Las nuevas inscripciones bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) parecen ser hasta un millón menos que el  número récord del año pasado, especialmente por problemas con el programa que enfrenta la saliente administración Biden.

La reelección de Donald Trump para un segundo mandato ha generado incertidumbre sobre el futuro de la ley de salud. Además, el gobierno implementó normas complejas para reducir las inscripciones fraudulentas y está combatiendo una demanda que busca evitar que un grupo de inmigrantes sin residencia legal adquieran cobertura en los mercados de seguros de salud.

Hasta ahora, el número de nuevos inscritos y reinscritos que utilizan cuidadodesalud.gov, el sitio del mercado federal que usan 31 estados, está por debajo del año pasado. A principios de diciembre, las nuevas inscripciones apenas superaban las 730,000, en comparación con 1.5 millones en el mismo período de 2023.

Para dar más tiempo a los consumidores de los estados del mercado federal para inscribirse, los Centros de Servicios de Medicare y Medicaid (CMS) extendieron hasta el 18 de diciembre el plazo para adquirir cobertura que comienza el 1 de enero. (El plazo del 15 de enero es para la que comenzaría el 1 de febrero).

También está en juego una regla emitida por la administración Biden que permite, por primera vez, que los Dreamers, las personas traídas al país de niños sin papeles, puedan inscribirse en los mercados y obtener subsidios.

El 9 de diciembre, un juez federal de Dakota del Norte falló a favor de 19 estados que buscaban bloquear esta directiva de la administración Biden.

El 16, el equipo de Biden obtuvo una suspensión temporal, pero el destino de esta opción todavía está por verse.

De prevalecer, la decisión en este caso, Kansas vs Estados Unidos, efectivamente prohíbiría a quienes han calificado para el programa de Acción Diferida para los Llegados en la Infancia (DACA) inscribirse o recibir subsidios para los planes de ACA en los 19 estados. Según los abogados que siguen el caso, no parece afectar la inscripción o la cobertura en otros estados.

Se espera una decisión final sobre la suspensión temporal en cualquier momento. Si se concede, podría permitir que los Dreamers sigan inscribiéndose mientras se escucha la apelación del gobierno a la decisión del tribunal de distrito, lo cual es poco probable que ocurra antes de que Trump asuma el cargo.

En sus documentos judiciales, la administración Biden argumenta que no conceder una suspensión sería muy disruptivo en medio del período de inscripción abierta, lo que causaría que el gobierno federal incurra en costos para reajustar su mercado para reflejar el cambio y notificar a aquellos que ya se han inscrito que sus planes han sido cancelados.

El caso original fue presentado en agosto en el Tribunal de Distrito de los Estados Unidos para el Distrito de Dakota del Norte y está siendo escuchado por el juez de distrito Daniel Traynor, nominado en 2019 por el entonces presidente Trump.

Previamente, el gobierno federal estimó que alrededor de 100,000 personas sin seguro de un total de medio millón de beneficiarios de DACA podrían inscribirse para tener cobertura de 2025. En su nuevo escrito, el gobierno dice que 2,700 se han inscrito en los estados que presentaron la demanda y que usan el mercado federal.

La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados “legalmente presentes” para los propósitos de inscribirse en planes bajo ACA, los cuales están abiertos a ciudadanos y aquellos denominados inmigrantes “legalmente presentes”.

Los abogados federales argumentan que Dakota del Norte no ha demostrado que sería perjudicado por la regla, por lo que no tiene legitimidad para presentar el caso. El estado argumentó que incurre en costos para aproximadamente 130 beneficiarios de DACA que viven allí, y que no tendría esos gastos si se les prohibiera inscribirse en ACA y, por lo tanto, decidieran abandonar el país.

Por su parte, el gobierno federal argumentó que un éxodo es poco probable. El escrito legal también cuestionó el cálculo de Dakota del Norte de que incurre en costos de $585 para emitir licencias de conducir a los beneficiarios de DACA y alrededor de $14,000 anuales para educar al menos a un miembro o dependiente de DACA.

