hourly employees make too much to qualify for Medicaid.

Walmart spokesperson Katrina Proffitt said that the company offers affordable medical coverage to most employees, including eligible part-time workers, and that most of its plans include no-cost virtual care options.

“Healthcare affordability and access to quality care remain real barriers for many Americans, and Walmart continues to be committed to being part of the solution,” Proffitt said.

The push to name and shame companies reflects dueling narratives about the biggest abusers of the joint state-federal Medicaid program, which reached nearly $932 billion in government spending in 2024. The Trump administration, led by Centers for Medicare & Medicaid Services Administrator Mehmet Oz, has called out blue states for not doing enough to fight insurer fraud and abuse. State Democratic leaders, meanwhile, are pushing back by calling attention to big employers that don’t offer affordable health benefits, which leaves taxpayers subsidizing healthcare costs for the low-wage workforce.

Some states have considered financial penalties. Democratic New Jersey Gov. Mikie Sherrill signed a bill in June to fine businesses that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid will pay $325 a year per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in Washington state and Colorado this year.

In Sacramento, California, Democrats want to figure out a way to make large businesses pay for their employees’ health coverage. State lawmakers struck a deal with Democratic Gov. Gavin Newsom, who is contemplating a presidential bid as he wraps up his final year in the governor’s office, to explore tax options. Any tax hike would be up to the new governor.

States face losing billions of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through a provision that requires nondisabled Medicaid enrollees ages 19 to 64 in most states to prove they are working, volunteering, or going to school at least 80 hours a month to keep their coverage.

Yet federal work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the Congressional Budget Office. Nebraska and Montana have begun enforcing the rule.

One health policy researcher said employer Medicaid reports highlight the lack of affordable healthcare options available to low-wage workers. More than half of adults enrolled in Medicaid who don’t have dependent children already meet the 80-hour-a-month requirement or face challenges that would likely qualify them for an exemption, according to KFF.

“There’s a whole set of people who are working — they may not satisfy the work requirement provisions, they may not get the exemption that they’re qualified for, and they don’t have access to that employer-sponsored insurance either,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Employers Push Back

While employer lists haven’t succeeded in bringing down Medicaid costs, supporters say measuring the burden can be the first step and help lawmakers make the case for further action.

In Nevada, Amazon has employed more Medicaid enrollees than any other company since 2020, according to the state’s report published in January. For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers have argued that the reports are misleading because they have included part-time and seasonal employees. The state’s latest report includes only full-time employees, plus those who could not be confirmed as either full- or part-time employees.

That came to 4,914 Amazon employees and 3,503 Walmart workers in Nevada on Medicaid in 2025.

There are no penalties for companies on the list.

Amazon said it pays its workers more than double the $7.25-an-hour federal minimum wage and noted that Medicaid eligibility is based on household income and size rather than an individual’s wage. That means two employees who earn the same pay may have different eligibility depending on whether they have children or live with parents.

“Pointing fingers at Amazon over Medicaid is a red herring,” said spokesperson Alisa Carroll. “What really needs to happen is a significant and large increase in the federal minimum wage — that would be a big boost for American families.”

Nevada Medicaid spent nearly $950 million on healthcare for more than 133,000 full-time employees and more than 140,000 of their dependents. While the total amount spent dipped in fiscal year 2025, the average cost per member per year increased by nearly 17%.

Yvanna Cancela, a former Nevada lawmaker who sponsored the legislation on Medicaid work reports, said the annual reports force an important conversation “about whether or not this is the kind of economy we want and whether or not it is right or just that people who work full-time don’t make enough to have health insurance.”

A Fraying Safety Net

Health researchers say that uninsured people delay or skip using healthcare and that their children may end up losing coverage, too.

One analysis found that more than 2 million fewer children were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the steepest enrollment losses among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. Her bill is pending in the legislature.

She compared Medi-Cal to a trampoline that has become a “very tattered kind of fishnet” overwhelmed by people falling into it. President Donald Trump’s spending-and-tax law pulls and rips at the safety net, she said.

When people lose food assistance and health benefits, they must choose between paying for medicine and paying for rent, Smallwood-Cuevas said.

