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The Rural Health Transformation Program calls for federal regulators to hand states $10 billion a year for five years starting in fiscal year 2026.

But the “devil’s in the details in terms of implementing,” said Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics.

“An investment of this amount and this style into rural — hopefully it goes to rural — is the type of investment that we and other advocates have been working on for a long time,” said Hohman, whose organization represents 5,600 rural health clinics.

People who live in the nation’s rural expanses have more chronic diseases, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services like obstetrics and mental health care.

Nearly 1 in 4 people in rural America use Medicaid, the state and federal program for low-income and disabled people. So, as Senate Republicans heatedly debated Medicaid spending reductions, lawmakers added the $50 billion program to quell opposition. But health advocates and researchers doubt it will be enough to offset expected cuts in federal funding.

Senate Majority Leader John Thune, a Republican from South Dakota, which has one of the largest percentages of rural residents in the nation, led the push to pass the budget bill. His website touts support for strengthening access to care in rural areas. But his office declined to respond on the record to questions about the rural health program included in the bill.

Sen. Susan Collins, a Republican from Maine who introduced an initial amendment to add the rural program, also did not respond to a request for comment. On July 15, Sen. Josh Hawley, a Republican from Missouri, introduced a bill to reverse future cuts to Medicaid and add to the rural program.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank headquartered in Washington, D.C., said the money was set aside because of politics and not necessarily for rural patients.

“As long as it’s a government slush fund where politics decides where the money goes, then there’s going to be a mismatch between where those funds go and what it is consumers need,” Cannon said.

The nonpartisan Congressional Budget Office estimates federal Medicaid spending will be reduced by about $1 trillion over the next decade.

“These dollar amounts translate to actual people,” said Fredric Blavin, a senior fellow and researcher at the Urban Institute, a Washington D.C.-based think tank that focuses on social and economic research.

Most states expanded their Medicaid programs to cover more low-income adults under the Affordable Care Act. That has lowered medical debt, improved health, and even reduced death rates, Blavin said.

By 2034, about 11.8 million people are expected to lose their health insurance from this bill, said Alice Burns, an associate director for KFF’s Program on Medicaid and the Uninsured. And she said the Medicaid rollback may have an outsize impact on rural areas.

In rural areas, federal Medicaid spending is expected to decline by $155 billion over 10 years, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

If the goal of the rural program was to transform rural health care, as its name suggests, it will fall short, Burns said. The $50 billion rural program distributed over five years won’t offset the losses expected over a decade of Medicaid reductions, she said.

In Kansas, Holton Community Hospital Chief Executive Carrie Lutz said she doesn’t “feel that the sky is falling right now.”

Lutz, whose 14-bed hospital is on the northern plains of the state, said she is bracing for the potential loss of Medicaid-covered patients and limits to provider taxes, which nearly all states use to get extra federal Medicaid money.

The reduction in provider taxes has been delayed until fiscal year 2028, Lutz said, but she still wants her state’s leaders to apply for a portion of the rural program funding, which is expected to be distributed sooner.

“Every little penny helps when you’ve got very negative margins to begin with,” Lutz said.

The program’s $50 billion will be spread over five years and may not be limited to bolstering rural areas or their hospitals. Half of the money will be distributed “equally” among states that apply to and win approval from the Centers for Medicare & Medicaid Services. The law’s current language “raises the possibility” that a small state like Vermont could receive the same amount as a large state like Texas, Burns said.

States are required to submit a “detailed rural health transformation plan” by the end of this year, according to the law.

The law says states should use the funds to pursue goals including improving access to hospitals and other providers, improving health outcomes, enhancing economic opportunity for health care workers, and prioritizing the use of emerging technologies.

Mehmet Oz, a Trump appointee leading Medicare and Medicaid, will determine how to distribute the other half, or $25 billion, using a formula based on states’ rural population and need. The law says the money is to be used for such things as increasing use of robotics, upgrading cybersecurity, and helping rural communities “to right size their health care delivery systems.”

Spokespeople for CMS did not respond to a list of questions.

Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, said there is “a pretty significant degree of discretion” for the White House and the Medicare and Medicaid administrator in approving state plans.

“We will urge states to include robust telehealth and virtual care options within their proposals going up to the federal government,” Zebley said.

Alexa McKinley Abel, government affairs and policy director for the National Rural Health Association, said that while the law calls for states to create and submit plans, it’s unclear what state agencies will perform the task, McKinley Abel said.

“There are a lot of gaps around application and implementation,” she said, noting that an earlier version of the bill called for state plans to be developed in consultation with federally funded state offices of rural health.

But those offices are proposed to be eliminated in Trump’s federal budget, which will face congressional approval in the fall. McKinley Abel said her organization supports state offices of rural health helping develop the plans and working with states to disburse the money, “since they intimately know the rural health community.”

Hohman, with the rural health clinic association, said she is not sure money from the transformation program will even reach her members. About 27% of the patients treated at rural health clinics are enrolled in Medicaid, she said.

“There’s just some confusion about who actually gets this money at the end of the day,” Hohman said. “What is it actually going to be used for?”

KFF Health News senior correspondent Phil Galewitz 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.

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Federal health officials do not inform consumers about severe safety violations in hospitals that specialize in physical rehabilitation. Nor does Medicare impose fines as it does for nursing homes, or provide easy-to-understand five-star ratings as it does for general hospitals, according to an investigation by KFF Health News and The New York Times. 

Medical rehab hospitals have become a highly lucrative niche within the health care industry, collectively generating profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency known as MedPAC. 

But MedPAC and independent researchers have found that for-profit rehabs tend to have higher rates of patients being readmitted to general hospitals than nonprofits do. 

In 2023, stand-alone for-profit rehabilitation hospitals overtook nonprofits as the places where most annual patient admissions occur, a KFF Health News and New York Times analysis found. These facilities are required to provide three hours of physical, occupational, or speech therapy a day, five days a week. 

Congress has not authorized Medicare to fine rehab hospitals for violations uncovered during inspections, even ones that resulted in death, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000. 

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used. Even the most serious violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems. 

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

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

Also read our consumer guide to finding the right place to get physical, occupational or speech therapy.

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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Most of the 24 million people in Affordable Care Act health plans face a potential one-two punch next year — double-digit premium increases along with a sharp drop in the federal subsidies that most consumers depend on to buy the coverage, also known as Obamacare.

Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, covid-era ACA tax subsidies to expire at the end of December.

“The out-of-pocket change for individuals will be immense, and many won’t actually be able to make ends meet and pay premiums, so they will go uninsured,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Donald Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won’t occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions.

“I am hearing on both sides — more from Republicans, but from both the House and Senate” — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups.

In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, according to an analysis for the Peterson-KFF Health System Tracker covering 19 states and the District of Columbia. KFF is a national health information nonprofit that includes KFF Health News.

That’s up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%.

