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HHS released a comprehensive review of evidence and best practices for promoting the health of youth with gender dysphoria.

Food bank shortages caused by high demand and cuts to federal aid programs have some residents of a small community that straddles Idaho and Nevada growing their own food to get by.

For those living in Duck Valley, a reservation of about 1,000 people that is home to the Shoshone-Paiute Tribes, there’s just one grocery store where prices are too high for many to afford, said Brandy Bull Chief, local director of a federal food distribution program for tribes. The next-closest grocery stores are more than 100 miles away in Mountain Home, Idaho, and Elko, Nevada. And the local food bank’s troubles are mirrored by many nationwide, squeezed between growing need and shrinking aid.

Reggie Premo, a community outreach specialist at the University of Nevada-Reno Extension, grew up cattle ranching and farming alfalfa in Duck Valley. He runs workshops to teach residents to grow produce. Premo said he has seen increased interest from tribal leaders in the state worried about high costs while living in food deserts.

“We’re just trying to bring back how it used to be in the old days,” Premo said, “when families used to grow gardens.”

Food bank managers across the country say their supplies have been strained by rising demand since the covid pandemic-era emergency Supplemental Nutrition Assistance Program benefits ended two years ago and steepening food prices. Now, they say, demand is compounded by recent cuts in federal funding to food distribution programs that supply staple food items to pantries nationwide.

In March, the U.S. Department of Agriculture cut $500 million from the Emergency Food Assistance Program, which buys food from domestic producers and sends it to pantries nationwide. The program has supplied more than 20% of the distributions by Feeding America, a nonprofit that serves a network of over 200 food banks and 60,000 meal programs.

The collision between rising demand and falling support is especially problematic for rural communities, where the federal program might cover 50% or more of food supplied to those in need, said Vince Hall, chief government relations officer of Feeding America. Deepening the challenge for local food aid organizations is an additional $500 million the Trump administration slashed from the USDA Local Food Purchase Assistance Cooperative Agreement Program, which helped state, tribal, and territorial governments buy fresh food from nearby producers.

“The urgency of this crisis cannot be overstated,” Hall said, adding that the Emergency Food Assistance Program is “rural America’s hunger lifeline.”

Farmers who benefited from the USDA programs that distributed their products to food banks and schools will also be affected. Bill Green is executive director for the Southeast region of Common Market, a nonprofit that connects farmers with organizations in the Mid-Atlantic, the Southeast, Texas, and the Great Lakes. Green said his organization won’t be able to fill the gap left by the federal cuts, but he hopes some schools and other institutions will continue buying from those farmers even after the federal support dries up.

“I think that that food access challenge has only been aggravated, and I think we just found the tip of the iceberg on that,” he said.

Food Bank for the Heartland in Omaha, Nebraska, for example, is experiencing four times the demand this year than in 2018, according to Stephanie Sullivan, its assistant director of marketing and communications. The organization expects to provide food to 580,000 households across the 93 counties it serves in Nebraska and western Iowa this fiscal year, the highest number in its history, she said.

“These numbers should be a wake-up call for all of us,” Sullivan said.

The South Plains Food Bank in Texas projects it will distribute approximately 121,000 food boxes this year to people in need across the 19 counties it serves, compared with an average 90,000 annually before the pandemic. CEO Dina Jeffries said the organization now is serving about 25% more people, while shouldering the burden of decreased funding and food products.

In Nevada, the food bank that helps serve communities in the northern part of the state, including the Shoshone-Paiute Tribes of the Duck Valley Reservation, provides food to an average of 160,000 people per month. That’s a 76% increase over its clientele before the pandemic, and the need continues to rise, said Jocelyn Lantrip, director of marketing and communications for the Food Bank of Northern Nevada.

Lantrip said one of the most troubling things for the food bank is that the USDA commodities shipped for local distribution often are foods that donations don’t usually cover — things like eggs, dairy, and meat.

“That’s really valuable food to our neighbors,” she said. “Protein is very difficult to replace.”

Forty percent of people who sought assistance from food banks during the pandemic did so for the first time, Hall said. “Many of those families have come to see their neighborhood food bank not as a temporary resource for emergency help but an essential component of their monthly budget equation.”

About 47 million people lived in food-insecure households in 2023, the most recent USDA data available.

Bull Chief, who also runs a small food pantry on the Duck Valley Reservation, said workers drive to Elko to pick up food distributed by the Food Bank of Northern Nevada. But sometimes there’s not much to choose from. In March, the food pantry cut down its operation to just two weeks a month. She said sometimes they must weigh whether it’s worth spending money on gas to pick up a small amount of food.

When the food pantry opened in 2020, Bull Chief said, it helped 10 to 20 households a month. That number is 60 or more now, made up of a broad range of community members — teens fresh out of high school and living on their own, elders, and people who don’t have permanent housing or jobs. She said providing even small amounts of food can help households make ends meet between paychecks or SNAP benefit deposits.

“Whatever they need to get to survive for the month,” Bull Chief said.

Pinched food banks, elevated need, and federal cuts mean there’s very little resiliency in the system, Hall said. Additional challenges, like an economic slowdown, policy changes to SNAP or other federal nutrition programs, or natural disasters could render food banks unable to meet needs “because they are stretched to the breaking point right now.”

A proposed budget resolution passed by the U.S. House of Representatives in April would require $1.7 trillion in net funding cuts, and anti-hunger advocates fear SNAP could be a target. More people living in rural parts of the country rely on SNAP than people in urban areas because of higher poverty rates, so they would be disproportionately affected.

An extension of the federal 2018 Farm Bill, which lasts until Sept. 30, included about $450 million for the Emergency Food Assistance Program for this year. But the funding that remains doesn’t offset the cuts, Hall said. He hopes lawmakers pass a new farm bill this year with enough money to do so.

“We don’t have a food shortage,” he said. “We have a shortage of political will.”

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Sumana Reddy, a primary care physician, struggles on thin financial margins to run Acacia Family Medical Group, the small independent practice she founded 27 years ago in Salinas, a predominantly Latino city in an agricultural valley often called “the salad bowl of the world.”

Reddy can’t match the salaries offered by larger health systems — a difficulty compounded by a widespread shortage of primary care doctors.

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care, making recruitment difficult. “It certainly is challenging to expose medical students early in their careers to the joys of this kind of integrated health care,” Reddy said. “The relationships we build and the care we provide truly allow people to live longer with a better quality of life.”

Hoping to increase revenue so Acacia can afford to pay more, Reddy has signed the practice up for alternative payment methods with health plans that offer bonuses for meeting certain primary care goals tied to child vaccinations, blood pressure control, and screenings for breast cancer, colorectal cancer, and mental health. Such pay-for-performance arrangements are among the many efforts by industry players and state officials to confront the problems plaguing primary care.

Medical students frequently opt not to go into primary care, and that’s not good for patients. People with regular primary care providers are more likely to get preventive care that avoids serious illnesses and feel more empowered to advocate for themselves. They’re also less likely to encounter language barriers, resort to costly emergency room visits, or forgo care.