“We’re going to see more people in their cars, more people on the street, and a lot more people in the emergency room,” she said. “That is dangerous for all of California.”

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

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Thousands of Americans who undergo a common knee surgery might be making their problems worse rather than better.

Researchers who followed patients for 10 years after they received either the actual procedure, arthroscopic knee surgery to trim degenerative cartilage tears, or merely “sham surgery” — a skin incision — for knee pain, found that the surgery provided little or no benefit and was, in fact, associated with accelerated osteoarthritis and higher rates of reoperation. That generally meant a total knee replacement.

“I don’t know how I would defend this procedure at all,” said one of the study’s authors, Teppo Järvinen, an orthopedist and the head of the Finnish Centre for Evidence-Based Orthopaedics. “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”

Järvinen said the Finnish study, published in April in the New England Journal of Medicine, was the first to show the surgery left many patients worse off. Though the study was small, the results were compelling, he said, because his team picked the patients “most likely to benefit.”

The study does not apply to cartilage tears incurred from an acute pain-causing injury. It included subjects middle-aged or older who were experiencing knee pain and whose MRIs showed cartilage tears.

Evidence has been accumulating steadily for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy. Arthroscopic rates in Finland have dropped 90%, Järvinen said. They have been falling in the U.S., too, but at a far slower rate.

One study of commercial claims in the U.S., which counted over 2 million meniscus surgeries from 2010 to 2020, found the number decreased by about 4% each year. Most procedures were performed on women and patients in their 50s.

In the traditional Medicare fee-for-service program, the number of procedures has declined steadily in recent years, from about 169,000 in 2014 to 91,000 in 2024, federal data shows. These figures do not include beneficiaries in Medicare Advantage, private insurance plans that cover more than half of Medicare enrollees.

Prior studies of scans have found that such tears are common in people over 50, the result of wear and tear and often not painful.

“Nothing supports the idea that a patient’s pain comes from the meniscus,” Järvinen said.

Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said that “evidence is growing for judicious use of this surgery in this population.” But, he noted, “many patients do benefit.”

All the same, he acknowledged that current practice among his peers is “all over the map.” For example, data shows that surgery for meniscus tears in the Medicare population is far more common in the South than in the Northeast.

A massive study committee of orthopedic societies in Europe and the U.S. last June released a consensus statement noting that “degenerative meniscus lesions can be treated with comparable results with either non-operative (including physical therapy) or surgical approach.” It recommended a trial of physical therapy before surgery but still endorsed the operation.

A concerted campaign by orthopedic specialty societies called the Save the Meniscus Society has been ongoing for years. The group advocates for protecting and maintaining long-term knee health through nonsurgical treatments, surgical repair, and other therapies.

One inherent issue in all medical specialties is that appropriate treatment is often in the eye of the physician beholder, meaning that specialists create the guidelines for when a treatment is in order. And financial considerations may influence that decision, Järvinen said.  

In the U.S., physician payments are decided by the Relative Value Scale Update Committee, or RUC, a committee of the American Medical Association composed largely of specialists. Department of Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers have reportedly looked into wresting control of that committee from the association, though it’s not clear how that could be done, since the AMA owns the billing codes used to calculate patients’ charges.

Arthroscopic knee surgery takes 30 to 60 minutes in the operating room, and the patients spend a few hours recovering in a surgery center or in a hospital outpatient department. Medicare allots on average $2,159 to $3,875 for the procedure, depending on where it is performed; patients pay 20% of the fee as coinsurance. There may be additional costs, for example, if more than one doctor is involved in the procedure. Commercial insurers average well more than twice that, said Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health, adding that the amount providers charge for the procedure varies widely. Those charges do not include the fees of the surgeons and the anesthesiologist.

Treating chronic knee pain has a variegated history.

Fifty years ago, the treatment for cartilage tears, from acute injury or from wear and tear, was to remove the entire piece of cartilage. At that time, doctors did not consider it a shock absorber but a useless, vestigial piece of tissue like the appendix.

Today, the first-line therapy for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the view of the surgeon about its utility.

