Vanessa Barahona received a call this past spring from Angelica at Kern Family Health Care in Bakersfield, California, telling her it was time to renew her coverage under Medi-Cal, the state’s version of Medicaid.

Angelica helped Barahona, 41, schedule an appointment to complete her paperwork in person at Kern Family’s offices before she submitted it to Kern County officials for approval. When Barahona had a conflict with her office-cleaning job, Angelica rescheduled the appointment. Barahona finished the process a little later than she’d planned but early enough to avoid an interruption in her coverage.

“It was easy. The fact that Angelica spoke Spanish when we were on the phone made it better,” Barahona, whom KFF Health News met through Kern Family Health Care, said via a translator. “It felt like I was talking to a real person.”

She definitely wasn’t.

“Angelica” is the name assigned to an AI program deployed last year by Kern Family Health Care, the largest provider of Medi-Cal services in Kern County. An estimated 52% of residents there rely on the safety net program for health coverage, among the highest enrollment rates in the state.

Kern Family has spent about $370,000 on the software from Careforce, a San Francisco startup, to facilitate rapid and repeated outreach to members when it’s time to renew their coverage — a process that is about to become more complex under new Medicaid eligibility rules established under Republicans’ One Big Beautiful Bill Act, signed into law last year by President Donald Trump. Mandatory work requirement documentation will take effect nationally beginning in 2027, and under the GOP’s new rules, most Medicaid patients will now have to renew their enrollment twice a year, rather than once a year.

Kern Family and other similar health plans have an interest in keeping people enrolled, since they’re paid through managed care contracts with Medi-Cal. They can also save money by using AI software to do what Kern says would otherwise require it to hire 40 full-time workers. Angelica does it at a fraction of the cost and without increasing payroll — or requiring Kern Family to navigate workers’ rights issues or government-mandated workplace protections.

Although Kern Family officials say no workers have lost jobs, the health plan, which is not unionized, estimated it would have had to spend $2.4 million in staffing costs to match the program’s more than 800,000 calls to its 387,000 members since Kern Family began using Angelica late last year.

As the federal government ended pandemic-era protections and states resumed screening people for Medicaid eligibility, health plans such as Kern Family began looking to technology to keep eligible people enrolled. Kern Family officials say that Angelica helps people, in their preferred language, set up appointments with the plan’s staffers, who make sure that applications are filled out correctly and delivered to county health officials for verification and processing.

Careforce CEO Huzaifa Sial said Kern Family is one of a few health insurers using his company’s software to help boost its Medi-Cal enrollment, and the company is also working with the Central California Alliance for Health in much the same way. “Most people don’t know what they need, and if they do, they have a hard time getting there,” Sial said. “That’s the hidden execution problem that nobody sees.”

“Angelica” is the name assigned to a conversational AI program deployed last year by California’s Kern Family Health Care, the largest provider of Medi-Cal services in Kern County. Kern Family has spent about $370,000 on the software by Careforce, a San Francisco startup, to facilitate rapid and repeated outreach to members when it’s time to renew their coverage. (Screengrab of Careforce.ai)

The rise of AI in the healthcare industry has prompted worries about who’s overseeing these tools and whether people are being improperly denied treatments or cut off from care. Unions have raised concerns about workplace surveillance and the prioritizing of savings over safety. Polling shows widespread fear over AI-driven job losses and growing income inequality, while health policy researchers have also raised red flags about algorithmic biases, transparency, data privacy, and safety risks.

Mark Duggan, a Stanford University economics professor who has studied the Medicaid system for 30 years, said one long-standing fear is that insurers could use such software to cherry-pick patients for coverage.

“When you have a new technology like this, you need to police it,” Duggan said.

Complying With Regulations

California health plan regulators say they are tracking AI use closely, and the state attorney general’s office has sent reminders to healthcare entities about their obligation to follow consumer protection rules.

Anthony Cava, a spokesperson for the state’s Department of Managed Health Care, said Medi-Cal health plans have flexibility in how they handle member renewals, including with the use of AI tools. But plans are responsible for ensuring that technology complies with state and federal regulations, including patient privacy and data security, he said.

Last year, the agency, foreseeing the huge volume of reenrollments that were going to be required in the state, began allowing managed care plans to contact members about renewals. State rules still prohibit Medi-Cal health plans from soliciting new enrollees, and only county health officials determine eligibility.

Emily Duran, CEO of Kern Health Services (which administers Kern Family), said that the plan worked closely with the Kern County Department of Human Services to obtain some data, allowing Kern Family to know when a member’s Medi-Cal eligibility will expire.

The health plan, in turn, lets the county know anytime it receives updated demographic or contact information for its Medi-Cal members. And the county has stationed workers inside Kern Family Health Care’s main facility in Bakersfield to answer enrollment questions for people who walk in to finish their paperwork.

“They have a leadership group that is very innovative and forward-thinking,” Vanessa Frando, the chief deputy director of Kern County Human Services, said of Kern Family. The agency also works closely with other Medi-Cal providers in the county, Frando said.

Duran said the health plan was initially concerned about how Angelica would be received.

“We had to set the tone to really be open to the idea, because you hear ‘AI’ and you’re like, ‘Oh, yeah, Jeff Bezos laid off 100,000 people because of that,’” Duran said. “But we are already stretched thin. We need this functionality to be much more effective and augment our efforts.”

Duran said Kern Family’s leadership and staff bought in after seeing a demonstration.

Today, it would take 40 Kern Family employees, each working 40 hours a week, to match Angelica’s calls to remind people to reenroll and talk them through what is involved, according to Jackie Byrd, a spokesperson for the health plan. The AI program’s settings are constantly adjusted to match the capacity of Kern Family’s full-time staff.

Full Conversations With AI

Barahona said she received a Medi-Cal packet in the mail but didn’t think about it until Angelica called days later. That exchange highlights one of local and state health officials’ biggest concerns — that people who’ve grown accustomed to automatic renewals aren’t aware of the reenrollment requirements.

Angelica speaks more than 30 languages and can answer lengthy questions. In samples of actual conversations provided to a reporter, Angelica sounded lifelike at first, although more than once cross-talk with a patient caused the program to pause suddenly. Barahona said it took her a minute before she realized she wasn’t speaking with a human, but she ended up having a full conversation with Angelica.

Duran said Kern Family was able to redirect full-time staff to focus on the more complex parts of the Medi-Cal process, such as making sure the patients’ information is complete and up to date. The Angelica software also operates at all hours, making it easier for patients to call back at their convenience. Another version, David, is used internally to help staffers navigate the technology.

“This will always be, in my opinion, an AI-human combination,” said Careforce’s Sial. Working with AI solutions for more than a decade at UnitedHealthcare and Optum, Sial said, he saw an opportunity to improve the enrollment process by helping people organize their paperwork.

Kern Family’s Medi-Cal renewal rate in April was 94.9%, delighting the plan’s officials, who feared a significant drop-off from patients who’d gotten used to being automatically renewed over the past several years. By comparison, Duran said that about 80% of enrollments had automatically renewed under federal pandemic-era rules, but that figure was cut in half as those protections began to expire.

Kern Family officials say there could be other uses for Careforce’s software in the future; Angelica, like other generative-AI large language models, can learn and adapt to new situations and requests.

Cesar Delgado, Kern Family’s chief information officer, said Angelica is already being used to make general greeting calls to new members and can discuss plan benefits and answer basic questions. But Kern Family officials say the program’s primary purpose, for now, is limited to contacting patients whose Medi-Cal eligibility is coming up for review.

Duggan, the Stanford professor, said Angelica could help Kern Family minimize the number of Medi-Cal enrollees who lose coverage as federal requirements take effect.

“The best-case scenario is helping people to stay on when they don’t realize that things are changing,” Duggan said. “It’s not an easy program to navigate.”

This article was produced in collaboration with Capital & Main, an independent, California-based nonprofit investigative news publication that reports on inequality, climate change and other issues.

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

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

A century-old hospital near Michigan’s southern border was one of the nation’s first to convert into a new emergency-focused model Congress created to save rural care.

Afterward, though, use of Sturgis Hospital’s emergency department fell, according to data collected at the state level. In June, three years after taking the federal lifeline, the hospital closed, leaving residents of Sturgis, a town of about 11,000 people, without critical healthcare. Its leaders had tried “every reasonable option” to remain open, including seeking a buyer, according to a hospital news release.

The closure “could be kind of a canary in the coal mine” for rural healthcare, said Lauren LaPine-Ray, the vice president of policy and rural health at the Michigan Health & Hospital Association.

Federal leaders have spent decades trying to prop up rural hospitals, which face persistent staffing shortages, low federal payment rates, and declining patient numbers.

About 1,700 hospitals nationwide are eligible to convert to the stripped-down Rural Emergency Hospital model. So far, more than 50 rural hospitals in over 20 states have signed on, but LaPine-Ray and other hospital leaders nationwide fear Sturgis’ failure is a sign the new model won’t be enough to keep doors open when the anticipated federal funding losses arrive from President Donald Trump’s signature One Big Beautiful Bill Act.

Last year, the survival of rural hospitals became a central negotiating point as Congress debated the massive tax and spending law, which is expected to reduce Medicaid funding by more than $900 billion over 10 years. The reductions are expected to have a substantial impact in rural areas that often have high Medicaid enrollment. Republicans added the new $50 billion Rural Health Transformation Program to win votes from a few holdouts in their ranks.

Sturgis’ facility is the only rural U.S. hospital to completely close in 2026. The day before it shuttered, four senators — including Maine Republican Susan Collins, an architect of the rural health fund — sent a letter to Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services. The letter said the way his agency structured the fund “may unintentionally disadvantage many of the rural hospitals and clinics the program was intended to support.”

Congress created the emergency hospital model, which took effect in 2023, as “a whole new way of providing care,” said George Pink, a senior research fellow at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. The Sheps Center tracks rural hospital closures and conversions, and Pink recently released early research showing converted hospitals reporting improved finances, though some are not yet in the black.

Hospitals that convert to the emergency model get a 5% boost in Medicare payments plus an extra monthly facility payment, totaling about $3.6 million a year, according to the Rural Health Redesign Center. In return, the hospitals must offer emergency services and give up their inpatient beds. They can continue offering outpatient services.

Janice Walters, CEO of the Rural Health Redesign Center, which has received federal funding to help hospitals change to the new model, said dozens of hospitals had reached out about converting during the first five months of 2026. It’s reasonable, she said, to presume that 10 or 11 might convert this year.

‘No Easy Answers’

More than 40% of all rural hospitals lose money, and hundreds have eliminated obstetrics, general surgery, and chemotherapy services, according to the healthcare consulting group Chartis.

Sen. Chuck Grassley (R-Iowa) sponsored the legislation that created the emergency hospital model. He touted the program last fall, pointing to hospitals such as Landmann-Jungman Memorial Hospital Avera in South Dakota, which he said would be able to use the model to enhance local health services.

Melissa Gale, the chief executive of the Scotland, South Dakota, hospital, said the facility averaged less than one inpatient a day and was “a little above or below break-even year-over-year for decades.”

Today, with additional federal funding from the emergency model, Gale said, the hospital could try to draw in more patients for mammograms and may add a wound care program. In the past year, the hospital has improved employee benefits and reinvested in the building, upgrading plumbing and the heating and air conditioning, she said.

“No one wants to see rural health fail,” Gale said, adding, “There’s no easy answers.”

Federal lawmakers have tried, and thus far failed, to update the emergency hospital model. One proposal, which is expected to be reintroduced, would allow converted hospitals to offer new services, such as beds for patients who need short-term recovery and in-house obstetric labor and delivery units. Another, which is in committee, would allow hospitals to use a federal drug discount program that many facilities use to generate revenue.

The current law is a “critical start, but it must evolve,” said Carrie Cochran-McClain, the chief policy officer for the National Rural Health Association, whose members include hospitals and clinics.

Residents of the southeastern Iowa town of Keokuk continue to hope their shuttered hospital will reopen under the program. The effort has been plagued by delays.

The Keokuk hospital went out of business in 2022 and was later purchased by a Michigan company that pledged to reopen it.

“It’s been a slower process than we envisioned,” said Insight Health Systems Vice President Dayne Walling. Many of the delays have been related to improvements needed to the aging building, he said. Without the emergency hospital model, Walling said, his company would not see a realistic path to reviving the hospital.

Walling said the emergency model would be even better if Congress approved the bill that would allow hospitals to make extra income from prescription medications.

Dierdra Sorrell, the CEO of Clifton-Fine Hospital in Star Lake, New York, said converting to an emergency hospital was not a “silver-bullet, magic pill.” But it “put us in a much better place.”

The 20-bed hospital lost more than $2.5 million annually before 2024, when it became New York’s first emergency hospital, Sorrell said. While converting, the hospital shut down inpatient beds and cut 20 employees.

The first year, Clifton-Fine lost only $600,000, and its emergency patient visits were “rock solid,” Sorrell said. The hospital also won state grant money to update its two-bed emergency room and pay for additions that could house visiting specialty doctors or new lines of services, such as a dental hygienist.

If Clifton-Fine had not converted, Sorrell said, anticipated Medicaid losses could have “put us under.”

‘One Important Tool’

Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, said the emergency model is “one important tool” for rural hospitals, “but each facility must determine whether this care model is appropriate.” Foster also said that the new five-year, $50 billion rural health fund was created to support “innovative, system-wide reforms” that strengthen the rural healthcare delivery system.

Of the 56 hospitals that have converted to the rural emergency model, two have closed, and three remain open but have changed what services they offer, according to Sheps.

In Holly Springs, Mississippi, Alliance HealthCare System was one of the first to convert to the emergency hospital designation, laying off staff and shutting down inpatient beds.

Then, federal officials said they made a mistake and required the hospital to recertify as a new hospital, a delay that cost an estimated $1.5 million in federal reimbursement, CEO Kenneth Williams said.

The hospital is “a shell of what it once was,” Williams said. The ER remains closed.

“We have survived, but survival has come at a tremendous cost,” he said.

Williams said he is closely watching the impact of upcoming Medicaid changes because cuts in insurance coverage or payments “ultimately affect patient access,” he said.

Sen. Josh Hawley (R-Mo.), who voted for the One Big Beautiful Bill Act — which included both the rural health fund and the Medicaid spending reductions — has asked for more support for rural hospitals. Ten full-service rural hospitals in Missouri have closed in the past 12 years, according to the Sheps Center.

Last year, Hawley introduced legislation to repeal the future Medicaid spending cuts. This June, he held a news conference to announce that he wanted to pay rural hospitals $1 million annually, or more if needed, to keep emergency rooms operating. A spokesperson said the bill would apply to all rural hospitals, including those using the emergency model.

Michigan’s Sturgis Hospital faced “some significant challenges” in 2023 when it converted to the emergency hospital model, said LaPine-Ray, of the state hospital association. In the news release, hospital officials said the closure was due to declining reimbursement rates, rising costs, and declining patient numbers. Bobby Morin, a former chief operating and financial officer at the hospital, declined to comment.

The hospital’s ER patient volume dropped 13% in the two years after it converted, LaPine-Ray said. Five rural hospitals have closed in the past 20 years in Michigan, and LaPine-Ray said she doubts the rural health fund Congress approved last year will stop the closures. The association, which worked with the governor’s office on the funding, expects less than 10% of Michigan’s $173 million in first-year rural health funding to trickle down to rural hospitals.

That money will pay for “very specific programs where rural hospitals have to create basically a new program and implement it with no funding on the front end,” LaPine-Ray said.

At the same time, she said, the association expects Michigan hospitals to lose $6 billion in Medicaid payments over the next decade because of the One Big Beautiful Bill Act.

“What’s it going to look like in the coming years?” LaPine-Ray said.

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

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

LUMBERTON, N.C. — Soybean fields surround Angie Lowery’s home in Robeson County, on a plot of rural land in southeastern North Carolina. Dozens of antique gas station signs, 20 feet tall, dominate her front yard. A framed re-creation of The Last Supper, Lone Ranger posters, and a 3-foot-wide tobacco harvesting basket adorn the walls of her home. A collector, Lowery over the years has amassed remnants of her region’s past.

But behind the house, the 44-year-old’s backyard garden showcases her goals for the future, one that involves a long, healthy life with her kids: collard greens, bell peppers, onions, tomatoes, red and white potatoes, kale.

Like Lowery, many in the small towns of Lumberton and nearby Pembroke are citizens of the Lumbee Tribe who have dealt with heart conditions. The mother of four struggled with obesity and had to take insulin pills and shots daily. By when her first grandchild was born, in 2024, Lowery imagined her own life ending the way her biological father’s did: Daily insulin shots for diabetes. Kidney dialysis treatments at home. Dead of a heart attack at 63. She wanted her grandkids to remember her.

“If I don’t get this weight off me, if I don’t change my eating habits, it’s going to take me over,” she recalled thinking.

So, she expanded her garden. She cut fatty foods and sugary drinks out of her diet, stopped eating fried and fast food, and started moving more. She lost 120 pounds in two years and weaned herself off the daily insulin pills.

The Lumbee Tribe of North Carolina late last year became the 575th tribe to secure federal recognition as a sovereign nation, a milestone that leaders and citizens celebrated in tears. The designation provides federal funding for an array of services, including for healthcare. John Lowery, chairman of the tribe and a state representative, declared that “the biggest benefit” would be access to the Indian Health Service — its clinics and hospitals, as well as funding that it could provide for the tribe to create its own health system.

But Lumbee researchers and healthcare providers say that money won’t be enough. For decades, IHS has been chronically underfunded, with the agency’s budget workgroup estimating that it’s nearly $55 billion short of what it needs this year. And that was before the Trump administration’s cuts to other federal agencies further pinched IHS. Slashes to the Centers for Disease Control and Prevention last year initially included laying off nearly 1,000 IHS employees, and President Donald Trump’s proposed 2027 budget cuts more than $150 million for a program to address diabetes in Native American tribes.

The nearest IHS facility is more than a two-hour drive to another state for most of the 55,000 Lumbee citizens in Robeson County. The county is one of the poorest in the U.S. and has some of the worst health outcomes.

Robeson County is mostly rural, agricultural land. Most of the members of the Lumbee Tribe live in the small towns of Lumberton and Pembroke, both about a half-hour drive from the South Carolina border. (Andrew Jones/KFF Health News)

The Congressional Budget Office in 2022 estimated that the tribe could increase IHS spending by $247 million over four years.

The tribe will have to rely on other revenue sources that are now allowed through recognition, such as a casino, to reverse the health disparities their people have faced for decades, Lumbee researchers said.

“None of us can depend on IHS alone, because we just don’t have the resources within that system,” said Donald Warne, a physician, a researcher at the Johns Hopkins Center for Indigenous Health, and a member of the Oglala Lakota tribe. “But it’s a great starting point.”

The IHS did not respond to questions about plans for the tribe’s health system. John Lowery did not respond to requests for an interview or a list of questions, but he said on a June podcast that he expected healthcare to be the largest portion of the tribe’s budget.

