HHS announced in Houston, Texas that eight communities will receive funding through the new STREETS program.

Democratic congressional members and candidates are already planning to use any midterm election gains to expand health coverage, including boosting Affordable Care Act subsidies, reversing Medicaid cuts, and lowering the Medicare eligibility age.

But Democratic strongholds across the country — including Oregon, California, New York, and Washington — have more ambitious goals: single-payer, universal healthcare systems.

No state is closer to that goal than Oregon. A panel created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. The nine-person Universal Health Plan Governance Board seeks to establish, starting in 2032, medical, vision, dental, and mental health benefits for every state resident from cradle to grave — with no premiums, deductibles, or copayments. Lawmakers could vote on a plan during the 2027 legislative session or refer it to voters as a ballot measure in 2028.

If approved, the state would be the first in the U.S. to implement what’s called a single-payer health coverage system. It could serve as a model for other states — and potentially the nation.

Proponents of the proposal argue that the public supports universal healthcare more than ever as healthcare spending and complexity grow. Surveys show patients often delay care due to out-of-pocket costs. And medical debt remains a leading cause of bankruptcy in the nation.

States have often served as laboratories to test health policies later implemented nationally. The Affordable Care Act was modeled after Massachusetts’ attempt to achieve universal health insurance coverage, once single-payer efforts there stalled. And Canada’s universal healthcare system began with a provincial plan in Saskatchewan.

“In the short to medium term, there is no chance that ‘Medicare for All’ can be passed at the national level,” said Jonathan Oberlander, a University of North Carolina health policy professor. “That’s where the states come in. A state like Oregon provides a more hospitable political environment and a more realistic path to single-payer reform.”

But advocates of the plan expect a significant fight from healthcare behemoths, including large hospital systems, seeking to sour public opinion on making such widespread changes. Nine of the Fortune 500 companies are health insurers. The industry’s deep pockets have helped derail myriad universal healthcare efforts at the federal and state levels.

In 2011, the Vermont Legislature voted to implement a universal healthcare plan but, three years later, Democratic Gov. Peter Shumlin, who had campaigned on the promise of single-payer, pulled the plug, citing “potential economic disruption.”

States that took the issue directly to voters have fared no better. Ballot measures in Colorado in 2016, Oregon in 2002, and California in 1994 all failed by large margins.

“The aspirations of progressive reformers usually run smack into sobering political realities,” Oberlander said. “Translating a slogan into a legislative and political reality is a daunting task.”

Valdez Bravo, president of Health Care for All Oregon, speaks at the nonprofit’s annual garden party in Portland on Sept. 12. The state will soon consider a plan for universal health coverage that the state legislature ordered in 2023. (Christena Dowsett for KFF Health News)

Redirected Healthcare Dollars

Oregon’s proposal seeks to maintain the current level of spending on healthcare by government, business, and consumers with new corporate and personal taxes to replace insurance premiums and other out-of-pocket costs. Those would be combined with federal and state spending to create a single fund from which all hospitals, doctors, and other practitioners would be paid.

Board members said savings from cutting red tape, reducing fraud, and negotiating drug costs should allow the state to provide better benefits to more people.

In examples prepared for consumer focus groups, the board estimated that a 30-year-old making $55,000 and purchasing a benchmark silver-level plan through the Affordable Care Act now pays $5,478 a year for insurance premiums in Oregon, but instead could pay $2,331 in taxes under the proposed plan.

Someone making $55,000 a year with coverage through their employer now pays $3,063 in premiums and out-of-pocket costs. Under the draft plan, that person could pay nothing for health services and could see any doctor in the state.

Currently, many employers pay much of the health insurance costs for their workers. The plan seeks to maintain those contributions by establishing a corporate payroll tax for companies whose payrolls exceed $500,000. Their employees could receive a partial tax credit for the taxes their employers pay. As a result, 31% to 60% of Oregonians wouldn’t pay anything for health benefits.

More affluent people, however, could end up paying more than they do now. The exact numbers would depend on how lawmakers set tax rates and payment thresholds.

“What we are proposing is something very different,” said Miriam McDonell, executive director of the Oregon board. “Everyone contributes based on the amount that they are able to contribute and not based on utilization.”

A work group created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. Lawmakers could vote on the plan as soon as the next legislative session or refer it to a ballot measure in 2028. The nonprofit Health Care for All Oregon hosted a garden party on Sept. 12 ahead of the reveal. (Christena Dowsett for KFF Health News) Backers of the universal healthcare coverage plan will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. (Christena Dowsett for KFF Health News)

Messaging Challenge Lies Ahead

The plan’s backers will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. Currently, hospitals hire scores of workers to bill dozens of public and private health plans, each with its own coverage and billing rules. A single plan covering everyone in the state could streamline the process, saving billions.

Rural hospitals could gain financial stability. They now often struggle to stay afloat because they typically have higher rates of patients who are uninsured or on Medicaid, with its often low reimbursement rates.

Hospitals aren’t so sure.

“The universal health plan proposal preserves much of the broken, fragmented status quo and adds new taxes and complexity that Oregonians can’t afford,” said Becky Hultberg, president and CEO of the Hospital Association of Oregon. “With federal policy changes looming, we are entering a period of tremendous upheaval. This proposal could destabilize a system that is already struggling.”

Under the proposal, doctors and other practitioners would be paid somewhere between what Medicare pays on the low end and what private insurance pays on the high end. Although total payments to doctors would remain unchanged, rates would be negotiated with physician groups to shift more money into primary care and less into specialty services.

But it is unclear whether doctors would agree that more patient time, fewer administrative hurdles, and no more unpaid bills would be worth a payment structure that could cause specialists to lose out.

Rebecca Schoon, an associate professor at Pacific University who attended last month’s Health Care for All Oregon garden party, says that communicating what universal healthcare is will be one of the biggest challenges ahead for Oregon’s proposed plan. (Christena Dowsett for KFF Health News)

“There’s always winners and losers in designing something like this, and so how to distribute those is the hardest part,” said Rebecca Schoon, an associate health policy professor at Pacific University who is slated to join the Oregon board in January. “But the second-hardest part is, I think, messaging this.”

Courtni Dresser, vice president of government relations for the Oregon Medical Association, said her physicians group shares many of the board’s goals in improving access to care and reducing administrative burdens. But the group has yet to declare its support or opposition to the effort.

Health insurers haven’t formally weighed in on Oregon’s proposal either, but a single-payer system would, in essence, close off Oregon to any private healthcare plans.

“We expect insurance companies to put every ounce of money they can against this idea because our system is broken and they profit from it,” said Collin Stackhouse, communications coordinator for Health Care for All Oregon, a consumer group advocating for universal healthcare.

Wendell Potter, a former insurance company executive who now works to expose industry influence, said he expects health plans to hammer the Oregon proposal with claims of high taxes, loss of choice, and the specter of “socialized medicine.”

“Most people go year to year without testing the limits of their health insurance policy,” Potter said. “And so, they’re easily scared into thinking that something valuable will be taken away from them, and that they will have something that’s inferior in its place.”

Health insurers argue their health plans help shield consumers from the full impact of rising healthcare costs.

“Americans consistently report strong satisfaction with their health coverage, including more than 180 million covered through work and 36 million who choose Medicare Advantage,” said Chris Bond, a spokesperson for the health insurance trade group AHIP. “Policy solutions are needed to rein in the ever-higher prices charged by hospitals and drugmakers and make care more affordable for everyone.”

Volunteers converse at the Sept. 12 garden party in Portland. Oregon’s legislature created a work group in 2023 to draw up a plan to create universal healthcare in the state. The proposal is due Dec. 1. (Christena Dowsett for KFF Health News)

Federal Approval Needed

It’s unclear whether Oregon could secure federal approval to redirect Medicare and Medicaid dollars into its universal plan. Backers of the proposal do not expect the Trump administration to be receptive but say it will be years before approval is needed and hope the 2028 presidential election ushers in a more supportive administration. If federal waivers are not secured, Oregon could proceed in stages, starting with the non-Medicare population.

In California, Democratic candidates for governor are not debating whether to implement single-payer but how. New York lawmakers are debating a single-payer bill called the New York Health Act. And in Washington, state legislators have created a commission to design a universal healthcare plan.

The Oregon board has had regular contact with teams working on single-payer proposals in California and Washington, sharing approaches and looking for ways to collaborate, McDonell said.

Richard Bruno, an Oregon family physician and a member of Physicians for a National Health Program, said he could envision the other West Coast states joining Oregon in implementing single-payer, much as California, Washington, and Hawai‘i have in public health efforts to counter changes in federal vaccine recommendations.

“If our four states could do it,” he said, “that would be the momentum we would need to get it nationally.”

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

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

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

KYLE, Texas — Kenney Blewett was diagnosed with lung disease more than a decade ago but started experiencing flare-ups this year that made him feel like he couldn’t breathe.

Blewett described those flare-ups as “the scariest thing in the world,” said his wife, Cindy, adding that while the episodes typically lasted no more than a few minutes, they had become more frequent.

On top of that, simple tasks, like taking out the trash, left Blewett winded. He rarely left the house and had recently lost 45 pounds. “That sounds like cancer,” Cindy remembered one of his doctors said. It was clear, she said, that her husband’s poor health, tied to decades of smoking, was getting worse.

That’s why, on June 2, Blewett’s pulmonologist wrote him a prescription for a new medication to improve the terrifying breathing issues caused by chronic obstructive pulmonary disease, or COPD. But the prescription wasn’t immediately filled. Two days after that doctor appointment, Blewett received an email from Walgreens explaining that, “due to an insurance issue that we’re working to resolve,” the medication was delayed.

“He was hopeful that it would work,” Cindy said of the drug, two months after her husband’s death. “I wish we had the chance to find out.”

Insurance delays and denials have become an infamous feature of the American healthcare system, with nearly 7 in 10 adults calling them “a major problem,” in a January KFF Health Tracking Poll.

In June 2025, six months after UnitedHealthcare’s CEO was shot in New York, the Trump administration announced a highly publicized industry pledge, signed by dozens of major health insurers, to remove some of the barriers that block or delay patients from accessing doctor-recommended care. And yet that pledge was voluntary, and it carries no penalties if companies fail to comply. Indeed, a report published by KFF Health News in July found that some insurers that signed the pledge would not implement all the promised initiatives as originally outlined.

Denied Insurers Hedge on Trump-Backed Pledge To Improve Denials Process

Last year, the Trump administration announced a voluntary pledge by dozens of insurers to improve prior authorization, which often requires patients to seek approval before treatments. But prior authorization remains commonplace, and there’s no evidence the government is trying to hold insurers to account.

By Lauren Sausser and Renuka Rayasam July 17, 2026

In recent years, lawmakers in most states, including Texas, have attempted to address delays and denials by regulating the insurance industry in the absence of substantial federal reform. But most health insurance plans, including traditional Medicare policies and employer-sponsored offerings, which together cover more than half of all Americans, typically aren’t under state jurisdiction.

Even some medical office staff and pharmacy employees find the patchwork of state and federal insurance rules and regulations confusing, a problem that is poised to become more complicated as artificial intelligence plays a larger role in approving and processing claims.

“It’s just gotten completely out of hand,” said Matt Toresco, CEO of Archō, a patient advocacy and consulting company. He argued that patients need more assistance facing insurance hurdles.

The Blewetts’ story illustrates how navigating these complexities remains a herculean task for patients and their caregivers.

Cindy has sought answers from Medicare; Kenney’s private Part D drug plan; his pulmonologist’s office; and Walgreens. She still has questions about who was responsible for the medication delay and how the holdup could have been prevented.

If the COPD flare-up Blewett experienced on the afternoon of Sunday, June 7, could have been avoided, she wondered, would he still have chosen to die by suicide that night?

Kenney Blewett, who was diagnosed with lung disease more than a decade ago, died by suicide in June. The Blewetts celebrated their 60th wedding anniversary earlier this year. (Callie Richmond for KFF Health News)

‘Complex and Convoluted’

During that first week of June, Cindy said her husband repeatedly asked if his prescription — a liquid medication meant to be inhaled through the nebulizer machine Kenney owned — was ready to be picked up from Walgreens.