Health insurers “are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes,” wrote Chris Bond, a spokesperson for AHIP, the industry’s lobbying group. The emailed response also called on lawmakers “to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026.”

Neither the White House nor the Department of Health and Human Services responded to requests for comment.

These are initial numbers and insurance commissioners in some states may alter requests before approval.

Still, “it’s the biggest increase we’ve seen in over five years,” said analysis co-author Cynthia Cox, a KFF vice president and director of its Program on the ACA.

Premiums will vary based on where consumers live, the type of plan they choose, and their insurer.

For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, according to an analysis of a smaller set of insurers by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA’s enhanced tax credits are extended.

Most insurers are asking for 10% to 20% increases, the KFF report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed.

But rising premiums are just part of the picture.

A bigger potential change for consumers’ pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden’s term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022.

Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to chip in 8.5% of their household income toward the premiums.

Across the board, but especially among lower-income policyholders, bigger subsidies helped fuel record enrollment in ACA plans.

But they’re also costly.

A permanent extension could cost $335 billion over the next decade, according to the Congressional Budget Office.

Such an extension was left out of the policy law Trump signed on July 4 that he called the “One Big Beautiful Bill.” Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels.

That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds four times the federal poverty level — $84,600 for a couple or $128,600 for a family of four this year — won’t get any subsidies at all.

If the subsidies expire, policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%. In some states, ACA premiums could double.

“There will be sticker shock,” said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses.

And enrollment could fall sharply. The Wakely Consulting Group estimates that the combination of expiring tax credits, the Trump law’s new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%.

According to KFF, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members.

Less common in the filings submitted so far, but noticeable, are increases pegged to Trump administration tariffs, Cox said.

“What they are assuming is tariffs will drive drug costs up significantly, with some saying that can have around a 3-percentage-point increase” in premiums as a result, she said.

Consumers will learn their new premium prices only late in the fall, or when open enrollment for the ACA begins on Nov. 1 and they can start shopping around.

Congress could still act, and discussions are ongoing, said insurance broker Brooker.

Some lawmakers, he said, are consulting with the CBO about the fiscal and coverage effects of various scenarios that don’t extend the subsidies as they currently exist but may offer a middle ground. One possibility involves allowing subsidies for families earning as much as five or six times the poverty level, he said.

But any such effort will draw pushback.

Some conservative think tanks, such as the Paragon Health Institute, say the more generous subsides led people to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization.

But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. In 2024, 56% of ACA enrollees lived in Republican congressional districts, and 76% were in states won by Trump.

Allowing the enhanced subsidies to expire could also reshape the market.

Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Trump’s new tax law allows people enrolled in either “bronze” or “catastrophic”-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs.

“Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options,” Brooker said.

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

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

The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Sandhya Raman CQ Roll Call @SandhyaWrites @SandhyaWrites.bsky.social Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

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

Julie Rovner: The New York Times’ “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich.

Joanne Kenen: The New Yorker’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons from Sweden,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

• The Atlantic’s “The Trump Administration Is About To Incinerate 500 Tons of Emergency Food,” by Hana Kiros.
• KFF Health News’ “Vested Interests. Influence Muscle. At RFK Jr.’s HHS, It’s Not Pharma. It’s Wellness,” by Stephanie Armour.
• The Washington Post’s “A Clinic Blames Its Closing on Trump’s Medicaid Cuts. Patients Don’t Buy It,” by Hannah Knowles.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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One of the world’s biggest genetic databases comprises DNA data donated over the years by more than a million retired military service members. It’s part of a project run by the Department of Veterans Affairs.

The initiative, dubbed the Million Veteran Program, is a “crown jewel of the country,” said David Shulkin, a physician who served as VA secretary during the first Trump administration. Data from the project has contributed to research on the genetics of anxiety and peripheral artery disease, for instance, and has resulted in hundreds of published papers. Researchers say the repository has the potential to help answer health questions not only specific to veterans — like who is most vulnerable to post-service mental health issues, or why they seem more prone to cancer — but also relevant to the nation as a whole.

“When the VA does research, it helps veterans, but it helps all Americans,” Shulkin said in an interview.  

Researchers now say they fear the program is in limbo, jeopardizing the years of work it took to gather the veterans’ genetic data and other information, like surveys and blood samples.

“There’s sort of this cone of silence,” said Amy Justice, a Yale epidemiologist with a VA appointment as a staff physician. “We’ve got to make sure this survives.”

Genetic data is enormously complex, and analyzing it requires vast computing power that VA doesn’t possess. Instead, it has relied on a partnership with the Energy Department, which provides its supercomputers for research purposes.

In late April, VA Secretary Doug Collins disclosed to Sen. Richard Blumenthal, the top Democrat on the Senate Veterans’ Affairs Committee, that agreements authorizing use of the computers for the genomics project remained unsigned, with some expiring in September, according to materials shared with KFF Health News by congressional Democrats.

Spokespeople for the two agencies did not reply to multiple requests for comment. Other current and former employees within the agencies — who asked not to be identified, for fear of reprisal from the Trump administration — said they don’t know whether the critical agreements will be renewed.

One researcher called computing “a key ingredient” to major advances in health research, such as the discovery of new drugs.

The agreement with the Energy Department “should be extended for the next 10 years,” the researcher said.

The uncertainty has caused “incremental” damage, Justice said, pointing to some Million Veteran Program grants that have lapsed. As the year progresses, she predicted, “people are going to be feeling it a lot.”

Because of their military experience, maintaining veterans’ health poses different challenges compared with caring for civilians. The program’s examinations of genetic and clinical data allow researchers to investigate questions that have bedeviled veterans for years. As examples, Shulkin cited “how we might be able to better diagnose earlier and start thinking about effective treatments for these toxic exposures” — such as to burn pits used to dispose of trash at military outposts overseas — as well as predispositions to post-traumatic stress disorder.

“The rest of the research community isn’t likely to focus specifically” on veterans, he said. The VA community, however, has delivered discoveries of importance to the world: Three VA researchers have won Nobel Prizes, and the agency created the first pacemaker. Its efforts also helped ignite the boom in GLP-1 weight loss drugs.

Yet turbulence has been felt throughout VA’s research enterprise. Like other government scientific agencies, it’s been buffeted by layoffs, contract cuts, and canceled research.

“There are planned trials that have not started, there are ongoing trials that have been stopped, and there are trials that have fallen apart due to staff layoffs — yes or no?” said Sen. Patty Murray (D-Wash.), pressing Collins in a May hearing of the Senate Veterans’ Affairs Committee.

The agency, which has a budget of roughly $1 billion for its research arm this fiscal year, has slashed infrastructure that supports scientific inquiry, according to documents shared with KFF Health News by Senate Democrats on the Veterans’ Affairs Committee. It has canceled at least 37 research-related contracts, including for genomic sequencing and for library and biostatistics services. The department has separately canceled four contracts for cancer registries for veterans, creating potential gaps in the nation’s statistics.