Six years after the influential California Future Health Workforce Commission made a series of recommendations to plug a projected shortage of 4,100 primary care providers in 2030, a number of public and private initiatives have proliferated around the state to address the problem. They include new residency slots, debt forgiveness, waived medical school tuition, new ways of paying doctors, expanded nurse practitioner roles, and a statewide target to increase primary care spending. Hundreds of millions of taxpayer dollars have been allocated for some of these efforts.

But numerous academic experts and medical professionals believe those moves, while well intended, have been scattershot and insufficient. “The pieces are there,” said Monica Soni, chief medical officer of Covered California, the state’s Affordable Care Act health insurance marketplace. “I am worried we started a little too late, and I think it’s a little too siloed.”

A study published in 2022 by the California Health Care Foundation found that substantial progress had been made on some of those goals, including recruitment of students from low-income households and communities of color. A separate analysis from the foundation showed that, from 2020 to 2023, California jumped about 10 spots in a ranking of states by primary care residents and fellows per capita.

However, the latest state data shows nearly 15 million Californians live in areas without enough primary care providers to meet patient needs.

State budget constraints and potential federal spending cuts, especially to Medicaid, could exacerbate shortages in areas already desperate for clinicians and dampen hopes of building a robust primary care system that state officials and virtually everyone in the industry agree would be a strong defense against serious — and costly — illnesses. Federal cuts could also hit medical training and hospital systems.

“Many of us are very scared about threats from both the Trump administration and Republicans in Congress,” said Kevin Grumbach, a family community medicine professor at the University of California-San Francisco.

Acute Primary Care Shortages

California’s lack of primary care providers, including doctors, nurse practitioners, and physician assistants, is most acute in rural parts of the state, particularly in the north and the Central Valley. Entire rural counties, including Del Norte, Madera, Tulare, and Yuba, are designated shortage areas, according to state data. Some densely populated urban areas, including parts of Los Angeles, also confront shortages.

Many Californians face months-long waits for appointments or have to travel long distances or go to emergency rooms for nonurgent medical needs, which means hours spent in crowded waiting rooms for unnecessarily expensive care.

In Chico, 90 miles north of Sacramento, the emergency room at the only hospital in town has seen a sharp increase in patients over the past decade, due in part to a lack of primary care providers in the area.

“People who don’t have a primary care provider — which is a lot, because there are not enough — end up in the ER when they need routine care,” said David Alonso, a local internal medicine doctor. “The ER then says, ‘OK, you should follow up with your primary care provider,’ and they’re like, ‘We don’t have one.’”

Yalda Jabbarpour, director of the Robert Graham Center for Policy Studies, a health policy think tank, said failure to invest robustly in primary care has robbed the public of its benefits.

The field has historically been underfunded, accounting for less than 5% of national health care spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.

The consequences are clear.

The U.S. spends significantly more per capita on health care than other industrialized nations, and yet Americans aren’t any healthier. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer's, as well as mental illness, account for 90% of the $4.5 trillion spent on health care every year.

Medical students, often faced with staggering educational debt, are increasingly choosing higher-paid specialties over primary care. The average salary of a family medicine physician is slightly over $300,000, compared with more than $565,000 for a cardiologist and over $763,000 for a neurosurgeon, according to one study.

“If you are going to pay over $300,000 to go to medical school, you want to be a neurosurgeon; you don’t want to be a family practice doctor,” said William Barcellona, executive vice president of government affairs at America’s Physician Groups, a Los Angeles-based professional association representing 360 medical groups and independent practice associations nationwide.

Barcellona said the Golden State’s high housing costs also make recruiting difficult.

But it’s not only pay that tempers enthusiasm for primary care. It’s also burnout from so many unpaid hours spent recording details of medical visits in electronic health records; haggling with insurance companies for treatment authorization; answering phone calls and emails from patients; or searching far and wide — often in a health care desert — for specialists with the right expertise.

Debby Lee, the daughter of Hmong immigrants from Laos, experienced this kind of frustration firsthand.

Cultural and linguistic barriers faced by her family motivated her to pursue internal medicine. Lee worked part of her residency at a community clinic serving Hmong in the Sacramento area. She loved the patients, as well as her co-workers. But she was burdened by outdated technology that limited the number of patients she could see. “I just saw myself kind of burning out being in that setting,” Lee said.

When the clinic invited her to stay, she declined, taking a job with a bigger health system.

Solutions to the Shortage

Besides residencies, other efforts support primary care.

The Health Plan of San Mateo offers grants to help medical practices retain and add to primary care staff. In exchange, the practices — some single physicians serving patients in California’s Medicaid program, Medi-Cal — must show they have increased their patient load and retained newly hired providers for five years.

The idea is to provide capital so doctors can hire the staff they need to run their practices efficiently, increase salaries, offer bonuses, and even take sabbaticals. Such efforts are consistent with one of the main thrusts of the 2019 workforce report: to increase investment in primary care.

California recently joined several other states, including Connecticut, Oklahoma, and Rhode Island, in setting a target to increase primary care spending. So far, those policies have yielded mixed results.

Late last year, California’s Office of Health Care Affordability set a target to make primary care account for 15% of total health care spending by 2034, more than double the current proportion. It imposes no requirements, relying on the goodwill of health plans to work with medical providers.

Greater spending on primary care would mean better pay and more people working in the field, said Richard Kronick, a public health professor at UC-San Diego and a member of the OHCA board. “That’s a big change. Will it happen? I don’t think anyone can predict the future with any certainty.”

Stephen Shortell, a professor emeritus of health policy and management at UC-Berkeley, said “some of that increase might occur, but at some point, it might need to be made mandatory.”

In its report, the workforce commission also cited the importance of alternative forms of primary care payment that offer extra cash for quality care. The affordability office has set targets to encourage such payment methods. The aim is to transform the system from one in which every medical service has a price tag to one that treats people holistically, and in which adherence to medical standards brings more money to doctors and their office staff.

Such arrangements are common among HMOs, though less so in primary care practices. Where they do exist, different health plans and other payers generally design them differently, which means primary care practices manage multiple payment models, adding to their administrative burden.

Reddy’s family practice is participating in a one-year demonstration project launched in January intended to reduce that burden by having multiple insurers work together in one payment plan.

The project brings together three large insurers — Health Net, Aetna, and Blue Shield of California — and 10 independent practices across the state with the goal of improving care while boosting revenue for the medical groups. It is administered by two industry groups, the Integrated Healthcare Association and the California Quality Collaborative.

On top of customary payments, either for services rendered or monthly per-member allotments, the medical practices receive bonuses for meeting targets or improving their performance on core measures.

Participating practices also receive monthly per-patient payments for “population health management,” which means managing the collective health of their patients. And they can search a single platform to find all their patients covered by one of the three plans.

In addition to extra payments and fewer administrative hassles, the health plans pay for a “practice coach,” whose job is to help primary care groups meet their targets and provide more seamless care.