Lowery makes beaded earrings, teaches culture classes, owns a gravestone business, and makes engravings in her Pembroke, North Carolina, shop. (Andrew Jones/KFF Health News) Antiques hang on Lowery’s walls at her home. She and her husband, Grant Hunt, are avid collectors. (Andrew Jones/KFF Health News)

‘Not Just Statistics’

Eighteen years ago, Andrea Blackburn, a doctor in Lumberton and a citizen of the tribe, was working at a nearby medical center. There, she said, she was taught that patients with certain last names “are often referred directly to cardiac catheterization,” a procedure to diagnose heart conditions.

Blackburn said she realized that common Lumbee surnames carried an expectation of disease.

“Nearly two decades later, I can tell you that reality has not changed,” she told assembled tribal leadership and citizens at a public hearing.

Robeson County’s rates of heart disease, diabetes, and risky substance use continue to rank among the highest in the state, Blackburn noted. In 2025, more than half of the county’s residents were Medicaid enrollees, the highest percentage of all counties in the state.

“But these are not just statistics to me,” she said. “These are my patients. These are our families.”

Andrea Blackburn, a citizen of the Lumbee Tribe, is a physician in Robeson County. (Andrew Jones/KFF Health News)

For Angie Lowery, breaking free from those statistics meant taking her health into her own hands.

She hopes a healthy diet is the answer to breaking her family’s cycle and living long enough to form relationships with her grandkids. And she brought the rest of the family with her. Her teenage daughter lost about 35 pounds. Two of her other children are now “health fanatics,” Lowery said.

Her granddaughter will be 2 in November. One Sunday morning in March, Lowery served up macaroni, cauliflower, and chickpeas for her as they spent the day together.

Lowery had supported building a casino, believing it would provide better education, infrastructure, and healthcare for her family.

“That vote, I’m thinking of my children’s future,” she said.

Lowery grows squash, onions, potatoes, and other produce in her backyard garden. Later this year, she’ll can some of the harvest for her family. (Andrew Jones/KFF Health News)

Casino Dreams in Limbo

Tribal citizens are deeply divided over how to reverse decades of economic decline that have led to poor living conditions, unaffordable health services, and chronic disease.

Four months after Trump signed the Lumbee Fairness Act — declaring “I love the Lumbee Tribe” — tribal leaders gathered at a business meeting to take the first steps toward building a casino and establishing gaming as a new revenue source. Hundreds of federally recognized tribes across 29 states have used gaming as a source of revenue, bringing in $43.9 billion in fiscal 2024, according to the latest report from the National Indian Gaming Commission.

The approach has been popular among tribal nations looking for more dollars to build up healthcare. The Choctaw Nation of Oklahoma in 1999 became the first tribe to build its own hospital, using roughly $25 million in gaming money, and the Eastern Band of Cherokee Indians in western North Carolina funded its own hospital in 2015 mostly with $82 million in gaming funds.

But the Lumbee Tribe’s effort to establish a casino collapsed in June.

More than 60% of voters rejected a Lumbee constitutional amendment that would have allowed tribal leaders to create infrastructure needed for a gaming business. John Lowery said on Facebook that he doesn’t plan on bringing back the initiative now that it was rejected “by the majority of Lumbee voters.” His term as chairman ends in two years.

A portrait of Lumbee Tribe Chairman John Lowery hangs beside a rendering of a proposed casino and resort meant to help bring in revenue for the newly federally recognized tribe. Citizens voted against the project. (Andrew Jones/KFF Health News)

Other funding sources to provide health services for the tribe could include gas stations or hotels, he said in a call with citizens before the vote.

Lumbee and other Native health researchers said they believe a twofold system — using IHS money and additional revenue — is necessary. Funds from gaming could compensate for what IHS can’t support.

Casinos’ impact on tribal health has been debated in research for decades. Studies show that the money from gaming helps tribes build more facilities, hire more doctors, and improve social services, but unhealthy substance use and smoking increase.

“There’s going to be negative impacts,” Brittany Locklear, a social work professor at the University of North Carolina and citizen of the Lumbee Tribe, said at a June panel discussion on gaming.

Ronny Bell, 62, a Lumbee citizen and a researcher studying Native health at UNC, said the community has felt ripple effects from systemic racism, having not been acknowledged as a tribal nation for so long, and the economic downturn following the loss of Robeson County’s manufacturing and tobacco jobs.

That history plays a part in the health statistics in Robeson today, Bell said. But with federal recognition, he said, the Lumbee people have achieved a victory they’ve fought for since 1888.

“I think about the resilience of the Lumbee people and how they’ve gone through this 100-plus-year fight for federal recognition,” Bell said. “I sort of see that as a continuation of this resilience, and how now we have this opportunity with federal recognition to bring in resources to help address those issues.”

The Lumbee Tribe government offices and citizen housing in Pembroke, North Carolina, stand amid long stretches of agricultural countryside. (Andrew Jones/KFF Health News)

Resolution and Uncertainty

Jada Brooks, a Lumbee citizen and UNC researcher who studies Indigenous health and lives in Robeson County, is conducting a study about heart health among Lumbee women. The initiative includes classes in which Lumbee women ages 18 to 50 signed up to discuss their health. That’s where she met Angie Lowery, who talked about her lifestyle changes with the group.

“I was just floored by, like, just the extent to which she went,” Brooks said.

She and other Lumbee researchers said federal recognition allows Lumbee citizens to be set apart in census data, paving a way to get clear information on heart health, cancer rates, diabetes diagnoses, and mental health risks.

“There’s challenges in even understanding the nuances of these complex health disparities, because a lot of data isn’t out there,” said Ryan Dial, a public health researcher at UNC and a member of the Lumbee Tribe.

But access and confidence may be the biggest barriers Lumbee people will have to overcome, Brooks said.

“I think what really matters is people feeling like they can trust the healthcare system.”

Brooks said she worried that a casino would encourage bad health habits, such as smoking and drinking.

“Let’s not create more problems for ourselves than we already have,” she said. She voted against the casino.

Like others in the tribe, Angie Lowery believes in her people’s power to help themselves, regardless of whether government steps in to help.

“Just because we’re federally recognized don’t mean that the doors are going to open up and money’s going to fall through the door like dirt,” she said.

Angie Lowery sits in her Ford F-250 reading the Lumbee Constitution on a hot June day. The tribe secured federal recognition in December 2025. (Andrew Jones/KFF Health News) KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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

A handful of former public health officials are campaigning for top statewide offices across the country, testing whether their experience with covid and other hot-button health issues will appeal to voters in November.

The officials, all Democrats, are running at a time when the Trump administration is reducing government funding for scientific research, restricting access to some vaccines, and making it more difficult for some Americans to obtain health insurance.

Shaughnessy Naughton, president of 3.14 Action, a political action committee that recruits Democratic candidates with science and health backgrounds, said it is unusual to see so many public health leaders running for office.

“But it’s not surprising given the moment we are living in, with an arsonist running HHS working to undermine the vaccine schedule and public health at large,” she said.

Health and Human Services Secretary Robert F. Kennedy Jr. is a longtime anti-vaccine activist who disparaged public health measures implemented during the pandemic, going as far as calling the covid vaccine the “deadliest vaccine ever made.”

Neither HHS nor the White House responded to requests for comment.

Several of the candidates benefit from name recognition built during the covid pandemic, political science scholars say, when daily news briefings from local health officials became must-see-TV for many citizens sheltering in place from the novel virus. But that cuts two ways.

While many Americans regarded public health officials as offering prudent advice and a steady voice, others criticized them for pushing school closures, mask mandates, and new, quickly created vaccines. The attacks have escalated under President Donald Trump, with Republicans targeting pandemic-era public health leaders such as Anthony Fauci with investigations and a former Fauci adviser even facing criminal prosecution.

National polls show healthcare is top of mind for many voters this year, with Democrats most worried about costs and Republicans about fraud. But that’s no guarantee of victory. Nirav Shah, an epidemiologist who led Maine’s top public health agency through the pandemic, lost a narrow Democratic primary in the state governor’s race in June.

Here are some of the public health officials on the ballot this year:

Xavier Becerra, Running for Governor in California

Xavier Becerra speaks to reporters in Los Angeles on Jan. 9. (David Crane/MediaNews Group/Los Angeles Daily News via Getty Images)

Becerra, who served as HHS secretary under President Joe Biden, is the highest-ranking former health official running this cycle. He won a crowded and expensive open primary and now faces Republican Steve Hilton, a British-born former Fox News host, in the general election.

Mark Peterson, a public policy professor at the UCLA Luskin School of Public Affairs, said with the pandemic in the rearview mirror, any judgment voters may have about the federal government’s response is more likely to reflect on Biden rather than Becerra, who has no medical background and maintained a low profile as HHS secretary.

Leading the nation’s health department as the pandemic lingered, Becerra focused more on expanding access to the Affordable Care Act and Medicaid, overseeing record numbers of people enrolled in the publicly financed programs during his tenure. He did face criticism over the processing and placement of a massive influx of migrant children at the U.S.-Mexico border, as well as his agency’s response to a baby formula shortage brought on, in part, by major product recalls.

Becerra has said he now wants to be California’s “healthcare governor,” a mantle outgoing Gov. Gavin Newsom tried to claim upon taking office in 2019.

Becerra’s campaign did not respond to a request for comment.

Before becoming HHS secretary, Becerra served as California’s attorney general and sued the first Trump administration more than 100 times, leading a coalition of states against GOP efforts to gut the ACA. He also started a unit in his office focused solely on healthcare. During Becerra’s tenure, his office reached a $575 million antitrust settlement with the California hospital system Sutter Health, pursued pharmaceutical companies that delayed generic drugs, and helped block a Trump administration rule that let employers choose whether to cover birth control.

Voters often regard decades of experience in government as a negative, Peterson said. But for the job of running the nation’s most populous state and the world’s fourth-largest economy, he added, “I think there are a lot of people out there who would like to have somebody who actually has run a big enterprise.”

In televised debates, Becerra has said California should maintain state-funded Medicaid coverage for immigrants without legal status. He is also a longtime supporter of implementing single-payer healthcare, though in recent interviews he has said it needs to be addressed at the federal level.

Amy Acton, Running for Governor in Ohio

Amy Acton addresses attendees at a campaign rally in Cincinnati on April 28. (Jon Cherry/Getty Images)

Acton ran Ohio’s health department from February 2019 to June 2020.

During the first months of the pandemic, Acton appeared at daily news conferences with the state’s Republican governor, Mike DeWine, that were jokingly dubbed “Wine With DeWine.” She earned fans with her calm and positive demeanor while explaining her approach to keeping covid at bay.

But she also attracted critics with her recommendations to stay at home, mask up, and shut down some businesses to curb the virus’ spread. Protesters even showed up at her home.

Acton’s Republican opponent in the governor’s race, Vivek Ramaswamy, has labeled her “Dr. Lockdown” on social media. His criticism of her role in shutting down businesses could prove effective with the economy at the top of many people’s minds, said Christopher Devine, a University of Dayton political science professor.

“It’s a double-edged sword, because she also really upset some people,” Devine said of Acton’s time as the health director during the pandemic.

He said that is a tricky attack for Ramaswamy to pursue, though, because DeWine — still the sitting governor and a popular conservative figure — endorsed the covid measures Acton recommended, granting her emergency powers to sign the orders, and has since said he takes all responsibility for those actions.

For her part, Acton has done little on the campaign trail to highlight her time as the state’s public health director. Instead, she has focused more on healthcare affordability, highlighting the Trump-led cuts to Medicaid and the scaled-back subsidies for ACA plans that have resulted in thousands of people dropping coverage in the state.

“I hear from families across Ohio that healthcare costs are rising and they just can’t keep up,” Acton said in an emailed statement. “That’s why I will fight to protect and expand access, reduce the price of prescription drugs, forgive medical debt holding Ohioans back, and lower premiums.”

Abdul El-Sayed, Running for U.S. Senate in Michigan

Abdul El-Sayed at a campaign event in Ferndale, Michigan, on July 25. (Emily Elconin/Getty Images)

El-Sayed — who ran the health departments in the city of Detroit and Wayne County, Michigan — is one of two leading Democratic candidates for Senate. The primary is Aug. 4.

El-Sayed, a progressive, is facing off against Haley Stevens, a four-term congresswoman. They are vying to run against Republican nominee Mike Rogers, a former congressman, for the Senate seat held by retiring Democrat Gary Peters.

From 2015 to 2017, El-Sayed ran the Detroit Health Department, which had been gutted and privatized as part of the city’s 2013 bankruptcy. In his role, he led efforts to test Detroit schools for lead in the wake of the Flint water crisis and provide free eyeglasses to children in public schools.

From 2022 until 2025, he ran the health department in Wayne County, the state’s most populous county, which includes Detroit. In that job, he initiated a program to retire medical debt for thousands of residents and make naloxone available in public areas to reverse the effects of opioid overdoses.

In an interview with KFF Health News, El-Sayed said his public health experience helped him become an effective communicator and challenge corporations and the role they play in healthcare.

“Politics have become overrun by big money and corporations, and my training and background in public health has taught me to think about that and push back against it,” he said.

El-Sayed, who did not practice medicine after completing his residency and is not licensed to do so, has faced criticism from some in his party for calling himself a doctor.  

El-Sayed, who has endorsements from Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Alexandria Ocasio-Cortez (D-N.Y.), supports “Medicare for All,” a policy favored by many progressives that would make more people eligible for the federal health program for people who are 65 and older or disabled.

David Dulio, a professor of political science at Oakland University in Rochester, Michigan, said that the broader economy, Trump’s tariffs, and trade are eclipsing healthcare this year as top concerns for voters in the state. But he added that “progressive stances such as Medicare for All are attractive in the Democratic primary electorate.”

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

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

One of America’s most competitive gubernatorial races could settle a heated argument over whether private insurance companies should run Medicaid.

The race is in Iowa, whose Medicaid program has been plagued with controversy since 2016, when the state hired national insurance companies to manage billions of dollars’ worth of benefits.

That shift was made by then-Gov. Terry Branstad, a Republican. With his executive order, Iowa joined most other states in privatizing the management of Medicaid, which covers healthcare for more than 67 million Americans with low incomes or disabilities.

The arguments have resurfaced this year during the competition to replace Republican Gov. Kim Reynolds, who was Branstad’s protégé and continued contracting with private companies to manage Medicaid benefits. Zach Lahn, the Republican candidate to succeed the retiring governor, supports the practice. Rob Sand, the Democratic candidate, wants to end it.

“It’s been a disaster,” said Sand, Iowa’s state auditor. “The number of complaints has been catastrophic.”

Pros and Cons

Supporters of privatization say the insurers, known as managed-care organizations, make Medicaid more effective and efficient. Critics contend the companies pad their profits by denying payment for crucial health services and by shortchanging agencies and professionals who provide care.

Iowa is among 41 states, plus the District of Columbia, that contract with outside companies to run at least part of their Medicaid programs. Overall, private insurers manage the benefits of more than three-quarters of Medicaid patients. Connecticut is the only state that has fully reversed course after privatizing its Medicaid system.

Sand has criticized privatized Medicaid for years. As state auditor, he published reports alleging that the national insurers systematically deny or delay payment for services to which Medicaid participants are entitled.

He has vowed not to renew state contracts with the three insurers managing care for more than 600,000 Iowans on Medicaid, which is jointly financed by the state and federal governments. He would resume having state employees review and pay bills from clinics, hospitals, and other healthcare providers.

Lahn told KFF Health News that Sand’s pledge to resume state administration of Medicaid “is the exact wrong idea.”

Lahn is a former activist for Americans for Prosperity, a national pro-business group affiliated with the Koch family. He contends that state governments and Medicaid participants benefit when insurers compete to serve them.

“There are very few things that government does more efficiently than the private sector,” he said.

Lahn, who is a businessman and farmer, emphasized that state officials should strictly enforce contract requirements, ensuring that the insurers treat Medicaid recipients fairly and make prompt payments to care providers. He also said he would bar insurers from using artificial intelligence systems to determine whether to pay for medical claims under Medicaid. “Iowans deserve to have a human looking at their case,” he said.

Sand said in a recent interview that he doesn’t want Iowa to fully return to a “fee-for-service” Medicaid system, in which hospitals, clinics, and other healthcare agencies would effectively be paid piecemeal for whatever services they provided. Instead, he said, state employees should take over operation of a managed-care system, in which administrators review services to help ensure Medicaid participants receive what they need without wasting public money on ineffective services.

A few months ago, Republicans controlling the Iowa Legislature considered a bill to require the state to have a privately managed Medicaid system. That proposal would have blocked future governors from unilaterally shifting back to public management of the program. But the bill failed to pass.

Sand, a former assistant state attorney general, said he is confident he would have legal authority as governor to stop contracting with private Medicaid managers, although he cautioned that the transition would be complicated and could take time.

Republican candidate Zach Lahn says that if he were elected Iowa governor he would continue contracting with private insurance companies to manage the state’s Medicaid program because he believes they are more efficient than the government. (Erin Murphy/The Gazette via AP) Democratic candidate Rob Sand says that if he were elected Iowa governor he would end private management of the state’s Medicaid program, which he says has been a disaster. (KC McGinnis/Bloomberg via Getty Images)

A Toss-Up Race

National political observers say the Iowa governor’s race could go either way.

This June, Lahn won an underdog primary campaign to beat a sitting congressman backed by President Donald Trump. Lahn gained Trump’s endorsement after winning the Republican primary. He is a vocal supporter of the Make America Healthy Again movement, led by Health and Human Services Secretary Robert F. Kennedy Jr., which aims to improve Americans’ diets and reduce environmental poisons.

Sand noted that Lahn’s past political activism included a failed 2014 attempt to defeat a proposal to cover more people under Montana’s Medicaid program.

Lahn said that at the time he worried the federal government would reduce how much money it would contribute to such Medicaid expansions, leaving states to foot much of the bill. He said he also didn’t want to see public programs such as Medicaid giving benefits to adults capable of providing for themselves. But he said those concerns have been allayed, partly by the Trump administration’s moves to require millions of Medicaid recipients to prove they are working, volunteering, or going to school.

If elected governor, he said, he would not try to reverse Iowa’s expansion of Medicaid, which happened in 2014 under Branstad.

Branstad also is the governor who decided in 2016 to hire private insurers to manage Medicaid.

Branstad, who declined to comment for this article, did not need the legislature to approve his momentous decision. He weathered controversy over the change, including allegations that the companies systematically denied payment for care that people with disabilities needed to remain in their homes.

Andy Schneider, a Georgetown University researcher who studies health policy issues, said it’s understandable that many government leaders see an advantage in hiring private Medicaid management companies. Each state’s Medicaid program pays claims for hundreds of thousands or even millions of members, and administrators must scrutinize bills from thousands of hospitals, clinics, and other healthcare organizations. “That’s a heavy lift,” said Schneider, who worked in federal Medicaid administration when Barack Obama was president.