Todos los estados que impugnan esta regla argumentan que causará cargas administrativas y económicas a medida que más individuos se inscriban, y que alentará a más personas a permanecer en Estados Unidos sin documentos.

Los estados demandantes son: Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Dakota del Norte, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.

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

USE OUR CONTENT

This story can be republished for free (details).

It’s open enrollment season for the Affordable Care Act — and there are ongoing challenges.

First up, enrollment.

New and returning sign-ups through healthcare.gov — the federal marketplace that serves 31 states — are well below last year’s rate. New enrollments were just over 730,000 in early December, compared with 1.5 million at the same time last year.

To give consumers in those states more time to enroll, the Centers for Medicare and Medicaid Services extended the deadline to Wednesday to sign up for coverage that starts Jan. 1. (Open enrollment itself ends in most states on Jan. 15, for coverage that would begin Feb. 1.)

Meanwhile, the Biden administration is seeking to put on hold an order by a federal judge in North Dakota who ruled in favor of 19 states that challenged a rule allowing — for the first time — enrollment in ACA coverage by “dreamers,” people brought to the United States as children without immigration paperwork.

The Dec. 9 ruling effectively barred those who qualified for the Deferred Action for Childhood Arrivals (DACA) program in the 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case have said.

On Monday, the U.S. Court of Appeals for the 8th Circuit granted a temporary stay of the order at the government’s request. A final decision, expected any day, could extend the stay while the court hears the appeal.

The Biden administration argues that North Dakota hasn’t proved it would be harmed by the rule — and that not granting a stay would be disruptive. The Dec. 9 order would cause the federal government to incur financial costs if it has to retool the marketplace to reflect the change and notify those who have already enrolled that their plans are canceled, the administration argued.

The original case was filed in August in U.S. District Court in North Dakota and is being heard by District Judge Daniel Traynor, who was nominated in 2019 by then-President Donald Trump.

Previously, the federal government estimated that about 100,000 uninsured people out of a half-million DACA recipients might sign up for 2025 coverage. In its new filing, the government says 2,700 have enrolled through the federal marketplace, and an unknown number in states involved in the litigation that run their own state-based marketplaces.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purpose of enrolling in plans under the ACA.

All the states challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the United States when they don’t have permanent legal authorization.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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.

USE OUR CONTENT

This story can be republished for free (details).

New enrollments under the Affordable Care Act are on pace to trail last year’s record numbers by as many as a million as the outgoing Biden administration confronts upheavals in the program.

Donald Trump’s election to a second term has cast uncertainty around the future of the health law. In addition, the Biden administration implemented cumbersome policies to reduce fraudulent enrollment and is combating a lawsuit that aims to block immigrants who lack legal residency from buying insurance under the program.

So far, the number of new and returning enrollees using healthcare.gov — the federal marketplace that serves 31 states — is below last year’s. New enrollments were just over 730,000 in early December, compared with 1.5 million at the same time last year.

To give consumers in federal marketplace states more time to enroll, the Centers for Medicare & Medicaid Services extended to Dec. 18 the deadline to sign up for coverage that starts Jan. 1. (The Jan. 15 deadline is for coverage that would begin Feb. 1.)

Also in flux is a rule issued by the Biden administration allowing — for the first time — enrollment in ACA coverage by people brought to the U.S. as children without immigration paperwork, known as “Dreamers.”

The Biden team was granted a temporary stay on Dec. 16 by the U.S. Court of Appeals for the 8th Circuit regarding a Dec. 9 order by a federal judge in North Dakota. That district court judge had ruled in favor of 19 states that sought to block the Biden administration’s Dreamers directive. Without a stay, the decision in that case, Kansas v. the United States, effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in the 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case have said.

A final decision on the temporary stay was expected any day now. If granted, it could allow Dreamers to continue enrolling while the government’s appeal of the district court ruling is heard, which is unlikely to occur before Trump takes office.