Cindy said she wasn’t initially surprised or worried by the delay. Since its acquisition by a private equity firm last year, Walgreens has cut thousands of jobs across the country, according to the Private Equity Stakeholder Project. Cindy said in August that their Walgreens pharmacy in Kyle seemed to her to have been understaffed for months, and that prescriptions were being filled more slowly.

When Cindy called the pharmacy a few days after Kenney’s appointment to find out more about the insurance delay, she said, a Walgreens employee told her the prescription required prior authorization. Also called preapproval or precertification, prior authorization is a practice widely used by health insurers that requires medical providers to seek permission before their patients may receive covered treatment.

But Cindy didn’t know which of Kenney’s insurers required prior authorization for this medication.

For years, she had helped manage multiple policies on behalf of her husband. Kenney was insured by Medicare parts A and B, the federal health insurance program for people 65 and older or with disabilities. But he also had a private Part D plan to cover drug costs through Wellcare Value Script, as well as a Medicare supplement plan through Blue Cross and Blue Shield of Texas — also called a “Medigap” plan — that paid for other out-of-pocket costs.

Initially, Cindy assumed that Kenney’s Part D plan had invoked prior authorization for his new medication. But because it was a liquid that is inhaled through a nebulizer machine, this drug was one of relatively few covered by Medicare Part B’s durable medical equipment benefit, not Part D.

The federal government had no record showing that this prescription had been billed to Kenney’s Part B policy, the Medicare agency told Cindy over the phone, she said.

Sarah Tanner and Myriea Amaya, spokespeople for Centene, Wellcare Value Script’s parent company, would not answer questions for this article.

After Kenney’s death, when Blewett sought clarification at the Walgreens pharmacy, she said the employee “kept saying different things.” She recalled his explaining that the prescription was submitted to Medicare Part B but without a necessary diagnostic code that the doctor should have included.

Carmen Lopez, a spokesperson for Walgreens, told KFF Health News in late September that the company “cannot comment on matters involving specific individuals.”

Subsequently, Cindy said, a district pharmacy supervisor for Walgreens reached out by phone, and told her the pharmacy tried to process the prescription through Part B on June 2, the same day as the pulmonologist appointment, but that the prescription was missing a diagnostic code from the physician. The supervisor said Walgreens sent a request for that code to the pulmonologist’s office later that day, Cindy recalled.

Kenney’s pulmonologist — Rajesh Shetty of LungDocs — did not respond to phone or email messages from KFF Health News. But Cindy said an employee at the practice told her they did not see a fax from Walgreens asking for a diagnostic code for the prescription.

Meanwhile, it couldn’t have been an issue with Kenney’s Medigap plan, since those policies don’t require prior authorization.

“Short of getting attorneys involved,” Cindy said, “I’m not sure how to find out what really happened.”

Cindy Blewett tried to figure out which of her husband’s insurers required prior authorization for his medication. (Callie Richmond for KFF Health News)

More Red Tape Ahead

Confusion surrounding these Part B and Part D distinctions is common, said Mike Hess, senior director of patient outreach and education at the nonprofit COPD Foundation. “Medicare has gotten to be so complex and convoluted over the years,” he said, that even medical office staff and pharmacy employees often misunderstand the nuances.

And with the introduction of AI to the preapproval process, navigating insurance hurdles will likely get more complex for Medicare beneficiaries, doctors say.

Historically, traditional Medicare, unlike Medicare Advantage, used prior authorization sparingly. But in January, Medicare launched a pilot program in six states — Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington — testing the use of AI to preapprove some healthcare services.

It is intended to “root out waste in Original Medicare,” CMS Administrator Mehmet Oz has said, but physicians and patients say the program is creating more red tape for Medicare beneficiaries and leading to inappropriate denials. The pilot program does not currently impose prior authorization requirements on COPD medications, but industry experts expect the scope of the initiative will grow to include more services and states.

On the night of June 7, hours after her husband’s last COPD flare-up, Cindy Blewett was sitting on their back porch when she heard a loud noise. She assumed a picture had fallen off the wall in the living room. In fact, it was a gunshot. She discovered Kenney’s body in their bedroom.

“I can’t tell you how horrible it was,” Cindy said.

She said her husband had struggled with his mental health for a long time and had attempted suicide once before, years ago. His deteriorating health only made things worse, she said.

Kenney confirmed that much in a note he left. He told Cindy that she was a wonderful wife, mother, and grandmother but that his health was too poor to continue living.

Cindy Blewett keeps an urn of her husband’s ashes. (Callie Richmond for KFF Health News)

A second COPD medication, which his pulmonologist ordered directly from the drug manufacturer during the June 2 appointment, arrived several weeks after Kenney’s suicide, she said.

“Perhaps, just perhaps,” Cindy said, “if he had received both medications in a timely manner, he would be here today, and we would have had many more years together.”

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

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

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

HHS released a memorandum detailing six documented forms of fraud perpetrated by various parties against the Unaccompanied Alien Children.

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

The big “Make America Healthy Again” summit at a glitzy Washington, D.C., hotel this week highlighted a split in the movement between moms who want pesticides and artificial ingredients out of their kids’ food and wellness entrepreneurs who want to promote their products to government regulators.

Meanwhile, as the new fiscal year begins, the Trump administration is refusing for the second year in a row to spend hundreds of millions of dollars Congress approved for the Department of Health and Human Services — and daring lawmakers or the courts to try to do something about it.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Rachana Pradhan of KFF Health News, and Rachel Roubein of The Washington Post.

Panelists Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Rachana Pradhan KFF Health News @rachanadpradhan Read Rachana's stories. Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories.

Among the takeaways from this week’s episode:

• The transformation of the Make America Healthy Again movement was on display at a MAHA Institute meeting in Washington this week. The gathering featured wellness companies hawking their wares and largely steered clear of the movement’s core issues, such as vaccines and pesticides. Many MAHA adherents have expressed disillusionment with the Trump administration, seeing it as favoring corporate interests over their priorities, and some progressives are starting to make a play for the support of these disaffected activists.
• The Trump administration is again attempting to cancel some congressionally appropriated health funding via a controversial strategy known as a pocket rescission. The 2026 fiscal year concluded this week, effectively running out the clock for Congress to force the Trump administration to distribute that money — and with the House already recessed until after the midterm elections.
• And the Hyde Amendment turned 50 this week. The legislative measure prohibits federal funding from being used to pay for abortions, effectively banning Medicaid funding of pregnancy termination unless states opt to spend their own money to offer that benefit for those who are low-income or disabled.

Also this week, Rovner interviews Aaron Carroll, president and CEO of AcademyHealth, to discuss the Trump administration’s dismantling of the federal Agency for Healthcare Research and Quality.

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

Julie Rovner: The New York Times’ “U. of Michigan Halts New Grading Plan After Backlash From Critics,” by Madaleine Rubin.

Shefali Luthra: The Atlantic’s “The Babies Left Behind in America,” by Caitlin Dickerson.

Rachana Pradhan: KFF Health News’ “US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims,” by Phil Galewitz, Andrew Jones, and Claudia Boyd-Barrett.

Rachel Roubein: Stat’s “Once Described as Obesity Medications for ‘Patients,’ GLP-1s Are Increasingly Lifestyle Drugs for ‘Customers,’” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Washington Post’s “This Senate Democratic Candidate Is Making a Play for RFK Jr.’s MAHA Supporters,” by Rachel Roubein.
• The Washington Post’s “White House Has Not Acted on RFK Jr.’s Push for Proof Ultra-Processed Foods Are Safe,” by Rachel Roubein.
• The New York Times’ “‘Zombified’ C.D.C., Hobbled by Cuts, Struggles To Fulfill Scientific Mission,” by Apoorva Mandavilli.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

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

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

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

HHS announced the Presidential Fitness School Innovation Challenge.

If you have medical debt, there’s a good chance you owe money to a hospital.

One way patients can avoid medical debt is through hospital financial assistance, also known as charity care. Most of the nation’s hospitals offer free or discounted medical care to patients with very high medical debt or low incomes.

Getting financial assistance, however, can be challenging. Many patients don’t know that hospitals offer financial help, surveys show, and complex application forms leave others stymied.

Hospitals often demand that applicants turn over bank statements, pay stubs, tax returns, divorce filings, or other materials, and submit their applications in person, by mail, or by fax.

“They don’t make it easy,” said Neale Mahoney, a Stanford University economist who studies medical debt.

Such hurdles leave many patients with unpaid bills they should never have had to pay in the first place. In a single year, hospitals and health systems billed patients for at least $2 billion that they likely didn’t owe, one analysis found.

As healthcare costs climb and more people lose their coverage, states and hospitals are testing an emerging approach to fix this problem: automatically screening patients to see if they qualify for assistance and proactively wiping out debt when they do. This is known as “presumptive eligibility.”

Under this approach, patients may have the cost of their care wiped out before they see any bills — but not always. Hospitals differ on when, how, and for whom they use auto-enrollment, potentially impinging on patients’ finances.

Here’s what you need to know about how auto-enrollment works.

What is hospital financial assistance?

In many states, hospitals set their own criteria for whom they provide financial aid. Eligibility is typically based on income for the patient’s entire household. The closer patients are to poverty, the less they have to pay. Patients with middle incomes and insurance are sometimes eligible for discounts, especially if their bills would gobble up a big chunk of what they earn.

At least 11 states require hospitals to wipe out bills for low-income patients, though income cutoffs vary. Georgia, for example, mandates free care for anyone with income slightly above the federal threshold for poverty. In several states — including Oregon, North Carolina, and Maryland — patients can earn double that amount and still get free care.

But in most states, many patients must complete applications to receive assistance.

Several states in recent years have launched investigations and passed legislation designed to make it easier for people to get help. Research into medical debt, however, suggests gaps persist.

How many hospitals use auto-enrollment?

Nearly all nonprofit hospitals say they screen and automatically reduce bills for certain patients.

Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or ding their credit over bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016.

In the first year under the new rules, about 70% of tax-exempt hospitals nationwide said they screened patients and proactively reduced bills, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. As of 2022, that figure was nearly 90%.

The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.

In six states, policymakers require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.

Who is eligible to be automatically enrolled in financial assistance?

In most states, hospitals decide which patients can skip the application.

Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like Christus Health, which will write off bills for anyone in a religious order who took a vow of poverty.

Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, state only that they may screen patients “with a sufficient unpaid balance.”

Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.

In Oregon, starting in 2024, hospitals had to screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. In 2025, roughly 80% of Oregon patients who got financial help with bills never filled out an application, based on data shared publicly by the first 26 hospitals to do so. The state’s legislature this year raised the screening threshold to include patients who owe at least $1,500 for a single visit.

Without an application, how do hospitals figure out who gets help?

Hospitals have several ways to find patients eligible for financial assistance.

Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.

For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine whether they qualify for free care.

Hospitals may also consider how likely patients are to pay bills, regardless of how much they earn. This is called “propensity to pay.” California and Oregon prohibit its use, concerned that hospitals may try to collect more often from people who dutifully pay their bills even though their incomes qualify them for financial assistance.

When do hospitals screen patients for financial aid?

It depends.

Illinois, North Carolina, and Oregon require hospitals to screen certain patients before they send any bills. California hospitals will have to do the same starting in 2027.

Some hospitals voluntarily screen patients before sending bills; others try to collect money from patients first. As long as they screen patients before suing them for very overdue bills, hospitals can stay within the letter of the federal law that pushed many of them to embrace presumptive eligibility.

For example, the policy of Christus Health is to screen patients only “after all other eligibility and payment sources have been exhausted.”

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they give out financial assistance.

“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”

Hospitals’ publicly posted policies may also be fuzzy about when they will screen for patients likely eligible for help. For example, Cook Children’s Health Care System in Fort Worth, Texas, says its goal is to determine a patient’s eligibility “as soon as sufficient information is available.”

Who pays the bills when patients get free care?

In one sense, we all do. Taxpayers cover some or all of the cost of financial assistance, though the amount varies by hospital.

About half the nation’s hospitals are nonprofit and legally get a pass on paying most taxes. KFF estimates that nonprofit hospitals pocketed $24 billion in 2020 that they would otherwise have paid as income, sales, or property taxes.