The idea is to add more insurers and medical groups over time, said Todd May, Health Net’s medical director for commercial health plans, who is among those driving the project. “In addition to better outcomes, we’d like to see a stronger, more robust, and more satisfied primary care workforce,” he said.

Reddy hopes she can increase Acacia’s revenue by 20%, using the extra money from this and other pay-for-performance arrangements. That, she said, would enable her to raise pay for her staff and hire clinicians.

For many years, her practice has limited the number of patients it has accepted. But after searching for the better part of five years, Reddy has hired a doctor on a half-time basis and another is coming on board in June.

“This is the most hopeful I have felt in decades,” Reddy said.

Phillip Reese contributed to this report.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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The Trump administration quietly restored federal family planning money to Tennessee and Oklahoma, despite court rulings that the states weren’t entitled to funds because they refused to provide women information about terminating pregnancies or abortion referrals on request.

The decision by the Department of Health and Human Services to restore millions of dollars for the two states came as it simultaneously withheld nearly $66 million from clinics in the Title X program elsewhere. Title X for more than 50 years has provided sexual and reproductive health services especially to low-income, hard-to-reach people, including minors.

The Biden administration in 2023 cut off funding to Tennessee and Oklahoma, saying they violated federal rules by not offering counseling to patients about abortion. The states sued federal health officials. And courts ruled against the states.

On March 31, HHS restored $3.1 million in family planning funds for the Tennessee Department of Health and nearly $2 million for the Oklahoma State Department of Health, according to court filings. In the notices, HHS said family planning funds were sent to the two states “pursuant to a settlement agreement with the recipient.”

Yet “there has been no agreement with Tennessee to settle this litigation,” Department of Justice lawyers wrote in an April 23 court filing.

Zach West, an official with the Office of the Oklahoma Attorney General, separately wrote on April 17 that the state’s grant notice “wrongly indicated that a settlement agreement had been reached. No agreement has yet been entertained or discussed in any substantial manner in this case.”

“To our knowledge no settlement has been reached between the State of Oklahoma and HHS in the pending litigation,” Erica Rankin-Riley, public information officer for the Oklahoma State Department of Health, said in an email in response to questions. She said the state’s Title X clinics are not providing referrals for abortion or counseling pregnant women about terminating pregnancies.

“We are appreciative of all that has been involved in restoring Oklahoma’s long-standing and successful Title X grant,” Rankin-Riley said, “and look forward to continuing these important services throughout the state as we have done for over 50 years.”

Spokespeople for HHS and the Tennessee Department of Health did not respond to requests for comment.

Title X was established to reduce unintended pregnancies and provide related preventive health care. As of 2023, more than 3,800 clinics across the country used federal grants to supply free or low-cost contraception, testing for sexually transmitted infections, screening for breast and cervical cancer, and pregnancy-related counseling.

Nationwide, more than 4 in 5 people who use Title X’s services are women, according to HHS.

Federal law prohibits clinics from using Title X money to pay for abortions. However, HHS regulations issued in 2021 say participating clinics must offer pregnant women information about prenatal care and delivery, infant care, foster care, adoption, and pregnancy termination. That includes counseling patients about abortion and providing abortion referrals on request.

HHS under President Donald Trump has not yet revised the Biden-era regulations, which means participating clinics are still required to provide abortion counseling and abortion referrals for pregnant women who request them.

After the Supreme Court’s June 2022 decision in Dobbs v. Jackson Women’s Health Organization, which ended the constitutional right to an abortion, Tennessee and Oklahoma enacted strict abortion bans with few exceptions. The states told their Title X clinics they could discuss or make referrals only for services that were legal in their states, effectively cutting off any talk about abortion.

“Continued funding is not in the best interest of the government,” two HHS officials wrote to Tennessee officials on March 20, 2023.

Tennessee and Oklahoma subsequently sued in federal court. A three-judge panel for the U.S. Court of Appeals for the 6th Circuit ruled against Tennessee, while Oklahoma asked the Supreme Court to review the case after that state lost in the U.S. Court of Appeals for the 10th Circuit.

State officials suggested even they weren’t sure why they got some of their funding back before the lawsuits were resolved. “If Oklahoma’s award is not being restored pursuant to a settlement agreement, then what is the reason for the partial restoration, and is it permanent?” West wrote.

“Tennessee has not yet ascertained the formal position of HHS with respect to whether HHS intends to fully restore Tennessee’s Title X funding,” Whitney Hermandorfer of the Office of the Tennessee Attorney General wrote in an April 7 letter.

A report from HHS’ Office of Population Affairs said 60% of roughly 2.8 million patients who received Title X services in 2023 had family incomes at or below the poverty line. Twenty-seven percent were uninsured, more than three times the national uninsured rate.

In fiscal 2024, the federal government awarded Title X grants to nearly 90 entities, a mix of state and local governments and private organizations. Those grantees distribute funds to public or private clinics.

The decision to restore some of Tennessee and Oklahoma’s funding diverges sharply from the approach HHS under Trump has taken with other Title X participants.

On March 31, HHS withheld family planning funds from 16 entities, including nine Planned Parenthood affiliates.

At least seven states — California, Hawaii, Maine, Mississippi, Missouri, Montana, and Utah — now do not have any Title X-funded family planning services, according to a lawsuit filed in federal court by the ACLU and the National Family Planning and Reproductive Health Association, which lobbies for Title X clinics.

Overall, 865 family planning clinics are unable to provide services to roughly 842,000 people, the lawsuit states.

“We know what happens when health care providers cannot use Title X funding: People across the country suffer, cancers go undetected, access to birth control is severely reduced, and the nation’s STI crisis worsens,” Alexis McGill Johnson, president and CEO of Planned Parenthood Action Fund, said in a statement.

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Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and complete some blood work.

The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn’t had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They’d tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken’s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that’s not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, “How did this happen?” They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. “Surely this is a misunderstanding.”

But their insurer sided with UI Health’s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois decided that “the labs were billed correctly as diagnostic.”

Under the plan’s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken’s bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.”

“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.

Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

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More from Bill of the Month

The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA’s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”

The Resolution

After the insurer denied their appeal, they “fell down a hole into despair about it for a while,” Aiken said.

“And then someone really wise was like, ‘You can pay it and then just stop thinking about it.’”

So that’s what Aiken did: “I put it on my credit card.”

UI Health’s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

“However, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost sharing,” she said. “In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they’d incur another large bill.

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it’s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

“Get vaccinated,” Hicks said. “We just do not have the same tools for many other cancers.”

Keep in mind that your coverage may vary — some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown’s Corlette said, “then we all potentially lose access to free, high-value preventive care, and that would be a real shame.”

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!

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When a woman collapsed on an escalator at the Buffalo, New York, airport last June, Phil Clough knew what to do. He and another bystander put her flat on her back and checked her pulse (faint) and her breathing (shallow and erratic). Then she stopped breathing altogether. Realizing that she might be having a cardiac arrest, Clough immediately started doing chest compressions, pressing hard and quickly on the center of her chest, while others nearby called 911 and ran to get an automated external defibrillator. Within seconds of receiving a shock from the AED, the woman opened her eyes. By the time the airport rescue team arrived a few minutes later, she was conscious and able to talk with rescuers.