In its court filings, the Biden administration argues that not granting a stay would be very disruptive in the middle of open enrollment, causing the federal government to incur costs in retooling its marketplace to reflect the change, and notifying those who have already enrolled that their plans are canceled.

The original case was filed in August in the U.S. District Court for the District of North Dakota and is being heard by District Judge Daniel Traynor, who was nominated in 2019 by then-President Trump.

Previously, the federal government estimated that about 100,000 uninsured people out of a half-million DACA recipients might sign up for 2025 coverage. In its new filing, the government says 2,700 have enrolled in those states that brought the suit and use the federal marketplace.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to citizens and those who are called “lawfully present” immigrants.

The federal lawyers argue that North Dakota has not proved it would be harmed by the rule, so it has no standing to bring the case. North Dakota argued that it incurs costs for approximately 130 DACA recipients who live in its state, and that it would not have those expenses if they were barred from enrolling in the ACA and thus decided to leave the country. An exodus is unlikely, the federal government argued. The legal brief also questioned North Dakota’s calculation that it incurs costs of $585 to issue driver’s licenses to the DACA recipients and about $14,000 annually to educate at least one DACA member or dependent.

All the states challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The plaintiff states are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.

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

USE OUR CONTENT

This story can be republished for free (details).

Ann Lewandowski knows all about pharmacy benefit managers, or PBMs, the companies that shape the U.S. drug market. Her job, as a policy advocate at drugmaker Johnson & Johnson, was to tell patient and physician groups about the PBMs’ role in high drug prices.

Armed with that knowledge, Lewandowski filed a potentially groundbreaking lawsuit in February. Rather than targeting the PBMs, however, she went after a big company that uses one — her own employer, Johnson & Johnson.

Lewandowski charges in her lawsuit that by contracting with the PBM Express Scripts, which is part of the insurance giant Cigna, Johnson & Johnson — which fired her in April — failed in its duty to ensure reasonable drug prices for its more than 50,000 U.S. employees.

By choosing an Express Scripts plan, she charged, J&J cost employees “millions of dollars in the form of higher payments for prescription drugs, higher premiums, higher deductibles, higher coinsurance, higher copays, and lower wages or limited wage growth.”

Lewandowski, 40, from outside Madison, Wisconsin, relies on an expensive multiple sclerosis drug. She brought the lawsuit, she said, because she “had trouble aligning the policy positions” she reported on as a J&J employee “with the actions I experienced as a health plan user.”

In recent years, the opaque business practices of PBMs have drawn fire. The Federal Trade Commission is conducting a lengthy investigation of the three biggest companies and sued them in September, accusing the firms of driving up insulin prices. Bipartisan bills in Congress would rein them in. And businesses such as Mark Cuban’s Cost Plus Drugs and smaller, “transparent PBMs” have tried to wean pharmaceutical companies and health plans from their reliance on the big PBMs.

But Lewandowski’s lawsuit goes to a sensitive spot that had been overlooked until recently: language in the 2021 appropriations bill that revised the 1974 Employee Retirement Income Security Act, known as ERISA. The original law focused on stopping fraudulent retirement plans.

Her lawsuit is based on congressional language specifying that the law’s requirement of prudent management covers health as well as retirement benefits. By providing workers with a health plan, employers aren’t “doing you a favor. They are holding your money and investing it in your health,” said Barak Richman, a George Washington University health law professor.

In July, a similar lawsuit was filed against Wells Fargo, and more suits are in the works.

PBMs demand discounts and rebates from drugmakers, which leads the manufacturers to charge higher list prices, which can drive up the price patients pay at the pharmacy. At the same time, retail pharmacies say PBMs are driving them out of business by paying them less than what the PBMs charge health plans — a practice known as spread pricing. Patients typically have no idea what they’ll pay for a drug, and neither do their employers, because many PBMs’ contracts contain nondisclosure clauses.

Dissatisfaction with the status quo and fear of liability are pushing employers to switch from the “Big Three” PBMs to “transparent PBMs,” which don’t shroud their pricing and drug choice decisions.