Government-owned and for-profit hospitals have their own sets of tax benefits to help offset costs for low-income patients. Government hospitals often get additional taxpayer support, and for-profit hospitals generally receive smaller government subsidies, like additional payments for caring for high numbers of uninsured and Medicaid patients.

Whether taxpayer dollars fully cover hospitals’ costs for financial assistance depends on the amount of government support they receive — information often not publicly available. It also hinges on how many patients need help, how many meet hospitals’ criteria for assistance, and how many get through an application. Research shows hospitals spend widely different amounts on financial assistance, from less than 1% of yearly expenses to more than 7%.

Philanthropy and hospitals’ income cover costs not absorbed by tax dollars.

This article is part of “Hidden Help,” an investigative series from Tradeoffs and KFF Health News about how hospitals can protect their patients from the life-altering harms of medical debt.

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. Sign up for the weekly newsletter to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

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

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

HHS Secretary Robert F. Kennedy, Jr. today released a new episode of The Real Food Show with Lori Taylor, founder of The Produce Moms.

HHS, through ARPA-H, launched a major effort to transform how clinical trials are designed and conducted through new SURPASS program.

About half of rural voters identify with Make America Healthy Again, a sprawling political movement championed by the Trump administration, but most said President Donald Trump’s healthcare policies have not benefited their communities, according to a new poll from The Associated Press in partnership with KFF.

About 8 in 10 rural voters — an important voting bloc for Trump and fellow Republicans in recent elections — said the Trump administration’s policies have had a negative effect or no impact on the health of people where they live. Most MAHA supporters, 68%, also feel this way, according to the national survey of more than 2,000 rural registered voters.

The findings signal an apparent disconnect between the Trump administration’s MAHA-branded policy priorities and rural America’s perception of their reach and effectiveness.

Iowa pastor Mike Jager, 58, is a registered Republican and considers himself part of the MAHA movement. The Trump administration’s health policies have had “minimal” impact on the health of his community, Jager said, but he added that Trump’s health secretary, Robert F. Kennedy Jr., is moving the needle “in the right direction.”

“It’s a beginning,” Jager said. “It’s a big ship to try and turn around and course-correct.”

Kennedy has used the MAHA label to support various agendas, including abandoning long-standing vaccine guidance, researching ultraprocessed foods, and investing in regenerative agriculture.

Jager lives in Sumner, Iowa, “less than a quarter mile from where the corn ends and the city begins.” He’s seen family members and neighbors develop diseases that he believes resulted in part from exposure to agricultural chemicals and consumption of unhealthy, processed foods.

In the June Republican primary for governor, Jager voted for Zach Lahn, a businessman and farmer, who ran on a MAHA platform and beat out Trump-backed U.S. Rep. Randy Feenstra. He plans to vote for him again in November.

Jager said that President Donald Trump’s health secretary, Robert F. Kennedy Jr., is moving the needle “in the right direction.” (Miriam Alarcón Avila for KFF Health News)

Many Rural Voters Are Prioritizing Health Issues

About two-thirds of rural voters who support MAHA said it’s “extremely” or “very” important to them to vote for a candidate who does, too, while only 4 in 10 rural voters overall said the same.

Trump sought to seize on MAHA support during his campaign for another term two years ago. Now, amid tight midterm races, Kennedy has campaigned to galvanize the movement’s support. In May, he attended a MAHA bill signing with Iowa Republican Gov. Kim Reynolds, and in August, he went fishing with Lahn, posting about it on social media.

Yet the survey indicates voters are noticing “this weird split in the Trump administration” between what Kennedy messages and what Trump says and does, said David Peterson, a political science professor at Iowa State University.

“It’s this mix of things coming out of D.C., out of different pieces of the administration, that’s confusing people,” Peterson said.

In Iowa, concerns about what’s causing rising cancer rates are “a big deal,” he said. For many people who identify with MAHA, being healthy includes taking on corporate agriculture and pharmaceutical companies that they think cause cancer, he added.

“The sort of populist messaging around that is appealing right now,” Peterson said.

In the poll, views on healthcare access and costs largely diverged along party lines. Most Democratic and independent voters said the Trump administration’s healthcare policies have had a negative impact on their healthcare costs and the health and well-being of people in their communities. Republicans were likelier to say there hasn’t been an impact.

Talking on the phone from her 200-acre farm in Carroll County, Iowa, 71-year-old Donna Klocke said that her husband had died from cancer and that she has neighbors who also have cancer.

“It’s just very prevalent,” Klocke said. “We’re in a farming community. We use chemicals and pesticides and all kinds of things that aren’t necessarily good for us.”

Klocke, a Democrat, said the MAHA movement is a good idea because she cares about being healthy, but she does not consider herself part of it and will not be voting for a candidate who represents the movement.

Kennedy, who was an anti-vaccine activist before entering politics and has sent mixed messages to Americans about getting the measles vaccine, scares her.

“Measles are coming back and polio,” Klocke said. “It’s the measles that really gets me. It’s like, do you not understand how dangerous it is?”

Donna Klocke cares about being healthy but does not consider herself part of the Make America Healthy Again movement. Her husband died from cancer after a life spent farming the family’s 200 acres in Carroll County, Iowa. (Kathyrn Gamble for KFF Health News)

Survey Reflects Angst Over Healthcare

About half of rural voters said their communities don’t have enough doctors or other healthcare providers, and even more said there aren’t enough mental health workers specifically. The share of rural voters who said their community does not have enough hospitals increased to 35% from 21% in a similar question asked in a KFF-Washington Post survey in 2017.

And as with the general population, healthcare, gas, and grocery costs are top pain points. More than 6 in 10 rural voters said they were worried about healthcare costs.

The level of worry varied based on coverage, with rural voters enrolled in employer plans or Medicare less likely to be worried. The survey found that 80% of working-age rural voters on Medicaid were very or somewhat worried about healthcare costs. Last year, Republicans passed a tax and spending bill that cut over $900 billion in projected Medicaid spending over a decade and mandated new eligibility requirements.

Among rural voters who purchase their own insurance, such as the individual coverage plans available on Affordable Care Act marketplaces, 77% said they were worried.

In the tiny community of Lipan, Texas, west of Dallas, Kim Solis and her husband have a handyman-and-home-remodel business and get their insurance on the marketplace. Since Trump was elected again, their premium payment jumped from zero to $166 a month. Their copays went up, and their deductibles each increased by $2,000.

Solis, 62, said she worries what will happen if they get a big medical bill.

“Certainly, we’d be in a world of hurt trying to take money out of savings or getting it out of our 401(k) just to be able to do something about it,” she said.

Most MAHA Voters Are Also MAGA — But Not All

Like the general population, rural voters said they trust their own doctors and healthcare providers for health information over government agencies or officials, according to the poll.

Trust in Kennedy and Trump fell largely along partisan lines. About 10% of rural Democratic voters reported having a “great deal” or “fair amount” of trust in Kennedy, compared with 74% of rural Republican voters. About 5% of rural Democrats and 69% of rural Republicans said they trust Trump a “great deal” or “fair amount” for reliable health information.

While Make America Great Again and MAHA identities are “linked in a lot of ways,” the rising costs of healthcare and groceries pose a challenge for those committed to the MAHA principles that Kennedy promotes, said Peterson, the Iowa State professor.

Buying healthy food “becomes, ‘I can’t afford to do that because of Trump’s policies,’” he said.

In Stamping Ground, Kentucky, Alma Johnson, 65, works as night security at a horse farm. Johnson said gas had gone up but her overall cost of living had decreased since Trump took office.

Johnson voted for Trump in 2016, 2020, and 2024 and said she “pretty much” likes how Trump is running the country. But she said she is not a MAGA devotee, preferring to “think for myself.”

MAHA, however, is an easy sell for Johnson because, she said, she doesn’t think people should be able to buy junk food through the Supplemental Nutrition Assistance Program, or SNAP.

Still, she said she hasn’t seen much impact from the Trump administration’s healthcare policies, including the new food pyramid.

“It takes a long time to change people, their habits, their thoughts, or the things they do,” Johnson said.

About the Poll

The KFF-AP Rural Voters Survey was conducted online and by telephone Aug. 12-24, 2026, among 2,241 registered voters living in rural areas, defined as census tracts that fall within codes 5-10 of the U.S. Department of Agriculture’s 2020 Rural-Urban Commuting Area codes. Voters were reached through a combination of the probability-based SSRS Opinion Panel and a registration-based sample from the L2 voter file. Overall results have a margin of sampling error of plus or minus 3 percentage points, including design effects due to weighting. Error margins are larger for subgroups. In collaboration with the AP, KFF researchers worked to design the survey sample and questionnaire and analyze and report findings.

This report is from a collaboration between KFF Health News and The Associated Press.

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

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

Hundreds of thousands of immigrants with legal status are at risk of losing government health coverage starting Oct. 1, state data shows, signaling that the impact of Medicaid changes in President Donald Trump’s signature legislation from 2025 may be greater than anticipated.

Many lawfully present immigrants will be among the first people to lose Medicaid coverage under congressional Republicans’ One Big Beautiful Bill Act, which is expected to cut spending by more than $900 billion through 2034 for the state-federal health program for people with low incomes or disabilities. The law will strip many more immigrants of their Affordable Care Act plan subsidies and Medicare coverage next year.

Those losing their health benefits who were previously eligible include refugees of war, asylees who fled persecution, victims of sex trafficking, and interpreters who risked their lives assisting U.S. service members in Afghanistan — all of whom are in the country with the federal government’s permission. The law does not affect coverage for a few groups, including those who hold green cards.

The Congressional Budget Office, the nonpartisan budget scorekeeper, estimated the law’s changes eliminating Medicaid eligibility for many noncitizen adults with legal status would lead to about 100,000 more immigrants being uninsured by 2034.

KFF Health News asked several states how many Medicaid enrollees they had identified as being at risk of losing coverage under the provision. More than 281,000 immigrants from nine states and the District of Columbia are expected to lose Medicaid in October.

While some may be able to obtain coverage elsewhere, the state numbers suggest hundreds of thousands of immigrants nationally are at imminent risk of becoming uninsured.

The CBO declined to comment.

Florida alone identified nearly 177,000 immigrants who would no longer qualify for the state’s Medicaid program starting in October, said Anna Holaday, a spokesperson for the Florida Department of Children and Families. The agency verified the enrollees’ immigration status through government databases and sent notices to people to give them an opportunity to provide more information proving they remain eligible, Holaday said.

Arizona predicts nearly 28,000 could lose eligibility. New Jersey expects 15,000 to 25,000 of its noncitizen residents to lose their Medicaid coverage. In North Carolina, it’s about 29,000, and in Washington state it’s 11,000. Final numbers from states on how many Medicaid enrollees have been terminated from the program won’t be available until later this fall.

Lawmakers rely on the CBO to understand the budgetary and economic impacts of proposed legislation. Yet the federal agency did not publish estimates on the One Big Beautiful Bill Act’s impact on noncitizens enrolled in Medicaid until a month after Congress passed the bill and Trump signed it into law.

Much of the attention around Medicaid changes in the law has centered on implementation of work requirements as a new condition of eligibility for many enrollees starting in January. The CBO estimates the requirements will increase the number of uninsured Americans by about 5 million by 2034.

Without health coverage, immigrants are likely to lose access to doctors, prescription drugs, and most other medical services. They still could qualify for coverage of emergency care under a separate program known as Emergency Medicaid.

“I came here to live a better life,” said Ahin, a refugee who left war-torn Syria for Turkey in 2011 and came to the U.S. in October 2024. She spoke with KFF Health News on the condition that she be identified by only her first name, out of concern for her privacy and security.

Soon after arriving in the U.S., she developed severe abdominal pain that required intestinal surgery. Those costs, along with ongoing visits to specialists, were covered by Medicaid.

“I’m really worried about this,” she said. “It’s truly a terrible situation.”

Ahin, 25, said she doesn’t know what she will do if she needs to go to the hospital — she wouldn’t be able to pay the bill. She lives in a small apartment in New Jersey with her mother. Medicaid has also been vital to her mother, who has asthma.