“I don’t want to ever feel helpless,” said Clough, who had flown to Buffalo that evening on a work trip for his engineering job in Denver. After an incident several years earlier in which he was unsure how to help a woman who collapsed at his gym, he took a college course to get certified as an emergency medical responder, who can provide basic life support interventions.

The woman who collapsed was lucky: She lost consciousness in a public place where bystanders knew how to help her. Most people aren’t so fortunate. In the United States, a lack of training and readiness to deal with this relatively common medical emergency contributes to thousands of deaths a year.

More than 350,000 cardiac arrests occur outside of a hospital setting in the United States annually, according to the American Heart Association. In 9 of 10 cases, the person dies because help doesn’t arrive quickly enough. Every minute that passes without intervention reduces the odds of survival by 10%. But if someone immediately receives cardiopulmonary resuscitation and an AED shock, if needed, their survival odds can double or even triple.

Fewer than half of people get that immediate help, according to the heart association. A cardiac arrest occurs when the heart stops suddenly, often because the heart’s electrical system malfunctions. About 70% of cardiac arrests occur at home. But even if someone collapses in a public place and an ambulance is called immediately, it takes roughly eight minutes, on average, for emergency personnel to arrive. In rural areas it can take much longer.

When someone has a cardiac arrest, they often require an electric shock from an AED to get their heart started again. These portable devices analyze the heart’s rhythm and instruct the user to deliver a shock, if necessary, through pads placed on the victim’s chest.

But although many states require that AEDs be available in public places such as airports, malls, and schools, they often aren’t easy to spot. A study of data from 2019 to 2022 found that after a cardiac arrest in a public place, bystanders used an AED 7% of the time and performed CPR 42% of the time.

The most comprehensive resource for identifying AEDs is a nonprofit foundation called PulsePoint, which has registered 185,000 AEDs in 5,400 communities in the United States, according to Shannon Smith, vice president of communications at PulsePoint. If requested, the organization will help a community build its AED registry and connect it to the area’s 911 service free of charge.

PulsePoint recently launched a national AED registry to further this effort.

Through a companion app, users trained in CPR can volunteer to be alerted to potential cardiac arrests within roughly a quarter-mile when calls come into a community’s emergency response dispatch service. The app also identifies registered AEDs nearby.

“PulsePoint is the closest thing we have to a national registry,” said Elijah White, president of the acute care technology division at Zoll, a leading AED manufacturer. The company has provided location information for all its AEDs to PulsePoint. Still, PulsePoint has registered only a fraction of AEDs in the country. “It’s just a start,” White said.

Other factors may also keep bystanders from stepping in to help. They may lack CPR training or confidence, or fear liability if something goes wrong.

Liability shouldn’t be a concern, in general. All 50 states and Washington, D.C., have “good Samaritan” laws that protect bystanders from legal liability if they intervene in a medical emergency in good faith.

But training can be a serious barrier. One study found that only 18% of people reported that they’d received CPR training within the previous two years, a key time frame for skills maintenance. Two-thirds of people reported having been trained at some point.

One way to boost training is to make it mandatory, and many states require that students receive CPR training to graduate. But even though 86% of high school students reported having received some training, only 58% said they knew how to apply their skills, and a similar proportion said they knew how to use an AED.

“We’ve got some work to do,” said Dianne Atkins, a pediatric cardiologist and longtime AHA volunteer, who said ensuring high school training is a top priority for the AHA.

Other countries have prioritized training their residents in AED use and CPR for many years, with some success.

In Denmark, such training has been required to get a driver’s license since the 2000s, and middle schoolers are also required to be trained. And in a survey, 45% of the population reported having received training through their workplace. In the study, 81% of respondents in the general public reported having been trained in CPR and 54% in how to use an AED.

Norway has provided first-aid training in primary schools since 1961 and mandates CPR training to receive a driver’s license. Ninety percent of the population reported they are trained in CPR.

In the United States,  many training courses are available, online and in person, that take only a few hours to complete. For someone who’s never learned basic life-support skills, the training can be eye-opening. This previously untrained reporter was taken aback to discover how forcefully and rapidly someone must press on a mannequin’s chest to do CPR correctly: 100 to 120 compressions a minute to a depth of at least 2 inches.

The most important thing is for ordinary people to know the basics well enough that “they would feel confident to call 911 and push hard and fast on someone’s chest,” said Audrey Blewer, an assistant professor of family medicine and community health at Duke University School of Medicine who has published numerous studies on bystander CPR and AED use. “That doesn’t require a certification card and recent training.”

During an emergency, 911 dispatchers can also play a crucial role in walking people through doing CPR and operating an AED, said David Hiltz, volunteer program director of the HeartSafe Communities program at the Citizen CPR Foundation, a nonprofit that works to improve cardiac arrest survival through training and education.

Phil Clough has stayed in touch with Rebecca Sada, the woman who collapsed at the Buffalo airport that June day as she was coming home from a trip to visit her daughter. Sada, who had no history of heart trouble before her cardiac arrest, now has an automated defibrillator implanted in her chest to stabilize a previously undiagnosed electrical problem with her heart. She and her husband have had Clough over for dinner, and they are friends for life, she said.

One other change that occurred as a result of Sada’s cardiac arrest: She and her husband got certified in CPR and AED.

“Now, if we needed to help someone down the road, we’d be able to,” Sada 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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Cuando una mujer se desplomó en una escalera mecánica en el aeropuerto de Buffalo, en Nueva York, el pasado junio, Phil Clough supo qué hacer.

Él y otro transeúnte la colocaron boca arriba y le revisaron el pulso (débil) y la respiración (superficial y errática). Luego dejó de respirar por completo. Al darse cuenta de que podría estar sufriendo un paro cardíaco, Clough comenzó de inmediato a realizar compresiones torácicas, presionando con fuerza y ​​rapidez en el centro del pecho, mientras otras personas llamaban al 911 y corrían a buscar un desfibrilador externo automático (DEA).

A los pocos segundos de recibir la descarga del DEA, la mujer abrió los ojos. Para cuando llegó el equipo de rescate del aeropuerto, unos minutos después, estaba consciente y podía hablar con los rescatistas.

“No quiero sentirme indefenso nunca”, dijo Clough, quien había volado a Buffalo esa noche en un viaje de trabajo por su puesto de ingeniería en Denver. Tras un incidente varios años antes, en el que no estaba seguro de cómo ayudar a una mujer que se desplomó en su gimnasio, realizó un curso universitario para certificarse como socorrista médico de emergencia, que puede brindar intervenciones de soporte vital básico.

La mujer que se desplomó tuvo suerte: perdió el conocimiento en un lugar público donde los transeúntes supieron cómo ayudarla. La mayoría de las personas no tienen tanta suerte. En Estados Unidos, la falta de capacitación y preparación para abordar esta emergencia médica relativamente común contribuye a miles de muertes al año.

