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Almost all people have health insurance in Vermont, a state famed for its maple syrup and Ben & Jerry’s ice cream, yet residents pay the nation’s highest insurance premiums for individual coverage and endure months-long waits for care — and most hospitals here are losing money, according to state reports and interviews with residents and industry officials.

For more than 15 years, federal and state policymakers have focused on increasing the number of people insured, which they expected would shore up hospital finances and make care more available and affordable.

“Vermont’s struggles are a wake-up call that insurance is only one piece of the puzzle to ensuring access to care,” said Keith Mueller, a rural health expert at the University of Iowa.

Regulators and consultants say the state’s small, aging population of about 650,000 makes spreading insurance risk difficult. That demographic challenge is compounded by geography, as many Vermonters live in rural areas, where it’s difficult to attract more health workers to address shortages.

Unlike most states, Vermont regulates hospital and insurance prices through an independent agency, the Green Mountain Care Board. Until recently, the board typically approved whatever price changes companies wanted, said Julie Wasserman, a health consultant in Vermont.

In September, Bruce Hamory, a consultant hired by the board, recommended changes including potentially converting four rural hospitals into outpatient facilities and consolidating specialty services at others.

He cautioned that any fix would require sacrifices from everyone, including patients. “There is no simple single policy solution.”

Lynne Drevik, who runs an inn and spa in northern Vermont, said her doctor told her in April that she needed knee replacement surgeries — but the earliest appointment would be in January for one knee and next April for the other.

Drevik said it hurts to climb the stairs in her 19th century farmhouse. “My life is on hold here, and it’s hard to make any plans.”

Andy Kehler often worries about the cost of providing health insurance to the 85 workers at Jasper Hill Farm, the cheesemaking business he co-owns in northern Vermont. The company pays half the cost of workers’ health insurance premiums because that’s all it can afford, he said.

“It’s an issue every year for us, and it looks like there is no end in sight,” he said.

Recent data shows the University of Vermont Health Network controls about two-thirds of the state’s hospital market, and its main facility, the University of Vermont Medical Center in Burlington, has some of the highest prices nationwide.

Hospital officials contend their prices are average for the industry.

But for 2025, the Green Mountain Care Board required the Burlington hospital to cut the prices it bills private insurers by 1 percent.

The nonprofit system says it is navigating its own challenges, including a lack of housing to recruit workers and a shortage of mental health providers, nursing homes and long-term care services, which often creates delays in discharging patients, adding to costs.

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William Lopez remembers clearly the day in June 2017 when he says he was asked to call the spouse of a college friend who had just died and ask for her eyes.

The spouse hadn’t responded to calls from other employees at the Rocky Mountain Lions Eye Bank, he said. As Lopez recalled, his supervisor thought a friend’s personal number would have more success.

Lopez refused. “I went for a walk,” he said.

Even without Lopez’s help, the eye bank that procures corneas from deceased donors in Wyoming and Colorado eventually collected his friend’s corneas, Lopez said. Lopez, who had entered the field to help people, became increasingly disillusioned during his three years working with the eye bank, despite rising from a technician to the distribution manager, and ultimately quit.

Checking the “donor” box on a driver’s license application, people may picture their heart, kidneys, or other organs saving another person’s life should the worst happen.

They are less likely to consider that tissues — corneas, tendons, bone marrow, skin, bone — are also covered by that checked box. In fact, donated tissues are collected much more frequently than organs, and corneas are the most commonly transplanted body part in the U.S., with nearly 51,000 transplants last year, according to the Eye Bank Association of America.

Organ and tissue donations are guided by different rules, with less transparency and what critics identify as more self-policing in the tissue donation industry. In Wyoming and Colorado, where the Rocky Mountain Lions Eye Bank estimates it collects eye tissue from about 2,500 deceased donors a year, that has contributed to a tense work environment resulting in damaged or wasted tissues due to accidents, four former eye bank employees say.

“I think there’s an urgent need for stricter oversight of the donation process in general, particularly for eye and tissue banks,” said Janell Lewis, who worked at the Rocky Mountain Lions Eye Bank for 12 years, managing public relations and overseeing fundraising before she quit in February 2023.

John Lohmeier, executive director of the Rocky Mountain Lions Eye Bank, declined to be interviewed for this article. In a prepared statement, he said he couldn’t comment on personnel matters or specific incidents raised by the former employees.

But generally, he wrote, “there are internal procedures that have been in place and continue to be followed to investigate and/or report any incident that would impact health and safety concerns.”

Lewis, Lopez, and two other former eye bank employees recalled one or more of the following problems during their time at Rocky Mountain Lions Eye Bank:

• Removal of eye tissue from the wrong body
• Damage or destruction of corneas due to improper removal
• Removal of corneas from a donor with a high-risk family history that could endanger a transplant recipient
• Lack of transparency about whether errors were being reported to federal agencies
• Pressuring and bullying of technicians
• High turnover and brief training of low-paid and inexperienced technicians

The Windshield of the Eye

The cornea is considered the windshield of the eye. It is a clear dome that protects the eye from contaminants, maintains fluid balance, and filters light. Recipients of cornea donations typically need transplants because of trauma, infection, or other conditions that cause blindness or blurred or cloudy vision.

The Rocky Mountain Lions Eye Bank is one of about 60 eye banks operating in the U.S., which leads the world in corneal transplants. New technicians often arrive at the eye bank untrained, sometimes with only a high school diploma, to perform the grim job of removing corneas from recently deceased corpses for about the same wages many fast-food workers earn.

But what eye bank technicians may lack in education and training, they generally make up for with a strong belief in the mission, according to the former employees. They said they joined the Rocky Mountain Lions Eye Bank because they wanted to help restore people’s sight.

The nonprofit employs about 70 people across Colorado and Wyoming, according to a tax filing submitted in 2023. Those records also show a net income of less than $1 million and more than $16 million in assets. Lohmeier was paid about $142,000.

Organs vs. Tissue

Organ donations fall under the purview of the Health Resources and Services Administration, and public data details performance and financial transaction records of organ procurement groups. Tissue donation is regulated by the Food and Drug Administration, as well as national industry groups, and tissue bank transactions, performance, and outcomes are not available to the public.

There’s no reason tissues and organs should be treated differently, said Robert Dickson, medical director for the Washtenaw County Tuberculosis Clinic in Michigan. A patient in his county died from a bone graft contaminated with tuberculosis just a couple of years after a contaminated bone graft killed eight other patients.

He compared the tissue regulatory environment to the Wild West and called it a major public health concern.

“It’s fundamentally no different from an organ transplant. You’re taking tissue from one deceased patient and putting it into a living recipient. But it is not regulated and not tested as rigorously,” he said.

Marc Pearce, president and CEO of the American Association of Tissue Banks, said such cases are very rare.

“We don’t believe that we’ve proven ourselves to be not capable of regulating ourselves,” he said.

FDA officials disagree that the tissue industry is largely self-regulated, pointing to federal rules that require certain organizations to register with the agency and provide a list of human cells or tissues they recover, store, or distribute.

The rules set donor eligibility requirements, and the agency inspects tissue establishments, including eye banks, said spokesperson Carly Pflaum.

“The FDA has implemented a tiered risk-based approach for the regulation of human cell, tissue and cellular and tissue-based products,” Pflaum wrote.