“We brought on nine Fortune 500s this year, 1.2 million patients,” said AJ Loiacono, CEO of New York City-based Capital Rx, a PBM founded in 2017. According to a recent survey, as many as half of U.S. employers are considering switching.

Cuban, in an interview with KFF Health News, said he has told hundreds of Fortune 500 executives, in one-on-one meetings and in groups, that they are overpaying on drug benefit plans skewed to fatten the wallets of big PBMs.

“You’re getting ripped off,” Cuban said he tells them. “You don’t really understand the elements, and that’s costing you money and costing you wellness. And now you are going to get sued. It’s not a question of if but a question of when.”

Pressuring a Purchasing Cartel

The billionaire, who launched Mark Cuban Cost Plus Drugs in 2022 to upend the byzantine $500 billion U.S. drug market, is convinced that the Lewandowski suit and others will end the dominance of the big PBMs, which control 80% of the business.

Cost Plus Drugs charges a straight 15% markup with small processing fees for the 2,500 drugs it sells, most of them generics, said co-founder Alex Oshmyansky. Its nearly 3 million customers — individuals, health plans, and transparent PBMs — appear to be saving money in many cases.

The big PBMs say their buying power and exclusive access to information enable them to save money for insurers, employers, and patients. Critics say they are skimming up to 25% from the drug market, perhaps $100 billion a year, according to Oshmyansky. The opaque strategies and conflicts of interest, critics say, often result in the poorest, sickest patients paying the most for medications.

The three PBMs amount to a “purchasing cartel,” Oshmyansky said in an interview at Cost Plus’ Dallas headquarters, once the office of broadcast.com, the internet radio company that made Cuban his first billion dollars when he sold it to Yahoo in 1999. “They buy all the drugs, they jack up the prices, and then they resell them.”

Richman and Amy Monahan of the University of Minnesota argued in a journal article this year that the Department of Labor, which has previously focused its ERISA oversight on retirement benefits, should issue standards for the use of health care dollars under the law.

When companies “enter into dumb contracts with insurers or PBMs, arguably they are in violation of ERISA,” Richman said. “Taking the law seriously would really require employers, who are spending half the health care dollars in the country, to spend that money in very different ways.”

Some drug market experts, however, doubt the ERISA lawsuits will succeed. Complex PBM money channels “make it hard to build a case,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University School of Medicine. “You might think your company is overpaying, but relative to what?”

The ERISA Industry Committee, which lobbies Congress for some of the biggest U.S. companies, is asking Congress to give PBMs the specific duty to represent their clients’ financial interests, said Melissa Bartlett, the group’s senior vice president for health policy. That could require patients to sue the PBMs rather than their employers.

A few big employers are already changing their drug plans.

In 2019, Connecticut became CVS’ first PBM customer to negotiate a transparent fee structure. Its contract required 100% of drug rebates be passed along to the state and eliminated spread pricing.

The state decided to go further when it sought a new contract for its 214,000 employees this year, said Joshua Wojcik, director of health policy and benefits in the state comptroller’s office. Instead of discounts and rebates, it demanded the lowest net cost per employee.

Of the three big PBMs, only CVS bid on the contract. It edged out a few “transparent PBMs” — a sign, in Wojcik’s view, that CVS at least doesn’t want to be left out as more customers ditch the current PBM business model.

With the change, Wojcik estimates the state will save up to $70 million a year.

$13.40 vs. $2,500

Changing drug benefit policies at big companies takes time, said Oshmyansky of Cost Plus. Their PBM contracts last three to five years, so “you have to capture them in that one year where they are evaluating other options,” he said. PBMs pay benefit plan consultants and the brokers big companies hire to steer business their way.

“We have this weird structure where multiple sclerosis, cancer patients subsidize everybody else’s drugs,” Oshmyansky said. Instead of creating a pool that spreads costs to everyone with insurance, there’s a “disproportionate burden placed on the sickest members.”