Según la Asociación Americana del Corazón (AHA), en Estados Unidos ocurren más de 350.000 paros cardíacos cada año fuera del ámbito hospitalario. En 9 de cada 10 casos, la persona muere porque la ayuda no llega con la suficiente rapidez.

Cada minuto que se pasa sin intervención reduce las probabilidades de supervivencia en un 10%. Pero si alguien recibe inmediatamente reanimación cardiopulmonar y una descarga de DEA, si es necesario, sus probabilidades de supervivencia pueden duplicarse o incluso triplicarse.

Según la asociación del corazón, menos de la mitad de las personas reciben esa ayuda inmediata. Un paro cardíaco ocurre cuando el corazón se detiene repentinamente, generalmente debido a un mal funcionamiento del sistema eléctrico cardíaco.

Alrededor del 70% de los paros cardíacos ocurren en el hogar. Pero incluso si alguien se desmaya en un lugar público y se llama a una ambulancia al instante, el personal de emergencia tarda unos ocho minutos, en promedio, en llegar. En zonas rurales, puede tardar mucho más.

Cuando alguien sufre un paro cardíaco, a menudo necesita una descarga eléctrica de un DEA para que su corazón vuelva a latir. Estos dispositivos portátiles analizan el ritmo cardíaco e indican al usuario que administre una descarga, si es necesario, a través de parches colocados en el pecho de la víctima.

Pero aunque muchos estados exigen la disponibilidad de DEA en lugares públicos como aeropuertos, centros comerciales y escuelas, a menudo no son fáciles de localizar.

Un estudio con datos de 2019 a 2022 reveló que, tras un paro cardíaco en un lugar público, los transeúntes utilizaron un DEA el 7% de las veces y realizaron resucitación cardiopulmonary (RCP) el 42 % de las veces.

El recurso más completo para identificar un DEA es una fundación sin fines de lucro llamada PulsePoint, que ha registrado 185.000 desfibriladores en 5.400 comunidades en el país, según Shannon Smith, vicepresidenta de comunicaciones de PulsePoint. Si se solicita, la organización ayudará a una comunidad a crear su registro de DEA y a conectarlo al servicio de emergencias de la zona de forma gratuita.

PulsePoint lanzó recientemente un registro nacional de DEA para impulsar esta iniciativa.

A través de una aplicación complementaria, los usuarios con formación en RCP pueden ofrecerse como voluntarios para recibir alertas sobre posibles paros cardíacos en un radio de aproximadamente 400 metros cuando se reciben llamadas del servicio de respuesta a emergencias de la comunidad. La aplicación también identifica los DEA registrados en las cercanías.

“PulsePoint es lo más parecido a un registro nacional que tenemos”, dijo Elijah White, presidente de la división de tecnología de cuidados intensivos de Zoll, un fabricante líder de DEA. La empresa ha proporcionado a PulsePoint la información de ubicación de todos sus DEA. Aun así, PulsePoint solo ha registrado una pequeña parte de los DEA en el país.

“Es solo el comienzo”, expresó White. Otros factores también pueden impedir que los transeúntes intervengan para ayudar. Pueden carecer de formación o confianza en la RCP, o temer responsabilidades si algo sale mal.

En general, la responsabilidad no debería ser una preocupación. Los 50 estados y Washington, D.C., cuentan con leyes de “buen samaritano” que protegen a los transeúntes de la responsabilidad legal si intervienen de buena fe en una emergencia médica.

Sin embargo, la formación puede ser un obstáculo importante. Un estudio reveló que solo el 18% de las personas informaron haber recibido formación en RCP en los dos años anteriores, un período clave para el mantenimiento de las habilidades. Dos tercios de las personas informaron haber recibido formación en algún momento.

Una forma de impulsar la formación es volverla obligatoria, y muchos estados exigen que los estudiantes reciban formación en RCP para graduarse.

Sin embargo, aunque el 86% de los estudiantes de secundaria informaron haber recibido algún tipo de formación, solo el 58% dijo saber cómo aplicar sus habilidades, y una proporción similar afirmó saber usar un DEA.

“Tenemos trabajo por hacer”, dijo Dianne Atkins, cardióloga pediátrica y voluntaria de la AHA desde hace mucho tiempo, quien dijo que garantizar la capacitación en la escuela secundaria es una prioridad absoluta para la AHA.

Otros países han priorizado la capacitación de sus residentes en el uso de DEA y RCP durante muchos años, con cierto éxito.

En Dinamarca, esta capacitación es obligatoria para obtener el permiso de conducir desde la década del 2000, y los estudiantes de secundaria también deben recibir capacitación. En una encuesta, el 45% de la población declaró haber recibido capacitación en su lugar de trabajo. En el estudio, el 81% de los encuestados del público general declaró haber recibido capacitación en RCP y el 54% en el uso de un DEA.

Noruega imparte capacitación en primeros auxilios en escuelas primarias desde 1961 y exige la capacitación en RCP para obtener la licencia de conducir. El 90% de la población declaró haber recibido capacitación en RCP.

En Estados Unidos, hay muchos cursos de capacitación disponibles, en línea y presenciales, que se completan en solo unas horas. Para alguien que nunca ha aprendido habilidades básicas de soporte vital, la capacitación puede ser reveladora.

Esta reportera, sin formación previa, se sorprendió al descubrir la fuerza y ​​rapidez con la que se debe presionar el pecho de un maniquí para realizar la RCP correctamente: de 100 a 120 compresiones por minuto a una profundidad de al menos 5 cm.

Lo más importante es que la gente común conozca los fundamentos lo suficiente como para “sentirse segura de llamar al 911 y presionar fuerte y rápido el pecho de alguien”, afirmó Audrey Blewer, profesora adjunta de medicina familiar y salud comunitaria en la Facultad de Medicina de la Universidad de Duke, quien ha publicado numerosos estudios sobre la RCP por parte de desconocidos, y el uso del DEA. “Eso no requiere una tarjeta de certificación ni formación reciente”.

Durante una emergencia, los operadores del 911 también pueden desempeñar un papel crucial al guiar a las personas en la RCP y el manejo del DEA, explicó David Hiltz, director del programa de voluntarios HeartSafe Communities de la Citizen CPR Foundation, una organización sin fines de lucro que trabaja para mejorar la supervivencia tras un paro cardíaco mediante la formación y la educación.

Phil Clough se ha mantenido en contacto con Rebecca Sada, la mujer que se desplomó en el aeropuerto de Buffalo ese día de junio mientras regresaba a casa de un viaje para visitar a su hija. Sada, quien no tenía antecedentes de problemas cardíacos antes de sufrir un paro, ahora tiene un desfibrilador automático implantado en el pecho para estabilizar un problema eléctrico en su corazón que no se le había diagnosticado previamente. Ella y su esposo han invitado a Clough a cenar y son amigos para toda la vida, dijo.