KFF Health News and WyoFile months ago requested reports of adverse events associated with the Rocky Mountain Lions Eye Bank, but the FDA has yet to provide them. FDA dashboards show the eye bank has not issued a recall since 2017, and inspections since at least 2009 have not resulted in any official action.

The tissue industry is largely self-monitored and the performance of eye banks is tracked internally, whereas the federal government publishes annual performance reports for organ procurement groups. Health care providers are not required to report to the FDA adverse events resulting from tissue transplants.

Organ transplant providers are required to report safety events in recipients within 72 hours to the Organ Procurement and Transplantation Network, which operates under contract with the U.S. Department of Health and Human Services. That includes an organ going unused because it was delivered to the wrong location. They have 24 hours if, for example, the recipient gets an infection or disease that may have been from the new organ.

Other countries have public registries detailing the outcomes of corneal transplants, including Australia, the United Kingdom, and Sweden. A similar registry in the U.S. could help monitor outcomes for patients and identify adverse events from transplant procedures, eye doctors and researchers wrote in the journal Ophthalmology Science.

Tissue bank industry groups are responsible for much of the oversight of their dues-paying members. Transplanting surgeons may report adverse reactions to the tissue bank, which generally then conducts a review and submits a report to the FDA and the Eye Bank Association of America or the American Association of Tissue Banks.

Nearly all eye banks in the U.S. are members of the Eye Bank Association of America, which inspects member banks at least every three years as part of its accreditation process, but such inspection reports aren’t publicly available. Safety is paramount, association president Kevin Corcoran said, and the association’s medical standards require eye banks to request patient outcome information from transplanting surgeons a few months after surgery.

“We want to make sure we don’t have an eye bank that is slipping in their performance or failing to recover tissue,” he said. He declined to comment on any individual eye bank’s performance or release quality or transplantation data, complaints filed, or investigations undertaken.

No investigations have resulted in corrective action, he said, in the 13 years he has been at the association. The Rocky Mountain Lions Eye Bank is an accredited member of the association.

Balancing Mission and Stress

Several of the former employees were hesitant to speak about the Rocky Mountain Lions Eye Bank because they didn’t want to sully the reputation of an industry they believe is essential for improving people’s lives and honoring the wishes of the dead.

But they described a high-pressure environment that they said led to many of their colleagues leaving and errors that reduced the number of successful retrievals.

Mackenzie Urban started recovering corneas as a technician for the eye bank in 2019 after finishing her bachelor’s degree. She saw it as a temporary job as she applied for medical school. But within a year of recovering her first cornea, she said, enough employees had left that she became the senior recovery technician and was training others.

She used limes for the training, guiding her students on how to use a scalpel to remove the peel without nicking the fruit beneath. Success meant lifting the peel off the lime without any juice spilling out.

“If you’re stressed, you’re going to shake,” Urban said.

Outside factors can compound the challenges of performing the delicate procedure. Maybe the coroner had drawn fluid from beneath the cornea, making collection much trickier, she said. After a person has been dead for about 24 hours, the eyes tend to deflate to the point of uselessness, adding time pressure to collecting donations, Urban said.

Sometimes, Urban said, another technician would be working on a body simultaneously, so that the entire body was moving around while she was trying to do the delicate procedure.

Interactions with grieving families could be intense, too. Sometimes, families would hug her, thankful that something good would come of their loss. Other times, they were hostile, such as the time one relative of a potential donor told her to “Cut your own f****** eyes out, you b****,” she recalled.

Urban appreciates the work the eye bank performs and doesn’t regret her time there. She said she respected that “they had a real commitment to serving the community and keeping prices low.” (It’s illegal to sell human body parts for transplant, but companies get reimbursed varying amounts for the expenses of harvesting, preparing, and shipping tissues.)

But the workplace culture made it untenable for her, she said. For example, Urban said, she was reprimanded and told that she needed to “buck up or get out” because she declined to harvest corneas from a person who died from an unknown cause. The body was purple from the neck down, covered in oozing blisters and with opaque flecks in the eyes, Urban said.

When Irish Eyes Are Smiling

The Rocky Mountain Lions Eye Bank has international contracts and ships corneas to Japan and the U.K., among other destinations. It became the exclusive eye tissue provider for Ireland when that country stopped collecting corneas over fears of transmitting mad cow disease. That means anyone who has received a cornea transplant in Ireland in the past two decades likely now sees thanks to a person who died in Colorado or Wyoming, according to the Irish Blood Transfusion Service.

Lohmeier, the eye bank CEO, said local needs are prioritized for donations, while international shipments help fulfill the eye bank’s mission and “ensure that all viable corneas are transplanted, giving the gift of restored sight.”

The U.S. is one of the few nations with a cornea surplus. FDA inspection reports confirmed that the Rocky Mountain Lions Eye Bank procures more tissue than its geographic area can use.

The demand for international orders contributed to the high-pressure environment, Lopez said.

Employee turnover and the stress of the job resulted in the collection of corneas of poor quality, Lewis said. Local hospitals inquired about why so many corneas weren’t being transplanted, she added.

The leading reason was recovery errors that damaged the tissue, Lewis said.

Lohmeier disagreed that there was a significant decline in corneas being placed. “We do not believe this description accurately reflects the state of corneal recovery and transplants,” he said.

Internal records showed that about half of recovered corneas in November 2022 had moderate to heavy stress. The Eye Bank Association of America does not have comparable national data. The closest figure it tracks is the proportion, among tissues that were prepared but not transplanted, that were unable to be transplanted because of damage during processing; in 2022, it was a quarter.

Ashi Moore, who used to lead the Rocky Mountain Lions Eye Bank’s quality assurance department, said she once filed a report to the FDA after a donor’s eye tissues were removed despite a family history indicating a high risk of Creutzfeldt-Jakob disease. The disease, which should have been disqualifying for donation purposes, is a fatal brain disorder that can be transmitted through infected tissue.

The issue was caught before the corneas could be placed in someone else’s eyes, but it should never have gotten to the point that the corneas were removed from the body, Moore said.

At least once, a technician retrieved corneas from the wrong body, according to Moore and other former employees (The FDA was unable to provide records to confirm that report by publication). Moore said she should have been told about the case of mistaken identity immediately but said she wasn’t made aware of it until after the eye bank’s leaders handled the situation themselves.

She said she couldn’t find evidence that the eye bank had reported the error to the FDA. It was one of the major reasons she decided to leave the organization, though she had derived a strong sense of purpose from working at the eye bank, she said.

When Lewis resigned, officials at the nonprofit eye bank offered her $5,000 to sign a severance agreement with a nondisparagement provision. She declined.

Lewis said she would like to see states hold tissue recovery agencies to the same standards as other organizations that handle corpses, such as hospitals, coroners, and funeral homes. And if they fail to meet those standards, they need to be held accountable to build public trust, she said.

Lewis’ and Lopez’s negative experiences with the eye bank had another consequence. Each decided they no longer wanted to be an organ or tissue donor.

“After witnessing and experiencing so many issues, I no longer feel comfortable with the potential of my family having to go through that when the time comes,” Lewis said.

WyoFile is an independent nonprofit news organization focused on Wyoming people, places, and policy.

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After their younger son was bitten by a rattlesnake and ended up in the pediatric intensive care unit, a San Diego couple received a huge bill. Listen to hear why antivenom is so expensive.

This spring, a San Diego toddler spent two days in a pediatric intensive care unit after a rattlesnake bit his hand in his family’s backyard.