Schneider noted that Medicaid expenses are among the biggest parts of any state’s budget. The costs can vary dramatically year to year, he said, which is hard for legislators and governors to plan for. Management companies sign contracts for set amounts of money per enrollee, depending on people’s ages and health conditions. Managed-care companies say they can improve Medicaid members’ health and reduce expenses. But Schneider said outside researchers have been unable to confirm or disprove those claims.

Federal law gives states flexibility in how they run their Medicaid programs, including whether they hire private insurers to manage the programs. “Unwinding those arrangements might take a little time, but there’s no question they can do it,” Schneider said.

Connecticut ended its use of private insurers to run Medicaid in 2012. Minnesota legislators decided to contract only with nonprofit insurers, starting in 2025, and that state’s governor has talked about doing away with private management altogether.

Gary Jessee, a former Texas Medicaid director who helped transition that state’s program into managed care, noted that most Americans’ health coverage is managed by some kind of insurance company, whether they obtain it on their own or get it through a government or employer plan.

Jessee now helps run a health policy consulting company whose clients include Medicaid managed-care companies. He said states rarely talk about totally scrapping contracts with such companies. Instead, he said, states have options to change the contracts, including to increase oversight or limit profits.

Overall, Jessee said, managed-care companies help Medicaid enrollees obtain the services they need to stay healthy. But it’s hard to calculate how much money the companies save states, he said, because all healthcare costs have been rising, and new members of managed-care plans may at first use more services as the insurance companies encourage them to get regular checkups instead of waiting for emergencies.

Iowa’s Medicaid program is managed by three insurers: Molina Healthcare, Elevance Health subsidiary Wellpoint, and Centene subsidiary Iowa Total Care.

None responded to requests for comment for this article.

Catherine Gray of Des Moines helps run a Facebook page for families who use Iowa’s Medicaid system. Her adult son, John, is on Medicaid because of a disability. Gray said the managed-care companies have made it much harder for people to obtain services, including mental healthcare, dental care, and transportation to health appointments. Iowa’s shift to the private system was abrupt and chaotic, she said. “We know people have died,” she said.

Gray said she probably will vote for Sand for governor, even though she doesn’t agree with every nuance of his stance on Medicaid. She suspects many other Iowans who use the program will do the same. “They’ve really been put through the wringer for 10 years, and they’re exhausted.”

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

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

Mark Vantrease regularly sees his Vietnam War buddies over breakfast, attends his grandchildren’s Little League games, and, when he’s up to it, tends to his lush front-yard garden, which is dotted with shells retrieved from his abalone-diving days.

Time is precious for him. Last year, doctors told the 76-year-old former truck driver that a combination of heart failure, lung disease, and liver damage had left him with only six months to live. “That was about 11 months ago,” Vantrease said in a May interview, smiling at having, for the moment, cheated death.

In June 2025, Vantrease began hospice, which focuses on quality of life for terminally ill patients, receiving regular visits from a nurse in his home in Novato, California. Medicare is covering those services for him. His hospice caregivers reminded him of the attention his unit received from medical staff in Vietnam.

“We used to call them guardian angels,” he said, “because they took such great care of you.”

But the Trump administration’s allegations of unchecked hospice fraud in California have tainted the industry’s reputation, prompting concerns that fewer patients will seek the care they need. Health policy researchers and hospice administrators worry that the negative attention on the industry and potential for overly punitive regulations could put California patients and taxpayers on the losing end.

“The fraud situation has done a lot of damage to the reputation of hospices overall and undone a lot of the progress that had been made in destigmatizing hospice,” said Lauren Hunt, an associate professor at the University of California-San Francisco’s Philip R. Lee Institute for Health Policy Studies who focuses on hospice care. “Policymakers should pursue targeted strategies that root out fraud and abuse without overburdening the many providers who are doing the right thing.”

Hospice care is facing sweeping restrictions. The Centers for Medicare & Medicaid Services in May announced a six-month national moratorium on hospice provider enrollment in Medicare and increased oversight in California and several other states with “elevated fraud risk”: Arizona, Georgia, Nevada, Ohio, and Texas.

In a statement, CMS spokesperson Timothy Foster said state inaction on hospice programs rife with fraud drove the need for federal intervention. Foster said CMS believes the crackdown won’t affect patients’ ability to obtain services, with roughly 7,000 hospices still approved nationwide, and that it will help ensure the hospices that remain provide the care “individuals near end of life deserve.”

“Ensuring patient safety and access to quality hospices and other certified healthcare services is paramount to CMS’ work,” Foster said.

Mehmet Oz, the CMS administrator, has said the strict approach also protects taxpayer money. Studies have concluded that even as for-profit hospices have expanded, the industry has saved Medicare money by offsetting other expensive care. A 2023 University of Chicago report commissioned by industry associations estimated that Medicare patients who used hospice over hospitals in 2019 saved taxpayers over $3 billion.

California has already been cracking down on the problems, with Democratic Attorney General Rob Bonta deeming hospice fraud an “epidemic” last year and asserting that the state is “on it.” The state has had its own moratorium on hospice licenses since 2021, charged numerous providers with crimes over the years, and implemented emergency regulations to curb fraud this June.

Hunt said she’s heard from California healthcare providers who are reluctant to refer patients to hospice because they’re unsure the patients will receive high-quality care and from patients who don’t know which hospice providers they can trust. California has the most hospice organizations of any state — approximately 2,800 as of 2022, according to the California state auditor’s office. That same year, CMS reported 5,800 hospice agencies nationwide.

Hospice administrators in good standing have already found themselves in the crosshairs: A Washington Post investigation in June found that the federal government’s new anti-fraud task force has already suspended licenses for 43 legitimate hospices.

Still, Hunt and other policy researchers welcome the efforts to target unscrupulous operators.

“While most hospices are committed to providing high-quality care, there are serious concerns about a subset that exploit patients and the system for financial gain,” she said.

The hospice industry is uniquely vulnerable to fraud because of insufficient licensing regulations and inadequate oversight, according to industry researchers. And the percentage of the population aging into Medicare is rapidly rising, with spending expected to accelerate in the next 10 years.

Most of the rapid growth in operators has been among for-profit hospices, a state auditor’s report in 2022 noted. In California, about 94% of hospice providers are now for-profit, a shift from 20 years ago, when nonprofits dominated the industry in California and nationally. On average, for-profit operators make around $2,100 more per patient in pretax profit and $49 more per patient-day than nonprofit hospice operators, according to one study.

Skelly Wingard, CEO of By the Bay Health, a Northern California nonprofit that provides services to Vantrease, acknowledges that fraud is a big problem in the industry. “These organizations that have exploited patients were extremely savvy,” she said.

But Wingard warns against losing sight of the bigger picture.

“Hospice, when done well, is one of the most compassionate and meaningful benefits in healthcare,” she said. “We should be working to protect that, not inadvertently erode confidence in it.”

By the Bay Health has been in business for 50 years and serves around 750 hospice patients in the Bay Area. About 89% of them are covered by Medicare, 3% by California’s Medicaid program, Medi-Cal, and the rest by commercial health plans, Wingard said.

At home in Novato, Vantrease lifts his shirt to show where a catheter was surgically implanted to drain uncomfortable fluid buildup in his abdomen. The hospital trained his wife, Paula Vantrease, a retired career counselor, to connect a suctioning device to the catheter to siphon the excess fluid. A hospice nurse from By the Bay, Blake Knier, helped her master the technique the first few times she tried it at home.

“Paula is the rock in my foundation,” Mark Vantrease said.

Knier orders all of Vantrease’s medications and rejiggers them when necessary to manage his bouts of intense nausea and pain. Every week, Knier checks the surgical incision around the catheter for infection, listens to Vantrease’s lungs, checks his blood pressure, and cleans and dresses the open wounds that sometimes form from burst blisters on his legs, a complication of the fluid buildup and weakened skin.

Hospice nurse Blake Knier listens to Mark Vantrease’s lungs. (Laurie Udesky for KFF Health News)

Knier helps usher hospice patients and their families through critical turning points. He recalled guiding one patient’s daughter through her mother’s loss of appetite.

“It’s OK if your mother isn’t eating vegetables,” he told the patient’s daughter. “Let her eat ice cream, if that’s what she wants.”

California’s emergency regulations against fraud took effect in late June. In addition to tighter prescreening of license applicants, they call for minimum professional qualifications for management, higher nurse-to-patient ratios, stricter rules around physical office space, and other restrictions.

Hunt said the new regulations are a step in the right direction but urged caution.

“The broader impact on the industry should be closely monitored, particularly to ensure that well-intentioned, high-quality providers are not placed under undue strain or forced to close,” she said.

Late one night last year, when Knier wasn’t available, another hospice nurse from By the Bay Health came promptly to the Vantreases’ home in response to an urgent call from Paula.

“I felt like I was about to die,” Mark Vantrease said, explaining he’d just had a premonition that he wouldn’t wake up in the morning. His sons were called to his bedside. The family needed reassurance. So a nurse arrived, examined him, and checked their father’s vitals.

By midnight, he was sleeping.

Mark and Paula Vantrease in their home in Novato, California. (Laurie Udesky for KFF Health News) KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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

Around the end of last year, Ronmel Rangel, 63, began to feel a familiar discomfort in his lower abdomen. Twenty-five years earlier, while living in his native Venezuela, he had undergone surgery to repair a hernia on the right side of his groin.

Now, the same pain had returned — on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an inguinal hernia, which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed as an outpatient procedure. There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are safe and effective.

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance — But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs — except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient covered by Medicare, which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to KFF Health News, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations — or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

Rangel collected estimates from facilities near and far from his home in Portland, Maine, including some outside the United States. “I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” he says. (Brianna Soukup for KFF Health News)

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. Research has found that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off — sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

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

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

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

Benjamin Pinckney has dreamed of becoming a physician assistant since he was 20 years old but says new student loan limits enacted by Congress in 2025 may prevent him from pursuing his goal. (Erica S. Lee for KFF Health News)

The federal government is capping the amount graduate students can borrow. The Department of Education says the new rules are designed to help curb student debt and pressure schools to lower tuition. But some loan experts fear those good intentions could leave many at the mercy of private lenders with higher interest rates. Saddling healthcare graduate students with pricier debt burdens can narrow their career choices.

KFF Health News correspondent Lauren Sausser joined WAMU’s Health Hub on July 22 to explain how the loan caps could make healthcare provider shortages worse or compromise the diversity of the workforce. Plus, she discusses how some states are pushing back against the new rules.

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

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

A tiny federal agency tasked with protecting the public from injuries caused by lawn mowers and coffeemakers is demanding that some of the nation’s biggest health systems turn over detailed, personally identifiable medical records of all patients who seek help at their emergency rooms.

The Consumer Product Safety Commission, responsible for tracking and issuing recalls of dangerous products sold in the U.S., began discreetly pressuring hospital executives this year to share personally identifiable health data with a private contractor. But hospital lawyers and other industry experts have questioned the agency’s authority to collect, its ability to safeguard such a swath of sensitive information, and whether it has followed the legal process to overhaul its surveillance system.

After KFF Health News asked the CPSC about the new system, the agency announced the program on July 21. Left unmentioned, however, is the alarm it has raised among hospital executives, as well as the nature and extent of the agency’s data demands.

In a stark departure from its product-focused mission, the agency’s goal is to obtain millions of Americans’ medical records from emergency room visits for most injuries, from a broken bone to a childhood vaccine reaction or even a suicide attempt, according to documents and emails obtained by KFF Health News, as well as interviews with five people involved or familiar with the discussions.

A CPSC official also insisted in the emails that the institutions provide all ER patients’ identifiable information — such as names, addresses, diagnoses, and other personal details — to the contractor, Konza Health, for analysis. In correspondence with hospital executives, Konza representatives described participation as “mandatory” or “required.”

As a condition of viewing the correspondence, KFF Health News agreed not to republish some of the emails it obtained.

The CPSC wants at least 100 hospitals to start sending detailed medical records by the end of this year, according to an internal memo.

“The whole thing is troubling,” said Sharona Hoffman, a professor of health law at Case Western Reserve University who noted that giving a private entity access to a sweeping collection of data will introduce risks to patient privacy. “If this company really is collecting identifiable information, that is worrisome for patients.”

The new project was launched amid upheaval at the traditionally independent agency, which is without a governing board since President Donald Trump fired the CPSC’s three Democratic board members. Nearly 1 in 5 career staffers left the CPSC in the first 16 months of the new administration, according to a KFF Health News analysis of federal workforce data.

The initiative also comes as the Trump administration has sought unprecedented access to millions of Americans’ medical records, with the Office of Personnel Management requesting federal workers’ sensitive health information and Health and Human Services Secretary Robert F. Kennedy Jr. using a private organization to collect more medical records for his studies on vaccines and autism.

Steve Roney, CPSC spokesperson, said in an emailed statement on July 10 that the CPSC is “modernizing” its surveillance system. Asked whether the CPSC will file complaints against hospitals that do not participate, he said only that while the previous system “operated as a voluntary program, the ability of hospitals to opt out limited the sample size and usefulness of the data.”

Roney also acknowledged that the agency had not yet notified the public, as “required by law.”

Federal law requires the agency to provide notice and a public comment period before requesting information from 10 or more entities, a step it has not taken despite plans for 100 hospitals to join the surveillance system. KFF Health News independently confirmed with over a dozen hospitals that they had been approached.

Federal public health authorities cannot legally mandate that private health data be reported. But CPSC officials have suggested publicly and privately that if hospitals decline to share data with the new surveillance system, they could be subject to strict penalties from a data-sharing regulation known as “information blocking.”

Yet some hospital executives say they are reluctant to share patients’ sensitive data because they’re concerned about a different violation — that of federal privacy law.

AI Takes Over

Dozens of ERs across the country already participate in the CPSC’s voluntary National Electronic Injury Surveillance System, or NEISS, through which trained hospital workers report injuries involving consumer products, almost always stripped of patients’ identifiable information. The system helps the CPSC identify products, such as baby loungers, toys, and household appliances, with a pattern of injuring consumers.

The new injury surveillance program goes much further.

At a toy industry trade event in February, acting CPSC Chairman Peter Feldman said the agency is “investing in AI-enabled workflows that improve the quality and quantity of injury surveillance data, while also building up digital infrastructure to handle a massive new volume of electronic health records.”

Konza Health, a Kansas-based organization that runs the state’s health data exchange, will automatically pull and analyze medical records of all patient visits from ERs nationwide. Konza won a five-year contract worth up to $15.9 million with the CPSC last fall.

In email correspondence with hospital technology officials, Konza Health President and CEO Laura McCrary also has described ERs’ participation as “required,” stipulating that they share patients’ records with identifying information.

McCrary told KFF Health News by email that the company is not using AI to process the records it receives, saying instead that Konza will use “advanced analytic parsing and filtering capabilities.” Roney, the CPSC spokesperson, did not answer questions about the use of AI.

For years, agency officials have discussed moving away from human contractors and automating NEISS to save time and money.

But without workers on-site, hospital staffers may no longer receive training to determine what clinical information is important to include for the CPSC. In short, the changes could dilute the quality of the product safety data the agency collects.

“They want to suck in as much data as possible, but I’m not sure how thoughtful they’re being about what is collected and what is actually needed by the agency,” said former CPSC chair Alexander Hoehn-Saric, one of the Democratic appointees Trump fired last year.

Wanted: Injuries From Vaccines and Stingrays

The CPSC’s new data collection appears to contradict its own 214-page operating manual, which instructs hospitals not to include identifiable information “such as names, birthdates, or addresses” when reporting cases.

The agency is supposed to receive patients’ identifying information only when needed for follow-up investigations, which happens in fewer than 1% of reported cases, according to the manual.

The CPSC has also historically limited the records it collects to minimize privacy violations in case of a data breach.

The risk is not hypothetical: From 2017 to 2019, the agency improperly released personal health information of around 30,000 people, a disclosure that a top Republican at the time called “concerning.”

Konza, however, will receive even more sensitive information on many more people. McCrary said in a statement that Konza will remove patients’ names, addresses, and medical information “not needed by CPSC” before sharing records with the agency.

Leaving a private organization to collect sensitive information introduces risks, including that it could be stolen or used for business purposes, said Hoffman, the Case Western professor.

“Very often, they will use information for marketing because now they’re going to know what conditions people have,” she said.

Roney said that its contract with Konza, which has not been made public, prohibits the organization from selling or marketing the data it collects.

The CPSC’s manual also identifies types of ER visits that should not be reported to the CPSC, which has jurisdiction over only certain consumer products. Excluded injuries are those caused by food, illegal drugs, medical devices, alcohol, or plants, as well as injuries that did not involve consumer products — such as a cut from a rock or broken bones from a fall on the ground — and suicide attempts by adults.

But in a contract offered to one hospital and reviewed by KFF Health News, Konza set no such limits on the information it would gather from ER records and said it would hold on to patient health information for at least 30 days.

In an email sent to hospital technology officials, McCrary wrote that Konza would provide the CPSC with records when a patient is treated in the ER for any of more than 10,000 conditions. The expansive list of diagnostic codes Konza provided in the email includes injuries that do not involve consumer products.

Child injuries resulting from “poisoning by” vaccines or contact with stingrays, neither of which is regulated by the CPSC, are included in the list.

A limited number of hospitals once shared deidentified data on all injuries — regardless of product involvement — through the NEISS using the Centers for Disease Control and Prevention’s injury-tracking program. But the CDC halted that data collection, after funding and staffing were cut last year, and has not restarted it.

Pressure on Hospitals

CPSC Chief Data Officer Elizabeth Puchek, who joined the agency late last year after engineering U.S. Citizenship and Immigration Services’ data system, has told hospitals in emails that they must seek an exemption from the program if they decline to share patients’ emergency room records with Konza.

The CPSC’s targeted outreach has included some of the nation’s largest urban and rural health systems, as well as small, publicly owned hospitals.

Staff members at Mary Greeley Medical Center in Ames, Iowa, said that Konza and federal officials told them their participation in the new program was mandatory. The hospital, which has long participated in NEISS, signed a new contract in April to share its ER records with Konza.

Yet the hospital is reevaluating its participation after being notified that the funds it received to participate in NEISS were “no longer available,” spokesperson Steve Sullivan said.

Several hospital executives, lawyers, and others have raised doubts about the CPSC’s claimed authority.

Harborview Medical Center spokesperson Susan Gregg said the Seattle hospital’s emergency room has “voluntarily submitted de-identified data for many years, but we are not obligated to report this information.”

In Boston, Mass General Brigham has declined to participate in the new program, with spokesperson Kelly Mitchell saying that “to protect patient privacy, we are unable to provide these medical records.”