Job worries also consume many scientists at the VA.

According to agency estimates in May, about 4,000 of its workers are on term limits, with contracts that expire after certain periods. Many of these individuals worked not only for the VA’s research groups but also with clinical teams or local medical centers.

When the new leaders first entered the agency, they instituted a hiring freeze, current and former VA researchers told KFF Health News. That prevented the agency’s research offices from renewing contracts for their scientists and support staff, which in previous years had frequently been a pro forma step. Some of those individuals who had been around for decades haven’t been rehired, one former researcher told KFF Health News.

The freeze and the uncertainty around it led to people simply departing the agency, a current VA researcher said.

The losses, the individual said, include some people who “had years of experience and expertise that can’t be replaced.”

Preserving jobs — or some jobs — has been a congressional focus. In May, after inquiries from Sen. Jerry Moran, the Republican who chairs the Veterans’ Affairs Committee, about staffing for agency research and the Million Veteran Program, Collins wrote in a letter that he was extending the terms of research employees for 90 days and developing exemptions to the hiring freeze for the genomics project and other research initiatives.

Holding jobs is one thing — doing them is another. In June, at the annual research meeting of AcademyHealth — an organization of researchers, policymakers, and others who study how U.S. health care is delivered — some VA researchers were unable to deliver a presentation touching on psychedelics and mental health disparities and another on discrimination against LGBTQ+ patients, Aaron Carroll, the organization’s president, told KFF Health News.

At that conference, reflecting a trend across the federal government, researchers from the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality also dropped out of presenting. “This drop in federal participation is deeply concerning, not only for our community of researchers and practitioners but for the public, who rely on transparency, collaboration, and evidence-based policy grounded in rigorous science,” Carroll said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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La terapia de rehabilitación puede ser una bendición después de una hospitalización por un derrame cerebral, una caída, un accidente, un reemplazo de articulación, una quemadura grave o una lesión de la médula espinal, entre otras afecciones.

La fisioterapia, la terapia ocupacional y la terapia del habla se ofrecen en diversos entornos: hospitales, residencias de adultos mayores, clínicas y a domicilio.

Es fundamental encontrar una opción segura y de alta calidad con profesionales con experiencia en el tratamiento de tu afección.

¿Qué tipos de terapia de rehabilitación podría necesitar?

La fisioterapia ayuda a los pacientes a mejorar su fuerza, estabilidad y movimiento, y a reducir el dolor, generalmente a través de ejercicios específicos.

Algunos fisioterapeutas se especializan en problemas neurológicos, cardiovasculares u ortopédicos. También hay especialistas en geriatría y pediatría. La terapia ocupacional se centra en actividades específicas (llamadas “ocupaciones”), que suelen requerir habilidades motoras finas, como cepillarse los dientes, cortar alimentos con un cuchillo o vestirse.

La terapia del habla y del lenguaje ayuda a las personas a comunicarse. Algunos pacientes pueden necesitar terapia respiratoria si tienen dificultad para respirar o necesitan que se les retire el respirador.

¿Los seguros cubren las sesiones de rehabilitación?

Medicare, las aseguradoras de salud, la compensación laboral y los planes de Medicaid en algunos estados cubren las terapias de rehabilitación, pero los planes pueden negarse a pagar en ciertos entornos y limitar la cantidad de sesiones.

Algunas aseguradoras pueden pedir una preautorización y otras cancelar la cobertura si no se mejora. Las aseguradoras privadas suelen establecer límites anuales para la terapia ambulatoria.

El Medicare tradicional suele ser el menos restrictivo, mientras que los planes privados Medicare Advantage pueden supervisar de cerca el progreso y limitar los lugares en dónde los pacientes pueden recibir terapia.

¿Debería buscar rehabilitación hospitalaria?

Los pacientes que aún necesitan atención médica o de enfermería, pero que pueden tolerar tres horas de terapia cinco días a la semana, podrían calificar para ser admitidos en un hospital de rehabilitación especializado o en una unidad que funcione dentro de un hospital general.

Los pacientes suelen necesitar al menos dos de los principales tipos de terapia de rehabilitación: fisioterapia, terapia ocupacional o terapia del habla. Las estadías duran un promedio unos 12 días.

¿Cómo elijo?

Busca un centro especializado en el tratamiento de personas con tu diagnóstico; muchos hospitales enumeran las especialidades en sus sitios de internet. Las personas con afecciones médicas complejas o graves podrían preferir un hospital de rehabilitación conectado a un centro médico académico a la vanguardia de los nuevos tratamientos, incluso si está a un vuelo de distancia.

“Verás a pacientes jóvenes con lesiones catastróficas”, como daño de la médula espinal, viajando a otro estado para recibir tratamiento, dijo Cheri Blauwet, directora médica de Spaulding Rehabilitation en Boston, uno de los 15 hospitales que el gobierno federal ha elogiado por su trabajo de avanzada.

Sin embargo, elegir un hospital cerca de familiares y amigos que puedan ayudar después del alta tiene sus ventajas. Los terapeutas pueden ayudar a capacitar a los que serán cuidadores en casa.

¿Cómo encuentro hospitales de rehabilitación?

El planificador de altas o el trabajador social del hospital de agudos debería ofrecerte opciones. Puedes buscar centros de rehabilitación para pacientes internados por ubicación o nombre en el sitio web Care Compare de Medicare. Allí puedes ver cuántos pacientes con tu misma afección ha tratado ese hospital; cuantos más, mejor.

Puedes buscar por especialidad a través de la Asociación Americana de Proveedores de Rehabilitación Médica, un grupo comercial que publica una lista de sus miembros.

Averigüa qué tecnologías especializadas tiene un hospital, como simuladores de manejo (un auto o camión que permite al paciente practicar subir y bajar de un vehículo) o una mesa de cocina con utensilios para practicar cocinar.

¿Cómo puedo saber si un hospital de rehabilitación es confiable?

No es fácil: Medicare no analiza al personal ni publica en su sitio de internet los resultados de las inspecciones de seguridad como sí lo hace con las residencias de adultos mayores. Puedes pedir a la agencia de salud pública de tu estado o al hospital que te proporcionen informes de inspección de los últimos tres años. Estos informes pueden ser técnicos, pero te ayudarán a comprender lo esencial. Si el informe indica que se declaró un “riesgo inmediato”, significa que los inspectores identificaron problemas de seguridad que ponen en peligro a los pacientes.

La tasa de pacientes readmitidos en un hospital general por una razón potencialmente prevenible es una medida de seguridad clave. En general, los centros de rehabilitación con fines de lucro tienen tasas de readmisión más altas que los que son sin fines de lucro, pero hay algunos con tasas de readmisión más bajas y otros con tasas más altas. Puede que no tengas otra opción cerca: hay menos de 400 hospitales de rehabilitación y la mayoría de los hospitales generales no cuentan con una unidad de rehabilitación.