The bills that followed were staggering, with the lifesaving antivenom the 2-year-old needed accounting for more than two-thirds of the total cost — $213,000.

Why is antivenom so expensive? One explanation is the markup hospitals add to balance overhead costs and make money. Another explanation is a lack of meaningful competition. There are only two rattlesnake antivenoms approved by the Food and Drug Administration.

Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center, said it can be difficult to sort out drug pricing because a hospital bill is often an instrument insurers and hospitals use to negotiate prices. Patients such as the Pfeffers often get stuck in the middle.

“When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost,” Dusetzina said.

Read more here.

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Indiana residents and federal officials are urging state health regulators to stop two rival hospitals in Terre Haute from merging. The deal, if approved, would leave residents with a hospital monopoly.

Union Health, a nonprofit whose main hospital is licensed as a 341-bed facility, would buy the county’s only other acute care hospital, the 278-bed Terre Haute Regional Hospital, owned by for-profit chain HCA Healthcare and located 5 miles south across the city’s downtown area. Union says the merger to create one larger nonprofit health system would improve the area’s poor public health rankings.

The Indiana Department of Health received hundreds of comments on the proposed merger, according to documents KFF Health News obtained through a state public records request. Most people expressed opposition to the deal, citing concerns about longer travel times to get emergency care, higher prices, and fewer choices for Terre Haute’s 58,000 residents and those in Vigo County’s nearby rural communities.

“Monopoly should be just a board game. Not a healthcare system,” a commenter listed as H. Osborne wrote to the state health agency.

Doctors, health economists, and the Federal Trade Commission called on the Indiana Department of Health to deny Union Hospital’s merger application. Such mergers became possible after Indiana enacted a Certificate of Public Advantage law, or COPA, in 2021, shielding the deals from federal anti-monopoly laws.

Two dozen states have had COPA laws on their books at some point, despite FTC warnings that such mergers can become difficult to control and may decrease the overall quality of care. The trend has come amid a broader wave of hospital consolidation, which research shows fuels price hikes and health care spending, driving up costs for families, employers, and taxpayers who foot the bill for Medicare and Medicaid.

Union Health said its proposed deal would improve care and increase access to services while “maintaining cost efficiency” for patients.

“This is not merely a business transaction; it is a strategic effort to improve healthcare delivery in our community,” Union said in a statement.

John Collett, an executive with Garmong Construction who also serves on the board of the Terre Haute Chamber of Commerce, wrote that the deal would help the region achieve its goal of boosting population and income levels. (Garmong Construction served as construction manager for Union on multiple projects, including one worth hundreds of millions of dollars, according to an online brochure of its past projects.)

“I firmly believe this to be a step in the right direction,” Collett wrote.

But the FTC — using italics for emphasis — said the deal is “unlikely to result in improved quality and access” and “would not lead to a healthier workforce or a stronger local economy,” according to comments the agency submitted to Indiana regulators.

Zack Cooper, a health economist and associate professor at Yale University, said the merger would probably damage the local economy and squeeze residents’ wallets. Cooper’s analysis estimates the price of care would rise by at least 10% for area residents and lead to 500 lost jobs, while nurses’ pay would drop by at least 7%. His research predicts the deal also would lead to unnecessary deaths from suicide or overdose, stemming from those job losses.

“I firmly believe this merger would harm members of the public in Terre Haute and Vigo County,” Cooper wrote.

As a condition of these types of mergers, state agencies typically agree to monitor hospital quality and prices to make up for the loss of competition. Union said monitoring would hold it accountable, according to its response to the FTC’s public comments opposing the deal.

The FTC pushed back, saying the oversight mechanism “would be insufficient to contain costs” and is a “poor substitute” for competition. Even though Union would face limits on raising prices in Vigo County, the FTC said, the system might be able to hike them elsewhere, including at its hospital in neighboring Vermillion County to the north.

Indiana has some of the highest hospital prices in the nation, according to studies by Rand Corp., a research organization.

In Terre Haute, some doctors worry the deal would exacerbate existing problems. Kathleen Stienstra, a physician in private practice, voiced her concerns about Union’s management style, saying it has led to an exodus of doctors.

“A monopoly will lead to further deterioration in services,” she wrote.

Separately, the FTC referenced KFF Health News’ reporting on Tennessee’s Ballad Health, a 20-hospital monopoly in Appalachia, as a cautionary tale against such mergers.

COPAs, such as the one that Ballad operates under, “have proven unwieldy,” are “difficult to manage,” and “have failed to protect local communities from the harmful effects of anticompetitive hospital mergers,” the FTC said in its comments on the Union-Regional merger.

Since Ballad launched in 2018 and became the nation’s largest state-approved hospital monopoly, it has not lived up to some of its promises, KFF Health News reported. It has fallen short on meeting quality and charity care goals, according to annual reports from Ballad and the Tennessee Department of Health. After years of problems and complaints from patients, the state is now trying to hold Ballad more accountable for its quality of care.

Ballad declined to respond to KFF Health News inquiries regarding the FTC’s comments.

Now the Indiana Department of Health must consider the comments and decide by early December whether the proposed merger would improve health outcomes, access to services, and quality of care. Under the department’s standards, those benefits must “outweigh any potential disadvantages.”

KFF Health News correspondent Brett Kelman contributed to this report.

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HHS OCR announces $100,000 penalty against Rio Hondo Community Mental Health Center for failure to provide timely access to patient’s medical records.

Tobacco-Related Disparities are a Persistent but Solvable Problem

Hospitals around the country are conserving critical intravenous fluid supplies to cope with a shortage that may last months. Some hospital administrators say they are changing how they think about IV fluid hydration altogether.

Hurricane Helene, which hit North Carolina in September, wrecked a Baxter International facility that produces 60% of the IV fluids used in the U.S., according to the American Hospital Association.

The company was forced to stop production and is rationing its products. In an update posted Nov. 7, Baxter said its North Cove facility had resumed producing some IV fluids. In an email to KFF Health News, the company wrote that customers will be able to order normal quantities of “certain IV solutions products” by the end of the year, but there is no timeline for when the North Cove facility will be back to prehurricane production levels.

Meanwhile, hospitals are facing seasonal strains on their already limited IV fluid resources, said Sam Elgawly, chief of resource stewardship at Inova, a health system in the Washington, D.C., area.

“We’ve been very aggressive in our conservation measures,” Elgawly said, stressing that he does not believe patient care has been compromised. He told KFF Health News that across the system IV fluid usage has dropped 55% since early October.

Elgawly called the shortage a crisis that he expects to have to continue managing for some time. “We are going to operate under the assumption that this is going to be the way it is through the end of 2024 and have adopted our demand/conservation measures accordingly,” he said.

At the end of the calendar year, many patients with insurance hurry to schedule surgical procedures before their deductibles reset in January. Elgawly is eyeing that typical surgical rush and the impending peak of respiratory virus season as he tries to stockpile IV fluid bags. Hospitals such as Inova’s are using different ways to conserve, such as giving some medications intravenously, but without a dedicated IV fluid bag, known as a push medication.

“You don’t even need a bag at all. You just give the medication without the bag,” he said. “There has been increasing literature over the last 10 to 20 years that indicates maybe you don’t need to use as much. And this accelerated our sort of innovation and testing of that idea.”