Cost Plus generates the biggest savings for its customers on about 50 extraordinarily high-priced generic drugs. The poster child is imatinib, a generic cancer pill that Cost Plus sells for $13.40 for a 30-day supply, compared with the $2,500 it retails for at pharmacies. A study conducted by Dusetzina and colleagues found Medicare could save $662 million a year just by buying imatinib and six other generic cancer drugs from Cost Plus rather than through a big PBM.

Ironically, though, most generic drugs are cheaper in the U.S. than in Europe or Canada — so cheap, in fact, that they fall into shortages as companies get out of the business or stop making needed improvements to their production lines.

In response, Cost Plus has started a compounding pharmacy to make common generics and soon hopes to have a sort of “private reserve” of 70 to 80 products that it can make on short notice if they go into shortage, Oshmyansky said.

While the company hasn’t yet set up purchase agreements for most brand-name drugs, Oshmyansky and Cuban are hopeful. Drugmakers, through their trade group Pharmaceutical Research and Manufacturers of America, have lobbied fiercely to rein in PBMs in the past two years.

At a Sept. 24 hearing at which Sen. Bernie Sanders (I-Vt.) grilled Novo Nordisk CEO Lars Fruergaard Jørgensen over high prices for diabetes and weight loss drugs Ozempic and Wegovy, the executive expressed support for a more transparent pricing model.

“On average for our products we give 74% in rebates to PBMs” for every $1 the company charges, he said. If, instead, “we simply paid the PBMs a small fee for the limited risk and contribution they make, I think patients would be significantly better off.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Among the biggest-grossing films in America in February 2002 were a war drama about American troops in Somalia (“Black Hawk Down”), an Arnold Schwarzenegger action movie (“Collateral Damage”), and a future Oscar winner about a brilliant mathematician struggling with schizophrenia (“A Beautiful Mind”).

But none of these films topped the box office that month. That title went to “John Q.,” a movie about health insurance.

Or, more precisely, a story about a desperate father — played by Denzel Washington — who takes a hospital emergency room hostage at gunpoint when his HMO refuses to cover a heart transplant for his young son.

John Q.’s violent quest for justice was, of course, fictional. And even in the film, no one ends up dead.

Tragically, that wasn’t the case on the streets of New York City on Dec. 4 when a gunman fatally shot Brian Thompson, CEO of health insurance giant UnitedHealthcare.

But there was nothing new about the anger at health insurers that Thompson’s shooting unleashed online — and which suspect Luigi Mangione expressed in a document he allegedly wrote.

In fact, eruptions of public rage have shadowed the American health care system for decades.

In the late 1990s and early 2000s, as “John Q.” was hitting movie screens, Americans were revolting against HMOs, whose practice of denying care to plan members to pad their bottom lines made them public enemy No. 1.

Just a few years later, health insurers stoked new ire for rescinding coverage after people were diagnosed with expensive illnesses like cancer. More recently, insurers’ widening use of cumbersome prior authorization procedures that slow patients’ access to care has provoked yet another round of fury.

The cycle of outrage periodically turns on others in the health care industry as well. Exorbitant bills and aggressive collection tactics, such as garnishing patients’ wages, are sapping public trust in hospitals and other medical providers.

And drug companies — perennial poster children for greed and profiteering — have enraged Americans since at least the 1950s, when new “wonder drugs” like steroids were fueling a growing industry.

When Sen. Estes Kefauver, a Tennessee Democrat who had led an investigation of the Mafia, convened hearings in 1959 to probe high prescription prices, his committee received mountains of mail from Americans who reported being fleeced by drugmakers. One retired rail worker told of having to spend more than a third of his retirement income on medicines for himself and his wife.

All this public outcry has occasionally sparked change. President Barack Obama and congressional Democrats leveraged anger at spiking insurance premiums in California to get the Affordable Care Act over the finish line in 2010, a landmark achievement that expanded health coverage to millions of Americans.

But more often, cycles of rage have been so much sound and fury, producing only modest reforms. In some cases, public anger has yielded more headaches for patients.