Puedes encontrar las tasas de readmisión de un hospital en la sección de calidad de Care Compare. Las tasas inferiores al promedio nacional son mejores.

Otra medida de calidad es la frecuencia con la que los pacientes son lo suficientemente funcionales como para irse a casa después de terminar la rehabilitación en lugar de ir a una residencia de adultos mayores, un hospital o una institución médica. Esta medida se denomina “alta a la comunidad” y se encuentra en la sección de calidad de Care Compare. Las tasas superiores al promedio nacional son mejores.

Busca reseñas del hospital en Yelp y otros sitios web. Pregunta si los pacientes ven al mismo terapeuta casi todos los días o no. Y si tienen certificaciones en la especialidad que necesitas.

Si es posible, visita el hospital y observa cómo opera. Si es posible, observa si las enfermeras responden rápido a las luces de llamada, si parecen estar sobrecargadas con demasiados pacientes o están mirando sus celulares. Pregunta a los pacientes actuales y a sus familiares si están satisfechos con la atención.

¿Qué pasa si no puedo tolerar tres horas de terapia al día?

Una residencia de personas mayores que ofrece rehabilitación podría ser adecuada para pacientes que no necesitan la supervisión de un médico, pero que no están listos para irse a casa. Las instalaciones generalmente brindan atención de enfermería las 24 horas. La duración de la rehabilitación varía según el paciente. Hay más de 14.500 centros de enfermería especializada en el país, 12 veces más que los hospitales que ofrecen rehabilitación, por lo que una de estas residencias podría ser tu mejor opción.

Puedes buscarlas a través del sitio web Care Compare de Medicare.

¿Qué sucede si los pacientes son demasiado frágiles incluso para una residencia de adultos mayores?

Podrían necesitar un hospital de cuidados de largo plazo. Estos se especializan en pacientes en coma, con respiradores y con afecciones médicas agudas que requieren la presencia de un médico. Los pacientes permanecen allí al menos cuatro semanas, y algunos meses. Care Compare te ayuda a buscar. Hay menos de 350 hospitales de este tipo.

Si tengo la fuerza suficiente para ir a casa. ¿Cómo recibo terapia?

Muchos hospitales de rehabilitación ofrecen terapia ambulatoria. También puedes ir a una clínica o un terapeuta puede ir a tu domicilio. Puedes contratar una agencia de atención médica a domicilio o encontrar un terapeuta que reciba tu seguro y haga visitas a domicilio.

Tu médico u hospital podría derivarte a otros profesionales. En Care Compare, las agencias de atención médica a domicilio indican si ofrecen fisioterapia, terapia ocupacional o terapia del habla. Puedes buscar terapeutas certificados en el sitio web de la Asociación Americana de Fisioterapia (APTA).

Durante la rehabilitación, los pacientes a veces se trasladan del hospital a un centro de enfermería y luego a su hogar, a menudo por insistencia de sus aseguradoras. Alice Bell, especialista senior de la APTA, señaló que los pacientes deberían intentar limitar el número de traslados, por su propia seguridad.

“Cada vez que un paciente cambia de un entorno a otro se encuentra en una zona de mayor riesgo”, afirmó.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alarming Mistakes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rapid Growth and a Troubled History

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

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

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

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

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

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

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

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

Medication Harms

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

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

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

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

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

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

Deadly Bedsores

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

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

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

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

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

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

METHODOLOGY

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

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

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

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

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

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

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

What kinds of rehab therapy might I need?

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

Will insurance cover rehab?

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

Should I seek inpatient rehabilitation?

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

How do I choose?

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

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

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

How do I find rehab hospitals?

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

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

How can I be confident a rehab hospital is reliable?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Outside Advisers

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

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

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

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

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

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

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

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

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

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

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

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

Ethics and Disclosures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But other factors were at work.

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

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

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

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

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

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

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

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

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

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

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

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

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

There were some successes, however, Kahn said.

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

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

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

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

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

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

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

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

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

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

But this time around, that message had little traction.

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

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

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

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

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

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

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

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

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

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

Chief Washington correspondent Julie Rovner contributed to this report.

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

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

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

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

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

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

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

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

That may soon change.

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

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

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

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

The Heritage Foundation did not respond to an interview request.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It wasn’t a mistake.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reducing Suicides and Addiction in Construction and Mining

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

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

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

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

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

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

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

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

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

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

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

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

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

Health Care Sector Braces for Fallout From NIOSH Cuts

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

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

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

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

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

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

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

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

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

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

Who Can Fill the Gap?

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

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

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

But others are skeptical that industry can replace NIOSH efforts.

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

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

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

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

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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.

Early Thursday afternoon, the House approved a budget reconciliation bill that not only would make permanent many of President Donald Trump’s 2017 tax cuts, but also impose deep cuts to Medicaid, the Affordable Care Act, and, indirectly, Medicare.

Meanwhile, those appointed by Health and Human Services Secretary Robert F. Kennedy Jr. to a key vaccine advisory panel used their first official meeting to cast doubt on a preservative that has been used in flu vaccines for decades — with studies showing no evidence of its harm in low doses.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Maya Goldman of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Panelists Maya Goldman Axios @mayagoldman_ @maya-goldman.bsky.social Read Maya's stories Sarah Karlin-Smith Pink Sheet @SarahKarlin @sarahkarlin-smith.bsky.social Read Sarah's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• This week the GOP steamrolled toward a major constriction of the nation’s social safety net, pushing through Trump’s tax and spending bill. The legislation contains significant changes to the way Medicaid is funded and delivered — in particular, through imposing the program’s first federal work requirement on many enrollees. Hospitals say the changes would be devastating, potentially resulting in the loss of services and facilities that could touch all patients, not only those on Medicaid.
• Some proposals in Trump’s bill were dropped during the Senate’s consideration, including a ban on Medicaid coverage for gender-affirming care and federal funding cuts for states that use their own Medicaid funds to cover immigrants without legal status. And for all the talk of not touching Medicare, the legislation’s repercussions for the deficit are expected to trigger spending cuts to the program that covers those over 65 and some with disabilities — potentially as soon as the next fiscal year.
• The newly reconstituted Advisory Committee on Immunization Practices met last week, and it looked pretty different from previous meetings: In addition to new members, there were fewer staffers on hand from the Centers for Disease Control and Prevention — and the notable presence of vaccine critics. The panel’s vote to reverse the recommendation of flu shots containing a mercury-based preservative — plus its plans to review the childhood vaccine schedule — hint at what’s to come.

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

Julie Rovner: The Lancet’s “Evaluating the Impact of Two Decades of USAID Interventions and Projecting the Effects of Defunding on Mortality up to 2030: A Retrospective Impact Evaluation and Forecasting Analysis,” by Daniella Medeiros Cavalcanti, et al.