Health Benefits Wane for Immigrants

The federal government required states to notify immigrants who will soon lose coverage, but immigrant rights advocates say some states did not begin sending letters until September. That’s given enrollees little time to react, including to respond if the state was mistakenly ending their coverage.

Cutting off Medicaid coverage is just the first move to drop government health benefits provided to many lawfully present immigrants. Under a change starting in January, the CBO estimates, about 1 million will lose eligibility for government subsidies to buy individual health coverage on Affordable Care Act marketplaces by 2034. And they will also lose access to Medicare, a change expected to affect about 100,000 immigrants, the agency forecasts.

Trump has argued that taxpayer-funded programs should be reserved for American citizens. As Congress debated the legislation in May 2025, the White House put out a news release with the misleading claim that the One Big Beautiful Bill Act would remove Medicaid coverage for people who are in the country without authorization.

Under long-standing law, people who are in the country without authorization do not qualify for the general Medicaid program that is funded by state and federal dollars.

The health coverage cuts are part of a broader Trump strategy to send a message that immigrants are not welcome in the United States, said Ben D’Avanzo, senior strategist for federal advocacy at the National Immigration Law Center. The Trump administration has also moved to kick people with legal status off the Supplemental Nutrition Assistance Program, or SNAP, and tried to do the same with the children’s program Head Start until a federal judge intervened. 

In addition to green card holders, people under age 19 and immigrants from Cuba, Haiti, or certain Pacific Island countries will not see their Medicaid coverage affected by the law.

A Few States Try To Fill in the Gaps

Some states are staving off the coverage loss using their own money. California expects about 148,000 immigrants to lose Medicaid coverage. But the state is spending $365 million for a separate program to keep them covered until July 2027, according to Tony Cava, a spokesperson for the California Department of Health Care Services.

New York and Pennsylvania also have state-funded health coverage for many of the immigrants who are affected.

Carlos Alarcón, health and public benefits policy manager with the California Immigrant Policy Center, an advocacy group, said taking away health coverage for immigrants will affect the health of the state as a whole. The fewer people who have access to healthcare, the easier it will be for contagious diseases to spread, as happened during the covid pandemic, he said.

Alarcón said he hopes the state-funded coverage will be extended under California’s next governor. Polling released in September showed Democrat Xavier Becerra, secretary of the Department of Health and Human Services under President Joe Biden, leading Republican Steve Hilton in the gubernatorial race. Becerra has vowed to issue an executive order to maintain health coverage for every Californian affected by federal cuts.

In California Governor’s Race, Voters Face Stark Choice on Immigrant Healthcare

California’s next governor will face tough decisions on a highly controversial piece of healthcare policy: what to do about health coverage for the more than 1.4 million low-income residents without legal status. Democrat Xavier Becerra and Republican Steve Hilton present starkly different choices as public opinion wavers.

By Christine Mai-Duc July 6, 2026

“I believe there’s folks in the legislature that will really want to fight to make sure that we restore things as much as we can,” Alarcón said.

Refugee assistance groups say they have been trying to educate people in their communities and direct them to health clinics that are government-funded or free.

“We’ve just been scrambling trying to find free medical care,” said Julianna Larsen, co-founder of the Arizona Refugee Center. “To not be a welcoming place is the most un-American thing I’ve ever experienced.”  

Andrea Mendez Perez, director at Interfaith-RISE, a refugee resettlement organization in southern New Jersey, said the Trump administration has elongated the process for people to get green cards and is now taking away coverage from those without them. Before 2025, it typically took about six months to qualify for a green card, documentation that allows a foreign national to live and work permanently in the United States, she said. Today, it’s well over a year.

For many of these immigrants on Medicaid, losing their ability to get their prescribed medications “is a life-or-death situation,” Mendez Perez said.

Ahin, the Syrian refugee, applied for permanent residency soon after arriving in the U.S. two years ago. Mendez Perez said she should have her green card by now, which would have spared her from being dropped under the GOP law. “She is stuck in the middle and has no control.”

Colleen McCauley, policy and advocacy director at the Camden Coalition, a nonprofit that helps connect people to healthcare in southern New Jersey, said the loss of coverage is devastating.

“None of them did anything wrong,” McCauley said, “and they are losing coverage.”

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

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

NEW RICHLAND, Minn. — Floodwater seeped through the nursing home’s front door just before sunrise.

Inside the New Richland Care Center, staff members rushed to move 36 residents out of the building on Sept. 19 while they still could. They pushed elderly residents in wheelchairs through 4-inch-deep water to buses waiting in the parking lot, said nursing home administrator Robert Johannsen.

Inches turned to feet as the last three residents were wheeled out on hospital beds, lifted “as high as they can go” to escape the rising water, Johannsen said. Firefighters and volunteers from a high school football team pushed the beds to safety across the street, he said.

“It’s pretty devastating,” Johannsen said of the now-shuttered nursing home. “There was at least 2½ feet of water flowing down the hallways.”

The small-town, government-run nursing home is about 100 yards from a drainage ditch in southern Minnesota. It has flooded three times in 16 years, including during the September storm that was large but far from historic, according to the National Weather Service.

New Richland is one of 100 U.S. nursing homes that face some of the nation’s worst flood risk — where at least 2 feet of water during a big storm could endanger residents — according to a KFF Health News analysis of peer-reviewed flood hazard mapping provided by Fathom, a United Kingdom-based company considered a leader in flood simulation.

The KFF Health News analysis builds upon a 2025 investigation that used Fathom’s mapping to identify at least 170 U.S. hospitals at risk of significant flooding. Fathom’s estimates are generally seen as more modern than official flood maps released by the Federal Emergency Management Agency, which are often out of date and don’t account for the changing climate.

“Every community across the United States carries some level of flood risk,” said Oliver Wing, the chief scientific officer at Fathom. “There is this idea that unless you can either see the ocean or the Mississippi from your front room, then you’re not at risk of flooding — when the reality is that anywhere rain can fall, it can flood.”

100 Nursing Homes at Risk of Dangerous Flooding

This map shows nursing homes located where severe weather is predicted to cause at least 2 feet of flooding — and, in some cases, far more — according to a KFF Health News analysis of proprietary flood hazard data.

Source: KFF Health News analysis of 100-year flood risk data from <a href="https://www.fathom.global/&quot; style="color:#0071ce;">Fathom</a>; Centers for Medicare & Medicaid Services <br> Credit: Holly K. Hacker, Brett Kelman, Daniel Chang, and Lydia Zuraw/KFF Health News

The U.S. has nearly 15,000 nursing homes housing more than 1.2 million people. In floods and other disasters, the residents are especially vulnerable because many are medically frail, cognitively impaired, or immobile. Some require daily care that can’t be reliably provided during a disaster, yet they are also so fragile that relocation could send them to the emergency room.

Additionally, many nursing homes were built near coastlines or waterways in the 1970s, before widespread concern about climate change, to keep residents cool and content, said David Dosa, the head of geriatrics at the UMass Chan Medical School.

“It’s a lot more comfortable than being in an urban jungle,” Dosa said. “Obviously, now you’re in places that are a little more at risk.”

Dosa has studied nursing home evacuations since Hurricane Katrina flooded the New Orleans area in 2005. Dozens of people were killed in facilities that tried to ride out the storm and flooded after the levees broke.

After Katrina, the nursing home industry pivoted toward evacuations, although some of those decisions also led to deaths, Dosa said.

In preparation for the next three Gulf hurricanes, more than 270 nursing home evacuations were recorded, according to a peer-reviewed study Dosa co-wrote in 2011. Within the 30 days that followed each storm, the regions hit saw a cumulative total of 277 more nursing home resident deaths than expected, suggesting a “significant increase in mortality and morbidity associated with evacuation,” according to the study.

“It’s Russian roulette. You’re damned if you do. You are damned if you don’t,” Dosa said of evacuations. “Older adults and disasters don’t mix.”

A similar study published in 2024 found a 16% greater chance of ER visits among residents of Florida assisted living facilities who were evacuated before Hurricane Irma in 2017. People in assisted living facilities generally need less care than those in nursing homes.

“Assisted living residents are quite frail in their own right,” said Cassandra Hua, an assistant professor at UMass Lowell, who led that study. “But nursing home residents are usually at higher risk. So anything you see in assisted living might be multiplied in a nursing home setting.”

Even a few inches of flooding can interrupt nursing home care and force an evacuation. For each of the 100 nursing homes identified by the KFF Health News analysis, Fathom’s data predicted a 100-year flood event could bring at least 2 feet of water to the buildings.

Aerial footage shows lingering floodwater in New Richland, Minnesota. The white-roofed New Richland Care Center can be seen along the upper-left edge of the ponding water. (WCCO/CBS Minnesota)

A 100-year flood is an intense weather event with a 1% chance of occurring in any given year, but it can happen more often. Climate scientists largely agree that extreme weather is worsening as the planet warms, which allows the atmosphere to hold more moisture and causes sea levels to rise.

And storms are drenching regions once considered at lower risk for flooding, where essential facilities and entire communities might be less prepared, said Drew Gronewold, a University of Michigan climate scientist. In other regions, storms are now less frequent but becoming “off-the-charts” powerful, he said.

“Storm tracks are changing their trajectory,” Gronewold said. “These types of, in air quotes, ‘unanticipated events’ are going to be part of our future.”

Some of the nursing homes KFF Health News has identified as at risk have flooded in the past five years, including facilities in Florida, Kentucky, Texas, and Washington.

Five of the facilities flooded in 2012 as Superstorm Sandy clobbered New York, according to a report from the Natural Resources Defense Council, while a sixth, the elevated Seagate Rehabilitation and Nursing Center, narrowly rode out the storm. In Indiana, more than 150 people were evacuated from the five-story Munster Med Inn during Hurricane Ike in 2008. Members of the National Guard carried some residents down flights of stairs in the dark.

Rescuers from the Indiana National Guard and the Munster Fire Department evacuate a resident of the Munster Med Inn in Indiana, in the wake of Hurricane Ike in 2008. More than 150 residents were evacuated, according to a U.S. Army news release. (Michael B. Krieg/Indiana National Guard)

Then there is the New Richland Care Center. Local media reports show it was evacuated due to flooding in 2010 and 2016, then partially surrounded by floodwater in 2023, before the Sept. 19 evacuation.

Storms dropped 4 to 8 inches of rain on much of southeastern Minnesota the day before, setting off widespread flooding, said National Weather Service meteorologist Brennan Dettmann. The rainfall was heavy for September but would not have been out of place in July, he said.

It was too much for New Richland. Storm runoff from nearby farms pooled in a low-lying baseball diamond at the edge of town before swamping nearby streets. Johannsen, the nursing home administrator, said maintenance workers who were trying to fix sewer drains called him in the middle of the night to warn about flooding in the park across the street.

“They said, ‘You need to come in. The water is rising,’” Johannsen said. “At that point, I think the water was a good 30 feet away from the building. I wasn’t really concerned.”

The New Richland Care Center in southeastern Minnesota flooded on Sept. 19, forcing the evacuation of 36 residents. Some residents were pushed on hospital beds through feet of floodwater to escape the facility, administrator Robert Johannsen says. (WCCO/CBS Minnesota)

Wing, the Fathom scientist, said the danger should have been obvious. Although Minnesota’s natural landscape once would have absorbed heavy rains, the farmland around New Richland funnels runoff into creeks and ditches that lead to a low-lying bowl near the nursing home. It’s almost as if the location is designed to flood, Wing said.

“The choice has been made that we don’t want water in our crop fields. We want it in the nursing homes of vulnerable people,” Wing said. “That’s the choice that has been made, politically, in that part of Minnesota.”

Inside the ruined nursing home, receding floodwaters left behind knee-high watermarks, mud-smeared floors, and a lingering smell that Johannsen said reminded him of growing up on a farm. Water destroyed treasured photo albums left behind in a low cabinet, he said.

Johannsen said the nursing home — which, with 85 employees, is one of the largest employers in town — will be closed for five months to a year for repairs. He said all its residents were moved into a school gymnasium and have been resettled across about nine area nursing homes.

“It was an awful experience that I hope nobody ever has to go through. Because these people lost homes,” Johannsen said. “My staff is losing their jobs. And I don’t know what to do.”