Monica Coleman is a nurse at a Department of Veterans Affairs hospital in North Chicago. She said using push medications takes more time out of a nurse’s already hectic schedule because then they need to monitor the patient.

“This could increase adverse effects within the patient, because we’re giving the medication at a faster rate,” she said.

Elgawly is also interested in retooling electronic health records to question doctor orders for more IV hydration.

“Does the patient actually need that second bag? How did they do today with eating or drinking water or juice? They did well? They don’t need the bag. So it’s little conservation mechanisms like that that, when you add them across, you know, the 2,000-patient system that Inova is, make a significant dent,” he said.

Simpler conservation measures could become common after the shortage abates, said Vince Green, chief medical officer for Pipeline Health, a small hospital system in the Los Angeles area that serves mainly people on Medicare and Medicaid.

First, Green would like to see data showing that patient outcomes aren’t affected. But for now, some of the new strategies just make sense to him. He has directed hospital staff to use up the entire IV bag before starting another.

“If they come in with IV fluids that the paramedics have started, let’s continue it. If it saves half a bag of fluids, so be it, but it adds up over time,” he said.

Patients may be asked to take more accountability for their hydration, by drinking Gatorade or water rather than the default of hydrating through an IV, he said.

“From an environmental aspect, we don’t need to have this much waste and fill up our landfills. If we could reduce stuff, I think it’d be wise,” he said.

But he’ll feel better when his hospitals receive a full order, which could be weeks away. Green said they are down to a two-week supply, with an expected increase in hospitalizations due to respiratory virus season.

“We’re purchasing every IV fluid bag that we can get,” 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.

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BOISE, Idaho — Physicians are expected to take the stand in Idaho’s capital on Tuesday to argue that the state’s near-total prohibition of abortion care is jeopardizing women’s health, forcing them to carry fetuses with deadly anomalies, and preventing doctors from intervening in potentially fatal medical emergencies.

Their testimony is scheduled to lead off the second week of a closely watched trial concerning one of the nation’s strictest abortion bans. The case, brought by four women, two physicians, and a group of medical professionals, seeks to limit the extent of the state’s ban, which prohibits abortion in almost all circumstances except to prevent a pregnant woman’s death, to stave off “substantial and irreversible impairment of a major bodily function,” or if the pregnancy was a result of a woman or girl being raped.

Over three days in district court last week, the women who brought the case shared emotional testimony about serious pregnancy complications that forced them out of state for medical care. That testimony drew objections from James Craig, an attorney with Idaho’s Office of the Attorney General, who interrupted the women frequently arguing that the details of their stories were not relevant.

Craig pushed back on assertions that Idaho’s criminal abortion laws are endangering women’s health care, while also casting abortion procedures in a negative light. Craig called abortion “barbaric and gruesome” in an opening statement.

“Abortion laws prevent unborn children from being exposed to pain,” he said.

At one point in the trial, Craig suggested that women could use any medical condition to sidestep the law, describing a scenario in which a pregnant woman who stepped on a rusty nail could claim she was at risk of infection and thus entitled to an abortion.

If the court finds in favor of the women, Craig said, “women [would] have a right to kill their unborn baby anytime it’s disabled, anytime they have an infection.”

During the plaintiffs’ testimony, as the women described what happened to their bodies during their pregnancies, Craig’s repeated objections drew reprimands from the 4th Judicial District Court judge overseeing the case, Jason Scott.

The patient plaintiffs’ testimony drew a warmer response from Scott, who said the women’s “circumstances are very worthy of sympathy.”

The case has drawn national attention to Idaho’s ban, one of the first enacted after the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization. As it proceeds, abortion rights advocates are watching to see whether court challenges — including in other Republican-led states, such as Tennessee, where a similar case is ongoing — will be successful.

The plaintiffs in the case are not seeking to overturn the Idaho ban but rather to enact medical exceptions to the law. Their prospects are unclear, though a similar challenge in Texas did not fare well.

As the trial played out in a Boise courtroom, Jillaine St. Michel sat with her husband as they tended to their 10-month-old son. St. Michel had faced a pregnancy in which her fetus developed in devastating ways — a lack of leg and arm bones, a missing bladder, fused kidneys. She was barred from ending her pregnancy.

“We were told in the state of Idaho an abortion was not legal, and my case was no exception,” she said. 

Instead, the family drove to Seattle for an abortion, she said, to spare the fetus she carried from further torment.

“The state talks about how barbaric it is, they keep using that term,” St. Michel said. “The idea of allowing your child to experience suffering beyond what is necessary, to me that feels barbaric. To put myself through that when that is not something I desired, that feels barbaric. To have that ripple down into my ability to parent my existing child, that feels barbaric.”

Earlier this year, the Texas Supreme Court ruled against 20 women and two OB-GYNs, upholding that state’s criminal law that allows abortion only to prevent a pregnant patient’s death. The court added one clarification ruling that abortions would be considered a crime when the amniotic sac breaks before 37 weeks of pregnancy, known as preterm premature rupture of membranes, because the condition can cause rapid and irreversible infection. That exception is not currently allowed in Idaho, and physicians who testified in the first week of the trial said they’d been forced to put their pregnant patients into cars and planes to receive abortions out of state.

In Idaho, a previous legal challenge to the state’s near-total abortion ban was rejected by the Idaho Supreme Court. In the case brought by Planned Parenthood, the justices wrote in a January 2023 ruling that the Idaho Constitution contains no right to an abortion, and that Idaho’s laws criminalizing abortion are constitutional.

This latest challenge, Adkins v. State of Idaho, comes on the heels of Donald Trump’s presidential victory. His Supreme Court appointments made way for the anti-abortion movement’s most vaunted goal of eliminating a woman’s constitutional right to abortion. 

Advocates for abortion rights say that a loss in the case would close off options for challenging bans.

“If this isn’t successful, it’s not really clear if there are really additional places to go for help,” said Gail Deady, a senior staff attorney at the Center for Reproductive Rights, a legal advocacy organization representing the plaintiffs.

Kayla Smith, one of the plaintiffs, sobbed during her testimony as she recalled suffering from preeclampsia during her pregnancy with her first child. When medication could not control the condition, physicians were concerned that the blood pressure disorder could cause Smith to have a stroke or seizure, so they induced birth early, and Smith delivered a daughter, who is now 4 years old.

She told the court her second pregnancy seemed normal until a routine anatomy scan showed her son had multiple lethal heart defects. She and her husband had named him Brooks.

Idaho’s abortion ban had taken effect two days earlier and no longer allowed a physician to allow women such as Smith to end a pregnancy involving lethal fetal anomalies.

Her husband recalled the moment when their doctor, Kylie Cooper, delivered the diagnosis. “I remember finally asking just her if Brooks was going to be able to survive, and Dr. Cooper, she broke down. And the three of us just cried. And I understood that we were helpless in Idaho at that point,” James Smith said.

Despite a frantic search, the Smiths could not find a fetal surgeon who would operate on Brooks. His heart could not be fixed.

“My son wasn’t going to survive,” Kayla said in an interview. “We wouldn’t bring a baby home. And we also didn’t want him to suffer, so we just decided to do the most compassionate thing for him and also for me.”

Idaho’s criminal abortion laws required either that Kayla stay pregnant until her condition deteriorated and an abortion would be needed to prevent her death, or that she give birth to Brooks, who would not survive.

“I was not willing to watch my son suffer and gasp for air,” she said about the couple’s decision to end the pregnancy.