Henry Ford Health in Detroit; St. Luke’s in Boise, Idaho; and Sanford Health based in Sioux Falls, South Dakota — which together handle over a million ER visits a year — are among the health systems that have been approached but not yet entered into an agreement with Konza, according to representatives. Several of the nation’s busiest hospital systems targeted for the program — including the Mayo Clinic in Minnesota, Yale New Haven Hospital in Connecticut, Nationwide Children’s Hospital and the Cleveland Clinic in Ohio, and Baylor Scott & White Health in Texas — declined to answer questions about whether they’re participating.

Hoehn-Saric, the agency’s former chairman, said he was surprised that the CPSC would insist that hospitals provide identifiable records from all emergency room visits.

“This idea that they can simply demand patient information from a hospital and that the hospital would provide it — I really don’t understand the basis for that,” he said.

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

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

President Donald Trump’s proposed tariffs on imported generic drugs could raise some prices for patients, a key GOP lawmaker on health issues said this week. But he said that’s a potentially worthwhile trade-off to protect the nation’s drug supply.

“The national security might be something worth paying for,” Sen. Bill Cassidy of Louisiana, chairman of the Senate Health, Education, Labor, and Pensions Committee, said July 22 in an exclusive interview with KFF Health News.

The U.S., which has grappled with drug shortages in recent years, relies primarily on China to produce the active ingredients in many antibiotics, according to a study published last fall in JAMA Health Forum. Domestic facilities have closed or shifted to producing other drugs.

“Do we want China to have that sort of leverage for these drugs to be produced principally, maybe 99%, over there, and we don’t have access to them if tension rises between the two countries?” said Cassidy, who is a physician.

On July 21, Trump said in a social media post that he would give generic drug companies two years to move production back to the U.S., after which he would impose 100% tariffs on imported products, rising to 200% the following year. Generic drugs make up an estimated 90% of all prescriptions filled in the U.S.

Cassidy, who has served in Congress since 2009, lost his bid for reelection in May after Trump endorsed a Republican primary challenger, Rep. Julia Letlow.

Last month, more than 16 months after his vote to confirm Robert F. Kennedy Jr. as head of the Department of Health and Human Services, Cassidy said on CBS News’ Face the Nation that the secretary broke promises he made to the senator, including that he would not change the federal recommendations for childhood vaccines.

Asked whether he would summon Kennedy again to discuss those promises, Cassidy said he had asked for him to appear before his committee but had not heard back about whether he would do so. Kennedy appeared before the Senate HELP panel in April to discuss the Trump administration’s fiscal 2027 budget request for HHS.

Cassidy told KFF Health News that when he agreed to vote to advance Kennedy’s nomination, he trusted that Kennedy would keep his word about not disparaging vaccines.

“If they agree to guardrails and disregard those guardrails, you can judge me,” Cassidy said. “You may decide my judgment wasn’t very good, but I don’t think you can say I acted in bad faith.”

Regardless, Cassidy added, Kennedy was going to exert influence in the administration, and he thought it would be better for Kennedy to be in an official post, where his work would be subject to oversight.

“I’m pretty sure that RFK was going to have the president’s ear whether he was in office or not,” he said.

While Kennedy’s efforts to roll back federal vaccine recommendations are being blocked by courts, this week researchers at Johns Hopkins University reported that the number of measles cases confirmed in the U.S. so far in 2026 has exceeded the total for 2025 — making it the highest number of cases in 35 years.

Cassidy, a principal author of the 2020 No Surprises Act targeting surprise medical bills, also said he doesn’t think Congress needs to make modifications to the law in the wake of reports that doctors and other healthcare providers are winning huge payouts under the arbitration system the law created. The No Surprises Act was intended to shield patients from receiving big bills for receiving medical care they didn’t know was outside their health plan’s network.

An analysis by The Wall Street Journal this week found that providers were awarded nearly $15 billion in disputed claims in 2025, more than triple the 2024 figure of $4.08 billion.

“The initial step to make sure that people are getting their best deal is price transparency,” Cassidy said.

The HELP Committee on July 22 overwhelmingly approved advancing the Patients Deserve Price Tags Act, a bipartisan bill that would further expand the requirements that hospitals, insurers, and other healthcare providers make prices public and available to patients and employers. A House committee advanced a similar bill this week, also with bipartisan support, but it remains unclear whether either measure will be approved by the full House and Senate.

The interview — in which Cassidy also discussed his Money and Value for Patients proposal — was part of the “How Would You Fix It?” series featuring Julie Rovner, KFF Health News’ chief Washington correspondent and host of the What the Health? podcast.

An abbreviated version of this interview aired July 23 in Episode 456 of What the Health? From KFF Health News: “A Shrinking Safety Net.”

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

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

This isn’t just a bad year for measles. It looks to be the start of a bad era. Confirmed measles cases just hit a 35-year high, and it’s only July. Together with last year, the number of cases has exceeded the combined total over the previous 25 years. The vast majority of cases stem from domestic outbreaks fueled by low rates of vaccination—and rates are declining.

For the first time in a quarter century, the U.S. no longer meets a main criterion for having eliminated measles as a public health threat. That status hinges on sporadic outbreaks fizzling out within a year. Utah’s outbreak has lasted for longer, since June 2025.

Nearly 400 people have been hospitalized with measles in the U.S. this year and last, three people have died, and at least three suffered brain swelling with lingering symptoms.

This month, the Centers for Disease Control and Prevention is set to finalize a comprehensive study of the nation’s measles situation, examining data from January 2025 through June 2026.

“I don’t think we could say with a straight face that there hasn’t been transmission over the past 12 months,” said a CDC scientist with knowledge of the agency’s measles report. (KFF Health News agreed not to name the researcher, who is concerned about retaliation.) The researcher said a national committee of measles specialists will review the CDC’s internal report, which then goes to the Pan American Health Organization, a group that evaluates the measles elimination status of countries throughout North, South, and Central America and the Caribbean.

PAHO will make its decisions at an annual meeting this fall, but scientists say the writing is on the wall. “The assessment for elimination isn’t until November, but that is a scheduling issue, basically,” said Anne Schuchat, who led the CDC’s immunization and respiratory disease group from 2006 to 2015.

“It’s just so sad, because some people will get brutally ill,” she said of measles’ return. “This is a wake-up call.”

Southwestern Utah has been hit hard by an ongoing measles outbreak that’s lasted for more than a year. (Amy Maxmen/KFF Health News)

Pediatricians in Utah have been on the front lines as measles and other vaccine-preventable ailments have returned to the U.S. In interviews with KFF Health News, six doctors shared insights on this new era of vaccine hesitancy — and what could be done to turn the situation around.

The conversations have been edited for clarity.

On Unvaccinated Children Hospitalized With Measles Complications

Emilie Morris, a hospital pediatrician in Salt Lake County and Utah County: When children come in, they’re often bent over. We call it tripoding, which is particular to upper respiratory infections and airway swelling. They have a rash — viruses cause rashes all the time — but in this context, the kid is hunched over, mouth open, drooling, crying, maybe not even producing tears, because they’re so dehydrated. Really labored breathing, kind of tugging in their belly, tugging between their ribs. Their eyes look kind of glazed over. It’s like they’re seeing through you.

Nathan Money, a hospital pediatrician in Salt Lake County and Utah County: If the child has a fever or trouble breathing, and they’re unvaccinated, I have to be way more aggressive from a medical standpoint, because they are at higher risk of having life-threatening illnesses. I have to do more blood work, or lumbar punctures to rule out meningitis. I have to do things which are painful, and it’s traumatic for the families.

I tell them, “Because your child doesn’t have vaccines, I have to be more worried about conditions like sepsis or meningitis, so therefore I need to do more workup.” The last thing I want to do is miss something. These are parents who love their children. They always tell me, “Do what you need to do to make sure my child is safe.”

On Treating Unvaccinated Children Hospitalized for Measles

Trahern W. Jones, a pediatric infectious disease specialist based in Salt Lake City: So I’m coming into a room and just hearing the most awful barking cough, just a cough and a high-pitch stridor as the child is trying to breathe. And he’s just coughing so hard it just makes you feel short of breath. He looks like he’s been beaten down for days, but he can’t rest, because the cough keeps him awake.

The parents tell me they’re not anti-vaccine, but in the past, somebody they know had a reaction to a vaccine — or something they thought was a reaction to a vaccine — and so they paused vaccines when the child was a baby. They were planning to catch up later.

In another case, the parent was stunned by how awful it was. I asked them what they knew about measles before their child was sick, and they said the only person who’d ever taught them anything about measles was their grandmother who had taken care of her kids with measles ages ago. That’s something I’ve heard from other parents. It’s such an awful illness. Even the best possible course is going to be one of the worst diseases most children ever go through.

There are multiple facets to it. Physically, the child has been beat down for multiple days by this virus. The parents don’t get to sleep, because they’re nursing their child. Then there’s the emotional component because the parent is regretting not getting the vaccine, not realizing how bad this was, and then feeling deeply ashamed, trying to reconcile with family members who are really upset at them for not getting their child vaccinated.

Morris: One child was from a family that was uninsured because they didn’t feel that they would need to use the medical system. They were faced with the high burden of cost of our healthcare system. The cost was playing into the parents’ decision on whether or not their child should receive necessary medical care. I said something like: “Please don’t go home. Your child needs oxygen. She has pneumonia. We will figure out a way to pay for this, because we acknowledge what we do is expensive.”

On top of that, the parent had several other children in the home who weren’t vaccinated. It was past the period where we could intervene with vaccines to try to prevent infection, so then our recommendation was to quarantine their children at home for 21 days: “Don’t interact with anybody else in your community. Don’t go to the grocery store, even with a mask. Please take this seriously.”

It takes time for parents to understand the level of concern I have, even when their child is physically ill in the hospital requiring ongoing care. It’s pretty indicative of the breakdown of trust between physicians and families. I say, “This is the gravity or severity of your child’s situation and how serious we need to be about protecting other people.”

It’s frustrating. How can I make people understand I have a very genuine concern for their child? And I know they share that concern, but maybe it’s not the same degree of concern, because they don’t understand the illness and how severe it can become.

Money: It’s heartbreaking to see these children struggling to survive when measles could have been easily prevented by a safe mechanism that is readily available and well studied. These are well-meaning parents who love their children, who have gotten bad information from federal leadership or from online sources. The saddest part to me is when I am caring for a child and the parent says, “I didn’t know that this could get so bad.”

On Conversations With Parents Who Don’t Vaccinate Their Children

Tim Duffy, a pediatrician in Salt Lake County: A lot of families aren’t aggressively anti-vax, but they’re hesitant. Younger parents who grew up in the digital age have done their research — “research” in quotation marks — for months. And they keep getting confirmation of their concerns on social media. They think they’re doing what’s best for their child.

I’ve told families: “You could do nothing I say as a pediatrician. You could sleep your child on their stomach. You could not put them in a car seat or, when they’re older, not use seat belts. You could do nothing I say, and for your individual child, they will probably be OK. But from my standpoint, where I’m taking care of thousands of kids, within a system that takes care of hundreds of thousands of kids, we will have bad outcomes. These children will show up at our facilities, and it’s so sad.”

Tim Duffy, a pediatrician in Salt Lake County, Utah, says many parents are concerned about incorrect claims about vaccines seen on social media. (Amy Maxmen/KFF Health News)

Pediatrician in southern Utah whom KFF Health News agreed not to name, because of concerns about harassment after being targeted by anti-vaccine activists in the past: A lot of parents are concerned about autism. I’ve told them that I’d be very concerned if there was any evidence that what we’re doing is causing autism. But if vaccines were causing autism, we should see more cases of autism in vaccinated kids compared to unvaccinated kids, and we’re just not seeing that.

I’ve also had families who say they want to be natural, or that they’re concerned about what is in the shots. A frequently asked question is: “Did you vaccinate your children?” I say that knowing what I know, I’m confident giving this to my kids. They’re all vaccinated.

On the Influence of Politics on Vaccine Hesitancy

Jones: Vaccines have become a political football. That wasn’t true 20 years ago. But now it’s used to drive a wedge between groups of people, which is unfortunate. Vaccines are one of the main reasons why we don’t have to worry about losing our kids.

Southern Utah pediatrician: People don’t know who to believe. If politics comes up, I tell parents that my messaging on vaccines is not politically motivated. When parents ask about changes to the vaccine schedule, I’m transparent. [In January, the Department of Health and Human Services controversially recommended reducing the number of vaccines given to children. A few months later, a federal judge blocked those changes.]

I’ve said there was a process for the approval of immunizations through ACIP [the Advisory Committee on Immunization Practices], which is made up of scientists, public health experts, and doctors, and all those people were let go, and a new panel was selected. A couple of individuals changed the recommendation outside of the time-tested, evidence-based process for evaluating vaccines. That raises concerns for me as a doctor. I tell parents that the American Academy of Pediatrics, the American Academy of Family Physicians, and several other professional organizations have issued statements saying that these changes are not based on evidence.

Ellie Brownstein, pediatrician in Salt Lake County and president-elect of the Utah chapter of the American Academy of Pediatrics: I avoid talking about politics, but what’s being said has added another layer to our work. One family asked me about changes to vaccine recommendations, so instead of just telling them what immunizations are due, I talk with them about why physicians and researchers have followed a different schedule for years, about the reasoning and the science behind it. I explain that I trust these experts over someone without a lot of experience.

The Southwest Utah Public Health Department stocks vaccines against measles, whooping cough, tetanus, hepatitis B, and other diseases. (Amy Maxmen/KFF Health News)

Money: People are not vaccinated, because they’ve lost trust in the medical community. They’re placing trust elsewhere. Rebuilding trust is a complicated process, but it comes from consistent messaging at every level, from the pediatrician to local health departments to community leaders, city leadership, district leadership, religious leadership, educational leadership.

We need consistent messaging from state leadership, which has been pretty absent. I want to see commercials on TV about the safety of the MMR [measles, mumps, and rubella] vaccine and the dangers of the measles, sponsored by my state leadership. I’d like to see this on billboards and in schools, in public buildings and grocery stores. I want to go to a sports event and see messages about the measles and the MMR vaccine. Right now, people have to go out of their way to find information from reputable sources.

We also need policy changes to support vaccination. This train is going in the wrong direction, and it can feel like a helpless situation, because we’re just not seeing the public messaging and leadership that’s needed to turn this around.

Advice on Talking With Parents Who Don’t Vaccinate Their Children

Jones: Approach them with as much compassion as you possibly can. Ask open-ended questions to learn about their experiences that led them to have these concerns. I think it’s really important to not come down on them, citing facts and figures and pointing to guidelines on why they need to get their kids vaccinated. But try to direct their attention to the fact that you’re a real person with your own real experiences and knowledge. I point out to families that I have my own kids, and I would never recommend something for your kids that I wouldn’t do for mine.

Southern Utah pediatrician: I’ve learned that if you come down hard, you’re going to lose people who need care. My number one goal now is to build bridges and maintain a relationship with families, because that’s what’s going to allow me to convince some of them.

I approach people differently depending on where they are. Parents who are very skeptical or anti-vax will say no when I tell them their child is due for immunizations. I’ll say: “Fine. You guys get to choose. You’re the parents. But I’m curious to know what your reasoning is.” Sometimes they’re just like, “It’s something I’ve decided.” They don’t want to have a conversation.

It’s a good day if I can have a conversation with someone who doesn’t want to vaccinate, even if I don’t convince them. I try to help them think through things rather than shoving anything down their throat. When they’re done talking, I’ll ask, “Can I share my perspectives on this?” Some will say yes enthusiastically, and others will say yes because they’re being polite.

A lot of parents aren’t sure what to do, and those are the people I focus most of my time on. I focus our conversation on their specific concerns, and I’m open about specific side effects that different immunizations can have. For example, I’ll tell them that some children get a fever after a vaccine, which is OK. The fever is not harmful, but it can make babies feel crummy as their body is building up antibodies against viruses and bacteria.

Brownstein: I don’t like the idea of excluding unvaccinated kids from my practice. I know some do that. But what that does is it ends any future discussion. I can’t keep talking with parents about vaccines if I kick them out of my practice, and if these parents find like-minded doctors, this situation will get worse.

On Being on the Front Lines of Measles’ Comeback in the U.S.

Money: I wish that people could see what I see. Everyone else sees what people post on Instagram. Or they think, “Someone I know had measles when they were a kid and they were fine.” But as a hospital-based pediatrician, I see what happens when things go poorly. I see what happens when children with measles aren’t able to breathe on their own, and they’re in a hospital bed with a cannula in their nose, struggling to breathe, an IV in their arm because they can’t drink on their own. And the child is terrified, and the parents are scared that their child might die.

It’s heartbreaking as a pediatrician and as a father to know that the entire situation could have been easily prevented.

Duffy: Even though parents say vaccination is their choice, I still feel personally responsible if something bad happens that’s preventable, because I feel like I didn’t say the right thing, I didn’t ask the right questions. Maybe I let it drop because of the look on a parent’s face.

Morris: Every pediatrician I know cares so deeply about what they do. Sometimes people forget that we are human beings practicing this discipline, and we bring all our concerns for our community into this space. I’m trying to navigate a lot of complex human emotions, like how it feels to hold grief with a family when something bad happens that was preventable — which is the worst situation, because you think, “Could I have done something differently?”

Jones: I think we’ll see more diseases start coming back that we thought we had gotten rid of. I think it’s going to take dramatic changes to actually prevent those outcomes. I’m not necessarily seeing those changes being done by those in power.

I think of that quote from The Lord of the Rings. It’s something like, you don’t get to choose the time that you’re born into, but you get to choose what you’re going to do about it. And if there’s any comfort that I have, it’s in knowing that there are right decisions to make and that I’m going to make them, and I’m going to help others make them, too.

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

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

Marie Noon takes eight medications a day. One keeps her heart rate from spiking to avoid a stroke. One prevents debilitating headaches. Another ensures she doesn’t retain excess fluid.

More than a decade ago, Noon said, she was diagnosed with adult-onset Still’s disease, a rare type of inflammatory arthritis that can cause rashes, debilitating pain, and fevers. The disease upended her life.

She had been living a typical suburban life in Michigan, shuttling her two kids to activities like cheerleading, choir practice, and track. She was active in the PTA. She managed a bank.

She went from that to crawling to the bathroom because she was in so much pain, “just crying all day long” from being so sick.

Noon, who is disabled, said she couldn’t work for eight years — a time marked by hospital stays that stretched for weeks.

“I honestly thought I was going to die,” Noon said.

So it was a shock when Michigan denied her application for Medicaid benefits last year after she lost private insurance. Worse yet, it came down to an IT error, according to an attorney who helped Noon overturn the denial.

“I can’t afford my medical care. I have to have insurance,” said Noon, who has returned to working.

Deloitte, a multibillion-dollar global consulting firm, has operated Michigan’s Medicaid eligibility system under contracts worth roughly $768 million since 2006, according to contracts reviewed by KFF Health News. Nationwide, Deloitte dominates this important slice of government business: At least 25 states have awarded the company contracts to build or run computer systems that control access to safety net benefits such as Medicaid.