New Richland Care Center administrator Robert Johannsen (left) examines the damaged nursing home in the wake of a Sept. 19 flood that forced the evacuation of 36 residents. Johannsen says the facility will be closed for months for repairs. (WCCO/CBS Minnesota)

Methodology

For this analysis, we used data from Fathom, a United Kingdom-based company that specializes in flood-risk modeling worldwide. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been peer-reviewed and used by insurance companies, the World Bank Group, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has validated Fathom’s U.S. data.

Through a data use agreement, Fathom shared U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of coastal, fluvial, and pluvial flooding and accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk nursing homes, we used a Centers for Medicare & Medicaid Services database to map more than 14,000 nursing homes. With GPS coordinates as the center point, we created a circle with a 100-yard radius around each nursing home, which in most cases captured the building and nearby grounds. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for nursing homes where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 750 nursing homes.

Then we visually inspected those facilities using mapping software and Google Maps to confirm that floodwaters were predicted to reach or surround the buildings. We trimmed our list to the 100 nursing homes where the most flooding was predicted, with additional weight given to deeper water.

Our analysis does not account for how flooding beyond a nursing home’s footprint could still affect employees or patients. And it does not assess what steps facilities may have already taken to prepare for severe weather events.

Fathom provided guidance and feedback as we developed our analysis.

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

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

In December 2024, Marjorie Tingley’s adult sons received an urgent email from the dementia care unit at Vista Grande Villa, a Michigan senior living community. They were told that their 85-year-old mother was a major safety threat.

On at least 10 days in the previous month, Tingley had hit, kicked, or elbowed aides when they were trying to help her change her briefs, get dressed, bathe, or go to the bathroom, according to Vista Grande behavior logs. Vista Grande wanted permission to sedate her.

Into the new year, Tingley’s sons and Vista Grande fiercely wrangled over one of the most contentious topics in long-term care: the use of antipsychotic medications to pacify agitated people with dementia. The medications come with risks: The Food and Drug Administration requires pharmaceutical companies to warn that these potent drugs increase the chance of death in older people with Alzheimer’s and similar diseases.

More than 5 million Medicare beneficiaries have a diagnosis of dementia. Despite a 14-year campaign by the federal government to reduce the use of psychotropics, 1 in 4 Medicare beneficiaries with dementia are potentially inappropriately prescribed antipsychotics and other brain-altering medications that can cause delirium, falls, and hospitalizations, a JAMA study estimated.

While some families and guardians agree that the benefits of these drugs outweigh the risks, those with misgivings confront a wrenching choice: consent to drugging loved ones or risk eviction from a long-term care facility.

As the Tingleys alternately acquiesced to and resisted Vista Grande’s insistence on medication, administrators started calling 911 after altercations, according to ambulance and police dispatch records. Tingley was repeatedly taken to the emergency room for assessment, hospital records show.

After four trips, Vista Grande gave Tingley a 30-day eviction notice, and it sent her to the hospital four more times while the family was arranging a new placement, medical records show.

“I want her out of here,” a flustered administrator told an ambulance crew, one entry shows.

Marjorie Tingley was taken to an emergency room eight times after a series of incidents in which she exhibited aggressive behavior at her memory care facility, according to medical and facility records. A pending lawsuit by her family alleges Vista Grande Villa, the senior living center in Michigan, initiated the ER trips in retaliation for disagreements with the family about Tingley’s care. Vista Grande and its director have denied the allegations. (David Tingley)

Tingley died at another facility in January 2025. The cause was plaque buildup in her brain, a hallmark of Alzheimer’s, a degenerative brain disease and the most common type of dementia.

“They just wanted to have her drugged up,” David Tingley, one of her five sons, said about Vista Grande in an interview. “It’s a lot easier to take care of someone who’s just out of it.”

Her sons’ lawsuit against Vista Grande and its director at the time accused them of negligence, causing emotional distress, and wrongful eviction. The suit also asserted Vista Grande initiated the ER trips in retaliation for the family’s disagreements about Tingley’s care. Vista Grande and its director have denied the allegations. Their attorneys and the director did not respond to requests for comment.

In a legal filing, Vista Grande called the drugs recommended to the Tingleys “routine medication” and said it sent their mother to the hospital “because of her family’s refusal to allow Ms. Tingley to be treated on site.”

A Michigan Circuit Court judge has dismissed the negligence claim on legal grounds. A trial is scheduled for early next year on the remainder of the lawsuit if mediation fails.

Earlier this year, Vista Grande, which was a nonprofit, became a wholly owned subsidiary of Otterbein SeniorLife, which renamed it Otterbein Jackson SeniorLife Community. Otterbein is not named in the lawsuit, and representatives did not respond to requests for comment.

Dangers of Aggression

Diseases that cause dementia damage the parts of the brain that regulate impulse control and perception. Impaired people can become aggressive because of fear — especially when they no longer recognize their caregivers — or because they have no other way to communicate that they are in pain, are hungry, or have some other need.

Altercations between agitated people with dementia and other residents or workers charged with caring for them are disturbingly common in long-term care facilities and private homes. KFF Health News previously found that federal inspectors have cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation.

Those dangers are particularly true in the more than 6,000 assisted living facilities that specialize in dementia care, usually in locked buildings or units populated by people with cognitive damage. These memory care facilities promise specially trained staff and meaningful activities for residents and usually charge more than standard assisted living.

The long-term care industry’s reliance on tranquilizing medications has been a concern of Congress for half a century. A 1975 Senate report stated that “an ugly pattern of prescription drug misuse, with harsh consequences to patients, exists in many nursing homes of the United States.”

A National Campaign

In 2012, the Centers for Medicare & Medicaid Services launched its Partnership to Improve Dementia Care to target overprescribing. It has shown some success with reducing the use of antipsychotics, which the FDA has approved primarily for people with schizophrenia. Excluding those patients, antipsychotics were given to 1 in 7 nursing home residents in 2025. An inspector general report released in March identified “alarming instances of inappropriate use of antipsychotic drugs.”

Nationally, nearly half of the 1 million people in assisted living facilities have Alzheimer’s or other diseases and conditions that cause dementia. Unlike nursing homes, assisted living facilities don’t provide skilled medical care around the clock, but they help people with fundamental activities like bathing and eating. States regulate them, not the federal government.

A study published in 2023 in JAMDA, the journal of the society representing post-acute and long-term care medicine, found that, on average, assisted living residents with dementia were prescribed an antipsychotic for 13% of the time they lived there. Other researchers looking at prescribing trends through 2017 concluded the federal campaign “did not appear to affect antipsychotic prescribing” in these residents.

Lauren Gerlach, a geriatric psychiatrist and an associate professor at the University of Michigan Medical School, said there is evidence that aggressive behaviors are better addressed by non-medication interventions, like looking for underlying medical issues or heading off situations that typically upset the person. But, she said, “for some patients, these behaviors are so severe that medications will be required.”

A Steady Decline

The details of Marjorie Tingley’s time at Vista Grande — as alleged in documents filed in the lawsuit; records provided by the Tingleys and their lawyer, Ron Marienfeld; and interviews and emails with the family — provide an unusually intimate look into what can happen when families and caregivers clash over brain-altering drugs.

A Detroit native, Tingley was a volunteer reading teacher in the Jackson, Michigan, public school system and worked in the general office. Later, she was a certified financial planner. Her sons said she was successful but made less money than she might have, because she didn’t direct investments to get the highest commissions. Instead, she did what she thought was best for clients.

“She was just so honest,” David Tingley said.

She was an active member of the Catholic Church. Her husband, Eugene, died in 2010.

Vista Grande Villa gave Marjorie Tingley an eviction notice after her sons resisted requests to sedate their mother with medications, medical records show. She died less than two weeks after moving to a new facility. (David Tingley)

Around 2018, her sons noticed she was becoming forgetful, not taking her regular medications or recognizing aides they had hired. David and his brother Mark, who shared power of attorney, said in an interview that their mother’s memory deteriorated further after a head injury in a 2019 car collision.

They hired caregivers to help at her home in Jackson, but by 2021, they decided she needed to be in a facility, choosing the assisted living unit at the nonprofit Vista Grande.

In 2023, Vista Grande told them that their mother’s dementia had progressed and that she needed to go into the memory care unit or leave. Vista Grande’s memory care marketing materials said its “dedicated team creates an individual program of support for each resident” and “provides for the precise services you need.”

David said they reluctantly agreed to the move but thought the quality of care was better in general assisted living, even though memory care cost more. Vista Grande charged Tingley $9,150 a month for memory care, her lease shows.

‘These Pills Have Side Effects’

Vista Grande first contacted the Tingleys in early December 2024 about behavioral incidents. According to facility records, Marjorie Tingley pushed an aide trying to help her use the bathroom and the aide almost fell. She yelled and kicked at staff trying to put on her shoes and socks. She wandered into another resident’s room and took a walker.

The facility requested permission to medicate Tingley, but her sons said they first wanted her checked for a urinary tract infection, which they said had caused her agitation in the past. “These pills have side effects,” Mark said. “I thought, ‘Personally, I don’t want her to have that.’”

Vista Grande collected the sample but didn’t ensure it was tested by a lab for more than a week, by which time the test had to be redone, according to facility and medical records.

In mid-December, Vista Grande sent Tingley to Henry Ford Jackson Hospital for a mental health evaluation, at which psychiatrists could decide whether she required involuntary hospitalization. Doctors did not find that necessary, but they confirmed a urinary tract infection and she was given antibiotics. Vista Grande declared she could not return unless the family agreed to sedating medication, according to hospital records.

In a court filing, Vista Grande said Tingley had become a “danger to herself and others.” Mark recalled feeling at the time that: “It’s like they’re holding her ransom unless I say she can have that pill.”

Medication Begins

The specific medications were prescribed either by hospital doctors or a nurse practitioner working for a medical group that serviced residents of Vista Grande and other long-term care facilities, medical records show. David said Vista Grande had encouraged the family to replace their mother’s longtime physician with that medical group. The lawsuit did not name the nurse, the medical group, or the hospital as defendants. Henry Ford Health declined to comment.

The brothers allowed Vista Grande to give their mother the drug Ativan, the brand name for lorazepam, as needed. Ativan is not an antipsychotic but a benzodiazepine that the FDA has approved for people with anxiety. The label says it can cause dizziness, unsteadiness, and weakness and is supposed to be used “with caution” in patients with breathing problems — like Tingley, who had sleep apnea. It can cause “paradoxical” reactions such as agitation and rage.

After a week, Vista Grande workers gave “mixed reports” about whether the Ativan was calming Tingley, according to her medical records. Employees said she still would yell and was “very agitated.”

The family said they authorized Vista Grande to replace Ativan with a low dose of Zyprexa, the brand name for the antipsychotic medication olanzapine, which the FDA has approved to treat schizophrenia and bipolar disorder. The FDA requires Zyprexa to carry a black box warning stating that it is not approved for the treatment of patients with dementia-related psychosis and places them at greater risk of death.

Nonetheless, Zyprexa has a long history of being prescribed that way. Eli Lilly, the drug’s manufacturer, pleaded guilty in 2009 to allegations that it improperly promoted the use of Zyprexa for dementia with long-term care providers and primary care physicians. The company agreed to pay a criminal fine and civil settlement totaling $1.4 billion.

The black box warning on Zyprexa alarmed the sons, and their online research made them worried that Zyprexa could damage their mother’s heart, since she had atrial fibrillation. While the family approved the prescription, they authorized only 2.5 grams of Zyprexa a day, half the starter dose recommended by Eli Lilly.

‘She Could Barely Function’

On both New Year’s Eve and New Year’s Day, Vista Grande sent Tingley to the emergency room. On Jan. 2, Vista Grande gave the family the 30-day eviction notice. “We have determined we are unable to meet the level of care and expectations required for your mother’s well-being,” it said in the letter.

While the family started looking for another facility, Vista Grande sent Tingley to the ER four more times.

Vista Grande Villa gave Marjorie Tingley an eviction notice after her sons resisted requests to sedate their mother with medications, medical records show. Tingley’s family said she was being excessively sedated. “She could barely function,” her son David says. (David Tingley)

A psychiatrist consulting with the hospital endorsed doubling the Zyprexa to the starter dose recommended by Eli Lilly, and the Tingleys consented, according to medical records.