Alice Miranda Ollstein: The New York Times’ “‘I Feel Like I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow.

Maya Goldman: Axios’ “New Docs Get Schooled in Old Diseases as Vax Rates Fall,” by Tina Reed.

Sarah Karlin-Smith: Wired’s “Snake Venom, Urine, and a Quest to Live Forever: Inside a Biohacking Conference Emboldened by MAHA,” by Will Bahr.

Also mentioned in this week’s episode:

• NBC News’ “Crisis Pregnancy Centers Told To Avoid Ultrasounds for Suspected Ectopic Pregnancies,” by Abigail Brooks.
• ProPublica’s “A ‘Striking’ Trend: After Texas Banned Abortion, More Women Nearly Bled to Death During Miscarriage,” by Kavitha Surana, Lizzie Presser, and Andrea Suozzo.
• The Washington Post’s “DOGE Loses Control Over Government Grants Website, Freeing Up Billions,” by Dan Diamond and Hannah Natanson.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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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.

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El “One Big Beautiful Bill” del presidente Donald Trump recorta el gasto federal en los mercados de Medicaid y la Ley de Cuidado de Salud a Bajo precio (ACA) en aproximadamente $1.000 millones a lo largo de una década, según la Oficina de Presupuesto del Congreso (CBO), una entidad no partidista. Esto amenaza la salud física y financiera de decenas de millones de estadounidenses.

El proyecto de ley, aprobado por el Senado el martes 1 de julio, revertiría muchos de los avances en cobertura médica de las administraciones Biden y Obama, cuyas políticas facilitaron el acceso a la atención médica a millones de personas y redujeron la tasa de personas sin seguro en el país a mínimos históricos.

El plan del Senado para recortar drásticamente la financiación de Medicaid y los mercados de ACA podría hacer que unas 12 millones de personas más no tuvieran seguro para 2034, según estima la CBO.

Esto, a su vez, perjudicaría las finanzas de hospitales, residencias de adultos mayores y centros de salud comunitarios —que tendrían que absorber una mayor parte del costo del tratamiento de las personas sin cobertura— y podría obligarlos a reducir servicios y personal, hasta a cerrar instalaciones.

La legislación está en el escritorio de Trump a la espera de su firma, aunque primero el Senado y la Cámara de Representantes deben aprobar la misma versión. La Cámara de Representantes aprobó su propia versión en mayo y se espera que considere la versión del Senado hoy (2 de julio), según Tom Emmer, líder de la mayoría en la Cámara.

A continuación, se presentan cinco maneras en que los planes del Partido Republicano podrían afectar el acceso a la atención médica.

¿Necesita Medicaid? Entonces consigue un trabajo

Los recortes más profundos al gasto en atención médica provienen de la propuesta de un requisito de trabajo para Medicaid, que cortaría la cobertura a millones de afiliados que no cumplen con estos nuevos estándares.

En 40 estados y Washington, D.C., que han ampliado Medicaid bajo ACA, algunos beneficiarios de Medicaid tendrían que presentar regularmente documentación que demuestre que trabajan, hacen voluntariado o asisten a la escuela al menos 80 horas al mes, o que califican para una exención, como por ejemplos el cuidado de un niño pequeño.

El requisito del proyecto de ley no se aplicaría a las personas en los 10 estados, mayoritariamente republicanos, que no han ampliado Medicaid.

Investigadores de salud afirman que la política tendría poco impacto en el empleo. Según KFF, la mayoría de los beneficiarios de Medicaid en edad laboral que no reciben prestaciones por discapacidad ya trabajan o buscan trabajo, o no pueden hacerlo porque tienen una discapacidad, asisten a la escuela o cuidan a un familiar.

Los experimentos estatales con requisitos de trabajo se han visto plagados de problemas administrativos, como la pérdida de cobertura de los beneficiarios elegibles por problemas con el papeleo, y más gasto.

El requisito de trabajo de Georgia, que se implementó oficialmente en julio de 2023, ha costado más de $90 millones, de los cuales solo 26 millones se han destinado a prestaciones de salud, según el  Georgia Budget & Policy Institute, una organización de investigación no partidista.

“Los costos ocultos son astronómicos”, afirmó Chima Ndumele, profesor de la Escuela de Salud Pública de Yale.

Menos dinero significa menos atención en las comunidades rurales

Las medidas de ajuste que se aplicarían a los estados podrían traducirse en una disminución de los servicios de salud, profesionales médicos e incluso hospitales, especialmente en las comunidades rurales.

El plan del Partido Republicano reduciría una práctica conocida como impuestos a los proveedores, que casi todos los estados han utilizado durante décadas para aumentar los pagos de Medicaid a hospitales, residencias de adultos mayores y otros proveedores, así como a empresas privadas de atención médica administrada.

Los estados suelen utilizar el dinero federal generado a través de los impuestos para pagar a las instituciones más de lo que Medicaid pagaría de otra manera. (Medicaid generalmente paga las tarifas más bajas por la atención médica, en comparación con Medicare, el programa para personas mayores de 65 años y algunas personas con discapacidad, y los seguros privados).

Los hospitales y residencias de adultos mayores afirman que utilizan estos fondos adicionales de Medicaid para ampliar o añadir nuevos servicios y mejorar la atención para todos los pacientes.

Los hospitales rurales suelen operar con márgenes de ganancia reducidos y dependen de los pagos de impuestos de Medicaid para sostenerlos. Investigadores del Cecil G. Sheps Center for Health Services Research que examinaron el proyecto de ley de la Cámara concluyeron que este obligaría a más de 300 hospitales rurales, muchos de ellos en Kentucky, Louisiana, California y Oklahoma, a reducir sus servicios o cerrar.

Los senadores republicanos agregaron un fondo de $50 mil millones a su versión del proyecto de ley para amortiguar el impacto en los hospitales rurales.

Más dificultad para obtener, y mantener, la cobertura de ACA

Para quienes tienen cobertura del mercado de seguros de salud de ACA, el plan republicano dificultaría la inscripción y el conservar los planes.

Los asegurados del mercado de seguros estarían obligados a actualizar sus ingresos, estatus migratorio y otra información cada año, en lugar de reinscribirse automáticamente, algo que más de 10 millones de personas hicieron este año.

También tendrían menos tiempo para inscribirse; el proyecto de ley acorta el período anual de inscripción abierta en aproximadamente un mes.

Las personas que soliciten cobertura fuera de ese período —por ejemplo, porque pierden su trabajo u otro seguro, o necesitan agregar a un recién nacido o cónyuge a una póliza existente— tendrían que esperar a que se procesen todos sus documentos antes de recibir subsidios del gobierno para ayudar a pagar sus primas mensuales. Actualmente, reciben hasta 90 días de ayuda con las primas durante el proceso de solicitud, que puede tardar semanas.