Michigan’s system has incorrectly directed people with disabilities into skimpier benefits that cover limited care or has denied coverage completely, a KFF Health News investigation found. Similar problems were at the center of a class-action suit in Tennessee, court documents show, and have occurred in Texas, according to interviews and state records.

The KFF Health News investigations are based on statements from state officials, allegations and declarations in court documents, emails obtained through public records requests, state government information provided to Medicaid enrollees and applicants, and interviews with attorneys and patients or their caregivers.

In an emailed statement, Deloitte spokesperson Karen Walsh said it found “no system anomalies causing routine denials of Medicaid for people with disabilities.”

“There are many reasons why someone may no longer be eligible for a benefit they once received or believe they deserve,” Walsh said. “All of the eligibility systems we support are owned by the states and built to their unique specifications. We will continue to work at the direction of our state clients.”

Lynn Sutfin, a spokesperson for Michigan’s Department of Health and Human Services, said it “is not aware of any widespread or systemic issues” within Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits, “related to disability‑based eligibility pathways.” 

Since 2006, Deloitte’s contracts with the state have said the company is responsible for development, implementation, maintenance, operations, and enhancements to the Michigan system.

Computer system problems foreshadow trouble as states prepare to roll out the most significant and complicated changes to their Medicaid programs in years. Those changes, dictated by President Donald Trump’s landmark One Big Beautiful Bill Act, have states rushing to update their Medicaid computer systems.

Nationwide, roughly 15.5 million people on Medicaid have a disability, according to KFF.

“When these administrative systems get overloaded, everyone gets impacted,” said Pamela Herd, a University of Michigan professor who researches bureaucratic obstacles to accessing government benefits. “The systems are going to be really, really strained.” 

In Michigan, Noon was eligible for Medicaid through a program that provides coverage to disabled adults who work. But the state’s computer system didn’t register that she is disabled and said she earned too much to qualify, according to documents reviewed by KFF Health News and interviews with Noon and Anastassia Kolosova, a disability rights attorney who helped her.

Without Medicaid coverage, Noon paid hundreds of dollars out-of-pocket for prescriptions, after scrounging for discount coupons. She takes some of the drugs twice a day.

Without them, “I’m toast,” she said. It was stressful “not knowing if my medicine’s going to be $50 or $500 this month, because it changes constantly.”

Noon said her doctor agreed to fewer visits to avoid medical bills.

“It was kind of a nightmare,” Noon said.

‘I Just Wanted To Give Up’

Medicaid, a safety net health program jointly run by the federal government and states, covers roughly 67 million people with low incomes or disabilities. State governments rely on companies like Deloitte to design and operate computer systems that assess whether people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps.

That technology has a history of errors that deprive eligible people of benefits, earlier KFF Health News investigations have shown. As reported previously, Kenneth Smith, a Deloitte executive who leads its national human services division, said Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.”

“They’re not Deloitte systems,” he said, noting Deloitte is one player among many who together administer Medicaid benefits.

States are under immense pressure to update their eligibility systems on a tight schedule to adhere to requirements in the Republicans’ sweeping 2025 tax and spending law. Companies including Deloitte, Accenture, and Optum are being paid millions in taxpayer funds to make the changes, which are projected to strip Medicaid from roughly 7.5 million people and SNAP from 2.4 million people by 2034.

Many coverage restrictions in the new federal law don’t apply to seniors, children, or people who are disabled, such as Noon. Nonetheless, the law’s demands on state agencies and the computer systems they oversee will disrupt benefits, advocates for Medicaid enrollees and other healthcare experts said in interviews.

The same systems also need to correctly classify why someone is eligible for Medicaid — and therefore which rules and restrictions apply.

The law’s SNAP restrictions began to take effect in 2025, and major Medicaid provisions begin later this year, generally after the midterm elections.

Kolosova is a supervising attorney with Disability Rights Michigan, a legal advocacy organization for people with disabilities. She said she has been unable to get a meeting with Michigan officials to understand the underlying problem that deprived Noon of health coverage.

Anastassia Kolosova, a supervising attorney with Disability Rights Michigan, helped Noon navigate the complicated process to obtain safety net health insurance through Medicaid. Kolosova says she has seen multiple wrongful coverage denials and fears problems will soon get worse because of changes required by federal law. (Kate Wells/KFF Health News)

State records show Deloitte has held contracts for at least 14 years for Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits. In its attempts to secure more business, the company often cites its nationwide footprint in Medicaid operations.

“Deloitte understands Bridges,” and its history in Michigan makes the company “the ideal vendor,” the firm said in its bid documents. Given Deloitte’s work on similar systems in 31 other states, the firm said, “Michigan benefits from our technical expertise drawn from across the nation.”

But advocates who work with people with disabilities say Michigan’s computer system has failed to recognize when certain adults should receive Medicaid benefits.

Problems aren’t unique to the Great Lakes State. Medicaid beneficiaries who brought a class-action lawsuit against Tennessee in 2020 said the state’s Deloitte-built system “does not reliably test for eligibility” for several categories of people with disabilities. The firm’s contract in Tennessee is worth $1.12 billion over a decade.

A federal judge in 2024 sided with the Medicaid beneficiaries, ruling that Tennessee violated federal law and the U.S. Constitution. The lawsuit does not name Deloitte as a defendant.

In Michigan, a 2010 report from the state’s Office of the Auditor General said government agencies “did not provide effective project administration” and failed to ensure that the state could “independently maintain and operate Bridges” because “the contractor did not transfer knowledge and skills” to state officials, according to the audit.

The auditor’s report said that, as a result, Deloitte’s original contract — valued at roughly $70 million — ballooned by $50 million over the initial cost, a 71% increase. State records show Michigan would go on to add millions more, bumping the cost of Deloitte’s initial contract to $124.1 million.

The audit said maintaining the contract would result “in significant additional costs.”

Sutfin said that “the state is now fully capable of operating and maintaining Bridges independently.”

Deloitte’s latest contract in Michigan — worth $197.4 million — is set to expire in 2030.

Noon applied for Medicaid in August, she and Kolosova said. In September, the Michigan Department of Health and Human Services sent a notice denying her coverage, citing incorrect income information and stating she wasn’t disabled, according to Kolosova and state documents reviewed by KFF Health News.

Noon said that when she called the state for help, state workers “didn’t know anything about” the Medicaid program she had applied to, Freedom to Work.

“I can’t tell you how many times I just wanted to give up,” she said.

For some people with disabilities, Medicaid is supposed to count only half their earnings when assessing whether they should receive benefits. That didn’t happen. Kolosova said she thinks Michigan’s eligibility system didn’t identify Noon as disabled, even though the state “already had all the information they needed” to show she was.

By failing to recognize her disability, the state used the wrong income formula and said Noon earned too much to qualify for Medicaid, she added. Deloitte and Michigan declined to respond to a detailed list of questions about Noon’s experience.

Kolosova said Disability Rights Michigan has seen a growing number of calls from people about Freedom to Work benefit denials. “Maybe two or three a month,” she said.

“There’s something wrong with the system if they’re relying on individual caseworkers to catch this,” Kolosova said. “The system needs to work.”

Noon at home with her dog, Ziggy. Despite being eligible for Medicaid, she was denied coverage in 2025 because of an error with the state’s benefits system. It took months of pushback before the state reversed its mistake. Even as a “tech-savvy” former bank manager, she says, she wanted to give up several times along the way. (Kate Wells/KFF Health News)

Enrolled in the Wrong Coverage

Noon’s experience isn’t the first time in recent years that people with disabilities have been denied benefits by Deloitte-run eligibility systems.

In Texas in 2023, Lilly Livingston, who has Down syndrome and is now 22, was abruptly cut off from Medicaid benefits, according to Livingston’s mother, Marie. She has undergone numerous surgeries to reconstruct her severely misaligned jaw, which caused sleep apnea and impaired her speech and chewing ability. She relied on an array of Medicaid services, including speech and occupational therapy.

When Livingston lost benefits, she was wrongly enrolled in Healthy Texas Women, a limited program that provides breast and cervical cancer screenings and family planning services.

“Trying to fix that was a nightmare,” Marie Livingston said.

Terry Anstee, an attorney with Disability Rights Texas, intervened.

In a September 2023 email with the subject line “URGENT,” Anstee begged a Texas Medicaid eligibility worker for help.

Some unknown “error” had occurred and stripped Livingston of her benefits, Anstee said in an email he sent to a state Medicaid staffer. “Lilly has had 2 major surgeries, and her recovery is contingent on Medicaid.”

It was clear that Livingston qualified for Medicaid through multiple paths, Anstee said: “It never made any sense.”

Deloitte declined to respond to a detailed list of questions about Livingston’s case. Jennifer Ruffcorn, a spokesperson for Texas Health and Human Services, confirmed that Livingston was erroneously enrolled in Healthy Texas Women. However, Ruffcorn said, Livingston did not experience a lapse in Medicaid coverage in 2023.

Anstee disputed the state’s characterization: “A glance in the system by a Texas HHS press officer or other staff 3 years after the fact may not tell the full story or show the issues that Ms. Livingston endured in August and September 2023. Ms. Livingston experienced lapses in coverage.”

The problem Livingston encountered in Texas was also reported in Michigan.

In 2024, mental health services advocates in Michigan raised red flags about a similar error: People with disabilities were being enrolled in a limited Medicaid program covering sexual health and family planning services. Plan First covers only services such as birth control and treatment for sexually transmitted infections. It doesn’t provide the comprehensive coverage that people with disabilities require.

But some enrollees were “being automatically enrolled in Plan First,” Malcolm Kletke, a lobbyist representing the Community Mental Health Association of Michigan and other mental health providers, wrote to a Michigan health official, according to emails obtained by KFF Health News through a public records request.

These enrollees had “long received Medicaid due to their disability,” and getting enrolled in the wrong plan meant losing access to “services essential to their recovery and quality of life,” Kletke wrote in September 2024 to Amy Epkey, a senior deputy director of the Michigan Department of Health and Human Services.

In fact, the state’s own records show that Medicaid enrollment for those with disabilities did decline.

Over roughly four years, enrollment in the Medicaid category that includes people with disabilities fell by 10% in the state, according to the Michigan House Fiscal Agency, which provides nonpartisan analysis to lawmakers. The drop was unusual given people generally leave the program because of death or having recovered from a temporary disability, and it’s unlikely those numbers would balloon, said Robert Sheehan, who was the mental health association’s CEO at the time.

Sutfin said the state examined the decline in enrollment and found “several contributing factors, including post‑covid renewal patterns, changes in beneficiary circumstances and movement to other coverage categories.”

After inquiries from KFF Health News, the Michigan health department acknowledged in April that it had made changes to “address concerns raised by advocates.”

Michigan’s computer system now prevents approval of Plan First benefits until all other coverage options are evaluated, Sutfin told KFF Health News. Sutfin said the changes were implemented but “not to correct system errors.”

Sutfin said the state submitted a change request to Deloitte to address this problem. The fix was implemented in January 2025.

Until presented with Kletke’s email, the state had denied there were problems related to Plan First.

Even after the state addressed that issue, other problems persisted.

Noon’s coverage denial notice arrived in September. She fought with the state for months to reverse its decision, “paying cash for all of the medicines through these appeals over and over and over again.”

It was only in January that she was approved.

“I literally cried,” Noon said. “It was a really big deal.”

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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ʻAIEA, Hawai‘i — Christian Alameda used a cane to push himself up out of bed in his cell at the Halawa Correctional Facility in Honolulu. He has been recovering in the prison’s medical infirmary since a January stroke left the right side of his body mostly paralyzed.

In February, Hawai‘i’s parole board granted the now-52-year-old compassionate release, which allows prisoners to receive early probation to seek medical attention for severe conditions.

But without a long-term care facility willing to accept him, Alameda has not been able to leave.

As of June, at least three other prisoners granted release to tend to their medical needs were living indefinitely in the infirmary after long-term care facilities were unwilling to accept them, primarily because of their criminal backgrounds, the state parole authority said.

“This is a challenge across the country,” said Molly Crane, an attorney for FAMM, which advocates for fairness in prison policies.

Every state allows compassionate release for prisoners, though Hawaiʻi is the only one without a specific law, relying instead on an internal policy. The prisoners who typically qualify for compassionate release can’t care for themselves or have terminal illnesses and may need an assisted living center, a nursing home, or hospice.

But many long-term care facilities nationwide decline to take such prisoners, leaving them incarcerated for months — or years — after they were granted release.

In Rhode Island, a study found that rejections from nursing homes soared after they were told that a patient was coming from prison. In Colorado, prisoners with extensive medical needs stayed an average of 200 days after being granted parole, because of denials from long-term care centers. And in New York, prisoners granted parole sued the state when they couldn’t get placed in nursing homes.

President Donald Trump’s signature One Big Beautiful Bill Act further strains long-term care providers’ ability to take people from incarceration. Prisoners don’t qualify for Medicaid, so parolees often need to apply after they’re granted the release. The law, enacted last summer, reduces the window in which facilities can get reimbursed retroactively for new Medicaid patients from three months to as little as 30 days before they apply. That means facilities risk not getting paid for new Medicaid patients whose applications are not submitted within the reduced timeframe.

The Centers for Medicare & Medicaid Services “encourages providers and beneficiaries to prioritize timely application submission to maximize coverage,” CMS spokesperson Timothy Foster said.

‘Risk Is Just Too High’

Most nursing homes nationwide already have a waiting list for new residents, according to a 2024 report by the American Health Care Association and the National Center for Assisted Living. Those waitlists are another hurdle to getting prisoners placed, said Bob Merce, a former attorney who advocates for prisoners’ compassionate release.

“We tell the nursing homes that most of the people who we are talking about cannot hurt somebody,” Merce said.

Some of the prisoners staying at the Halawa infirmary in June couldn’t walk or dress themselves. One man couldn’t recall what his illness was. Another with brain cancer couldn’t coherently respond to questions.

Sean Sanada, the Oʻahu Region CEO with the Hawaiʻi Health Systems Corp., oversees the region’s two state-funded long-term care facilities, Leahi Hospital and Maluhia. Sanada said that the health system has reviewed dozens of compassionate release referrals but has never accepted any of them.

Sanada said the facilities don’t discriminate based on where the resident comes from. His main concerns, he said, were his staff’s safety and the lack of resources to adequately care for the patient.

“The risk is just too high in most of those instances,” Sanada said.

Violent incidents in long-term care facilities have been well documented. A 2024 study observing 14 assisted living facilities found that in just one month, 15% of residents experienced resident-to-resident aggression.

When long-term care facilities refuse to accept prisoners who have been granted compassionate release, it leaves state taxpayers footing a larger bill. The annual cost to incarcerate an individual in Hawai‘i with complex needs is up to eight times the $112,505 average of housing one person in prison, according to FAMM. In comparison, the average Medicaid reimbursement for a long-term care patient at a Hawaiʻi Health Systems Corp. facility is about $135,000 a year.

Even after being granted compassionate release, prisoners who cannot find placements at long-term care facilities can wait for months or longer in the infirmary at the Halawa Correctional Facility in Honolulu. (Ashley Mizuo/KFF Health News)

Four states — Connecticut, Georgia, Massachusetts, and Vermont — contract with nursing facilities to take prisoners who are granted compassionate release, according to FAMM.

The iCare Health Network’s MissionCare Health, which operates nursing homes for people coming out of prison, secured contracts in three of those states. David Skoczulek, iCare’s vice president of business development and communication, estimated that its rates are $100 to $350 a day more per patient than the average nursing home rates in the states where they operate.

In Hawaiʻi, the correctional department determines recommendations to send to the parole board, which decides whether to grant the release. Prisoners who are granted the early probation can be released to family members who commit to caring for them or to a long-term care facility.

Corey Reincke, head of the Hawaiʻi Paroling Authority, said that in his 24-year career he couldn’t recall getting anyone placed into a long-term care facility without family intervening, for instance by contacting facilities themselves.

“Parole has to find a facility that can meet their medical needs and is also willing to take them,” Reincke said. “That’s where we’re hitting the roadblocks.”

For one parolee, Reincke called more than 100 care homes, he said, but they all declined to accept the patient, over safety concerns. According to a 2024 state report, while Hawaiʻi’s long-term care facilities use about 80% of their bed capacity, workforce strains make it difficult to maintain even those levels.

Hawaiʻi Prisoners’ Refuge: Family

Last year, 69-year-old Paul Kupihea died at a hospital five days after the state granted him compassionate release to his family. He died before he could get on a flight to his home island.

In July 2025, Lahela Kruse, the mother of Kupihea’s child, received a call from a Honolulu hospital informing her that his condition had become severe. By then he had been diagnosed with an incurable form of cancer and had been in and out of the hospital while still in custody.

Kruse and their daughter flew to Oʻahu to see him and were shocked when they saw how sick he was. Their daughter agreed to take him into her home in Hilo, on Hawaiʻi Island, despite not having a relationship with him for most of her life.

“She knew he was sick,” Kruse said. “I told her that, but she didn’t know the severity of it. I didn’t truly know.”

Her daughter’s willingness to take him prompted his compassionate release. But Kruse said the notification about Kupihea’s illness came too late.

FAMM’s Crane has been working on expanding compassionate release laws in states to allow for more prisoners to qualify and strengthen transparency in the process. Hawaiʻi lawmakers have tried for years to pass bills on compassionate release, but none has succeeded.

Crane said without a law that outlines a formal process and who qualifies, even family support isn’t enough. Prisoners can still face life-threatening delays, she said.

“The absence of a compassionate release statute means that people who need compassionate release languish and even die in prison,” Crane said.

Because Medicaid does not cover healthcare in prisons like the Halawa Correctional Facility, the high cost of care for sick prisoners is left to state taxpayers. (Ashley Mizuo/KFF Health News)

In Alameda’s cell, two beds stood about 3 feet apart, with a seatless metal toilet in the corner and a window looking out on a concrete wall. The smell of bleach permeated the room. Alameda said he hoped to see his daughter soon. She recently turned 5.

“I made some mistakes in my life,” said Alameda, who has been incarcerated since 2024 for drug possession, driving a stolen vehicle, and jumping bail. “I tried when my daughter was born, but I know I’ll change, because she needs me out of here.”

Merce, the former attorney, is still trying to find a place for Alameda, who committed no violent crimes. Merce became aware of prisoners’ struggles through his work as a trial lawyer. He said he has helped about 15 prisoners leave Hawaiʻi correctional facilities for medical treatment.

He said he’s seen cases in which people have waited years to get out.

“The ones that stick with me, though,” Merce said, “are the ones that I never found placements for.”

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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Sam Ato Timaloa, a paroled sex offender who also served time for attempted murder, had dementia and an acute intolerance of noise — especially from roommates at Sunrise Post Acute, a nursing home in Banning, California. Over four months in 2025, a state investigative report found, Sunrise switched Timaloa’s room eight times, the last into one occupied by Attilio Cecchetto, 92, a retired tile installer whose dementia led him to frequently moan, mumble, and yell.