The Smiths drove with their toddler to Seattle, where physicians induced labor at about 20 weeks into her pregnancy, and Kayla and James were able to hold Brooks, who did not survive.

Attorneys for the state of Idaho are expected to call one witness this week, Ingrid Skop, an OB-GYN anti-abortion advocate.

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HHS OCR is announcing an agreement with the State of Illinois Department of Human Services to enforce Federal disability rights laws.

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In March, newly installed Social Security chief Martin O’Malley criticized agency “injustices” that “shock our shared sense of equity and good conscience as Americans.”

He promised to overhaul the Social Security Administration’s often heavy-handed efforts to claw back money that millions of recipients — including people who are living in poverty, are elderly, or have disabilities — were allegedly overpaid, as described by a KFF Health News and Cox Media Group investigation last year.

“Innocent people can be badly hurt,” O’Malley said at the time.

Nearly eight months since he appeared before Congress and announced a series of policy changes, and with two months left in his term, O’Malley’s effort to fix the system has made inroads but remains a work in progress.

For instance, one change, moving away from withholding 100% of people’s monthly Social Security benefits to recover alleged overpayments, has been a major improvement, say advocates for beneficiaries.

“It is a tremendous change,” said Kate Lang of Justice in Aging, who called it “life-changing for many people.”

The number of people from whom the Social Security Administration was withholding full monthly benefits to recoup money declined sharply — from about 46,000 in January to about 7,000 in September, the agency said.

Asked to clarify whether those numbers and others provided for this article covered all programs administered by the agency, the SSA press office did not respond.

Another potentially significant change — relieving beneficiaries of having to prove that an overpayment was not their fault — has not been implemented. The agency said it is working on that.

Meanwhile, the agency seems to be looking to Congress to take the lead on a change some observers see as crucial: limiting how far back the government can reach to recover an alleged overpayment.

Barbara Hubbell of Watkins Glen, New York, called the absence of a statute of limitations “despicable.” Hubbell said her mother was held liable for $43,000 because of an SSA error going back 19 years.

“In what universe is that even legal?” Hubbell said. Paying down the overpayment balance left her mother “essentially penniless,” she added.

In response to questions for this article, Social Security spokesperson Mark Hinkle said legislation is “the best and fastest way” to set a time limit.

Establishing a statute of limitations was not among the policy changes O’Malley announced in his March congressional testimony. In an interview at the time, he said he expected an announcement on it “within the next couple few months.” It could probably be done by regulation, without an act of Congress, he said.

Speaking generally, Hinkle said the agency has “made substantial progress on overpayments,” reducing the hardship they cause, and “continues to work diligently” to update policies.

The agency is underfunded, he added, is at a near 50-year low in staffing, and could do better with more employees. The SSA did not respond to requests for an interview with O’Malley.

O’Malley announced the policy changes after KFF Health News and Cox Media Group jointly published and broadcast investigative reporting on the damage overpayments and clawbacks have done to millions of beneficiaries.

When O’Malley, a former Democratic governor of Maryland, presented his plans to three congressional committees in March, lawmakers greeted him with rare bipartisan praise. But the past several months have shown how hard it can be to turn around a federal bureaucracy that is massive, complex, deeply dysfunctional, and, as it says, understaffed.

Now O’Malley’s time may be running out.

Lang of Justice in Aging, among the advocacy groups that have been meeting with O’Malley and other Social Security officials, said she appreciates how much the commissioner has achieved in a short time. But she added that O’Malley has “not been interested in hearing about our feelings that things have fallen short.”

One long-standing policy O’Malley set out to change involves the burden of proof. When the Social Security Administration alleges someone has been overpaid and demands the money back, the burden is on the beneficiary to prove they were not at fault.

Cecilia Malone, 24, a beneficiary in Lithonia, Georgia, said she and her parents spent hundreds of hours trying to get errors corrected. “Why is the burden on us to ‘prove’ we weren’t overpaid?” Malone said.

It can be exceedingly difficult for beneficiaries to appeal a decision. The alleged overpayments, which can reach tens of thousands of dollars or more, often span years. And people struggling just to survive may have extra difficulty producing financial records from long ago.

What’s more, in letters demanding repayment, the government does not typically spell out its case against the beneficiary — making it hard to mount a defense.

Testifying before House and Senate committees in March, O’Malley promised to shift the burden of proof.

“That should be on the agency,” he said.

The agency expects to finalize “guidance” on the subject “in the coming months,” Hinkle said.

The agency points to reduced wait times and other improvements in a phone system known to leave beneficiaries on hold. “In September, we answered calls to our national 800 number in an average of 11 minutes — a tremendous improvement from 42 minutes one year ago,” Hinkle said.

Still, in response to a nonrepresentative survey by KFF Health News and Cox Media Group focused on overpayments, about half of respondents who said they contacted the agency by phone since April rated that experience as “poor,” and few rated it “good” or “excellent.”

The survey was sent to about 600 people who had contacted KFF Health News to share their overpayment stories since September 2023. Almost 200 people answered the survey in September and October of this year.

Most of those who said they contacted the agency by mail since April rated their experience as “poor.”

Jennifer Campbell, 60, a beneficiary in Nelsonville, Ohio, said in late October that she was still waiting for someone at the agency to follow up as described during a phone call in May.

“VERY POOR customer service!!!!!” Campbell wrote.

“Nearly impossible to get a hold of someone,” wrote Kathryn Duff of Colorado Springs, Colorado, who has been helping a disabled family member.

Letters from SSA have left Duff mystified. One was postmarked July 9, 2024, but dated more than two years earlier. Another, dated Aug. 18, 2024, said her family member was overpaid $31,635.80 in benefits from the Supplemental Security Income program, which provides money to people with little or no income or other resources who are disabled, blind, or at least 65. But Duff said her relative never received SSI benefits.

What’s more, for the dates in question, payments listed in the letter to back up the agency’s math didn’t come close to $31,635.80; they totaled about a quarter of that amount.

Regarding the 100% clawbacks, O’Malley in March said it’s “unconscionable that someone would find themselves facing homelessness or unable to pay bills, because Social Security withheld their entire payment for recovery of an overpayment.”

He said that, starting March 25, if a beneficiary doesn’t respond to a new overpayment notice, the agency would default to withholding 10%. The agency warned of “a short transition period.”

That change wasn’t automated until June 25, Hinkle said.

The number of people newly placed in full withholding plummeted from 6,771 in February to 51 in September, according to data the agency provided.

SSA said it would notify recipients they could request reduced withholding if it was already clawing back more than 10% of their monthly checks.

Nonetheless, dozens of beneficiaries or their family members told KFF Health News and Cox Media Group they hadn’t heard they could request reduced withholding. Among those who did ask, roughly half said their requests were approved.

According to the SSA, there has been almost a 20% decline in the number of people facing clawbacks of more than 10% but less than 100% of their monthly checks — from 141,316 as of March 8 to 114,950 as of Oct. 25, agency spokesperson Nicole Tiggemann said.

Meanwhile, the number of people from whom the agency was withholding exactly 10% soared more than fortyfold — from just over 5,000 to well over 200,000. And the number of beneficiaries having any benefits withheld to recover an overpayment increased from almost 600,000 to almost 785,000, according to data Tiggemann provided.