Otro cambio que se produjo a raíz del paro cardíaco de Sada: ella y su esposo se certificaron en RCP y DEA.

“Ahora, si necesitáramos ayudar a alguien en el futuro, podríamos hacerlo”, aseguró Sada.

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 first 100 days of the Trump administration have been historic

Expanding educational freedom and opportunities

Adelaide Tovar, a University of Michigan scientist who researches genes related to diabetes, used to feel like an impostor in a laboratory. Tovar, 32, grew up poor and was the first in her family to graduate from high school. During her first year in college, she realized she didn’t know how to study.

But after years of studying biology and genetics, Tovar finally got proof that she belonged. Last fall, the National Institutes of Health awarded her a prestigious grant. It would fund her research and put her on track to be a university professor and eventually launch a laboratory of her own.

“I felt like receiving the award was a form of acceptance, like I had finally made it,” Tovar said. “But I think many of us now fear that this is going to poison the rest of our careers.”

Tovar is one of nearly 200 young scientists across the nation whose research and job prospects have been jeopardized by the sudden termination of the NIH’s MOSAIC grant program, one of many ended by sweeping cuts across the federal scientific agencies. The grant was created by the first Trump administration to foster a new generation of diverse scientists in biomedical research, then defunded in the second Trump administration’s ongoing purge of diversity, equity, and inclusion programs.

In interviews with KFF Health News, Tovar and three other grant recipients worried that the loss of funding — coupled with President Donald Trump’s crusade against diversity programs — may transform a grant that was supposed to jump-start their careers into a blemish on their résumés that could cost them the jobs and funding that make their research possible.

“We might end up blacklisted by the NIH because of having this award — for who we are,” said Erica Rodriguez, 35, a grant recipient at Columbia University who conducts brain research that could lead to a better understanding of psychiatric disorders.

“Because not only is it for people with diverse backgrounds,” she said, “but it’s for people who advocate for other people with diverse backgrounds.”

The MOSAIC program — short for “Maximizing Opportunities for Scientific and Academic Independent Careers” — was created in 2019 to provide early-career support to promising scientists from “underrepresented backgrounds” with a long-term goal to “enhance diversity in the biomedical research workforce,” according to NIH grant documents.

The five-year grant was awarded to scientists who have finished their doctorates and work in research laboratories at universities across the country. In the first two years, scientists generally receive $100,000 to $150,000, which is largely used to pay their salaries.

By the third year, the scientists are expected to have been hired as a professor, likely at a different university, where the grant funding helps them launch their own research lab. In the final three years of the grant, funding increases to about $250,000 a year, which is used to buy supplies and hire other young scientists to work in the lab, completing the cycle.

MOSAIC awardees were chosen using a broad definition of diversity beyond race, gender, and disability. It includes those who grew up in poor households or rural areas or were raised by parents who do not have college degrees. Many of those chosen for the grant also have a history of supporting other budding scientists from underrepresented backgrounds.

MOSAIC funds research on cancer, Alzheimer’s disease, spinal cord injuries, cochlear implants, fentanyl overdoses, stroke recovery, neurodevelopmental disorders, and more.

But in recent weeks the NIH has notified most MOSAIC recipients that the program was “terminated” and their funding will end by this summer, regardless of the years left on their grant, according to NIH emails reviewed by KFF Health News. Other awardees have received no official notification and only learned through word of mouth that their funding was canceled.

Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, confirmed in an email statement to KFF Health News that MOSAIC had been defunded. She said the grants “no longer align” with agency priorities or the president’s executive orders “eliminating wasteful, ideologically driven DEI initiatives.”

Trump signed one of those orders on his first day back in the White House, instructing the entire federal government to end programs that promoted diversity, referring to them as “shameful,” “immoral,” and an “immense public waste.”

Diversity programs have been slashed across the government, including at the NIH and other HHS agencies, which have canceled hundreds of grants worth billions of dollars since March. On April 21, the NIH issued a notice that banned recipients from receiving grants if they have DEI programs and said the agency could “recover all funds” from those that do not comply.

“At HHS, we are dedicated to restoring our agencies to their tradition of gold-standard, evidence-based science – not one driven by political ideology,” Rodriguez Feliciano said. “We will leave no stone unturned in identifying the root causes of the chronic disease epidemic as part of our mission to Make America Healthy Again.”

Many MOSAIC scientists are focused on chronic diseases. Tovar, for example, researches specific genes that make people more susceptible to diabetes, which affects about 38 million Americans.

“We have a lot of treatments for diabetes that are great for the people that they work for,” Tovar said. “In my research, I use genetics to help find better drug targets so we can find medicines for people who don’t already have therapies that work.”

In interviews, Tovar and the other MOSAIC recipients described how the sudden loss of funding will throw research and careers into upheaval: Some postdoctoral researchers may lose their current jobs when funding runs dry in months; awardees competing for professor jobs will lose research funding that made them stronger candidates; and those already hired will have less money for salaries and supplies in their research labs.

Ashley Albright, 32, who grew up poor in rural North Carolina, is now a scientist at the University of California-San Francisco, where she studies Stentor coeruleus, a large single-celled organism with regenerative abilities. She plans to start applying for professor jobs this fall.

Albright said MOSAIC funding would have given her a “better shot at my dream,” which was to give other scientists from diverse backgrounds opportunities to work in her research lab.

“I feel crushed,” she said. “I feel like someone is stepping on half of my life. … I’ve spent the last 10 years in grad school and my postdoc working toward this so I can do science, but also help other people do science.”

Hannah Grunwald, 33, a grant recipient at Harvard who studies eyeless cave fish to better understand complex genetic traits, said one of her worst fears was that universities won’t hire MOSAIC awardees at a time when the White House is ordering schools to abandon DEI programs and withholding billions from those that do not bend to the Trump agenda.

“There has been an enormous debate in our community about what we should say on our résumés,” Grunwald said. “I just don’t know if having my grant canceled because it had to do with diversity is going to limit my ability to get funding in the future.”

The termination of MOSAIC drew quick condemnation from several scientific organizations that receive grant funding to work closely with the awarded scientists, with some calling it “short-sighted” and “a significant step backward.”

Mary Munson, president of the American Society for Cell Biology, who has mentored awardees since MOSAIC began, became choked up and covered her face with her hands as she considered the possibility the grant could end up holding them back.

“Taking this grant away now does not take away the fact that they won this competitive award. It doesn’t take away that they are amazing scientists,” Munson said. “I hope that institutions will still see that nonetheless.”

Stefano Bertuzzi, CEO of the American Society for Microbiology, which also mentors grant awardees, said the mass termination of MOSAIC and other NIH grants may have a cumulative effect that will stifle scientific innovation for decades.

Bertuzzi, who immigrated from Italy in the ’90s because of America’s robust funding for science, said scientists will not stay in or flock to a nation where research funding vanishes on a political whim.

“We are going to be losing a full generation of scientists,” Bertuzzi said. “Other countries in the world will thrive.”