Overnight, a nurse aide walked into their room and saw blood splattered on the floor, walls, and ceiling, according to a grand jury transcript. Cecchetto’s face “looked twisted and smashed,” the aide testified. A Banning city police officer testified that Timaloa, 77, told him that he had punched Cecchetto twice.

“He just kept saying that Attilio was being too loud: ‘He talks too much,’” the officer said.

Attilio Cecchetto (right), a retired tile installer pictured with his son Gino, often moaned or yelled, a symptom of his dementia. His California nursing home assigned him a new roommate, a former convict whose dementia made him react strongly to noise, a state report said. (Marco Cecchetto)

Cecchetto died two days later from blunt force facial trauma.

“You get placed in a facility like this to be taken care of, not to be murdered,” one of his sons, Gino Cecchetto, said in an interview. “This was completely preventable at many different points.”

Timaloa pleaded not guilty to assault. The charges were later upgraded to murder, and a judge ordered a mental health evaluation. The judge will rule as early as August on whether Timaloa is competent to stand trial.

PACS Group, the nursing home chain that owns Sunrise, denied negligence. “We strive to provide quality care to everyone we serve, and our hearts continue to go out to the Cecchetto family for their loss,” PACS spokesman Brooks Stevenson said in an email.

In nursing homes primarily occupied by impoverished people as well as posh assisted living facilities that cost upward of $10,000 a month, agitated residents have shoved, punched, bit, and kicked others. They have wielded canes, walkers, pens, a plate, a mop stick, a shoe, a belt buckle, and even the footrests of wheelchairs as weapons, federal inspection reports show.

How often these altercations take place nationwide is unknown, but an in-depth study of 14 assisted living facilities in New York state led by Cornell University researchers estimated 1 in 7 residents experienced aggression within a month, including verbal, physical, or sexual acts. Their separate study of 10 New York state nursing homes estimated 1 in 5 residents experienced an altercation in a month. Researchers have found that these assailants are disproportionately likely to have dementia.

The diseases that cause dementia can impair brain circuits involved in impulse control and threat perception, raising the risk of aggressive behavior. Residents with Alzheimer’s disease and other dementias constitute more than 900,000 of the 2.2 million people living in these settings, many of which include specialized memory care units.

Often, altercations involving a resident with dementia erupt after danger signals are missed or ineffectively addressed, according to a KFF Health News examination of court records, police reports, and state and federal inspection reports.

Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show. The federal records do not include assisted living facilities, which are regulated by states.

In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees, the reports show.

The long-term care industry says not every clash can be averted. Presbyterian Homes & Services, a nonprofit Christian chain of senior living facilities, said in a statement: “Caring for individuals living with advanced dementia is complex, and behaviors can change in ways that are difficult to fully predict or prevent, even with clinical interventions in place.”

Eilon Caspi, a dementia consultant and researcher who studies resident-on-resident altercations, said that usually there is a specific unmet need that precedes an altercation. “In the vast majority of incidents,” he said, “there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”

Fertile Battlegrounds

One psychological theory about Alzheimer’s, the most common dementia disease, holds that as the brain’s networks deteriorate, the balance shifts between the prefrontal cortex, which helps govern judgment and self-control, and limbic regions including the amygdala, which helps process fear and threat responses.

As cognition clouds, people lose the ability to understand what is happening around them and to put distress into words, researchers say. Pain, infection, medication side effects, and other physical and emotional distresses may be expressed through shouting, intimidating gestures, kicking, pushing, or punching. Long-term care facilities can be triggering environments, with intimate care often delivered by a changing stream of aides whom residents can’t recognize. Amid noise, close quarters, and rigid routines, interactions become flash points.

“You don’t feel safe, because you don’t know these strangers who are coming in and taking off your clothes,” said Al Power, a geriatrician and an advocate for alternative models of care for people with cognitive issues. “These things will be distressing to anybody.”

The Cornell researchers found verbal altercations were the most common type of aggressive interaction but estimated 4% of assisted living residents and 5% of nursing home residents in their studies experienced physical assaults in a month.

Another Cornell study found that Connecticut police were called to nursing homes for resident-to-resident clashes more often than allegations of staff abuse, theft, and residents wandering away without supervision combined. A national analysis of survey data from the Centers for Disease Control and Prevention calculated nearly 8% of residents in assisted living facilities engaged in physical aggression or abuse toward other residents or staff members.

Many of the physical aggressions KFF Health News identified in CMS inspection reports were perpetrated by residents with diagnoses of dementia, schizophrenia, or other cognitive disorders. In some physical altercations, both residents were aggressors, while other fights were one-sided. Sometimes the residents were roommates.

Laura Mosqueda, a geriatrician at the University of Southern California’s Keck Medicine in Los Angeles and a senior adviser to the National Center on Elder Abuse, said: “What worries me is that we just end up blaming two people who have either cognitive impairment or severe, uncontrolled mental health issues, when they’re supposed to be in an environment where people are safe.”

‘Only a Matter of Time’

Gladys Lynch, a retired department store accountant, transferred into the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, in September 2025. Her monthly cost was more than $10,000, according to an invoice provided by the family.

One of Lynch’s daughters, Rebecca Norton, installed web cameras in her room and often saw another resident inside. “Every day I looked at it, this woman would be walking into my mom’s room, harassing her, digging through her things, using her bathroom, yelling at her,” Norton said in an interview. She informed Harbor Crossing’s administration, and the facility said it would start locking her mother’s door.

Norton emailed a Harbor Crossing administrator a list of issues with her mother’s care. “My biggest concern,” she wrote, was that her mother’s door was not consistently locked and the webcam showed the woman had again entered, rummaged through the bathroom, and taken a couple of adult diapers.

A Minnesota investigative report determined Gladys Lynch’s memory care home failed to protect her from another resident known for behaving aggressively. “My mom deserved better than what they gave her,” says her daughter Rebecca Norton, seen here holding a photo of Lynch. The home has asked the state to reconsider its findings. (Liam James Doyle for KFF Health News)

Unknown to Norton, Harbor aides had raised concerns about the other resident, who like Lynch was new to Harbor Crossing’s memory unit, according to a Minnesota Department of Health report. Diagnosed with Alzheimer’s, severe dementia with agitation, depression, and anxiety, the woman was confused, had difficulty communicating her needs, and hit aides.

Aides repeatedly reported that the woman had “ongoing aggression, entered other residents’ apartments, invaded others’ personal space, and was difficult to redirect,” the health report said. They said medications had been ineffective and pressed for new ones. The report said one nurse told the woman’s doctor it was “only a matter of time before” she “hurts another resident.”

Captured on Camera

On the last day of September, she entered Lynch’s room and resisted leaving, the state report said. The next morning, she reappeared. Video of the incident was described in the police and state reports and reviewed by KFF Health News. It shows Lynch guided the woman out and appeared to attempt to lock the door, but the woman opened it and returned once more.

The woman declared it was her house, went into Lynch’s bathroom, used the toilet, and then returned to the room Lynch was in. Lynch can be seen repeatedly pressing the alert pendant around her neck to signal nurses for help.

The video shows the woman was almost out of her apartment door when she attempted to touch an object near the door. Lynch put her hands up to block her. The woman slapped at her hands and said, “I’m going to kill you if you don’t quit it.” She pushed Lynch, who fell, her head hitting the floor and blood seeping out.

Aides arrived 13 minutes after she had initially pressed her pendant, the state report said. Lynch suffered a brain hemorrhage and fractures to her eye socket and ribs, according to the state report. She died in the hospital five days later at age 96; the medical examiner’s office declared it a homicide.

Norton said her mother was kind and pleasant and never combative. “My mom deserved better than what they gave her,” she said.

Gladys Lynch was a department store accountant and raised three daughters before developing dementia. Here her daughter Rebecca Norton shows a collection of Lynch’s personal letters and photographs at Norton’s home in Hugo, Minnesota. (Liam James Doyle for KFF Health News)

Prosecutors declined to bring charges, according to the police report. The state investigation concluded Harbor Crossing was responsible for neglect because it was aware the woman “exhibited violent and aggressive behaviors” and yet had failed to put in place effective interventions. Harbor Crossing has requested the state reconsider its findings.

In June, Suzanne Scheller, the attorney for Lynch’s family, filed a wrongful death lawsuit against Presbyterian Homes, which owns Harbor Crossing.

Presbyterian said in a statement: “We are deeply saddened by the loss of Ms. Lynch, and our thoughts remain with her family and all those impacted.” It declined to comment further on the incident or the lawsuit.

Before Gladys Lynch’s death, employees at the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, struggled to keep the resident who fatally assaulted her from behaving aggressively and wandering into other residents’ rooms, a state report found. Harbor Crossing has asked the state to reconsider its findings of negligence. (Liam James Doyle for KFF Health News)

Preventive Tactics

Geriatricians, researchers, and resident advocates say long-term care homes should employ strategies to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces.

Each resident should have a care plan, and homes should train staff to be alert to a resident’s triggers and intervene quickly, dementia specialists say. Organized activities are essential to keep residents occupied and engaged. Antipsychotics and other psychotropic medications are often prescribed, but they can increase the risk of falls, strokes, and even death.

An aide can be assigned to watch a particularly challenging resident one-on-one, but many places lack enough staff for protracted, dedicated supervision. Some assisted living facilities will tell a resident’s family they must hire a personal aide, who can cost thousands of dollars extra each month. In extreme situations, facilities might send a resident to an emergency room for evaluation or to a psychiatric hospital, or evict or discharge them.

Camille Russell, who served as Kansas’ long-term care ombudsman until 2024, said she observed nurses and aides were often “woefully undertrained” in basic elements of dementia care.

“We’ve gotten too far away from making decisions that are caring decisions,” Russell said. “There has to be a balance, and the balance has gotten too far to the profit side.”

A Debilitating Kick

Many physical altercations between residents result in a scratch or a bruise, but nonfatal scraps can leave permanent damage on deeply frail residents.

Linda Twiddy’s first weeks in a Chesapeake, Virginia, memory care unit in August 2024 were happy, her daughter, Barbara Howerin, said in a May interview. Twiddy, a former church secretary with vascular dementia, sang along with a visiting church choir, decorated pumpkins, and visited a cat cafe. The facility, The Vero at Chesapeake, charged Twiddy a one-time $6,825 move-in fee and monthly charges of $7,475, according to the lease.

Seven weeks after Twiddy started living there, a nurse called Howerin. She told her that her mother had been kicked in an altercation with another resident and was being sent to the hospital.

When Howerin arrived at the hospital, she was shocked by the extent of the injury. “It was like 10 inches long by 6 inches wide, the whole front of her shin,” she said. “The calf was just like dangling down.”

According to an internal facility incident report the family obtained, an aide heard Twiddy scream for help and raced over to see a male resident with dementia trying to hit Twiddy as she sat on the floor in “a pool of blood.” The report said, “Linda was screaming get him away from me, he pushed and kicked me.”

The man had prior episodes of aggression, according to documents Twiddy’s family obtained in a lawsuit they brought against The Vero in Chesapeake Circuit Court. At his previous facility, a progress note from 2023 stated, he was “becoming very aggressive in tone and actions to residents and staff.” He “grabbed another resident by the wrists and pushed her,” according to the note. He was sent to an emergency room for evaluation of agitation, according to a hospital report. It did not make clear whether he was discharged back to the facility or elsewhere.

Agitation Tied to Pain

The male resident’s medical records at The Vero said he was diagnosed with late-onset Alzheimer’s disease, agitation, and anxiety, according to his doctor’s deposition. He had chronic pain in his back and trouble sleeping. He could answer simple yes-or-no questions but had trouble providing more extensive answers and couldn’t communicate that he was in pain, she testified. His behavioral changes usually occurred when he had a urinary tract infection, the doctor said.

When he was agitated, aides could sometimes calm him by turning on the television so he could watch his beloved New England Patriots, one aide testified in a deposition. A former aide said she tried to avoid dealing with him altogether. “If you go up to him and he was agitated, he’d reach out to try to grab you,” she testified. “If he had that cane, he would swing that cane or he would punch at you.”

In a court filing, The Vero denied allegations by Twiddy’s family that it should have protected residents from him. The filing said The Vero complied with all standards of care and that any injuries Twiddy sustained “were caused by her own negligence” or acts of others.

In their investigation of the incident, Virginia regulators alleged The Vero had failed to assume responsibility for the health, safety, and well-being of its residents. The inspection report said The Vero pledged to appropriately staff the memory care unit based on the number of residents and to ensure someone completed rounds at least every two hours during sleeping hours.

Twiddy underwent three surgeries at the hospital for her leg, including a skin graft, then spent a month in rehabilitation. “She was never able to walk again,” her son, Doug Twiddy, said in a May interview.

The family moved Linda Twiddy to a different memory care facility where the nursing station had a clear view of all the rooms. She lived there until her death earlier this year.

The lawsuit was settled on confidential terms in early June. Carlton Bennett, the family’s attorney, declined to comment. In an email, Lauren Rogers, a spokesperson for Sinceri Senior Living, which operates The Vero, said the company was pleased the legal case had been resolved but could not comment further, citing confidentiality and patient privacy.

“The Vero at Chesapeake is committed to providing a caring, supportive environment where resident health, safety, and well-being remain our highest priorities,” she said.

A History of Violence

After Attilio Cecchetto was fatally bludgeoned at Sunrise Post Acute, his adult children and their attorney, Jody Moore, discovered disturbing details about Sam Ato Timaloa. He had been imprisoned in 1999 after being convicted of raping an underage girl and sentenced in 2008 to 24 years in prison for attempted murder involving domestic violence, according to Riverside County court records. His public defender declined to comment.

Cecchetto’s sons, Moore, and her colleagues at Moore Hutchins Moore also learned more about the home’s owner, PACS Group, a publicly traded company with more than 300 long-term care facilities. Last year, PACS earned $191 million on revenue of $5.3 billion, according to its annual securities filing.

In the lawsuit the Cecchettos and their father’s widow filed against PACS, they accused the company’s founders, Jason Murray and Mark Hancock, of draining resources from their nursing homes to pay for the chain’s expansion and swell their personal wealth.

The two had earned more than $650 million through stock sales since taking the company public and bought two private luxury jets, according to the lawsuit and securities filings. PACS has also purchased corporate sponsorships for Utah sports teams even though it owns no nursing homes in the state, the lawsuit said.

Attilio Cecchetto was allegedly beaten by his roommate at a California nursing home. Police photographed Cecchetto’s bed after he was taken to a hospital. He died two days later. (Banning Police Department)

California regulators fined Sunrise $120,000 for failing to protect Cecchetto and for not taking Timaloa’s articulated dislike of noise into account when assigning rooms. Medicare issued its own $62,810 fine.

In legal papers responding to the Cecchettos’ lawsuit, PACS denied negligence for his death and alleged he “failed to exercise ordinary care on his own behalf for his own safety.” It has sued to overturn the $120,000 state fine, saying it was issued too late and that Sunrise “did what might reasonably be expected of a long-term health care facility licensee acting under similar circumstances” to comply with state rules.

The Cecchettos’ lawsuit asks for a judge to impose robust procedures PACS homes must follow for admissions, staff training, room changes, and the reporting of altercations between residents. The suit asks for a court-appointed monitor to oversee compliance. In its written statement to KFF Health News, PACS said “important context” would come out during the process and declined further comment.

In an interview, Cecchetto’s three sons, Dino, Gino, and Marco Cecchetto, described their father’s life. He spent his childhood on a farm in Italy, growing up under Benito Mussolini. After World War II he moved to Canada, where he learned to tile and lay marble and terrazzo, a decorative flooring material made of chips of stone, glass, or other materials embedded in cement or resin. He relocated to California in the early 1960s, became naturalized, and worked as a tile journeyman and a contractor for decades.

“We don’t want this to happen to somebody again,” Gino Cecchetto said. “With the life he led, he deserved a quiet, dignified death. Instead, he ended his life in pain and fear.”

Data Methodology

KFF Health News’ analysis of federal nursing home inspection reports focused on citations for violations of Medicare and Medicaid regulations stating that each resident has the right to be free of abuse, neglect, and exploitation.

The analysis looked at the most serious levels of citations, those in which inspectors determined that one or more residents had been harmed, or that the facility’s actions caused — or were likely to place residents in immediate jeopardy of — serious injury, harm, impairment, or death. We reviewed the reports since January 2024 and tallied those that explicitly described resident-to-resident altercations.

We conducted a more granular analysis of a subset of the inspection reports from January through March 2026 involving harm or immediate jeopardy. Each report was reviewed and categorized by the type of abuse, neglect, or exploitation.

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

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

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Alice Thornton has spent more than two decades treating people living with HIV in Lexington, Kentucky.

Her team tends to “cringe” anytime they hear about patients having to fill out lots of paperwork, like when applying for Social Security Disability payments, because it can be a difficult, burdensome process.

Thornton tries to support her patients, she said, but understands the limits of her training.

“A lot of times the forms are so complex that I don’t really know what’s the true definition of what this form is asking me,” she said. “We refer them to a disability provider.”

Doctors including Thornton worry they’ll see more of those kinds of requests because of coming changes to Medicaid, the government health insurance program for people with low incomes or disabilities. Starting Jan. 1 in most of the country, some enrollees — mainly adults without dependents — must prove they’re working or performing other qualifying activities 80 hours a month.

Final regulations issued in June say people can obtain an exemption if they’re “medically frail,” or too sick or disabled to work, which may require them to submit documentation from a medical professional. That standard prompted a lawsuit at the end of June from dozens of mostly Democratic-led states and has Thornton worried it could force her and her staff to assess things like how much a patient can lift or how far they can walk.

“If I’m asked, ‘Is this person medically frail?’ What does that even mean?” Thornton said. “I don’t know, and I’ve been doing this for 25 years.”

Last year’s GOP tax-and-spending law known as the One Big Beautiful Bill Act established the work rule, which will affect an estimated 18.5 million Americans when more states start enforcing it. The mandate is expected to cause a larger increase in the number of people without health insurance than any other part of the law, notes KFF, a health information nonprofit that includes KFF Health News.

Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.

“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.

The Centers for Medicare & Medicaid Services declined to respond on the record about doctors’ concerns. But the agency confirmed that enrollees may need to get documentation from a clinician to prove they’re too sick to work and said states would make final determinations.

The Trump administration has previously said states should use available data sources — such as medical claims and payment data — before making patients submit proof of medical frailty from a provider.

“Documentation should be relatively easy to provide,” Mehmet Oz, the CMS administrator, said during a June 1 press call.

But deciding whether a patient is too sick to work is a subjective, high-stakes decision, said Chen, who also practices as a hospitalist at Valley Medical Center in Renton, Washington.

“We’re trained to take care of people,” he said. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We’re not trained to make these kinds of work determinations.”