For five days, there were no incidents at Vista Grande, according to her medical records. But the family alleged in court filings that Tingley was being excessively sedated. They instructed that the Zyprexa be cut back to its initial level, according to her medical records.

“She could barely function,” David said in the interview.

The sons said they were especially disturbed to learn she was being given both Ativan and Zyprexa after they had approved Zyprexa as a replacement drug.

Reports from emergency room crews and the hospital made the sons doubt their mother was as aggressive as Vista Grande described, they said. Those records show that throughout the ER trips, Henry Ford employees and ambulance workers generally found Tingley cooperative and polite.

A nurse said Tingley allowed her to braid her hair and blew her kisses when she left. “Just the sweetest patient and very loving,” another ER worker wrote in the medical records. A physician noted the discrepancy from what Vista Grande was reporting, writing in her record: “Her behavior on what I am witnessing is completely contrary to what they are indicating.”

In a legal filing, Vista Grande attributed Tingley’s calm to medication and the “familial love and attention” her sons gave her at the emergency room.

“The next time Ms. Tingley decompensated, the cycle predictably resumed,” Vista Grande said in the filing.

Vista Grande reported that aggressive behaviors resumed and continued sending Tingley to the hospital. On the last trip, Jennifer Wheeler, then-director of Vista Grande’s memory care unit, told ambulance workers that Marjorie would not be accepted back, according to EMS notes. “She is a danger to other residents and a danger to my staff,” Wheeler said.

Tingley stayed in the hospital until she was moved to another memory care facility in Jackson. She died on Jan. 26, 2025, less than two weeks later.

Her sons asserted in their lawsuit that the frequent trips back and forth to the hospital hastened their mother’s demise.

“They weren’t really caring about my mom,” Mark said. “If they were, they would know that all this back-and-forth to the hospital was no good for her.”

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

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

HHS Office for Civil Rights Clarifies Privacy Rules for State Medicaid Programs

MISSOULA, Mont. — Bethany Zulick went back to school in January to become a high school English teacher.

Years ago, she taught English as a second language overseas and loved it.

“It’s so exciting to me to watch someone learn a new word or have that spark of understanding,” she said.

Zulick knew she could earn enough money as a substitute teacher to make going back to school financially viable — except for the cost of health insurance. She didn’t want to risk being unable to see her doctor for her allergies, or for preventative care.

The health insurance offered through Montana State University was too expensive, Zulick said, almost as much as her tuition. But then she found a solution that allowed her to make the leap: Medicaid. She wouldn’t have to pay any monthly premiums.

It worked well for a few months, as Zulick taught by day and took online classes at night.

But in June, the state sent a letter that she said left her “completely confused.” She knew Montana was rolling out a system for work requirements over the summer, but she thought she wouldn’t have to prove she met the requirements until next year, when her Medicaid enrollment came up for renewal.

Yet the letter from the Montana Department of Public Health and Human Services outlining the new requirements gave conflicting information on when Zulick would have to prove she was meeting them. First it said at her next renewal, which would be sometime next spring. Lower down it told her she would have to submit paperwork to prove compliance much earlier — “within 30 days” of the date on the letter, June 26. She wondered: Was it a boilerplate mass-mailing letter she could ignore, or was her insurance on the line?

Most states must implement the new work requirements by Jan. 1, but three states — Montana, Nebraska, and Arkansas — have already gotten started. Medicaid advocates worry that the expedited timeline in those states will lead to thousands of people losing coverage because they’re confused about the new rules, even if they are eligible for the program — and that Montana may offer a troubling preview of what will happen nationwide next year.

State health department officials maintain they are well prepared and told state lawmakers they plan to process roughly 5,000 enrollees monthly.

Growing Confusion, Dwindling Help

Rep. SJ Howell of the Montana House has gotten dozens of calls from confused constituents, specifically about letters like the one Zulick received.

“The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on,” said the Democratic legislator, who asked health department leaders about those letters at a hearing in early September. Letters being sent to enrollees have been updated to be clearer, state health officials told lawmakers at the hearing.

In Montana, nearly 71,000 people are subject to the new rules. Medicaid costs are split between the federal and state governments, and states are responsible for administering the program, which provides health insurance for people with low incomes or disabilities.

Under the new work requirements, enrollees must document that they’re working, volunteering, or studying 80 hours per month — or they must show that they qualify for one of a range of exemptions, such as being “medically frail” or being the primary caretaker for a family member.

Montana began with a soft launch of the work requirements in July and gave enrollees until Oct. 1 to comply.

Critics contend that isn’t enough time, because the state hasn’t finished setting up new computer systems or hiring the staff it said it would need. Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing, adding that numbers had fluctuated amid staff turnover.

State health officials have said they’ll eventually be able to automatically verify that students are enrolled in public universities. However, that computer system isn’t expected to be up and running until next year, leaving students like Zulick to track down and submit the correct paperwork to prove their college enrollment.

However, there are fewer outside resources to help residents with these bureaucratic tasks.

For example, Cover Montana, a nonprofit that helps Montanans fill out such paperwork, lost federal funding last year, going from a staff of 18 to two part-time employees working a phone line.

The state does operate a helpline, but federal data shows that Montanans stay on hold much longer than the national average and that many callers hang up before they connect with a state employee.

“We were worried about chaos that could be generated by the state rushing,” said Aaron Wernham, CEO of the Montana Healthcare Foundation, a nonprofit aimed at improving health in the state. “Given how little information the state has provided about what they are doing, I’m much more worried about chaos.”

Wernham pointed to a similar upheaval in 2023, when states undertook a massive process to redetermine the eligibility of all Medicaid enrollees, after regular eligibility checks were paused during the pandemic.

Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork — roughly 87,000, according to state data from two years ago.

Even vulnerable Montanans who didn’t need to file paperwork, because their coverage should have been automatically renewed, were dropped from the Medicaid rolls, including people who were homeless.

Montana House Democrat Mary Caferro addresses protesters in July at the Montana Capitol in Helena. Montana is among three states that have adopted Medicaid work requirements months ahead of the federal deadline. The new rules have confused some Montanans on Medicaid, and critics say that confusion will lead to people unnecessarily losing coverage. (Aaron Bolton/MTPR)

Long-Sought Requirements in State

The Montana Legislature passed a measure in 2019 expressing its desire to add work requirements to Medicaid, but the state didn’t have permission from the federal government to move forward until now.

Having work requirements creates accountability for people who rely on the social safety net, said Montana Senate President Matt Regier, a Republican.

“In an economy like this, if you’re an able-bodied adult that’s able to work, you really do need to step up,” he said.

Asked about confusion among enrollees about the rules, Regier responded that the Oct. 1 deadline offered more than enough time to work out the kinks in the new system.

In the end, Zulick learned she didn’t need to worry about that deadline, because she got married in July and no longer qualified for Medicaid, although she didn’t know that would be the case when she got the June letter.

But others remain scared about losing coverage, including Heather Reel, who attended a rally at the state capitol in July to push back against Montana’s early rollout.

Reel relies on Medicaid for its mental health coverage. Without it, she said, she would struggle to care for her teenage son, who has autism and is nonverbal. Between her shifts at a fast food restaurant and caring for her son, she’s scared she’ll be too busy to figure out how to report her work hours.

Montana’s Rollout a Potential Preview

The handful of states that are implementing the Medicaid work requirements early are building the plane as they’re taking off, said Akeiisa Coleman, who provides Medicaid analysis for The Commonwealth Fund, a nonprofit focused on making healthcare more equitable.

“Montana is going to be an example for what we might see nationally as things roll out,” she said.

Although most other states are sticking to the Jan. 1 deadline to build and test their Medicaid systems, they still might not have all the components in place, she said.

If states can’t automatically renew or deny coverage based on the new rules, state workers will have to do so manually, on a case-by-case basis. That could create backlogs and more disruption, leading more people to lose coverage, Coleman said.

Jon Ebelt, a spokesperson for the state’s health department, said in a statement that Montana’s Medicaid office is ready for the change on Oct. 1.

“We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely,” Ebelt said.

Democratic state lawmakers have repeatedly asked state health officials to extend the Oct. 1 deadline for enrollees to comply with the new rules, but they’ve said they have no plans to do so.

This article is from a partnership that includes Montana Public Radio, NPR, and KFF Health News.

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

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

This story describes a lethal injection procedure used in state executions.

In May, a group of healthcare workers spent about an hour trying to establish complete IV access so they could inject Tony Carruthers, an inmate at the Riverbend Maximum Security Institution in Nashville, Tennessee, with a lethal dose of sedative.

Maria DeLiberato, an attorney for Carruthers, was in the room. She said the workers stuck his arms and feet with needles, to no avail. A doctor then tried to insert a central line through his collarbone and shoulder. That didn’t work, either.

Carruthers groaned in pain and blood oozed from puncture wounds, DeLiberato said in a news briefing.

After more than an hour, Gov. Bill Lee called the warden, ordering him to halt the execution attempt. He later granted Carruthers a one-year reprieve.

Now, as another death row inmate’s execution approaches, doctors and nurses in the state say they want medical professionals removed from the execution process. They’ve also joined defense attorneys and nine Republican state lawmakers in demanding a moratorium on the death penalty and an overhaul of the state’s execution methods.

The doctors’ arguments echoed those the American Medical Association has made before the U.S. Supreme Court and in its code of ethics.

Tennessee is among 27 states where the death penalty is legal, according to the Death Penalty Information Center, a nonprofit that offers data and analysis on issues surrounding capital punishment.

Governors in four of those states have halted all executions, citing moral concerns and logistical ones, such as being unable to obtain lethal injection drugs amid pharmaceutical companies’ refusal to sell them for use in executions. Lethal injection is still the primary execution method nationwide, but some states may use gas, a firing squad, or electrocution.

Since the beginning of 2020, 170 people have been executed in 17 states, with most occurring in Florida, Texas, and Oklahoma. In that time, six states have had botched lethal injections, according to the Death Penalty Information Center, which defines those as executions that include a departure from the protocol because of unanticipated problems and that cause more pain for the prisoner than anticipated, whether they ultimately end with a death or not. Several of the stories read like Carruthers’ — protracted but ultimately failed attempts to establish IV access.

Tennessee Health Workers’ Concerns

The IV team gave up on trying to place a typical line into Carruthers after several failed attempts, according to DeLiberato’s account. Following protocol, physician Mark Fowler, a contractor for the state’s prison system, then tried to place a central line in a deeper vein. That’s a quasi-surgical procedure in which a plastic tube is inserted in the chest, groin, or neck. Fowler used a series of syringes, trying to insert the tube under Carruthers’ collarbone and then through his shoulder.

In an October 2025 deposition, Fowler said he hadn’t done such a procedure in the 12 years since he had stopped working in an emergency room, and didn’t know that placing a central line could be among his execution duties.

Fowler told NPR by phone on Sept. 24 that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.” He did not have further comment.

Two months after the halted lethal injection, more than 40 doctors and nurses sent a letter to Lee, calling on the Republican governor to pause executions and redesign the protocol to omit health workers from the process.

The letter said that Tennessee’s rules requiring the participation of pharmacists, physicians, and other healthcare workers in executions are at odds with medical ethics, as well as guidelines explicitly laid out by groups such as the American Medical Association. The AMA code says doctors are to preserve life when there is hope of doing so and bars participation in executions.

“This means that the health care professionals who agree to take part in Tennessee’s executions are those willing to set aside their professional ethics,” the letter to Lee reads. “The problems that we have seen, such as in Mr. Carruthers’s case, are the predictable result of working with such unscrupulous actors.”

John Greer, a retired Nashville hematologist, said in a news conference about the letter that he wasn’t surprised the central line placement went awry.

“Placing a central line is not just sticking a needle in a person’s arm,” he said.

Greer said the doctor has to tap a large vessel above the heart. He said that it’s a risky procedure in which an error could cause a collapsed lung or heavy bleeding — and that only those with specific training and routine practice should attempt.

“And I cannot imagine that there would be someone who’s doing these routinely who would be involved in this procedure,” Greer said.

Some Republican state senators also called for a hold on executions and an overhaul of the process, saying that “incompetent administration” of capital punishment gives its critics more ammunition.