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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POLSON, Mont. — When someone accused of a crime in this small northwestern Montana town needs mental health care, chances are they’ll be locked in a basement jail cell the size of a walk-in closet.

Prisoners, some held in this isolation cell for months, have scratched initials and the phrase “love hurts” into the metal door’s brown paint. Their pacing has worn a path into the cement floor. Many are held in a sort of limbo, not convicted of a crime but not stable enough to be released. They sleep on a narrow cot next to a toilet. The only view is a fluorescent-lit hallway visible through a small window in the door.

Lake County Attorney James Lapotka stood at the cell’s center talking about the people he helps confine here. He stretched out his arms, his fingertips just shy of touching opposite walls. “I’m getting anxiety just being in here,” Lapotka said.

Last year, a man sentenced for stealing a rifle stayed in that cell 129 days. He was waiting for a spot to open at Montana’s only state-run psychiatric hospital after a mental health evaluator deemed he needed care, according to court records.

A man in the next cell around the same time was on the same waitlist roughly five months. He faced near-daily stints in the jail’s emergency restraint chair — a steel contraption wrapped in foam with straps for his shoulders, arms, and legs. He regularly saw the jail’s mental health doctor. Still, Joel Shearer, a Lake County detention commander, said the man routinely experienced psychotic episodes and asked to be locked in the chair when he felt one coming on and stayed there until his screams subsided.

“Somebody who’s having a mental health crisis — they don’t belong here,” Lapotka said. “We don’t have anywhere else.”

Lake County’s two, roughly 30-square-foot isolation cells are an example of how communities nationwide are failing to provide mental health services — crisis care, in particular. Nearly half of the people locked in local jails in the U.S. have a mental illness.

More than half of Wyoming’s 23 sheriffs told lawmakers there that they were housing people in crisis awaiting mental health care for months, WyoFile reported in January. Nevada has struggled despite a $500 daily fine for each jailed patient whose treatment is delayed. Disability Rights Oregon has said delays in that state continue after two people died in jail while on the state’s psychiatric waitlist.

In Montana, counties are jailing mental health patients they’re not equipped to handle when the Montana State Hospital is at capacity. Few local hospitals have their own inpatient psychiatric beds. As a result, people arrested for anything from petty theft to felony assault can be jailed for months or longer as their mental health worsens. Many haven’t been convicted of a crime.

Montana officials have known for years they have a problem. State officials have said they don’t have space for all the people ordered to the hospital. The psychiatric hospital has 270 beds, with 54 for people in the criminal justice system. Staffing shortages can shrink that capacity further.

The Montana Department of Public Health and Human Services backed two bills this legislative session that would shield the state from liability for delays when the Montana State Hospital is full. Ahead of the bills, the agency wrote the hospital has “struggled to maintain appropriate levels of care” due to money and staffing constraints, a lack of community-based services, and having no control over the flow patients Montana courts send its way.

The agency also announced April 23 that $6.5 million was available through one-time grants to help set up jail-based mental health stabilization services.

Officials have said patients deserve care closer to home, in less restrictive settings. But counties say the local services needed don’t exist.

“You have to do the hard things first,” said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness. “You have to build the beds.”

Health advocates have backed a proposal that would require the state to pay for community commitments. That measure is headed to Republican Gov. Greg Gianforte after passing the state House and Senate. Another bill that was still pending would create a new psychiatric hospital for people in the justice system. But implementing those ideas could take years.

The number of inpatient beds for people with a serious mental illness nationwide has plummeted. At one time, that drop was intentional, part of a movement away from locking people up in state-run mental hospitals. But the intended fix, local homelike centers, hasn’t filled the void.

One of Montana’s biggest providers, Western Montana Mental Health Center, had to close some of its crisis sites because of money problems, said Western’s CEO, Bob Lopp. That includes a facility less than a mile from the Lake County jail.

“If that’s not where the funding is, you can’t just do it for the sake of argument and hope that it comes,” Lopp said.

Gianforte has promised to pour money into rebuilding the state’s behavioral health system. Mental health workers in small towns find such promises hard to trust after seeing local services come and go for years.

Health department spokesperson Holly Matkin said the agency is proud of its work to fix “systems that have been broken for too long” and that it will improve services for people who need inpatient care in their communities.

Lake County is known to outsiders as an Instagram-worthy stop on their way to Glacier National Park. It overlaps with the Flathead Indian Reservation, land of the Bitterroot Salish, Upper Pend d’Oreille, and Kootenai tribes. It’s home to a slice of the Rocky Mountains and a gateway to millions of acres of wilderness. Polson, the county seat and site of the jail, is a town of 5,600 on the southern shore of Flathead Lake, one of the largest lakes west of the Mississippi River.

Vincent River has worked as the jail’s sole mental health clinician for 25 years. He said he’s not always available because he’s the only psychologist in four northwestern Montana counties evaluating whether a person in jail needs psychiatric care.

Some are released without care if they linger too long on the state hospital’s waitlist.

“I talk to these family members. I hear them plead with me with their fear in their voices and tell me all that’s been going on for days or weeks or months,” River said. “And then I can’t get people into the hospital. That is a giant crisis.”

It’s not just the state hospital. River said he can’t get people into any psychiatric bed in Montana because there are too few. Instead, he tries to stabilize people while they’re jailed. That has shortfalls.

The jail can’t force someone in psychosis to take medication without a court order and a qualified doctor on hand to administer the prescription. Lake County’s aging facility has faced lawsuits because of poor conditions amid overcrowding, and River has to see patients wherever there’s room.

There isn’t even space for the jail’s restraint chair. Jail workers leave strapped-down prisoners in a hallway or locker room.

River said many gradually get better and leave isolation. Some don’t.

“They languish there, psychotic and lonely,” he said, “at the mercy of what the voices are telling them.”

Locals are working to fill some gaps. A mobile team launched in February is staffed by people who have lived with mental and substance use disorders to provide peer support. But someone truly in crisis has only two options: jail or an emergency room.

The room reserved for people in crisis at Providence St. Joseph Medical Center in Polson leaves patients both isolated and without privacy. The locked door’s thick glass looks onto a busy emergency room hallway.

Those who deteriorate enough to be deemed dangerous to themselves or others are sent down the road to jail.

Rebecca Bontadelli, an ER physician, said patients can be housed in the room for days as hospital staffers scour Montana and nearby states for an open psychiatric bed. Some reject care in the meantime.

“We’re not really helping them,” Bontadelli said. “They feel like they’re in prison.”

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

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Federal Investigations Probe Reports of Race-Based Criteria Used In lieu of Merit-Based Standards for Journal Membership and Article Publication

For several years, Fred Neary had been seeing five doctors at the Baylor Scott & White Health system, whose 52 hospitals serve central and northern Texas, including Neary’s home in Dallas. But in October, his Humana Medicare Advantage plan — an alternative to government-run Medicare — warned that Baylor and the insurer were fighting over a new contract. If they couldn’t reach an agreement, he’d have to find new doctors or new health insurance.