There is also a menu of injections: Steroids have proved scientifically valuable in the short term. And injections of stem cells and plasma-rich protein are widely offered but are controversial — and not covered by most insurance — because studies have been at best inconclusive about their benefit.

And as orthopedists are backing away from shaving off meniscus tears, they are highlighting a newer procedure — sewing the torn cartilage back into a whole. But that is typically an option for patients under 50 with acute injuries and clean tears, and it is unclear exactly which patients might benefit.

When all else fails, there’s a different surgery that’s also a big moneymaker for hospitals and doctors: knee replacement.

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 <a target="_blank" href="https://kffhealthnews.org/health-industry/knee-surgery-arthroscopic-cartilage-meniscus-finnish-study-osteoarthritis/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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

Eight days before my 33rd birthday in April, a social worker at a crisis clinic near Denver determined I was an imminent danger to myself. She placed me on an involuntary 72-hour mental health hold.

What came next wasn’t treatment, but a search for a bed. Clinic staffers called area hospitals with inpatient psychiatric units, asking if they had available beds. They didn’t. So, I was told I had to spend the night at the clinic, which is open 24/7. I settled into a recliner, trying to make myself comfortable as my mind drifted in a blank, disassociated haze. Sleep came in brief bursts.

Since the 1950s, the United States has seen a dramatic decline in the number of psychiatric beds nationwide due in part to deinstitutionalization and the rise of antipsychotics. But that has created a critical shortage for those needing help. From 2011 to 2023, the number of hospitals with inpatient psychiatric units dropped significantly, according to a 2025 study. Another study from that year found that this country has 28.4 inpatient psychiatric beds per 100,000 people — not even half the 60-bed ratio researchers frequently refer to as the optimal level.

The shortage has created what the American Psychiatric Association calls a crisis: emergency rooms overwhelmed with people suffering from severe mental health illnesses, inpatient stays prematurely shortened to speed up bed turnover, and acutely ill individuals left without critical care.

(Oona Zenda/KFF Health News)

“Where are these people going?” said Zoe Lindenfeld, an assistant health policy professor at Rutgers University, who co-authored those 2025 studies. “For people who don’t receive this care, they don’t just go away. How is it affecting them? Society? Their families?”

Meanwhile, the White House shut down the part of the national suicide hotline catering to LGBTQ+ youth, President Donald Trump’s 2027 budget proposal calls for cuts to agencies engaged in mental health work, and Health and Human Services Secretary Robert F. Kennedy Jr. recently announced a plan to reduce the “overuse of psychiatric medications.”

A Fractured System

I was already intimately familiar with the country’s fractured mental healthcare system before I was involuntarily committed. What I had yet to experience myself, I saw through my wife: waitlists, outpatient programs stretched beyond capacity, and inpatient psychiatric care so scarce that access often depends on surviving a crisis severe enough to justify it.

She died by suicide after we had separated.

As the years passed, grief and anxiety pushed me from observer to patient.

At the crisis clinic, I woke up the following morning disoriented and groggy. In the bathroom — its door deliberately unable to latch, swinging both ways so staffers could enter in case of an emergency — I stood at the sink and watched the faucet run, trying to piece together how I had ended up here.

(Oona Zenda/KFF Health News)

America’s history of treating mental illness is long and complicated.

The 19th and 20th centuries saw the removal of people with severe mental disorders from jails and poorhouses — squalid facilities designed to house the poor — to state asylums that promised “moral treatment” (though they ultimately became overcrowded hospitals for the impoverished). From the 1860s to the 1930s, the number of psychiatric hospitals increased dramatically, according to the American Psychiatric Association, and by 1955, the number of psychiatric beds in the U.S. peaked at more than half a million.

However, owing to the development of antipsychotics, the belief that psychiatric institutions were inhumane, and President John F. Kennedy’s 1963 Community Mental Health Act to free thousands of Americans from a life in institutions, many state hospitals shut down. An estimated 61,000 inpatient psychiatric beds for adults and kids are left in a country where more than 14 million experience severe mental illness each year.