This summer, Lee said he didn’t want a pause.

“The Department of Correction did exactly what they should,” he said. “It should not affect executions in the future.”

“It’s one of the most difficult things that we do in this state,” Lee said later. “But I am committed to making sure that it is done in the way that it should be.”

The state’s lethal injection protocol orders the prison to keep a curtain over the media witnesses’ viewing window until the IVs are established, so none of them could offer a visual account of the failed execution attempt.

A lawsuit challenging that policy has been filed has been filed by the Reporters Committee for Freedom of the Press and news outlets including NPR member station WPLN. The lawsuit argues the lack of transparency during the IV placement process obscures problems like the ones that happened in Carruthers’ case.

There’s a broad understanding in the U.S. that the medical establishment doesn’t participate in executions, said Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado’s medical school.

“We came out of World War II with a whole bioethics and medical ethics enterprise that is really strongly opposed to medicine serving as an arm of the state and using specialized medical skills to hurt people or kill people,” Wynia said.

A history of medical abuses by government doctors — such as forced sterilizations and unethical studies of untreated syphilis in the U.S., and murder and torture in Nazi Germany — forged that consensus, he said.

Wynia mentioned other nations where medical professionals still participate in executions.

“But they are, you know, Iran and Saudi Arabia and Russia, sort of authoritarian states, where medicine is an arm of the government,” Wynia said. “Medical involvement in executions ends up happening because medicine is unable to say, ‘No, we don’t do that.’”

Upcoming Execution

On Sept. 30, Tennessee is scheduled to execute Christa Pike, who was 18 years old when she and her boyfriend killed Colleen Slemmer.

Pike’s attorneys this year raised several concerns that the state’s lethal injection protocol would violate her rights. Among them is their contention that because she suffers from a platelet disorder, it’s likely she will need a central line placed. They also argued that she was at risk of needless suffering, alleging Carruthers’ execution showed that Fowler — who has confirmed publicly that he will oversee Pike’s execution — is incompetent at placing central lines.

In June, they put all of those concerns in a request to the Tennessee Supreme Court, asking for a special investigator to collect evidence and hold hearings to determine whether they warranted an order to delay her execution and design a method for only her.

The court did appoint a special investigator, Senior Judge Mark Ward. He held a series of hearings in Knoxville last month. Ward said he didn’t believe Pike’s rights would be violated by the process and submitted his report to the court.

On Sept. 23, the Tennessee Supreme Court denied Pike’s stay, agreeing with Ward, saying none of the concerns amounted to a constitutional violation. On Sept. 28, Lee announced he would not grant her clemency.

This article is from a partnership that includes WPLN, NPR, and KFF Health News.

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

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

Autumn Daniels is no stranger to migraine headaches, which have troubled her since childhood.

The migraine tormenting the 32-year-old in April was even worse than usual. After a week of piercing head pain, she went to an urgent care center near her home in Champaign, Illinois, and received an injection of Toradol, a non-steroidal anti-inflammatory drug that usually helps with her symptoms. The doctor at the clinic told her that if the pain didn’t improve, she should go to an emergency room the next day.

It didn’t improve. So the next morning, Daniels’ sister took her to a nearby ER, at Carle Foundation Hospital in Urbana. She said the ER didn’t seem very busy when she registered at the front desk and was taken briefly to an exam room, where a staffer checked her vital signs and asked whether she had migraines frequently. Then they told her to sit in the waiting room until she was called.

She and her sister waited. And waited. By then, Daniels said, she was vomiting every 10 minutes, a not-uncommon occurrence during one of her serious migraine attacks.

After four hours, with no indication that Daniels would be seen anytime soon, her sister took her to another hospital. There, after a wait of about an hour and a half, Daniels was seen and received treatment, including more Toradol and anti-nausea medication.

Having left Carle without getting treatment, Daniels didn’t expect to be charged.

Then the bill came.

The Medical Service

Daniels said a staffer checked her pulse, temperature, and blood pressure when she arrived at Carle. She said she received no other services, nor was she seen by a doctor.

At one point while they sat in the waiting room, Daniels said, her sister asked for an ice pack for her head, but the staff wouldn’t provide one.

“ER triage is driven by risk of death or serious harm, not by level of suffering,” said Jennifer Robblee, a neurologist at the Barrow Neurological Institute in Phoenix and a board member at the Association of Migraine Disorders. “Migraine patients without red flags are unlikely to be prioritized, as they are not at immediate risk of dying.”

The Bill

$410 for an “Emergency Room Level 1” visit. Daniels said she requested an itemized bill showing how the hospital arrived at that figure but never received one.

This is not the first time that a patient has complained to KFF Health News’ “Bill of the Month” about receiving a bill after leaving a Carle Health emergency room without being treated. In 2023, Maggi Wettstein took her toddler to a different Carle Health hospital and was billed $445 for a nasal swab test for covid and influenza. They, too, left before getting treatment.

The Billing Problem: What Counts as Care?

Though Daniels left the emergency room after a four-hour wait without being treated, the hospital billed her anyway. Her health plan, provided through her job as a state employee, paid for her treatment at the second hospital but denied the Carle claim, leaving her on the hook for the charges.

“Under the terms of her health plan, claims associated with a patient leaving the facility against medical advice are not eligible for coverage,” Leslie Porras, a spokesperson for HealthLink, which administers Daniels’ plan, said in a statement.

When Daniels asked about her bill, a Carle representative responded in an email that said: “Effective March 1, 2026, Emergency Department visits may result in charges even if you are not seen directly by a provider. When you arrive at the Emergency Department, your visit begins as soon as care is initiated.”

The email said “care” could mean registration and nursing assessment, in addition to diagnostic testing and treatment. It said that even if patients leave without being seen by a provider, they may still be charged, because the hospital is using resources to maintain its staff, space, and equipment.

Carle Health declined to discuss Daniels’ bill or her care with KFF Health News, even though Daniels signed a privacy waiver that authorized it to do so.

Daniels was not expecting to be charged after leaving an emergency room without receiving treatment. But a health system representative later told her an ER visit begins “as soon as care is initiated,” which could mean when the patient registers at the front desk and is assessed for triage purposes. (Taylor Glascock for KFF Health News)

In a statement, Carle Health spokesperson Brittany Simon said, “Our Emergency Department has consistent billing practices for triage care,” referring to the process through which patients are evaluated to ensure the most critical cases are treated first.

“Carle Health takes patient concerns seriously and supports transparency in our billing processes,” she said.

Typically, an ER bill would include separate dollar amounts for physician charges and hospital charges, said Amber Padron, assistant director of case management at the Patient Advocate Foundation, a nonprofit that assists patients with chronic or life-threatening conditions.

Daniels’ bill listed a single charge, for $410. Under the description, it said “Emergency Room Level 1” and included the current procedural terminology code “99281.” CPT codes are used to bill for evaluation and management, or E/M, services provided by a medical professional. Level 1 is the lowest level of emergency care.

But there’s a catch: According to the American Medical Association’s CPT guide, “Triage alone is not an E/M service; therefore, it cannot be reported with an E/M code.”

It gets murkier. According to Robert Mills, a spokesperson for the AMA, the physician charge for an emergency visit under that CPT code would generally be significantly less than $410.

“It is likely the hospital consolidated the provider-billed charge with a facility fee,” Mills said, referring to a fee that hospitals tack onto bills to cover their overhead costs, such as utilities.

Amid the billing uncertainty, Daniels is clear about one thing: The decision to charge ER patients who leave without getting treatment is recent.

In 2025, she went to the same emergency room with gastrointestinal problems. After waiting for several hours, she went elsewhere for care. She said that before leaving, her mother, who accompanied her that day, confirmed with the front desk that Daniels wouldn’t be charged if they left then. And she wasn’t.

“So when I went in for this visit in April, I had no idea I was going to be charged, because it was a very similar set of circumstances,” Daniels said.

The health system didn’t respond to a question about why it changed its policy.

The Resolution

Carle didn’t budge. According to the health system’s email to Daniels, “the charges have been determined to be accurate and fully supported by the medical record documentation.”

Daniels said she paid $25 of the $410 bill and has applied for financial assistance.

Meanwhile, according to HealthLink’s statement to KFF Health News, Daniels can contest her health plan’s denial: “Ms. Daniels has the right to appeal the decision through the established appeals process.”

She’s considering it, but she remains outraged about what happened.

“How is it ethical or even legal for a hospital to essentially bill for occupying a waiting room?” she asked.

Daniels is considering contesting her health plan’s denial of coverage for the ER bill: “How is it ethical or even legal for a hospital to essentially bill for occupying a waiting room?” (Taylor Glascock for KFF Health News)

The Takeaway

Don’t assume you won’t be billed if you leave a hospital before receiving medical care. You can check with the front desk about the facility’s policy, as well as ask your insurer whether it provides coverage for such bills.

If the hospital billing department isn’t giving you information about what services you’re being billed for, request your medical records, said Padron, of the Patient Advocate Foundation.

Furthermore, when your health plan processes a claim, you should receive an explanation of benefits informing you of that and explaining what you may owe. Keep an eye on your mail and your insurance portal.

When a claim is denied, filing an appeal with your health plan is always a smart idea, Padron said.

“It’s always going to be a no if you don’t appeal,” she said.

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

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

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

HHS announced an ambitious new research initiative to address how the nation combats ticks and tickborne diseases.

The run-up to the midterm elections is turning into a food fight — literally.

The summer was marred by a massive foodborne outbreak that sickened scores of people and the recall of tens of thousands of pounds of imported meat, turning the safety of the U.S. food supply into a topic of national conversation and a political cause.

Late-night talk show hosts joked about symptoms that included explosive diarrhea. As a precaution, chain restaurants such as Chipotle and Taco Bell yanked lettuce, jalapeños, and other suspected products from menus. Some food safety scientists blamed the outbreaks on federal cuts to public health.

These dynamics collectively have raised questions about whether it’s safe to order a salad or burger.

Democrats have come out on the offensive, saying voters worried about the safety of the U.S. food supply should oust Republicans in the midterm elections. The Trump administration has countered by accusing Democrats of scaremongering over food safety to score political points.

The political fracas reflects the toll that large-scale outbreaks have had on the public psyche. Midterm voters have long cared about pocketbook issues such as grocery prices, but the spate of recalls has them worried about whether the food they’re buying is safe to eat — and political leaders are paying attention.

The outbreak linked to cyclospora in lettuce led to almost 20,000 laboratory-confirmed cases of illness from May through August, compared with 1,180 cases during the same span in 2025, according to the Centers for Disease Control and Prevention. That makes it the largest recorded outbreak of the parasite.

“One of the reasons food safety is in the news this year, and people have been rightfully concerned, is the combination of high-profile restaurant names and the absolute colossal number of illnesses,” said Teresa Murray, consumer watchdog director with the U.S. Public Interest Research Group, or PIRG, an advocacy group, referring to a recent cyclosporiasis outbreak. “It’s thousands of people. It makes it more real.”

Data shows there have been about 200 food recalls so far in 2026, which is about on par with the number at this time last year, according to PIRG data.

Following the Numbers

A majority of registered voters have little or no confidence in government oversight of food safety, with Democrats far more likely than Republicans to doubt the protections in place, according to a July survey by Quinnipiac University. Ninety-four percent of U.S. adults indicated they were concerned about the frequency of food recalls in a poll by GS1 US, a data standards organization.

The share of consumers who strongly agree that the U.S. food system produces food that’s safe to eat declined to about 30% in August, from 40% in November, based on survey data released in September by the University of Illinois and Purdue University.

Democrats have jumped at the chance to repeat criticisms of President Donald Trump’s budget cuts and priorities.

The Democratic National Committee recently posted a list of recalled food items on social media while calling Health and Human Services Secretary Robert F. Kennedy Jr. a “complete disaster” who must resign.

“Trump is dismantling our government — and it’s harming people,” Sen. Elizabeth Warren (D-Mass.) posted Sept. 2 on the social platform X, adding: “Slashed food safety agencies → cyclospora outbreak.” Just weeks earlier, she had written to Kennedy demanding answers for what she described as the administration’s “failed response” and its connection to political contributions.