“All my medical information is with Baylor Scott & White,” said Neary, 87, who retired from a career in financial services. His doctors are a five-minute drive from his house. “After so many years, starting over with that many new doctor relationships didn’t feel like an option.”

After several anxious weeks, Neary learned Humana and Baylor were parting ways as of this year, and he was forced to choose between the two. Because the breakup happened during the annual fall enrollment period for Medicare Advantage, he was able to pick a new Advantage plan with coverage starting Jan. 1, a day after his Humana plan ended.

Other Advantage members who lose providers are not as lucky. Although disputes between health systems and insurers happen all the time, members are usually locked into their plans for the year and restricted to a network of providers, even if that network shrinks. Unless members qualify for what’s called a special enrollment period, switching plans or returning to traditional Medicare is allowed only at year’s end, with new coverage starting in January.

But in the past 15 months, the Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, has quietly offered roughly three-month special enrollment periods allowing thousands of Advantage members in at least 13 states to change plans. They were also allowed to leave Advantage plans entirely and choose traditional Medicare coverage without penalty, regardless of when they lost their providers. But even when CMS lets Advantage members leave a plan that lost a key provider, insurers can still enroll new members without telling them the network has shrunk.

At least 41 hospital systems have dropped out of 62 Advantage plans serving all or parts of 25 states since July, according to Becker’s Hospital Review. Over the past two years, separations between Advantage plans and health systems have tripled, said FTI Consulting, which tracks reports of the disputes.

CMS spokesperson Catherine Howden said it is “a routine occurrence” for the agency to determine that provider network changes trigger a special enrollment period for their members. “It has happened many times in the past, though we have seen an uptick in recent years.”

Still, CMS would not identify plans whose members were allowed to disenroll after losing health providers. The agency also would not say whether the plans violated federal provider network rules intended to ensure that Medicare Advantage members have sufficient providers within certain distances and travel times.

The secrecy around when and how Advantage members can escape plans after their doctors and hospitals drop out worries Sen. Ron Wyden of Oregon, the senior Democrat on the Senate Finance Committee, which oversees CMS.

“Seniors enrolled in Medicare Advantage plans deserve to know they can change their plan when their local doctor or hospital exits the plan due to profit-driven business practices,” Wyden said.

The increase in insurer-provider breakups isn’t surprising, given the growing popularity of Medicare Advantage. The plans attracted about 54% of the 61.2 million people who had both Medicare Parts A and B and were eligible to sign up for Medicare Advantage in 2024, according to KFF, a health information nonprofit that includes KFF Health News.

The plans can offer supplemental benefits unavailable from traditional Medicare because the federal government pays insurers about 20% more per member than traditional Medicare per-member costs, according to the Medicare Payment Advisory Commission, which advises Congress. The extra spending, which some lawmakers call wasteful, will total about $84 billion in 2025, MedPAC estimates. While traditional Medicare does not offer the additional benefits Advantage plans advertise, it does not limit beneficiaries’ choice of providers. They can go to any doctor or hospital that accepts Medicare, as nearly all do.

Sanford Health, the largest rural health system in the U.S., serving parts of seven states from South Dakota to Michigan, decided to leave a Humana Medicare Advantage plan last year that covered 15,000 of its patients. “It’s not so much about the finances or administrative burden, although those are real concerns,” said Nick Olson, Sanford Health’s chief financial officer. “The most important thing for us is the fact that coverage denials and prior authorization delays impact the care a patient receives, and that’s unacceptable.”

The National Association of Insurance Commissioners, representing insurance regulators from every state, Puerto Rico, and the District of Columbia, has appealed to CMS to help Advantage members.

“State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care,” the group wrote in September. “Lack of CMS guidance could result in unnecessary financial or medical injury to America’s seniors.”

The commissioners appealed again last month to Health and Human Services Secretary Robert F. Kennedy Jr. “Significant network changes trigger important rights for beneficiaries, and they should receive clear notice of their rights and have access to counseling to help them make appropriate choices,” they wrote.

The insurance commissioners asked CMS to consider offering a special enrollment period for all Advantage members who lose the same major provider, instead of placing the burden on individuals to find help on their own. No matter what time of year, members would be able to change plans or enroll in government-run Medicare.

Advantage members granted this special enrollment period who choose traditional Medicare get a bonus: If they want to purchase a Medigap policy — supplemental insurance that helps cover Medicare’s considerable out-of-pocket costs — insurers can’t turn them away or charge them more because of preexisting health conditions.

Those potential extra costs have long been a deterrent for people who want to leave Medicare Advantage for traditional Medicare.

“People are being trapped in Medicare Advantage because they can’t get a Medigap plan,” said Bonnie Burns, a training and policy specialist at California Health Advocates, a nonprofit watchdog that helps seniors navigate Medicare.

Guaranteed access to Medigap coverage is especially important when providers drop out of all Advantage plans. Only four states — Connecticut, Massachusetts, Maine, and New York — offer that guarantee to anyone who wants to reenroll in Medicare.

But some hospital systems, including Great Plains Health in North Platte, Nebraska, are so frustrated by Advantage plans that they won’t participate in any of them.

It had the same problems with delays and denials of coverage as other providers, but one incident stands out for CEO Ivan Mitchell: A patient too sick to go home had to stay in the hospital an extra six weeks because her plan wouldn’t cover care in a rehabilitation facility.

With traditional Medicare the only option this year for Great Plains Health patients, Nebraska insurance commissioner Eric Dunning asked for a special enrollment period with guaranteed Medigap access for some 1,200 beneficiaries. After six months, CMS agreed.

Once Delaware’s insurance commissioner contacted CMS about the Bayhealth medical system dropping out of a Cigna Advantage plan, members received a special enrollment period starting in January.

Maine’s congressional delegation pushed for an enrollment period for nearly 4,000 patients of Northern Light Health after the 10-hospital system dropped out of a Humana Advantage plan last year.

“Our constituents have told us that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers,” the delegation told CMS.

CMS granted the request to ensure “that MA enrollees have access to medically necessary care,” then-CMS Administrator Chiquita Brooks-LaSure wrote to Sen. Angus King (I-Maine).

Minnesota insurance officials appealed to CMS on behalf of some 75,000 members of Aetna, Humana, and UnitedHealthcare Advantage plans after six health systems announced last year they would leave the plans in 2025. So many provider changes caused “tremendous problems,” said Kelli Jo Greiner, director of the Minnesota State Health Insurance Assistance Program, known as a SHIP, at the Minnesota Board on Aging. SHIP counselors across the country provide Medicare beneficiaries free help choosing and using Medicare drug and Advantage plans.

Providers serving about 15,000 of Minnesota’s Advantage members ultimately agreed to stay in the insurers’ networks. CMS decided 14,000 Humana members qualified for a network-change special enrollment period.

The remaining 46,000 people — Aetna and UnitedHealthcare Advantage members — who lost access to four health systems were not eligible for the special enrollment period. CMS decided their plans still had enough other providers to care for them.

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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