Two years after JFK’s legislation passed, a new policy prohibited federal Medicaid funds from covering inpatient psychiatric care in facilities with more than 16 beds. The goal was to encourage states to move patients out of large, often substandard psychiatric institutions into community-based care settings.

The consequences of these changes, however, have been far-ranging. People with severe mental illnesses are often forced to board in emergency departments as they wait for a bed to open. The length of stay in state psychiatric hospitals is shrinking while readmission rates rise, according to research by the Treatment Advocacy Center, a national organization focused on eliminating barriers to the treatment of severe mental illness. And some people with mental illness languish for months, or even years, in jail.

From 1986 to 2014, as the behavioral health crisis intensified, mental health expenditures in the U.S. rose from $32 billion to $186 billion — though the proportion of that spending allocated to inpatient care fell from 42% to 27%.

This period also recorded major policy shifts affecting inpatient hospitalization rates, notably the 1999 U.S. Supreme Court decision in Olmstead v. L.C. The ruling shifted care away from psychiatric facilities by mandating states provide home and community-based services to people with developmental and mental disabilities.

“The road to hell is paved with good intentions,” said Leslie Carpenter, legislative advocacy manager at the Treatment Advocacy Center. “A lot of these bills, including the Community Mental Health Act, were really well intended and ended up with adverse consequences.”

For me, that next day at the clinic passed both painfully slowly and in a blur. A staff member I hadn’t met before told me they were still reaching out to hospitals across the region. The search for a bed continued.

(Oona Zenda/KFF Health News)

‘No One Wants To Pay for Any of This Care’

Last year, members of Congress introduced two bills to change the 16-bed Medicaid funding cap at inpatient psychiatric facilities, the Repealing the Institution for Mental Diseases Exclusion Act and the Michelle Alyssa Go Act, which would increase the cap to 36 beds. Both have stalled in the House.

According to the Congressional Budget Office, a federal agency that analyzes budgetary and economic issues, eliminating the 16-bed limit would increase Medicaid expenditures by $33.5 billion from 2024 to 2033.

“No one wants to pay for any of this care that people need,” said Colorado state Sen. Judy Amabile, a Democrat who has witnessed limitations to Colorado’s mental healthcare system firsthand because her son has schizoaffective disorder.

In lieu of federal action, states are stepping up to bridge the gaps.

Colorado, 15 other states, and Washington, D.C., now operate under waivers allowing Medicaid to fund inpatient facilities with more than 16 beds for mental health treatment, according to KFF data. Seven additional states have waivers pending. One 2025 study found that these waivers may be tied to fewer hospitalizations, emergency department visits, and incarcerations among adults with serious mental illness.

Yet even local efforts to improve mental healthcare face resistance. In California, Colorado, Iowa, Missouri, Nebraska, and New York, locals have pushed back against proposed psychiatric facilities for minors, claiming such facilities will worsen safety and lower property values. Behavioral health advocates have disputed these claims and argued they are rooted in stigma.

That psychiatric facility in Colorado was ultimately greenlit. The state has nearly 20 inpatient beds per 100,000 people, ranking 24th nationwide, according to 2022 data across all 50 states plus Washington, D.C., collected by the Treatment Advocacy Center. Wyoming ranked first with 47.3 beds per 100,000 residents, although, as the least populous state, it has only 275 total inpatient beds compared with California’s 5,703. Minnesota ranked last, with only 4.3 inpatient beds per 100,000 residents.

While increasing the number of inpatient psychiatric beds is vital, mental health advocates are also calling for more community-based supports, such as peer support specialists and clubhouses, where people with serious mental illnesses can learn life skills and find community.

(Oona Zenda/KFF Health News)

When it came time for me to use our mental health safety net, I was among the fortunate ones: At noon the day after my hold began, a bed opened at a hospital in Denver — a rare stroke of luck in a system in which many people wait days or weeks for the care they need. An ambulance transferred me to the hospital at 3 p.m., marking 21 hours into my 72-hour hold.

Two days later, on my last day at the psychiatric hospital, I stood outside the nurse’s station awaiting discharge papers.

A man I had not seen before looked at me and asked, “Are you leaving?”

“Yes,” I said. “Are you being admitted?”