Rep. Gabe Amo (D-R.I.) posted Sept. 5 on X: “I’m calling on Trump to stop gutting the FDA & restore its inspectors. We deserve safe food.”

The campaign for Rep. Judy Chu (D-Calif.) posted Sept. 5 on X: “Trump is cutting our food safety funding and workforce, and we have seen far too many food recalls this summer.”

But the number of recalls doesn’t tell the whole story.

While recalls aren’t markedly up this year compared with 2025, they are up over a broader time span. The country saw 320 food recalls by the Food and Drug Administration and the U.S. Department of Agriculture in 2025, up from 296 in 2024, according to PIRG.

The total number of recalls grew 21% from 2021 to 2025, based on an analysis by Trace One, a provider of regulatory guidance software. A rise in Class I recalls, which are the highest priority because the products could cause serious illness or death, drove much of the increase.

But recall numbers can be misleading. For starters, federal agencies do not publicize all recalls, especially if products are no longer on the market. Recall data itself is suspect because a single contaminated food can result in multiple recalls if the item is incorporated into processed food or other products.

A far better measure is the number of people sickened, epidemiologists say. And this summer’s specific multistate outbreak from cyclospora was exceptional, affecting people in 21 states.

When it comes to bacterial contamination of food — which is more common and includes E. coli, listeria, and salmonella — the overall trend points to outbreaks in which fewer people are falling ill. That’s a promising sign, some food safety leaders say, although the CDC says an estimated 48 million people each year in the U.S. experience foodborne illness.

“That’s an indication we’re finding more outbreaks and finding more when they are smaller and limiting the extent to which they can get bigger,” said Craig Hedberg, a public health professor at the University of Minnesota and leader in food safety surveillance.

Still, the perception that the food supply is riskier has been enough to ignite political rancor.

The FDA recently asserted on X that recalls for fiscal year 2026 are among the lowest levels recorded in over a decade, stating, “Don’t believe the fake news.” It included a chart that showed recalls dropping to 1,836 in fiscal 2026 from almost 4,000 in fiscal year 2013.

On the same day, HHS senior adviser Calley Means doubled down on the claim, posting on X that Kennedy is doing so well that Democratic operatives are slamming the FDA for doing its job by conducting food recalls.

“It makes sense that these craven, disingenuous attacks are all these influencers have,” he wrote.

But some food safety experts question the numbers, noting that the agency’s recall totals cover a range of products. The tally also includes drugs and medical devices, based on an analysis of the posted data by Susan Mayne, who was director of the FDA’s Center for Food Safety and Applied Nutrition from 2015 to 2023. Some food safety leaders say it’s misleading to imply that food safety recalls have declined if the data the claim is based on includes recalls not related to food.

“This HHS assertion appears to be based on incorrect data,” Mayne said on LinkedIn, a job-oriented social networking site.

It’s About More Than Recalls

Food safety has occasionally taken center stage in politics. In 1993, for example, an E. coli outbreak traced to Jack in the Box fast-food outlets pressured newly inaugurated President Bill Clinton to make it an agenda item at his first Cabinet meeting. His administration wound up adopting a new approach focused on preventing foodborne illness and credited with drastically reducing E. coli infections.

Concern about food safety has especially taken hold now, public health leaders say, because the administration is portraying itself as a safety crusader while cutting staffing and funding for federal agencies responsible for surveillance and inspection.

“There’s a level of hypocrisy from the administration when they promise to make our food safer and then eviscerate the agencies and programs that detect and prevent outbreaks,” said Sarah Sorscher, regulatory affairs director at the Center for Science in the Public Interest.

The FDA continues to have the staff required for outbreak investigations, and no FDA investigators were affected by staffing changes or reductions in force, HHS spokesperson Grace Davis Jamison said in an email.

The CDC lab supporting foodborne outbreak investigations also was not impacted by reductions in force, she said, and the agency maintains a dedicated team investigating foodborne outbreaks and working closely with state and local health departments.

“The Trump Administration has mounted a robust response to each outbreak, working closely with health departments in all 50 states and leading the public health response by promptly identifying known sources and providing Americans with the information they need to protect themselves,” she said.

The administration’s initiatives risk weakening food safety protections. Trump in late August said he would take action to make it easier for small livestock operations to slaughter and process their own meat, raising concerns among food safety leaders that the change could allow inadequately inspected beef to enter the food system.

Trump also announced the U.S. would import more beef from Argentina and Brazil, despite concerns about inspections and safety. The European Union has implemented a ban on Brazilian beef imports because of noncompliance with food safety and antibiotic use.

The administration withdrew a proposed Biden-era rule that would have stopped the sale of raw turkey and chicken containing high levels of salmonella. And it said it would delay compliance with a rule requiring grocery stores and companies to trace food in their supply chains, allowing for quick removal in cases of contamination. Implementation, originally set for Jan. 20 of this year, would instead occur in July 2028.

The actions came after hearing concerns from stakeholders about the time needed to comply, Davis Jamison said.

Some food safety leaders say the administration should do more to prevent foodborne illnesses, saying that failing to direct more resources into preventing problems makes it harder for Kennedy’s campaign to encourage people to eat more fresh foods.

In fact, almost half of consumers changed their habits regarding which groceries they bought and 40% modified purchases at restaurants in the past month due to foodborne illness concerns, according to the survey by the University of Illinois and Purdue University. Concerns about foodborne illness exposure via fresh vegetables increased in August compared with feedback from the previous two years.

“If you want people to eat real food, fresh fruits and vegetables, they have to be safe,” said Sandra Eskin, chief executive at Stop Foodborne Illness, a nonprofit public health organization. “Instead, we have had farmers plowing under fields because people aren’t buying lettuce.”

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

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

Amye Joseph says America’s political polarization has made it an “interesting time” in her Tennessee household. She and her husband, Charlie, have been married 35 years. She’s a Republican. He’s a Democrat.

But their shared disenchantment with profit-driven healthcare has provided a unifying target: pharmacy benefit managers, known as PBMs. The Josephs’ frustration is focused on CVS Health. The conglomerate, which reported $400 billion in revenue last year, includes a major health insurer (Aetna), one of the country’s dominant PBMs (CVS Caremark), and America’s largest retail pharmacy chain.

“We hate CVS. I’m going to be straight-up,” Amye Joseph said.

She laments the lack of face-to-face interaction with pharmacists, prices that seem to rise without explanation, and pressure from the couple’s CVS Caremark drug plan to use CVS stores instead of their local pharmacy. “They’re not even a middleman,” she said. “They’re a money grab for CVS.”

PBMs were conceived as a way to manage prescriptions and hold down costs. But these middlemen have become bipartisan punching bags, accused of sucking up profits at the expense of employers, governments, and patients.

And while healthcare debates still divide Democrats and Republicans in Washington, D.C., taking on PBMs has become a unifying cause in an era of widespread frustration over rising healthcare costs.

In recent years, every state has imposed restrictions on PBMs. The Josephs’ home state of Tennessee, where the GOP has a lock on state government, is among a growing number looking to outlaw companies that own PBMs from also owning brick-and-mortar pharmacies, as CVS does.

That’s aligned conservative, business-friendly Republicans with Democrats traditionally more open to government regulation.

This legislative push reflects a feeling even in the GOP that the market for prescription drugs is being gamed, said Antonio Ciaccia, CEO of 46brooklyn Research, a nonprofit think tank that tracks drug pricing.

“Republicans are looking at this issue, saying, We know what competition is supposed to do, and it isn’t happening,” said Ciaccia, a critic of the PBM industry. “This is not a free market.”

Charlie Joseph, a retired fire captain who now works as a custodian, was miffed when he realized he could save money on his blood pressure medication if he paid cash at his local pharmacy rather than using his CVS Caremark drug plan. He now buys a 90-day supply for the same price he would have paid for a 30-day supply through the CVS plan.

The Josephs don’t like dealing with pharmacy benefit managers. PBMs, designed as intermediaries between drugmakers and insurance companies to negotiate drug prices, have become targets of bipartisan anger over health costs. (Earl Neikirk for KFF Health News)

“Right now, it’s more of an inconvenience than anything else as far as it goes, but there’s no consistency,” he said. “The whole healthcare thing is just frustrating, on a good day.”

CVS spokesperson Phil Blando said the price of individual drugs can vary.

“Looking at the price of a single prescription does not reflect the value of a comprehensive pharmacy benefit,” he said in a statement. “Our focus remains delivering the lowest possible total cost and the greatest overall value for members and plan sponsors.”

Unified Opposition

PBM officials say their industry has been unfairly maligned. “PBMs are the only part of the prescription drug supply chain working to lower drug costs, which makes PBMs the target of powerful groups, Big Pharma and pharmacists,” said Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, which represents PBMs across the nation.

“Drug manufacturers attempt to shift blame for high drug costs to PBMs in order to retain their profit margins and weaken PBMs’ ability to lower costs,” he said.

Drugmakers have worked for years to cast PBMs as unnecessary go-betweens, said Barak Richman, a lawyer and economist who studies healthcare competition at George Washington University. He called the fight between the two industries a corporate “cage match.”

“We have wildly passionate partisan divides on a lot of healthcare,” he said. “But there’s a lot of healthcare policy that I don’t think is obviously partisan.”

PBMs haven’t won over many Democrats or Republicans. Attorneys general from nearly 40 states and U.S. territories wrote a letter last year to congressional leaders arguing that “horizontal consolidation and vertical integration have transformed PBMs from useful administrative service providers into market-dominating behemoths.”

In state legislatures like Tennessee’s, shared ownership of PBMs and pharmacies has drawn particular fire. Independent pharmacies have little choice but to contract with major PBMs while also competing with the conglomerate-owned pharmacies. Many lawmakers have said they want to protect small businesses.

“If a corporation argues that its pharmacy cannot survive unless it is owned by the same entity that sets the reimbursement rate, then we’re not talking about a free market. We’re talking about control,” Tennessee state Sen. Bobby Harshbarger said in a February legislative hearing.

Harshbarger, a Republican who led the legislative push, is a pharmacist in a small city in northeastern Tennessee.

His mother, U.S. Rep. Diana Harshbarger (R-Tenn.), is also a pharmacist and has sponsored a similar PBM ownership ban at the federal level. The Senate version has brought together some unlikely bedfellows, such as Sens. Elizabeth Warren (D-Mass.) and Josh Hawley (R-Mo.).

State Lawmakers vs. CVS

CVS officials argued the Tennessee legislation was misguided. “Any proposed reform should be evaluated based on whether it improves access to care, simplifies the patient experience, and enhances affordability,” Blando said.

It’s unclear whether the PBM ownership ban will do that in Tennessee. An analysis by the state legislature’s researchers concluded that the bill could drive up healthcare costs in the short term.

To fight the bill, CVS launched a $7 million TV advertising campaign, claiming it would have to close all its 134 pharmacies in the state, similar to its threat in neighboring Arkansas when state lawmakers there passed a similar measure in 2025.

CVS also sent text messages to Tennessee customers, asking them to contact their lawmakers to keep pharmacies open. Ominous texts from CVS helped kill a PBM ownership ban in Louisiana last year.

Sponsors of the legislation said closure wasn’t the only option: CVS could also divest either its stores or its PBM.

Tennessee lawmakers moved forward. State Sen. Rusty Crowe, a Republican from northeastern Tennessee, where the Josephs live, told his colleagues before the vote that they should consider the fierce resistance a sign that they were onto something.

“I learned when I was in the Vietnam War, when you start taking on flak, you know you’re over the damn target,” he said.

As with most votes in Tennessee’s legislature, Republicans didn’t need support from Democrats. But they got it anyway.

State Rep. Antonio Parkinson, a Democrat from Memphis, said he felt like he was voting in favor of lower drug prices and supporting “ma and pa” pharmacies. “If there’s a benefit to my people, I’m supporting it.”

CVS has not divested or closed its pharmacies in states that have passed ownership bans — the laws have yet to take effect. The Arkansas ban is being held up in court after CVS challenged the constitutionality of the law. CVS also sued in Tennessee, though the ownership ban doesn’t take effect until 2028.

This article is from a partnership that includes Nashville Public Radio, NPR, and KFF Health News.

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

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