Lorraine Anne Davis, 72, of Houston, said she hasn’t received her monthly Social Security payment since June due to an alleged overpayment. Her Medicare premium was being deducted from her monthly benefit, so she’s been left to pay that out-of-pocket.

Davis said she’s going to need a kidney transplant and had been trying to save money for when she’d be unable to work.

A letter from the SSA dated April 8, 2024, two weeks after the new 10% withholding policy was slated to take effect, said it had overpaid her $13,538 and demanded she pay it back within 30 days.

Apparently, the SSA hadn’t accounted for a pension Davis receives from overseas; Davis said she disclosed it when she filed for benefits.

In a letter to her dated June 29, the agency said that, under its new policy, it would change the withholding to only 10% if she asked.

Davis said she asked by phone repeatedly, and to no avail.

“Nobody seems to know what’s going on” and “no one seems to be able to help you,” Davis said. “You’re just held captive.”

In October, the agency said she’d receive a payment — in March 2025.

Marley Presiado, a research assistant on the Public Opinion and Survey Research team at KFF, contributed to this report.

Do you have an experience with Social Security overpayments you’d like to share? Click here to contact our reporting team.

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President-elect Donald Trump’s incoming administration could try to remove fluoride from drinking water, according to Robert F. Kennedy Jr.

Kennedy, who was tapped last week by Trump to lead the Department of Health and Human Services, called fluoride an “industrial waste” and linked it to cancer and other diseases and disorders while campaigning for Trump.

“On January 20, the Trump White House will advise all U.S. water systems to remove fluoride from public water. Fluoride is an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease,” Kennedy wrote Nov. 2 on X. Kennedy linked to a video from an attorney who recently successfully sued the Environmental Protection Agency to take additional measures to regulate fluoride in drinking water.

Kennedy, who has long advocated ending water fluoridation, persisted with his pledge following Trump’s election win. When asked before the election whether his administration would remove fluoride from drinking water, Trump said, “Well, I haven’t talked to him about it yet, but it sounds OK to me. You know it’s possible.”

Kennedy is an influential vaccine skeptic whose campaign of conspiracy theories earned PolitiFact’s 2023 “Lie of the Year.”

Longtime research has found that adding fluoride to U.S. drinking water is a safe way to boost children’s oral health. Since 2015, the recommended level in the U.S. has been 0.7 milligrams per liter. Public health organizations, including the American Dental Association, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention, support the practice.

Recent studies, however, have shown possible links between fluoride and bone problems and children’s IQs, particularly when fluoride is above the U.S. recommended levels.

“There is evidence that fluoride exposure has been associated with the diseases [and] disorders that RFK listed, but with caveats,” said Ashley Malin, who is an assistant professor in the University of Florida’s Epidemiology Department and has studied fluoride’s effects in pregnant women.

Malin referred to studies showing that higher fluoride exposure, particularly during pregnancy, is associated with reduced child IQ, and that prenatal exposure also is linked to decreased intellectual functioning and executive function. For high exposure in pregnancy, the studies showed symptoms associated with other neurobehavioral issues, such as attention-deficit/hyperactivity disorder.

However, many of these studies took place in countries other than the U.S. and looked at fluoride in drinking water at sometimes twice the United States’ recommended level. Also, some of the other ailments that Kennedy listed, such as an association with bone cancer, have less robust evidence and need more study.

“Aside from fluoride’s impacts on neurodevelopment, I think that there is more that we don’t know about health effects of low-level fluoride exposure than what we do know, particularly for adult health outcomes,” Malin said.

David Bellinger, a Harvard Medical School neurology professor and professor in Harvard School of Public Health’s Environmental Health Department, said the risk-benefit calculation of added fluoride differs depending on whether typical fluoride exposure levels cause health problems, or if problems occur only when recommended levels are exceeded.

“In toxicology, ‘the dose makes the poison’ is a long-standing principle,” he said. “So a general statement that fluoride is associated with diseases X, Y, and Z is not very helpful unless the dose that might be responsible is specified.”

PolitiFact contacted Kennedy through his Children’s Health Defense organization but received no reply. The organization sued PolitiFact and Meta related to a 2020 fact check. That lawsuit was dismissed by a federal court. The dismissal was upheld on appeal, and the case is pending a possible appeal to the U.S. Supreme Court.

What Is Fluoride and What Are Its Benefits?

Fluoride is a mineral naturally occurring in soil, water, and some foods that helps prevent tooth decay and cavities. It strengthens tooth enamel that acid from bacteria, plaque, and sugar can wear away.

Water fluoridation has been happening in the U.S. since 1945.

The federal Public Health Service first recommended fluoridation of tap water in 1962, but the decision still lies with states and municipalities. Around 72% of the U.S. population, or about 209 million people, had access to fluoridated water in 2022, the CDC reported. Fluoride also has been added to oral care products such as toothpaste and mouth rinse.

In 2015, U.S. health officials lowered the recommended amount of fluoride in drinking water to 0.7 milligrams per liter, saying a higher level was less necessary given other sources of fluoride, and that the lowered amount would still help protect teeth without staining them.

Pediatric dentists note that applying fluoride with toothpaste and rinses is beneficial, but small amounts circulating in the body via water consumption helps younger children who still have their baby teeth, because it can benefit the developing permanent teeth.

The American Dental Association says studies have shown that fluoride in community water systems prevents at least 25% of tooth decay in children and adults and that “for more than 75 years, the best scientific evidence has consistently shown that fluoridation is safe and effective.”

The association says on its website: “It’s similar to fortifying other foods and beverages — for example, fortifying salt with iodine, milk with vitamin D, orange juice with calcium, and bread with folic acid.”

According to the CDC, health experts and scientists from the U.S. and other countries have so far “not found convincing scientific evidence linking community water fluoridation with any potential adverse health effect or systemic disorder such as an increased risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, immune disorders, low intelligence, renal disorders, Alzheimer’s disease, or allergic reactions.”

The agency says risks of water fluoridation are limited to dental fluorosis, which can alter dental enamel and cause white flecks, spots, lines, or brown stains on the teeth when too much fluoride is consumed.

Do Studies Show Fluoride Posing Any Other Risks?

Some studies have said that excess fluoride exposure, often at higher levels than the recommended U.S. limit, can harm infants’ and young children’s developing brains and that higher levels of fluoride exposure during pregnancy were associated with declines in children’s IQs.

A study published in May that Malin led with University of Southern California and Indiana University researchers suggested that fluoride exposure during pregnancy was linked to an increased risk of childhood neurobehavioral problems and said more studies were “urgently needed to understand and mitigate the impacts in the entire U.S. population.”

Experts noted prenatal fluoride exposure is most strongly linked to children’s IQ loss, and said timing of fluoride consumption might need to be considered when making recommendations.

A federal review of dozens of studies published in August by the Department of Health and Human Services’ National Toxicology Program concluded that higher levels of fluoride exposure were linked to lower IQs in children. But the report was based primarily on studies in countries such as Canada, China, India, Iran, Mexico, and Pakistan and involved fluoride levels at or above 1.5 milligrams per liter, twice the recommended U.S. limit. The authors said more research is needed to understand whether lower exposure has any adverse effects.

In the report, researchers said they found no evidence that fluoride exposure adversely affected adult cognition.

Bellinger, of Harvard, pointed to the review as an example of how the amount of fluoride matters. He noted how researchers concluded that a very small percentage of people in the U.S. are exposed to levels that correlate with IQ loss.