When they apply and every six months after, Medicaid enrollees subject to the rule will have to prove that they’re performing the minimum monthly hours of qualifying activities — or will likely have to prove as frequently that they qualify for an exemption.

If states can’t find sufficient evidence that someone is too sick to work, that person will be able to self-attest to it under penalty of perjury — but only for a short time. States may take someone’s word that they’re medically frail twice in 2027 and only once in 2028.

Last month, 25 mostly Democratic-led states sued the Trump administration over the final regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.

The standard, they argue, requires state Medicaid agencies to “take on the role of occupational medicine experts” or adds that burden to physicians who are not necessarily trained in occupational medicine.

CMS declined to comment on the litigation.

The Trump administration has crusaded against fraud in government health programs including Medicaid. It recently charged hundreds of defendants — including medical professionals — over more than $6.5 billion in alleged fraud schemes.

CMS has said it will keep a close watch on how states administer the work requirements and may take corrective action if states step out of line.

That has doctors concerned about the potential repercussions if they incorrectly assess whether someone is too sick to work, as farfetched as those worries might be, said Rahul Vanjani, a primary care and addiction medicine physician and researcher at Brown University.

“We, using our imaginations, wonder if someone is auditing these forms in the background and if they’re going to reach out to the licensing board.”

The country is short thousands of primary care providers, and it could be hard for people seeking an exemption to find a clinician to help them document that they’re too sick to work, doctors said.

It will be even more challenging for someone without insurance, said Jennifer Wagner, who researches Medicaid eligibility at the left-leaning Center on Budget and Policy Priorities.

“How could an applicant who doesn’t have health coverage get a doctor’s note?” she asked.

The American Medical Association, the nation’s largest professional association of doctors and medical students, lobbied federal officials to change the standard for documenting medical frailty in the days before the final regulations were made public.

In May, the AMA sent a letter to Oz, the CMS administrator, arguing that forcing doctors to attest to their patients’ ability to work wouldn’t just be an administrative headache but would affect the way they interact with those in their care.

In a statement, the association’s president, Willie Underwood III, said the work rule “transforms the clinical encounter into an eligibility gatekeeping process.”

“Patients will likely sense that shift,” he said. “And if they begin to suspect that what they share with their physician could affect their coverage, the conditions for open and honest communication will start to break down.”

Doctors have a fixed amount of time to spend with patients and would rather focus on treating medical conditions than filling out forms, especially ones that put them in a position to “represent the state,” said John Ayanian, an internal medicine physician and researcher at the University of Michigan.

“Their first obligation is to serve the best interest of their patients,” Ayanian said.

Lauren Davis, an attorney with Community Legal Services of Philadelphia, helps clients navigate other public benefit programs, such as the Supplemental Nutrition Assistance Program, which has a similar work rule. Enrollees can get an exemption from it if they’re too sick to work.

She recalled a client with a cognitive condition that affected her memory. The client’s doctor wasn’t comfortable filling out an exemption form without seeing her in person, but she kept forgetting to make an appointment and eventually gave up, said Davis, who worries Medicaid enrollees could face similar barriers to getting exemptions.

“This person is eligible,” Davis said. “The reason that they’re not able to get what they need to show that they’re eligible is because of their medical condition.”

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

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

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BELZONI, Miss. — Harmony Ball-Stribling’s path to pregnancy had been turbulent, from an endometriosis diagnosis to an arduous in vitro fertilization process and sky-high blood pressure. But as her due date approached in the summer of 2021, her health improved and those storm clouds seemed to scatter.

“It was just too perfect,” said her mother, Shenelle Ball-Green, of those calm, hot weeks.

Then, early on July 5, four days shy of her scheduled cesarean section, Ball-Stribling began experiencing complications from preeclampsia, a potentially life-threatening blood pressure disorder. Speeding up to 110 mph, her husband drove her to the nearest hospital 25 miles away from their home in Belzoni, a Mississippi Delta town of about 1,900 people.

Minutes before reaching the facility, Ball-Stribling suffered a seizure in the passenger seat. Her husband pulled her from the car and performed CPR on the side of the road. It was too late. She and the couple’s unborn daughter, Harper, died on the side of U.S. Route 49.

The tragedy might have had a different outcome if the hospital in Belzoni, a five-minute drive from Ball-Stribling’s home, hadn’t closed 13 years ago. Today, Humphreys County has no hospital, no emergency room, no urgent care clinic, and no county health department. It is one of more than 100 rural hospitals in the U.S. that have fully closed since 2005.

In Belzoni, self-proclaimed “The Heart of the Delta,” and its surrounding area, communities are close-knit, and Harmony’s story is well known. Now, her death has galvanized local and state leaders determined to bring a hospital back to the county that has suffered without one.

“It was a tremendous eye-opener for this community,” said state Rep. Timaka James-Jones, a Democrat who represents the district that includes Belzoni and is Ball-Stribling’s aunt. “It brought to light how we are so without.”

Poverty often shapes the health disparities Humphreys County residents experience. Approximately 1 in 7 Humphreys County residents under age 65 lack health insurance coverage, compared with about 1 in 11 people nationwide. Humphreys County also has the highest rate of Medicaid enrollment of any Mississippi county, reflecting the economic challenges many residents face. These disparities are evident in the county’s infant mortality rate, which is among the highest in the state at roughly 15 deaths for every 1,000 births.

James-Jones has watched these circumstances influence the lives — and deaths — of her loved ones. She said she wants to see a hospital reestablished before her four-year term is up in early 2028.

But that may be easier said than done. In Belzoni, local leaders hoping to restore healthcare services face a tangled web of policy challenges that are especially demanding for a small town with limited resources. Its story reflects what many healthcare policy experts warn: Once a rural community loses a hospital, bringing it back can be nearly impossible.

Belzoni, Mississippi (Vickie D. King/Mississippi Today)

Humphreys County’s Healthcare Losses

Humphreys County Memorial Hospital opened in Belzoni in 1951 as part of a nationwide hospital building boom fueled by a Truman-era law called the Hill-Burton Act. The legislation provided billions of dollars in grants and loans to build and modernize healthcare facilities. At the time, roughly 40% of all U.S. counties had no hospital. When the building boom began to subside by 1970, all but seven counties in Mississippi had at least one hospital.

But by the 2000s, many rural hospitals in the U.S. confronted financial difficulties. Low patient volumes, an increase in outpatient care, and meager revenues left many on precarious footing. Many had high rates of uninsured patients or those covered through government programs such as Medicaid, which typically reimburse providers at lower rates than commercial insurers.

Humphreys County’s hospital was among those struggling facilities. It was burdened with millions of dollars in debt, and county officials sold it in 2008 to a private company. It was renamed the Patients’ Choice Medical Center. The hospital shut down five years later after Ray Shoemaker, the company’s CEO, was convicted on healthcare fraud charges related to another hospital he owned.

“I do hope they reopen,” Shoemaker wrote in a recent text message to Mississippi Today. “The community needs a hospital.” He said he stepped down from the company before going to prison in 2012.

In 2017, the University of Mississippi Medical Center partnered with the county supervisors and U.S. Rep. Bennie Thompson, a Democrat whose district includes Humphreys County, to secure a nearly $1 million grant from the U.S. Department of Agriculture to open an after-hours acute care clinic in Belzoni. The clinic shut down in 2020, and UMMC officials declined to say why.

G.A. Carmichael Family Health Center, a Canton-based federally qualified health center with five other locations in Mississippi, took it over but did not maintain the extended hours, again leaving Humphreys County residents without after-hours care. Other public health services in the county have closed outright. Three years ago, the county’s health department stopped providing clinical services, said Greg Flynn, a spokesperson for the Mississippi State Department of Health. The county department closed entirely last year, citing staffing shortages and low patient volumes.

In the years since the hospital closed, the county has lost a fourth of its population, falling to 7,000 people, according to census data. James-Jones said she does not believe the community can experience growth until healthcare services are reestablished.

“I don’t know how I can see us growing any other way,” she said.

Shenelle Ball-Green lost her daughter, Harmony Ball-Stribling, and unborn grandchild in July 2021 during a medical emergency as Ball-Stribling was en route with her husband to the nearest hospital, 25 miles away. (Vickie D. King/Mississippi Today)

‘Something’s Way Better Than Nothing’

Months after losing her daughter and unborn granddaughter, Ball-Green climbed the steps of the stately, tan, brick Humphreys County Courthouse to attend a crowded Board of Supervisors meeting.

She stood at the dais and urged the supervisors to reestablish emergency healthcare services in the county to protect other residents from the fates of her loved ones.

“I wanted to let them know at any given moment that could be your child, your mother,” she said. “We’re a small town. Everyone knows everyone.”

She remembered the disappointment she felt when the supervisors told her there was nothing they could do. But when the board’s makeup changed after the 2023 elections, she said, she saw these attitudes shift.

The Humphreys County Courthouse is located in Belzoni, Mississippi. (Vickie D. King/Mississippi Today)

Among the newly elected officials was Reggie Pinkston, who is now the president of the board and previously worked as an EMT when the hospital was open. His own family has suffered the consequences of limited healthcare access. A cousin living in Louise, a town about 20 miles south of Belzoni in the county, had a stroke in 2021 and waited an hour for an ambulance to arrive. She died two days later.

Pinkston said witnessing residents’ delays in care has made expanding access to healthcare services one of his priorities.

“We’re losing too many people in our county because of lack of healthcare,” Pinkston said.

The board enlisted several consultants to develop a strategy for expanding healthcare access and identifying funding sources to support these efforts. In late 2025, Thompson secured approximately $1 million for Humphreys County through the congressional Community Project Funding process, which allows lawmakers to request federal support for specific projects.

The funds will be used to expand services at G.A. Carmichael’s Belzoni location in a county-owned building on U.S. Route 49, Pinkston said. Expansion plans include extending its hours of operation overnight to 5 a.m., purchasing equipment, and a possible renovation of the facility. It could begin its expanded operations by September, said James Coleman Jr., the health center’s CEO.

Establishing an after-hours urgent care clinic is a starting point toward reestablishing emergency care services or a hospital, James-Jones said.

“Something’s way better than nothing,” she said.

Mississippi state Rep. Timaka James-Jones, a Democrat who represents the district that includes Belzoni, is one of the community leaders spearheading an effort to reestablish a hospital in Humphreys County. (Vickie D. King/Mississippi Today)

‘Not for the Faint of Heart’

Despite that encouraging first step, Humphreys County faces steep obstacles to opening a hospital.

At the University of North Carolina-Chapel Hill, George Pink is a senior research fellow at the Cecil G. Sheps Center for Health Services Research and tracks rural hospital closures across the U.S. He said he’s aware of only a few communities that have successfully reopened a hospital after it closed.

“I can count that on one hand,” said Pink, who knows of roughly five such examples.

Communities face significant hurdles to reestablishing a hospital, including securing financing for construction or renovation, recruiting qualified staff, and covering substantial operating expenses during the licensing process before the facility can treat patients and generate revenue, said Brock Slabach, the National Rural Health Association’s chief operations officer and a former rural hospital administrator in southwestern Mississippi.

“Reopening a hospital is not for the faint of heart,” Slabach said. “Once they close, it’s very difficult to reopen them.”

To finance a potential hospital project in Humphreys County, local and state leaders said they plan to seek funding through the Rural Health Transformation Program, a federal initiative that will distribute $50 billion to states over five years. The federal government allocated Mississippi nearly $206 million in December for the program’s first year.

The program is meant to offset budget cuts passed into law last summer that could harm rural hospitals. Republicans’ One Big Beautiful Bill Act will cut the federal government’s Medicaid spending by $911 billion over 10 years and increase the number of uninsured people by 10 million, according to Congressional Budget Office estimates. Mississippi hospitals are projected to lose roughly $160 million annually beginning in 2029, according to Cindy Bradshaw, executive director of the Mississippi Division of Medicaid.

But according to federal guidelines, the program’s funding cannot be used for construction or major building expansions. Officials said the county will instead consider applying for funds through the program to support the recruitment of healthcare professionals.

The federal Rural Emergency Hospital designation is another way rural communities can keep emergency and outpatient services. Hospitals in that program receive over $3 million annually from the federal government and a higher Medicare reimbursement rate, but they cannot offer inpatient care.

Research by Pink’s team shows that many hospitals that converted to the model, which was established in 2023, saw an increase in profitability.

But there’s a catch. To receive the designation, a hospital must have been open in 2020, making Humphreys County ineligible. Mississippi’s junior U.S. senator, Republican Cindy Hyde-Smith, introduced legislation in 2024 to extend the cutoff to 2014, a threshold that would have still excluded Humphreys County.

James-Jones said county leaders have urged Hyde-Smith to amend the proposed legislation so Humphreys County could qualify. Hyde-Smith did not respond to a request for comment for this article.

Belzoni, Mississippi, is self-proclaimed “The Heart of the Delta.” (Vickie D. King/Mississippi Today)

For county leaders, the path to widening healthcare access means navigating a thicket of state and federal policies, funding streams, and regulatory hurdles.

Some recent state-level policy changes have created opportunities for healthcare expansion in Humphreys County. In March, Republican Gov. Tate Reeves signed legislation exempting Humphreys County from Mississippi’s certificate of need requirements, which are meant to prevent unnecessary healthcare expansions.

The exemption could make the county more attractive to prospective healthcare providers. But the financial challenges that contributed to the closure of Patients’ Choice Medical Center in 2013 remain, and Mississippi lawmakers have continued to reject Medicaid expansion, limiting a potential source of reimbursement for rural hospitals and clinics.

Industry officials expect hospitals’ financial pressures to intensify as Medicaid funding cuts take effect. The latest challenge is predicting how these cuts will affect the bottom lines of these facilities and whether additional cuts will come in the future, said Richard Roberson, president and CEO of the Mississippi Hospital Association.

“If someone’s trying to run a business, they’ve got to be able to know what those numbers look like,” Roberson said. “And it’s really hard to try to project that out right now.”

The G.A. Carmichael Family Health Center, a federally qualified health center with five other locations in Mississippi, took over an acute care clinic in Belzoni, which shut down in 2020. (Vickie D. King/Mississippi Today)

‘Now I Understand’

For Ball-Green, giving in to these obstacles would be a disservice to the Humphreys County residents who face health emergencies similar to the one her daughter experienced.

It has been five years since the funeral, but Ball-Green remembers it clearly. The day was stormy, but attendees brightened the gathering by wearing yellow, Ball-Stribling’s favorite color.

As friends and family gathered to pay their respects, her mother thought back on a relative’s funeral four months earlier. At that service, Ball-Stribling sang the gospel classic You Are My Strength to a roomful of mourners.

“She was singing, and she looked at me,” Ball-Green said, describing a peaceful but eerie expression on her daughter’s face in that moment — a sign of something to come, though she didn’t yet know what. “She turned around, and it was just that look, you know?”

Months later, as she sat at her daughter’s funeral, she began to interpret the foreboding glance differently. She came to believe it was a sign that Ball-Stribling’s gift for helping others by sharing her story would not end with her death.

That purpose had taken shape years earlier in her work as a teacher and continued as she shared candid social media posts about her fertility struggles and IVF journey in the final months of her life. Ball-Green said the community became deeply invested in her and Harper’s story.

In the years since, this gift has endured, she said. Ball-Stribling’s story has continued to resonate throughout Humphreys County, serving as a reminder of what residents stand to lose if they do not reopen the hospital.

“I think back on when she looked back at me,” Ball-Green said. “Now I understand.”

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 this “How Would You Fix It?” interview, Julie Rovner, KFF Health News’ chief Washington correspondent and host of the What the Health? podcast, sat down with Elizabeth Mitchell, the president and CEO of the Purchaser Business Group on Health, which represents many large employers and other institutional buyers of healthcare coverage.

Mitchell noted that employers, which offer coverage to more than 160 million Americans, are a big player in the nation’s healthcare system — a role they came into because of “an accident of history,” she said.

“They weren’t looking to get into the healthcare business,” she continued, but “they were looking for alternatives to wages when there were limits on what they could offer, and they started with what was a pretty inexpensive offering — helping pay for hospital care — and that has now grown to be the second-largest line item in their budgets after payroll.”

Rovner and Mitchell discussed the fact that while large employers do have market power, the rest of the healthcare system banded together in response.

“There’s been this arms race of consolidation, meaning that even the largest employers in the world are smaller and don’t have the leverage many times,” Mitchell said.

Asked to identify the systemic changes large employers would like to see, Mitchell pointed to boosting primary care and referring patients to high-quality specialists. She said changes to business policies — in particular, banning anti-competitive practices and increasing price transparency — would help, too.

“We have a very real affordability crisis,” she said.

An abbreviated version of this interview aired July 16 during Episode 455 of What the Health? From KFF Health News: “States Start Their Medicaid Cuts.”

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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One year after the Trump administration announced that dozens of health insurers had signed a six-part pledge promising to reduce barriers to doctor-recommended care, some insurers now say they won’t implement all the promised initiatives.

Meanwhile, patients, their advocates, and clinicians say little has improved.

“It has never been this bad for patients,” said U.S. Rep. Greg Murphy (R-N.C.), a physician who co-chairs the GOP Doctors Caucus.

The overarching intent of the June 2025 pledge was to improve a controversial process called prior authorization, which regularly requires patients or someone on their medical team to seek approval from insurers before proceeding with treatment.

According to AHIP, the health insurance industry trade group, health plans have eliminated 6.5 million prior authorizations for patients — equal to an 11% reduction — since the announcement.

But critics remain skeptical. Sally Nix, a patient advocate who has a chronic disease, described the voluntary pledge as “performative.” And Murphy, who participated in the news conference with Health and Human Services Secretary Robert F. Kennedy Jr. announcing the pledge last year, said it has “no teeth.”

Voluntary insurer pledges rarely make things better for patients, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.

“In the absence of clear rules, policies, standards, and mandates,” she said, insurance companies are “going to do what makes sense for them to do financially.”

The Department of Health and Human Services did not respond to questions for this report. It isn’t clear how, or whether, the Trump administration is holding insurers accountable.

‘Zero Faith’

Prior authorization — sometimes called preauthorization or precertification — has been around for decades. The insurance industry has long argued that the practice, which varies by company, helps control costs, reduces waste and fraud, and prevents potential harm to patients. It’s regularly invoked for a huge swath of services, ranging from low-cost urgent care to expensive cancer treatment.

“Prior authorization is a vital patient safeguard,” said Chris Bond, a spokesperson for AHIP.

The 2024 killing of UnitedHealthcare CEO Brian Thompson sparked a national groundswell of anger about insurance denials, with patients and doctors becoming increasingly vocal about the tactics they say insurance companies use to boost profits at the expense of care.

Prior authorization reform is one of the rare healthcare issues Democrats and Republicans tend to agree on. On July 15, the House Ways and Means Committee unanimously advanced a bill that would force Medicare Advantage plans to provide to the federal government a list of all items and services that are subject to prior authorization, and to report data about denials and grievances, among other requirements.