Los legisladores republicanos y algunos centros de estudios de políticas conservadoras, incluido el Paragon Health Institute, afirman que los cambios son necesarios para reducir las inscripciones fraudulentas, mientras que los opositores afirman que son el último intento de desmantelar el Obamacare.

La legislación tampoco contempla una extensión de los subsidios mejorados implementados durante la pandemia de covid-19. Si el Congreso no actúa, estos subsidios expirarán a finales de año, lo que resultará en un aumento promedio del 75% en las primas el próximo año, según KFF.

¿Tienes Medicaid? Se pagará más por las consultas médicas

Muchos beneficiarios de Medicaid podrían tener que pagar más de su bolsillo por las citas.

El proyecto de ley exigiría a los estados que han ampliado Medicaid cobrar a los beneficiarios hasta $35 por algunos servicios si sus ingresos se encuentran entre el nivel federal de pobreza (este año, $15.650 por persona) y el 138% de esa cantidad ($21.597).

Los beneficiarios de Medicaid generalmente no pagan nada cuando buscan servicios médicos, ya que estudios han demostrado que cobrar incluso copagos pequeños lleva a las personas de bajos ingresos a renunciar a atención necesaria. En los últimos años, algunos estados han agregado cargos inferiores a $10 por algunos servicios.

Esta política no se aplicaría a las personas que buscan atención primaria, atención de salud mental o tratamiento de adicciones.

Recortes para inmigrantes con residencia legal

El plan republicano podría provocar que al menos cientos de miles de inmigrantes con residencia legal —incluyendo solicitantes de asilo, víctimas de tráfico humano y refugiados— pierdan su cobertura del mercado de seguros al eliminar los subsidios que hacen que las primas sean asequibles. La restricción no se aplicaría a los titulares de tarjetas de residencia permanente (Green Card o tarjeta verde).

Dado que los inmigrantes que perderían subsidios bajo este plan tienden a ser más jóvenes que la población general, su salida dejaría una población de afiliados de mayor edad, con mayor riesgo de enfermedad y costos más elevados, lo que incrementaría aún más las primas del mercado, según directores de los mercados de seguros de salud en California, Maryland y Massachusetts, y analistas de salud.

Quitar el acceso a la atención médica a los inmigrantes que viven legalmente en el país “causará un daño irreparable a las personas que hemos prometido proteger e impondrá costos innecesarios a los sistemas locales que ya están sobrecargados”, declaró John Slocum, director ejecutivo del Refugee Council USA, un grupo de defensa, en un comunicado.

Tanto la versión de la Cámara de Representantes como la del Senado del proyecto de ley reflejan el enfoque restrictivo de la administración Trump hacia la inmigración.

Sin embargo, debido a que contravenía las normas del Senado, la legislación no incluirá una propuesta que habría reducido los pagos federales de Medicaid a estados como California, que utilizan sus propios fondos para cubrir a inmigrantes sin papeles.

La corresponsal principal de KFF Health News en Washington, Julie Rovner, contribuyó con este artículo.

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

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The Trump administration has declared that it will aggressively combat chronic disease in America.

Yet in its feverish purge of federal health programs, it has proposed eliminating the National Center for Chronic Disease Prevention and Health Promotion and its annual funding of $1.4 billion.

That’s one of many disconnects between what the administration says about health — notably, in the “MAHA Report” that President Donald Trump recently presented at the White House — and what it’s actually doing, scientists and public health advocates say.

Among other contradictions:

• The report says more research is needed on health-related topics such as chronic diseases and the cumulative effects of chemicals in the environment. But the Trump administration’s mass cancellation of federal research grants to scientists at universities, including Harvard, has derailed studies on those subjects.
• The report denounces industry-funded research on chemicals and health as widespread and unreliable. But the administration is seeking to cut government funding that could serve as a counterweight.
• The report calls for “fearless gold-standard science.” But the administration has sowed widespread fear in the scientific world that it is out to stifle or skew research that challenges its desired conclusions.

“There are many inconsistencies between rhetoric and action,” said Alonzo Plough, chief science officer at the Robert Wood Johnson Foundation, a philanthropy focused on health.

The report, a cornerstone of President Donald Trump’s “Make America Healthy Again” agenda, was issued by a commission that includes Secretary of Health and Human Services Robert F. Kennedy Jr. and other top administration officials.

News organizations found that it footnoted nonexistent sources and contained signs that it was produced with help from artificial intelligence. White House Press Secretary Karoline Leavitt described the problems as “formatting issues,” and the administration revised the report.

Trump ordered the report to assess causes of a “childhood chronic disease crisis.” His commission is now working on a plan of action.

Spokespeople for the White House and Department of Health and Human Services did not respond to questions for this article.

Studies Derailed

The MAHA report says environmental chemicals may pose risks to children’s health. Citing the National Institutes of Health, it said there’s a “need for continued studies from the public and private sectors, especially the NIH, to better understand the cumulative load of multiple exposures and how it may impact children’s health.”

Meanwhile, the administration has cut funding for related studies.

For example, in 2020 the Environmental Protection Agency asked scientists to propose ways of researching children’s exposure to chemicals from soil and dust. It said that, for kids ages 6 months to 6 years, ingesting particulates — by putting their hands on the ground or floor then in their mouths — could be a significant means of exposure to contaminants such as herbicides, pesticides, and a group of chemicals known as PFAS.

One of the grants — for almost $1.4 million over several years — went to a team of scientists at Johns Hopkins University and the University of California-San Francisco. Researchers gained permission to collect samples from people’s homes, including dust and diapers.

But, beyond a small test run, they didn’t get to analyze the urine and stool samples because the grant was terminated this spring, said study leader Keeve Nachman, a professor of environmental health and engineering at Hopkins.

“The objectives of the award are no longer consistent with EPA funding priorities,” the agency said in a May 10 termination notice.

Another EPA solicitation from 2020 addressed many of the issues the MAHA report highlighted: cumulative exposures to chemicals and developmental problems such as attention-deficit/hyperactivity disorder, obesity, anxiety, and depression. One of the resulting grants funded the Center for Early Life Exposures and Neurotoxicity at the University of North Carolina-Chapel Hill. That grant was ended weeks early in May, said the center’s director, Stephanie Engel, a UNC professor of epidemiology.

In a statement, EPA press secretary Brigit Hirsch said the agency “is continuing to invest in research and labs to advance the mission of protecting human health and the environment.” Due to an agency reorganization, “the way these grants are administered will be different going forward,” said Hirsch, who did not otherwise answer questions about specific grants.

In its battle with Harvard, the Trump administration has stopped paying for research the NIH had commissioned on topics such as how autism might be related to paternal exposure to air pollution.

The loss of millions of dollars of NIH funding has also undermined data-gathering for long-term research on chronic diseases, Harvard researchers said. A series of projects with names like Nurses’ Health Study II and Nurses’ Health Study 3 have been tracking thousands of people for decades and aimed to keep tracking them as long as possible as well as enrolling new participants, even across generations.