“Second, the fact that there are now multiple pathways of exposure to fluoride besides fluoridated water (toothpaste and other dental products, etc.) makes it really difficult to attribute a particular adverse effect to the fluoride added to the water,” he wrote via email. “It is the cumulative exposure from all sources that contribute to any adverse health effects.”

In September, a federal judge ordered the Environmental Protection Agency to further regulate fluoride in drinking water because of the potential risk that higher levels could affect children’s intellectual development.

U.S. District Judge Edward Chen wrote that the court’s finding didn’t “conclude with certainty that fluoridated water is injurious to public health,” saying it’s unclear whether the amount of fluoride typically added to water is causing children’s IQs to drop. But he wrote that there was enough risk to warrant investigation and that the EPA must act to further regulate it. The ruling did not specify what actions the agency should take, and the EPA is reviewing the decision.

After the ruling, the American Association of Pediatrics issued a statement that fluoride in drinking water is safe for children and said the policy is based on a robust foundation of evidence.

Besides dental fluorosis, experts say that fluoride exposure over many years above the U.S. recommended amount can cause skeletal fluorosis, a rare condition that causes weaker bones, stiffness, and joint pain. Although the Public Health Service recommends a fluoride concentration of 0.7 milligrams per liter for community water systems, the EPA, under the Safe Drinking Water Act, sets enforceable standards for drinking-water quality. Currently, to prevent skeletal fluorosis, the EPA requires that water systems not exceed 4 milligrams of fluoride per liter of water.

Malin said she and her research team are investigating a potential link between fluoride and bone fractures. She said that although several studies have found high fluoride exposure associated with increased risk of bone fractures, and some have linked fluoride with thyroid disease, rigorous, U.S.-based studies haven’t been done.

The CDC concluded that recent research found no link between cancer risk and high levels of fluoride in drinking water.

The American Cancer Society reviewed a possible link between water fluoridation and cancer risk. An organization spokesperson pointed PolitiFact to its review and said it has no data showing a definitive answer.

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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HHS Shares Health Sector Climate Resilience and Emissions Reduction Announcements at COP29

KFF Health News contributor Andy Miller discussed the Trump presidency and health care on WUGA’s “The Georgia Health Report” on Nov. 8.

• Click here to hear Miller on “The Georgia Health Report”
• Read Stephanie Armour’s “Trump’s White House Return Poised To Tangle Health Care Safety Net”

KFF Health News correspondent Brett Kelman discussed dental implants on KCBS on Nov. 4.

• Click here to hear Kelman on KCBS
• Read Kelman’s “Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn,” with reporting from Anna Werner, CBS News

KFF Health News California correspondent Christine Mai-Duc discussed an abortion clinic lawsuit on KCBS on Oct. 31.

• Click here to hear Mai-Duc on KCBS
• Read Mai-Duc’s “‘A Pressure Campaign’: Beverly Hills Settles After Allegedly Blocking Abortion Clinic”

KFF Health News South Dakota correspondent Arielle Zionts discussed the Purchased/Referred Care program for Native American patients on “Native America Calling” on Oct. 24.

• Click here to hear Zionts on “Native America Calling”
• Read Zionts’, “Patients Suffer When Indian Health Service Doesn’t Pay for Outside Care,” with reporting from Katheryn Houghton

KFF Health News senior fellow and editor-at-large for public health Céline Gounder shared tips for preventing cardiovascular disease on CBS’ “CBS Mornings” on Oct. 24. Gounder also joined “CBS News 24/7” to discuss McDonald’s Quarter Pounder hamburgers linked to an E. coli outbreak and “CBS Mornings” to discuss a frozen waffle recall due to a potential listeria contamination, both on Oct. 22.

• Click here to watch Gounder on “CBS Mornings” on Oct. 24
• Click here to watch Gounder on “CBS News 24/7” on Oct. 22
• Click here to watch Gounder on “CBS Mornings” on Oct. 22

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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HHS Takes Action on the Not Invisible Act Commission’s Findings.

En abril, cuando apenas llevaba 12 semanas de embarazo, Kathleen Clark estaba en la recepción de su ginecólogo-obstetra cuando le pidieron que pagara $960, el total que la consulta calculaba que tendría que pagar después del parto.

Clark, de 39 años, se sorprendió de que le pidieran pagar esa cantidad en su segunda visita prenatal. Normalmente, las pacientes reciben la factura después que el seguro haya pagado su parte, y en el caso de las embarazadas eso suele ocurrir cuando termina el embarazo. Pasarían meses antes de que la consulta presentara el reclamo a su seguro médico.

Clark dijo que se sintió atrapada. La consulta de obstetricia de Cleveland, Tennessee, estaba asociada a un centro de maternidad donde ella quería dar a luz. Además, ella y su marido llevaban mucho tiempo deseando tener un hijo. Y Clark se sentía especialmente sensible porque unas semanas antes había muerto su madre.

“Estás ahí, en la ventanilla, rodeada de gente, y tratas de ser lo más amable posible”, recordó Clark, entre lágrimas. “Así que lo pagué”.

En las comunidades sobre bebés en internet y en otros foros de las redes sociales, las embarazadas afirman que sus proveedores les piden que paguen antes de lo previsto. La práctica es legal, pero los defensores de los pacientes la califican de poco ética. Los médicos alegan que pedir el pago por adelantado les garantiza una compensación por sus servicios.

Es difícil saber con qué frecuencia ocurre porque se considera una transacción privada entre el proveedor y el paciente. Por lo tanto, los pagos no se registran en los datos de reclamos de seguros y, por ende, los expertos no los analizan.

Pacientes, expertos en facturación médica y activistas afirman que esta práctica de facturación provoca una ansiedad inesperada en un momento de estrés y presión financiera ya de por sí elevados. En ocasiones, las estimaciones pueden ser superiores a lo que el paciente deba en última instancia y obligan a las personas a luchar por un reembolso si la cantidad abonada era superior a la factura final.

Los pagos por adelantado también ponen trabas a las mujeres que quieran cambiar de proveedor si no están satisfechas con la atención. En algunos casos, pueden hacer que las mujeres renuncien por completo a la atención prenatal, sobre todo en lugares donde existen pocas opciones de atención materna.

Es como “secuestrar el tratamiento”, afirmó Caitlin Donovan, directora de la Patient Advocate Foundation.

Expertos en facturación médica y salud de la mujer creen que las consultas de ginecología y obstetricia adoptaron esta práctica para gestionar el elevado costo de la atención materna y la forma en que se factura en Estados Unidos.

Cuando un embarazo llega a término, los ginecólogos y obstetras suelen presentar un único reclamo al seguro por los cuidados prenatales rutinarios, el trabajo de parto, el parto y, a menudo, la atención posparto. Esta práctica de agrupar toda la atención materna en un único código de facturación comenzó hace tres décadas, según Lisa Satterfield, directora de salud y política de pagos del American College of Obstetricians and Gynecologists. Sin embargo, la facturación agrupada ha quedado obsoleta.

Antes, las pacientes embarazadas estaban sujetas a copagos por cada visita prenatal, lo que podía llevarlas a saltarse citas cruciales para ahorrar dinero. Pero ahora la Ley de Cuidado de Salud a Bajo Precio (ACA) exige que todas las aseguradoras comerciales cubran íntegramente determinados servicios prenatales. Además, cada vez es más frecuente que las embarazadas cambien de proveedor o que diferentes proveedores se encarguen de la atención prenatal y el parto, sobre todo en las zonas rurales, donde son frecuentes los traslados de pacientes.