Last year’s industry pledge was organized as a direct response to public anger, Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said when it was announced. “There’s violence in the streets over these issues,” he said.

“Americans are upset about it,” Oz said, later adding, “I’m looking forward to seeing the results.”

Mike Gartner, founder of Health Access Innovation, an organization that helps patients overturn insurance denials, said he doubts that insurance companies are changing their policies in meaningful ways. The 11% reduction in prior authorization cited by AHIP “hides a lot of nuance,” Gartner said.

Patients who need the costliest services, such as cancer treatment, are still being disproportionately denied access to doctor-recommended care, he said.

AHIP said its data included reductions in prior authorization for medical services, not prescription medicines. The trade group didn’t provide details explaining which services have been dropped from prior authorization or how those reductions differ across individual insurers.

Last year, Oz said the federal government would be “evaluating progress” toward the pledge and “driving accountability,” and he foreshadowed “public dashboards.” But no such dashboards exist, and federal officials did not respond to questions about how they’re holding companies accountable.

Murphy, the North Carolina congressman, said he has “zero faith” in the industry policing itself.

He didn’t believe insurance companies then, he said, “and I don’t believe them now.”

‘At War’ With an Insurer

In February, days after Betsy Adler and Justin Young’s daughter Coco was born with a serious heart defect, the Stillwater, Minnesota, family received paperwork showing they were racking up out-of-network costs.

During Adler’s pregnancy, the family had switched insurers, moving to Medica, a for-profit company based in Minnetonka, Minnesota, and one of many insurers that initially signed the industry pledge. Adler said she’d checked with her employer’s human resources department and on Medica’s website to make sure her maternal-fetal specialists and hospital were in-network before their new health plan went into effect earlier this year.

But then, the insurance company started processing some claims as out-of-network. By mid-March, the family had accrued more than $4,000 in out-of-network charges, on top of more than $3,000 for in-network bills. And the bills kept coming.

Shortly after Betsy Adler’s daughter Coco was born with a serious heart defect, she started receiving estimates showing her family could owe thousands of dollars in out–of-network costs. (Justin Young) Adler had switched insurers to Medica during her pregnancy and said she was assured that her care would be covered at in-network rates. (Justin Young)

When Adler, a psychotherapist, called to figure out what was going on, she said, an insurance company representative said she hadn’t submitted a referral from her primary care provider beforehand. Attempts to fix the problem went nowhere. At one point, Adler said, Medica required her to visit a clinic she’d never been to before to obtain a referral. But she said a Medica representative told her the referral was never received, because the insurer’s fax machine was down.

“I have a critically ill child,” Adler remembered thinking shortly after Coco was discharged from the cardiovascular intensive care unit. “I can either spend my emotional energy at war with Medica, or I can let it go and just enjoy my time with my daughter.”

Medica spokesperson Greg Bury said he wouldn’t discuss the case, citing patient privacy rules. In an emailed statement, he wrote the company is “committed to working with her to ensure she understands what is covered under her benefits and our responsibilities.”

One of six specific promises all insurers made when they signed the pledge was to honor a 90-day grace period when patients switch insurance plans, starting Jan. 1 of this year. Often called “continuity of care,” this grace period allows patients to temporarily continue receiving services and medications that were authorized under a previous insurer.

But that applies only in some circumstances, Georgetown’s Corlette said. The wording of the pledge suggests that insurance companies aren’t obligated to honor another company’s network parameters. When Adler and Young switched insurers, for example, Medica was not obligated to cover the cost of out-of-network providers as if they were in-network, even though they were in-network under the family’s old plan.

Adler and Young switched insurance companies again when Coco was a month old, to avoid accruing more out-of-network costs.

Denial After Approval

Sally Nix with her service dog, Jon Snow, at home in Statesville, North Carolina. Nix, a patient advocate, recently had her health insurer process, then later deny, a claim for injections to relieve her chronic nerve pain. She’s skeptical about industry promises to reform the health insurance denial process. (Logan Cyrus for KFF Health News)

The percentages cited by AHIP don’t tell the whole story, said Nix, the patient advocate. Insurers are “not including the data for the loopholes they create,” she said.

For example, nothing in the pledge prevents insurance companies from retroactively denying payment, even when care is preapproved. “Patients are going to see a lot more retroactive denials,” said Nix, who recently had her insurer process, then later deny, a claim for injections to relieve her nerve pain.

Something similar recently happened to Jocelyn Austin, 49, of Amherst, New York. Over the course of nearly 20 years, she developed an addiction to sleeping and anxiety pills prescribed to her by a doctor. Last year, she spent weeks at an inpatient treatment center for substance abuse. Her insurer, Independent Health, had approved the admission. Austin said she has been substance-free since her discharge.

But the facility sent her a bill for more than $12,000 in December showing her insurer had not paid for the treatment she received, according to documents Austin shared with KFF Health News. This was in addition to the $10,000 she paid at the beginning of her treatment to satisfy her out-of-network deductible. The approval letters from Independent Health had specified that “authorization is not a guarantee of claim payment.”

Frank Sava, a spokesperson for Independent Health, said a denial was issued and upheld in this case because the services provided “were inconsistent with the care that was authorized” and “the medical record did not sufficiently support what was billed.” He said those findings were reviewed and confirmed by an outside consultant.

An explanation of benefits issued by the insurer last summer indicated the “provider,” not the patient, was responsible for the cost of her treatment. And yet the treatment facility has continued to pressure her for payment, she said.

Austin, who has not paid her outstanding bill, said insurance companies “should be held accountable.”

‘Significant Work Ahead’

Another one of the six commitments insurers made last year was to adopt new technology that would standardize the electronic submission of prior authorization requests. During the news conference announcing the pledge last summer, Chris Klomp, the director of Medicare and a deputy CMS administrator, said more than 50% of prior authorizations are still paper-based and processed by phone or fax machine.

In April, AHIP released an update related to that technology initiative, explaining that participating insurers would adopt the new standards on a rolling basis. Health insurers agreed to implement the pledge’s various commitments by predetermined deadlines, and this initiative is scheduled to be operational by Jan. 1, 2027. But eight insurers that initially signed the pledge last year didn’t sign the technology update when it was announced in April, AHIP told KFF Health News.

Those insurers are Alignment Health Plan, EmblemHealth, HealthFirst, Independent Health, Medica, MVP Health Care, Point32Health, and SummaCare. Their beneficiaries span the country, from California to New York. None of those eight insurers agreed to interviews for this report, but most sent KFF Health News emailed statements indicating that they remain committed to prior authorization reform.

AHIP’s approach to continuity of care “would have required the transfer of confidential member health information through a non-standardized process involving third-party participation,” wrote Jerry Slowey, a spokesperson for Alignment Health, which offers Medicare Advantage policies in Arizona, California, Nevada, North Carolina, and Texas. “We do not believe that level of data sharing was contemplated in the original commitment.”

Bury, the spokesperson for Medica, which covers beneficiaries in Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, and Wisconsin, said the company “supports the goal of these standardization efforts.” But the April update “raised a significant technical and operational hurdle that we are not able to commit to at this time,” he said.

Alex Gomez, a spokesperson for EmblemHealth, said in late June the company “will sign onto the commitment” after KFF Health News posed questions about why it had not endorsed the April update.

“We anticipate more plans will be added over the coming months,” said Bond, the AHIP spokesperson. Health plans are “working continuously to implement their commitments to simplify and improve the experience.” He acknowledged that “there is still significant work ahead.”

The original pledge also included a promise that insurance companies would enhance transparency and use “clear, easy-to-understand explanations” when communicating to patients — something they were already supposed to be doing under the Affordable Care Act.

Yet companies still regularly neglect to explain why care has been denied, and their communications often contain “inconsistent and contradictory information,” said Gartner, of Health Access Innovation. He and Murphy also said they suspect insurance companies are increasingly using artificial intelligence to generate denials.

“They craft the pathways to basically deny things immediately with the hope that people will give up,” Murphy said.

The congressman said he wishes President Donald Trump would sign executive orders addressing some of these issues. “The problem is the insurance industry is the strongest lobby in this town.”

Do you have an experience with prior authorization you’d like to share? Click here to tell KFF Health News your story.

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

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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.

When Republicans passed their big budget bill in 2025, they scheduled many of the Medicaid reductions to take effect in 2027, after the 2026 midterm elections. But in anticipation of getting less money from Washington come January, many states are already cutting their Medicaid programs, making the issue more relevant for voters in November.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Sandhya Raman of Bloomberg Law.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Sandhya Raman Bloomberg Law @SandhyaWrites @sandhyawrites.bsky.social Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Congress has no clear path to passing its annual spending bills, with the issue of Medicaid funding for Planned Parenthood again threatening to gum up the works. Meanwhile, senators this week screened President Donald Trump’s newest health nominees: Erica Schwartz to lead the Centers for Disease Control and Prevention and Sean Kaufman to lead the Administration for Strategic Preparedness and Response. But Schwartz undermined some senators’ confidence by claiming ignorance about a number of Trump administration funding cuts, and Kaufman faced fiery questions over a deleted social media post about the hepatitis B vaccine.
• The confirmation hearing for Todd Blanche as attorney general also trod into health territory, with Blanche saying he would review potentially using the 19th-century Comstock Act to block distribution of medication abortion drugs by mail. Such a move could block not only mifepristone but also misoprostol, which is the second abortion medication in the two-drug regimen — and is also used for non-abortion purposes. Trump promised on the campaign trail not to invoke the Comstock Act.
• In politics, Maine Democrats are cautiously eying the abortion stances of a replacement Senate candidate, hoping to pin the rollback of abortion rights on Sen. Susan Collins, the Republican incumbent. And Sen. Ron Wyden (D-Ore.) is calling for an investigation into whether Health and Human Services Secretary Robert F. Kennedy Jr. violated a federal law aimed at preventing electioneering by officials when he made recent calls to persuade some candidates to drop out of congressional races.
• And the gastrointestinal infection cyclosporiasis is sickening more Americans and drawing attention to the Trump administration’s actions undermining food safety surveillance programs. The cyclospora parasite was once subject to mandatory reporting but has since been made voluntary, challenging efforts to track the source and contain the outbreak.

Also this week, Rovner interviews Elizabeth Mitchell of the Purchaser Business Group on Health as part of the “How Would You Fix It?” series.

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

Julie Rovner: Mississippi Today’s “Mississippi Is Getting Hotter. Experts Say It’s Hurting Moms and Babies,” by Sophia Paffenroth and Joanne Kenen.

Anna Edney: Bloomberg News’ “Almost $1 Billion Later, the US Still Can’t Make a Medical Glove,” by Anna Edney.

Alice Miranda Ollstein: Politico’s “Fraud Investigations Are Crumbling This State’s Medicaid System,” by Amanda Chu and Robert King.

Sandhya Raman: Bloomberg Law’s “Unverified GLP-1-Related Claims Flood Food, Supplement Markets,” by Nyah Phengsitthy and Skye Witley.

Also mentioned in this week’s podcast:

• Stat’s “As States Absorb Medicaid Funding Cuts, Family Caregivers Face Financial Ruin,” by O. Rose Broderick.
• NPR’s “Trump’s HHS Shelves Threat To Withhold Medicare and Medicaid Funding Over Trans Care,” by Selina Simmons-Duffin.
• Stat’s “Flood of Comments on White House Grantmaking Overhaul Is Largely Negative, Analysis Shows,” by Anil Oza and J. Emory Parker.
• Politico’s “Trump Admin Asks Appeals Court To Roll Back Obamacare’s Contraception Coverage,” by Alice Miranda Ollstein.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

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

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

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

A Tragic, Deadly Denial

I read your article in The Washington Post about the woman whose Humana policy required prior authorization for a drug she’d been taking (Bill of the Month: “She Struggled To Get a Lifesaving Drug Even After Insurers Vowed To Help,” June 29).

My husband, Kenney, had chronic obstructive pulmonary disease. On June 7, he fatally shot himself after a COPD exacerbation event.

His pulmonologist had prescribed two new nebulizer prescriptions on June 2. One was a specialty medication that would come directly from the drug company. A couple of days later, we called Walgreens to see why the other one hadn’t been filled. Turns out it required prior authorization.

Why the doctor who prescribed it needed to tell his health insurer that he really did think his patient needed it, I will never understand. The pharmacist said she would send the request to the doctor. And why she hadn’t already done that, again, I do not understand. By June 7, of course, it still wasn’t filled.

That day, a Sunday, Kenney experienced the flare-up when I was out mowing the yard. How terrifying it must have been for him to be unable to breathe and me not being there at least to hold his hand. That night he killed himself, leaving a note saying that he hated to leave me but that he couldn’t keep living like that — with the constant anxiety of not knowing when he wouldn’t be able to draw a breath.

Not long ago, a “welcome” packet came in the mail about the other nebulizer treatment — 25 days after it had been prescribed.

Admittedly, my husband’s health was not great. He did have COPD, but we still went out to eat once in a while, and he didn’t have to take his oxygen on those trips. He rarely used it just walking around the house.

He did make a serious suicide attempt six years ago (our daughter and granddaughter had died), but after seeing what it did to me and our son, he promised he’d never do it again. It was only when these exacerbation/flare-up events started this year that he indicated life was getting bad.

Perhaps, just perhaps, if he had received both medications in a timely manner, he would be here today, and we would have had many more years together. We met when we were 16 and had been together ever since. He was 78 when he died.

— Cindy Clements Blewett; Kyle, Texas

Navigating GLP-1 Coverage

Sydney Lupkin’s thoughtful article about the obstacles in obtaining weight loss drugs was interesting (Healthcare Helpline: “Trouble Getting Weight Loss Drugs Covered by Insurance? Here’s What To Know,” June 26). It would have been more helpful had it included a discussion of Medicare’s decision to cover these drugs as of July 1, 2026, and how to navigate the rocky shores of obtaining a prescription that won’t be denied.

— Sharie Hartman; Manteca, California

Beyond the Veil of Pregnancy Centers

I would like to address the article about a pregnancy resource center providing prenatal care in Sandpoint, Idaho (“Religious Anti-Abortion Center Finds Opportunity in Town Without OB-GYNs,” May 20). It is unfortunate that many still do not understand what pregnancy resource centers do, nor the high-quality care they provide. While there are some “crisis pregnancy centers” that provide limited offerings, most centers are aligned with a national organization like the National Institute of Family and Life Advocates, the Heartbeat Pregnancy Center, or Care Net. All these organizations require centers to have a medical director (a licensed healthcare practitioner) and require that the nurses who perform the ultrasounds have appropriate training. While I am not affiliated with 7B Care Clinic, I am concerned that the article may not have accurately reflected what is provided in such clinics. I offer my experiences to bring further clarity.

I work at a life-affirming women’s clinic. I am a board-certified family physician. I have delivered approximately 1,000 babies in my career. I have been performing ultrasounds for my patients for over a decade, and fought for this ability under the scrutiny of maternal-fetal medicine specialists, spending time alongside their registered diagnostic medical sonographer technicians, and having my scans reviewed by maternal-fetal medicine physicians. I have practiced medicine in three states over three decades.

Second, while I am life-affirming, I am not “anti-abortion.” I happen to believe that there are better choices, and I know that some women will still choose abortion, even after hearing all their options. I will gladly see those women for follow-up to answer questions and evaluate for complications — something that the abortion clinics in my area apparently will not do. I say this because that is what the women I see tell me. The clinic that performed the procedure or gave them the pills will not see a patient after the abortion for any follow-up. I have always willingly seen patients for any reason, whether I was working at a private clinic or hospital-owned clinic. That is no different now that I work for a life-affirming women’s clinic.

We provide a variety of services — free of charge. We are also stepping up to provide prenatal care up to 20 weeks because there is a shortage of obstetrical clinicians in our county. We encourage women to see a clinic where they can be followed throughout the entire pregnancy, if possible, and we are in no way marketing ourselves as competition. We are stepping in to fill the large gap that exists.

Just because the clinic in Sandpoint chooses to respect life does not make it a fake clinic. This clinic seeks to bring in physicians to provide prenatal care. They are bringing in OB-GYNs from Washington state, which has no restrictions on abortion. With this information taken into consideration, I ask you to reconsider any concerns about a clinic bringing board-certified OB-GYNs into an area where there is a shortage.

— James Heid, Vancouver, Washington

The Root of All Good

The article Claudia Boyd-Barrett wrote about how immigrant parents’ arrests are creating a mental health crisis for children was moving and brought awareness to the mental health challenges faced by them (Growing Up Scared: “Arrests of Immigrant Parents Create Mental Health Crisis for Children,” June 18). It was important to note how every story was different but focused on how much children missed and yearned for their parents to come back home. You also wrote about how it affected them by not having a parental figure in the home. That really touched me. Specifically, Jacob’s story and when he listed all the things he missed about his mom but especially being close to her.

I am currently a master’s student in social work working to become a better ally to the Hispanic immigrant community. I’ve seen how being afraid and sad over the immigration policies has affected my friends in this community. Losing a close parent and not being able to have that security with them anymore is hard to go through, and trauma affects children as they grow.

In this article, you have recognized the worth of a person, which is a core principle in social work. These children are worthy and have the right to feel taken care of and secure.

I would love to see more mental health services accessible to immigrant communities and their families. This would benefit children as they learn to cope with their feelings and how to make sense of a new world.

— Stacy Xiong, Athens, Georgia

Bagging a Bargain

Author Susan Jaffe mentioned GoodRx in the article “Thousands of Medicare Beneficiaries Thought Their Drug Plan Was Free. Then They Lost It” (July 7), but she failed to mention a much better discount drug site, Mark Cuban’s costplusdrugs.com, where a 90-day supply of 2.5 milligrams of rivaroxaban, a generic for Xarelto, is available for under $50. This could help the thousands of people who lost coverage through unpaid premiums from Wellcare Value Script obtain their medications. The problem of yearly increasing penalties for losing Part D coverage is something that has to be addressed by the Centers for Medicare & Medicaid Services.

Thanks to KFF Health News for the relevant coverage.

— Jackie Button; Miami

Fleshing Out the Details

Your report identifying alpha-gal syndrome as a red meat allergy is accurate in that respect but inadequate in its breadth (“Would Hunters Take a Lyme Disease Vaccine? We Asked,” June 30). Alpha-gal is an allergic reaction to virtually all mammalian products. If you explore that, you’ll find an interesting story, as mammalian products are everywhere, including in pharmaceuticals, cosmetics, and other non-meat products. Alpha-gal is growing rapidly, and too many people, including doctors, do not realize that AGS is far worse than just a red meat allergy.

I suggest you help build understanding of the threat by describing the allergy in the future as an allergy to mammalian products. If you do not think your audience will understand that term, perhaps you can explain that it includes pork and anything derived from animals with hooves. As a former and now retired reporter, I encourage you to cover this allergy because its implications are surprising and scary.

— John Varner, Surry, Virginia

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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