“Yeah,” he responded. “This is my third time being hospitalized in a year.”

I shook his hand. “Good luck,” I said, and I walked out the door.

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 <a target="_blank" href="https://kffhealthnews.org/health-industry/psychiatric-bed-shortage-overburdened-health-system/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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For the second year in a row, many Affordable Care Act insurers are proposing double-digit premium increases, driven by rising medical costs as well as policy changes by Congress and the Trump administration.

In preliminary filings with state regulators, insurers are seeking a median rate increase of 14% for 2027, according to an analysis of filings in 16 states and the District of Columbia by the Peterson-KFF Health System Tracker.

If those rates are ultimately approved, it would be the second-highest increase since 2018.

That would be a “triple whammy“ for consumers, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF, because they have already had to pay higher premiums in 2026 and saw the expiration of more generous tax credits to offset their premiums at the end of last year.

President Joe Biden sought to bolster the program known as Obamacare by enacting more generous tax subsidies, driving down out-of-pocket costs for consumers and increasing enrollment to more than 20 million Americans. But under President Donald Trump, Republicans have sought to scale back taxpayer support for ACA coverage, allowing the Biden-era enhanced subsidies to expire.

As of February, ACA enrollment had fallen by about 3 million people compared with the same time last year. While Cox and other policy experts say that’s because increased costs for the plans drove out people who feel they can get by without insurance, the Trump administration asserts that much of the enrollment growth under Biden was fraudulent.

The main factor driving proposed premium increases for 2027, as in most years, is the rising cost and use of medical care.

There’s growing demand for costly specialty medications and for the weight loss drugs known as GLP-1s, the Peterson-KFF report notes.

But the report also said that about 4 percentage points’ worth of the premium increases insurers proposed are due to lasting effects of the expiration of enhanced subsidies. Insurers expect that with young and healthy people leaving the program rather than paying higher premiums, their remaining customers will be older, sicker, and therefore costlier on average.

 “It’s likely that the people who dropped their coverage were also the healthier people, because sicker people were probably going to try to make it work however they could, to stretch their budget to keep their health insurance,” said Cox, of KFF, a health information nonprofit that includes KFF Health News.

In their rate filings, some insurers also said they had to raise premiums in part because of policy changes by the Trump administration that are expected to make it harder for some people to enroll.

Together with the expiration of the larger subsidies, the new rules “account for 12.7% of the requested rate change,” the insurer UnitedHealthcare wrote in its rate filing with New York state, according to the Peterson-KFF report.

“It is not surprising insurance conglomerates that profited massively off of Biden-era fraud are complaining about efforts to clean up the program,” White House spokesman Kush Desai said in a statement. He added that the administration “has made it clear that it will not follow its predecessors in giving out taxpayer funded subsidies to big insurance companies through the form of fraudulent and corrupt polices” and that it would “hold big insurance companies accountable.”

Another driver of higher premiums cited by several insurers is that claims submitted on behalf of patients have tended to be for more intense — and costly — levels of care than in the past. Such increased severity may be because patients are actually sicker, or it may reflect that hospitals or doctors are using artificial intelligence to find billing codes that can maximize their payments, the report noted.

The use of AI to maximize bills is also a factor driving up the cost of health coverage offered by employers, according to the consulting firm PwC, which forecast that the cost of caring for people with job-based coverage will rise by 9% in 2027.

In the ACA, premium increases will primarily affect enrollees with incomes just above 400% of the federal poverty level, amounting to about $62,600 this year for an individual. That’s because they’re no longer eligible for subsidies following the expiration of the enhanced tax credits.

People below that level get tax credits to help pay their monthly premium, based on how much they earn and the cost of a “benchmark” ACA plan where they live. As a result, as premiums rise, so do subsidies, shielding many consumers from rising prices but also raising costs for the federal government.

They may have to shop around when enrollment opens for 2027 coverage in October, however. Depending on their particular plan’s premium, they may need to switch plans to keep premiums fixed, said Matthew Fiedler, a senior fellow at the Brookings Institution.

KFF Health News senior correspondent Julie Appleby contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

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

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