The work has included periodically surveying participants — mainly nurses and other health professionals who enrolled to support science — and collecting biological samples such as blood, urine, stool, or toenail clippings.

Researchers studying health problems such as autism, ADHD, or cancer could tap the data and samples to trace potential contributing factors, said Francine Laden, an environmental epidemiologist at Harvard’s T.H. Chan School of Public Health. The information could retrospectively reveal exposures before people were born — when they were still in utero — and exposures their parents experienced before they were conceived.

Harvard expected that some of the grants wouldn’t be renewed, but the Trump administration brought ongoing funding to an abrupt end, said Walter Willett, a professor of epidemiology and nutrition at the Chan school.

As a result, researchers are scrambling to find money to keep following more than 200,000 people who enrolled in studies beginning in the 1980s — including children of participants who are now adults themselves — and to preserve about 2 million samples, Willett said.

“So now our ability to do exactly what the administration wants to do is jeopardized,” said Jorge Chavarro, a professor of nutrition and epidemiology at the Chan school. “And there’s not an equivalent resource. It’s not like you can magically recreate these resources without having to wait 20 or 30 years to be able to answer the questions” that the Trump administration “wants answered now.”

Over the past few months, the administration has fired or pushed out almost 5,000 NIH employees, blocked almost $3 billion in grant funding from being awarded, and terminated almost 2,500 grants totaling almost $5 billion, said Sen. Patty Murray (D-Wash.), vice chair of the Senate Appropriations Committee, at a June 10 hearing on the NIH budget.

In addition, research institutions have been waiting months to receive money under grants they’ve already been awarded, Murray said.

In canceling hundreds of grants with race, gender, or sexuality dimensions, the administration engaged in blatant discrimination, a federal judge ruled on June 16.

Cutting Funding

After issuing the MAHA report, the administration published budget proposals to cut funding for the NIH by $17.0 billion, or 38%, the Centers for Disease Control and Prevention by $550 million, or 12%, and the EPA by $5 billion, or 54%.

“This budget reflects the President’s vision of making Americans the healthiest in the world while achieving his goal of transforming the bureaucracy,” the HHS “Budget in Brief” document says. Elements of Trump’s proposed budget for the 2026 fiscal year clash with priorities laid out in the MAHA report.

Kennedy has cited diabetes as part of a crisis in children’s health. The $1.4 billion unit the White House has proposed to eliminate at the CDC — the National Center for Chronic Disease Prevention and Health Promotion — has housed a program to track diabetes in children, adolescents, and young adults.

“To say that you want to focus on chronic diseases” and then “to, for all practical purposes, eliminate the entity at the Centers for Disease Control and Prevention which does chronic diseases,” said Georges Benjamin, executive director of the American Public Health Association, “obviously doesn’t make a lot of sense.”

In a May letter, Office of Management and Budget Director Russell Vought listed the chronic disease center as “duplicative, DEI, or simply unnecessary,” using an abbreviation for diversity, equity, and inclusion programs.

Within the NIH, the White House has proposed cutting $320 million from the National Institute of Environmental Health Sciences, a reduction of 35%. That unit funds or conducts a wide array of research on issues such as chronic disease.

Trump’s budget proposes spending $500 million “to tackle priority activities to Make America Healthy Again,” including $260 million for his new Administration for a Healthy America to address the “chronic illness epidemic.”

Ceding Ground to Industry

The MAHA report argues that corporate influence has compromised government agencies and public health through “corporate capture.”

It alleges that most research on chronic childhood diseases is funded by the food, pharmaceutical, and chemical industries, as well as special interest organizations and professional associations. It says, for example, that a “significant portion of environmental toxicology and epidemiology studies are conducted by private corporations,” including pesticide manufacturers, and it cites “potential biases in industry-funded research.”

It’s “self-evident that cutbacks in federal funding leave the field open to the very corporate funding RFK has decried,” said Peter Lurie, president of the Center for Science in the Public Interest, a watchdog group focused on food and health.

Lurie shared the report’s concern about industry-funded research but said ceding ground to industry won’t help. “Industry will tend to fund those studies that look to them like they will yield results beneficial to industry,” he said.

In search of new funding sources, Harvard’s school of public health “is now ramping up targeted outreach to potential corporate partners, with careful review to ensure the science meets the highest standards of research integrity,” Andrea Baccarelli, dean of the school’s faculty, wrote in a June 11 letter to students, faculty, and others.

“It’s just simple math that if you devastate governmental funding by tens of billions of dollars, then the percentage of industry funding dollars will go up,” said Plough, who is also a clinical professor at the University of Washington School of Public Health.

“So therefore, what they claim to fear more,” he said, will “become even more influential.”

The MAHA report says “the U.S. government is committed to fostering radical transparency and gold-standard science.”

But many scientists and other scholars see the Trump administration waging a war on science that conflicts with its agenda.

In March, members of the National Academies of Sciences, Engineering, and Medicine accused the administration of “destroying” scientific independence, “engaging in censorship,” and “pressuring researchers to alter or abandon their work on ideological grounds.”

In May, NIH employees wrote that the administration was politicizing research — for example, by halting or censoring work on health disparities, health impacts of climate change, gender identity, and immunizations.

Recent comments by Kennedy pose another threat to transparency, researchers and health advocates say.

Kennedy said on a podcast that he would probably create in-house government journals and stop NIH scientists from publishing their research in The Lancet, The New England Journal of Medicine, The Journal of the American Medical Association, and others.

Creating new government outlets for research would be a plus, said Dariush Mozaffarian, director of the Food is Medicine Institute at the Friedman School of Nutrition Science and Policy at Tufts University.

But confining government scientists to government journals, he said, “would be a disaster” and “would basically amount to censorship.”

“That’s just not a good idea for science,” Mozaffarian said.

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The tax and spending legislation the House voted to send to President Donald Trump’s desk on Thursday, enacting much of his domestic agenda, cuts federal health spending by about $1 trillion over a decade in ways that will jeopardize the physical and financial health of tens of millions of Americans.

The bill, passed in both the House and the Senate without a single Democratic vote, is expected to reverse many of the health coverage gains of the Biden and Obama administrations. Their policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows, though Republicans say the trade-off was far higher costs borne by taxpayers and increased fraud.

Under the legislation Trump’s expected to sign on Friday, Independence Day, reductions in federal support for Medicaid and Affordable Care Act marketplaces will cause nearly 12 million more people to be without insurance by 2034, the Congressional Budget Office estimates. That in turn is expected to undermine the finances of hospitals, nursing homes, and community health centers — which will have to absorb more of the cost of treating uninsured people. Some may reduce services and employees or close altogether.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.

The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.

Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF, a health information nonprofit that includes KFF Health News.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that targets states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan curtails a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. Medicaid generally pays lower fees for care than Medicare, the program for people over 65 and some with disabilities, and private insurance. But thanks to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on payments from Medicaid taxes to sustain them. Researchers from the Cecil G. Sheps Center for Health Services Research who examined the original House version of the bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republicans in the Senate tacked a $50 billion fund onto the legislation to cushion the blow to rural hospitals. The money will be distributed starting in 2027 and continue for five years.

Harder To Get, and Keep, ACA Coverage

For those with Obamacare plans, the new legislation will make it harder to enroll and to retain their coverage.

ACA marketplace policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.

The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

Trump’s legislation requires states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for certain services.

The policy won’t apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction won’t apply to green-card holders.

Because the immigrants who will lose subsidies under the legislation tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said in a statement.

The bill reflects the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation doesn’t include a proposal that would have reduced federal Medicaid payments to states such as California that use their own money to cover immigrants without legal status.

KFF Health News chief Washington correspondent Julie Rovner contributed reporting.

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

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The Trump administration has launched investigations into health care organizations in an effort to allow providers to refuse care for transgender patients on religious or moral grounds.

One of the most recent actions by the Department of Health and Human Services, launched in mid-June, targets the University of Michigan Health system over a former employee’s claims that she was fired for requesting a religious exemption from providing gender-affirming care.

An administration release announcing the probe says the Michigan case is the third investigation in “a larger effort to strengthen enforcement of laws protecting conscience and religious exercise” for medical providers, citing federal laws known as the Church Amendments.

The probes are the first time HHS has explicitly claimed the amendments “allow providers to refuse gender-affirming care or to misgender patients,” said Elizabeth Sepper, a professor at the University of Texas who studies conscience laws. Those laws, Sepper said, primarily allow objections to performing abortions or sterilizations but “don’t apply to gender-affirming care, by their very own text.”

But religious freedom groups that supported the health worker in the Michigan case, Valerie Kloosterman, say the investigation is a welcome recognition of existing protections for medical professionals to refuse to provide some types of care that conflict with their beliefs.

“We are pleased to learn that the Department of Health and Human Services is taking its responsibility seriously to enforce the federal statutes protecting religious health care providers,” said Kloosterman’s attorney Kayla Toney, of the First Liberty Institute, which advocates for religious liberty plaintiffs.

The two other cases HHS announced in recent months involve ultrasound technicians who didn’t want to be involved in “abortion procedures contrary to their religious beliefs or moral convictions,” and a nurse who asked for a religious exemption to “avoid administering puberty blockers and cross-sex hormones to children,” according to HHS. The department did not disclose the locations for those investigations.

Sepper said opening investigations into gender-affirming care cases is a new tactic for HHS after federal courts blocked a 2019 effort by the previous Trump administration to broaden conscience rules.

And it sends a message that this administration will “investigate or otherwise harass providers of gender-affirming care, even when that provision is legal in the states where they operate,” said Sam Bagenstos, a general counsel at HHS during the Biden administration and a professor at the University of Michigan.

HHS spokesperson Andrew Nixon declined to comment, citing the ongoing investigation.

HHS launched its investigation years after Kloosterman filed a lawsuit against her former employer. She started working for Metropolitan Hospital in Caledonia, Michigan, as a physician assistant in 2004. When the hospital merged to become part of University of Michigan Health-West in 2021, Kloosterman took part in a “mandatory diversity training,” according to a federal lawsuit filed in 2022.

In that training and follow-up discussions, the health system “attempted to compel Ms. Kloosterman to pledge, against her sincerely held religious convictions and her medical conscience, that she would speak biology-obscuring pronouns and make referrals for ‘gender transition’ drugs and procedures,” according to the lawsuit by Kloosterman’s attorneys.

These were, at this point, purely hypotheticals: “No patient ever asked her for a referral for such drugs or procedures, and she never used pronouns contrary to a patient’s wishes,” the suit claimed.

But when Kloosterman requested a religious accommodation, she was “summoned” to a meeting with administrators, who “called her ‘evil’ and a ‘liar,’ mockingly told her that she could not take the Bible or her religious beliefs to work with her, and blamed her for gender dysphoria-related suicides,” according to the lawsuit, which alleges she was fired in August 2021, shortly after the meeting.

The health system denied all allegations, and in April 2024, U.S. District Judge Jane Beckering dismissed Kloosterman’s case to proceed into arbitration. Kloosterman’s lawyers filed an appeal with the U.S. Court of Appeals for the 6th Circuit. Appellate judges heard oral arguments in the case in February but have not issued a decision.

HHS initiated its investigation under the Church Amendments because it’s “committed to enforcing Federal conscience laws in health care,” said Paula M. Stannard, director of the department’s Office for Civil Rights, in a statement announcing the investigation. “Health care workers should be able to practice both their professions and their faith.”

But the investigation “represents a real expansion beyond what the Trump administration did in the first term, and also in terms of the text of the law,” Sepper said.

The Church Amendments date to the 1970s and allow health care institutions and providers to refuse to participate in abortion or sterilization procedures.

“Some of these also apply to end-of-life care and to physician aid in dying. So they have relatively narrow scope,” Sepper said. “They focus on a set of procedures. They don’t allow health care providers or institutions to refuse to provide all kinds of care based on their religious or moral objections.”

There is one broader provision in these laws that “is about the conscience-based decision to perform, or not to perform, a lawful medical procedure,” said Bagenstos, the former HHS general counsel during the Biden administration. But that applies only to recipients of a “grant or contract for biomedical or behavioral research,” he said. So this case is “an extreme stretch of the conscience protections, and probably more than a stretch.”

But Ismail Royer, director of Islam and religious freedom at the Religious Freedom Institute, which filed an amicus brief supporting Kloosterman’s lawsuit, said the Church Amendments are just a few of the laws HHS enforces, along with broad civil rights protections and laws that prohibit discrimination on the basis of religion.

“This is not a case where someone is refusing to treat someone who is LGBT,” Royer said. “This is a case of someone who does not believe that they should be forced to use pronouns that would constitute a lie.”

Other providers are available if a patient’s “feelings are hurt,” he said. “But hurt feelings do not constitute the basis for the government violating our constitutional rights.”

The stakes for a health system are very different in an HHS investigation than in civil suits, Sepper said. The government agency, which oversees the vast majority of health care spending, could decide to strip Medicare and Medicaid funding from the health system. HHS has previously been hesitant to remove funding, Sepper said.

But it would be highly unusual — and possibly illegal — for HHS to actually withhold funding from the health system over a case like this, Bagenstos said.

By taking up these investigations so publicly, Sepper said, HHS is putting health systems “in a very difficult situation.” Antidiscrimination laws require them to treat transgender patients equally, she said. But now the administration is prioritizing “employees that might want to make it more difficult for transgender patients to receive care.”

These investigations are “meant to offer red meat to the anti-LGBT rights movement, to tell them that HHS is squarely on their side,” Sepper said.

This article is from a partnership with Michigan Public and NPR.

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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