Algunos proveedores afirman que los pagos por adelantado les permiten repartir los pagos únicos a lo largo del embarazo para asegurarse de que se los compensa por la atención que prestan, aunque finalmente no atiendan el parto.

“Desgraciadamente hay personas que no cobran por su trabajo”, afirmó Pamela Boatner, partera en un hospital de Georgia.

Aunque cree que las mujeres deben recibir atención durante el embarazo independientemente de su capacidad de pago, también entiende que algunos proveedores quieran asegurarse de que no se ignora su factura después de que nazca el bebé. Los nuevos padres pueden verse desbordados por las facturas del hospital y los costos de cuidar a un nuevo hijo, y pueden no tener ingresos suficientes si uno de los progenitores no trabaja, explicó Boatner.

En Estados Unidos, tener un bebé puede resultar caro. Las personas que están cubiertas por un seguro médico a través de grandes empresas pagan un promedio de unos $3.000 de su bolsillo por los cuidados durante el embarazo, el parto y el posparto, según el Peterson-KFF Health System Tracker. Además, muchos optan por planes médicos con deducibles elevados, lo que les obliga a asumir una mayor parte de los costos. De los 100 millones de estadounidenses con deudas médicas, el 12% atribuye al menos parte de ellas a los cuidados de maternidad, según una encuesta de KFF de 2022.

Las familias necesitan tiempo para ahorrar y poder así hacer frente a los elevados costos del embarazo, el parto y el cuidado de los hijos, en especial si no tienen licencia por maternidad remunerada, dijo Joy Burkhard, CEO del Policy Center for Maternal Mental Health, un think tank con sede en Los Angeles. Pedirles que paguen por adelantado “es un golpe bajo”, agregó. “¿Y si no tienes dinero? ¿Lo cargas a tarjetas de crédito y esperas que funcione?”.

Calcular los costos finales del parto depende de múltiples factores, como el momento del embarazo, las prestaciones del plan y las complicaciones de salud, afirmó Erin Duffy, investigadora de políticas de salud del Centro Schaeffer de Política y Economía de la Salud de la Universidad del Sur de California. La factura final para la paciente no está clara hasta que el plan de salud decide qué parte cubrirá, explicó.

Pero a veces se elimina la opción de esperar a la aseguradora.

Durante el primer embarazo de Jamie Daw, en 2020, su ginecólogo-obstetra aceptó su negativa a pagar por adelantado porque Daw quería ver la factura final. Pero en 2023, durante su segundo embarazo, en una consulta privada de obstetricia de Nueva York le dijeron que, como tenía un plan con deducible alto, era obligatorio pagar $2.000, en pagos mensuales.

Daw, investigadora de políticas de salud en la Universidad de Columbia, dio a luz en septiembre de 2023 y recibió un cheque de reembolso ese noviembre por $640 para cubrir la diferencia entre la estimación y la factura final.

“Yo me dedico a estudiar los seguros de salud”, dijo. “Pero una no se imagina lo enormemente complicado que es cuando lo vives en persona”.

Aunque ACA obliga a las aseguradoras a cubrir algunos servicios prenatales, no prohíbe a los proveedores enviar la factura final a los pacientes antes de tiempo. Sería un reto político y práctico para los gobiernos estatales y federal intentar regular el momento de la solicitud de pago, señaló Sabrina Corlette, codirectora del Centro de Reformas de Seguros de Salud de la Universidad de Georgetown. Los grupos de presión médicos son poderosos y los contratos entre aseguradoras y proveedores médicos están protegidos por derechos de propiedad intelectual.

Debido a la zona gris legal, Lacy Marshall, corredora de seguros de Rapha Health and Life en Texas, aconseja a sus clientes que pregunten a la aseguradora si pueden negarse a pagar por adelantado su deducible. Algunos planes prohíben a los proveedores de su red exigir el pago por adelantado.

Si la aseguradora les dice que pueden negarse a pagar por adelantado, Marshall les recomienda a los clientes establecer una relación con una consulta antes de negarse a pagar, de modo que el proveedor no pueda rechazar el tratamiento.

Clark dijo que alcanzó el deducible de su seguro después de pagar las pruebas genéticas, las ecografías adicionales y otros servicios con su cuenta de salud de gastos flexibles. Entonces llamó a la consulta de su ginecólogo y pidió que le devolvieran el dinero.

“Perdí el miedo”, dijo Clark, que antes había trabajado en una aseguradora de salud y en un consultorio médico. Recibió un primer cheque por la mitad de los $960 que había pagado inicialmente.

En agosto, Clark fue trasladada al hospital después que su presión arterial se disparara. Un especialista en embarazos de alto riesgo, y no su ginecólogo-obstetra original, atendió el parto prematuro de su hijo Peter mediante cesárea de urgencia a las 30 semanas de embarazo.

Hasta que no resolvió la mayoría de las facturas del parto no recibió el resto del reembolso de la otra consulta de ginecología y obstetricia.

El último cheque llegó en octubre, pocos días después de que Clark saliera del hospital con Peter para llevarlo a su hogar y tras múltiples llamadas a la consulta. Dijo que todo eso sumó estrés a un período ya de por sí estresante.

“¿Por qué tengo que pagar el precio como paciente?”, se preguntó. “Sólo intento tener un bebé”.

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 April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN’s office when she was asked to pay $960, the total the office estimated she would owe after she delivered.

Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that’s usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer.

Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died.

“You’re standing there at the window, and there’s people all around, and you’re trying to be really nice,” recalled Clark, through tears. “So, I paid it.”

On online baby message boards and other social media forums, pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services.

How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers.

Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill.

Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo prenatal care altogether, especially in places where few other maternity care options exist.

It’s “holding their treatment hostage,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

Medical billing and women’s health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S.

When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing has become outdated, she said.

Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it’s become more common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery — especially in rural areas where patient transfers are common.

Some providers say prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don’t ultimately deliver the baby.

“You have people who, unfortunately, are not getting paid for the work that they do,” said Pamela Boatner, who works as a midwife in a Georgia hospital.

While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn’t ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn’t working, Boatner said.

In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker. In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll.

Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay “is another gut punch,” she said. “What if you don’t have the money? Do you put it on credit cards and hope your credit card goes through?”

Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy, plan benefits, and health complications, said Erin Duffy, a health policy researcher at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option to wait for the insurer is taken away.

During Jamie Daw’s first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments.

Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 to cover the difference between the estimate and the final bill.

“I study health insurance,” she said. “But, as most of us know, it’s so complicated when you’re really living it.”

While the Affordable Care Act requires insurers to cover some prenatal services, it doesn’t prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary.

Because of the legal gray area, Lacy Marshall, an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front.

If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can’t refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN’s office and asked for a refund.

“I got my spine back,” said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.

It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice.

This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period.

“Why am I having to pay the price as a patient?” she said. “I’m just trying to have a baby.”

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 United States has made almost no progress in closing racial health disparities despite promises, research shows. The government, some critics argue, is often the underlying culprit.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients. 

During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

The video features senior correspondents Fred Clasen-Kelly and Renuka Rayasam, along with Morris Brown, a family care physician in Kingstree, South Carolina.

Learn more about the “Systemic Sickness” series here.

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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This story can be republished for free (details).