The HMO backlash in the late 1990s and early 2000s, for example, prompted employers — from whom about half of Americans get their health coverage — to embrace high-deductible health plans. Many employers saw these plans as a way to hold down costs if they couldn’t limit patients’ choice of medical providers through HMOs. These deductibles, which can reach thousands of dollars a year, are driving tens of millions of Americans into debt.

To many on the left who have long argued for a single-payer, government-run health system, the obstacle to more meaningful relief has been the political power of the same industries — health insurers, drug companies, hospitals — that fuel patient anger.

These industries have indeed proven adept at resisting change that threatened their bottom lines. They’ve also benefited from a paradox in how Americans think about their health care.

Patients may get angry. They may even lose faith in the system. This year, public views of health care quality fell to the lowest point since Gallup began asking about it in 2001, with 44% of Americans rating quality as excellent or good, down from a high of 62%.

Yet more than 70% said their own health care is excellent or good.

There is much debate about what accounts for this paradox. Are Americans just grateful to have the health protections they do? Are they satisfied because most don’t have to use the health care system on a regular basis? Do they simply like their doctor, in the way that voters routinely say they like their own member of Congress but hate Washington politicians? Or do they worry that no matter how frustrating the current system can be, any change risks making the situation worse?

The answer is probably a bit of all of this. Together, such sentiments represent a major challenge for those who hope the current wave of anger at health insurers will drive big improvements.

Could that change? Maybe. These are volatile and unpredictable political times. And the pressure of big medical bills is real. Medical debt, in particular, is exacting a fearsome toll on millions of Americans, KFF Health News’ reporting has shown.

But to drive change, advocates looking to harness public anger at the health care industry probably need to rethink their favored solutions. Old ideas like “Medicare for All,” long cherished on the left, or a deregulated health care market, long championed by the right, haven’t swayed Americans so far, no matter how angry they’ve been.

I don’t know when we’ll see meaningful alternatives. One thing that’s almost certainly on the way: Hollywood’s spin on the death of a health insurance executive gunned down in Midtown Manhattan.

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.

USE OUR CONTENT

This story can be republished for free (details).

Tescha Hawley learned that hospital bills from her son’s birth had been sent to debt collectors only when she checked her credit score while attending a home-buying class. The new mom’s plans to buy a house stalled.

Hawley said she didn’t owe those thousands of dollars in debts. The federal government did.Hawley, a citizen of the Gros Ventre Tribe, lives on the Fort Belknap Indian Reservation in Montana. The Indian Health Service is a federal agency that provides free health care to Native Americans, but its services are limited by a chronic shortage of funding and staff.

Hawley’s local Indian Health Service hospital wasn’t equipped to deliver babies. But she said staff there agreed that the agency would pay for her care at a privately owned hospital more than an hour away.

That arrangement came through the Purchased/Referred Care program, which pays for services Native Americans can’t get through an agency-funded clinic or hospital. Federal law stresses that patients approved for the program aren’t responsible for any of the costs.

But tribal leaders, health officials, and a new federal report say patients are routinely billed anyway as a result of backlogs or mistakes from the Indian Health Service, financial middlemen, hospitals, and clinics.

The financial consequences for patients can last years. Those sent to collections can face damaged credit scores, which can prevent them from securing loans or require them to pay higher interest rates.

The December report, by the federal Consumer Financial Protection Bureau, found these long-standing problems contribute to people in Native American-majority communities being nearly twice as likely to have medical debt in collections compared with the national average. And their amount of medical debt is significantly higher.

The report found the program is often late to pay bills. In some cases, hospitals or collection agencies hound tribal citizens for more money after bills are paid.

Hawley’s son was born in 2003. She had to wait another year to buy a home, as she struggled to pay off the debt. It took seven years for it to drop from her credit report.

“I don’t think a person ever recovers from debt,” Hawley said.

Hawley, a cancer survivor, still must navigate the referral program. In 2024 alone, she received two notices from clinics about overdue bills.

Frank White Clay, chairman of the Crow Tribe in Montana, testified about the impact of wrongful billing during a U.S. House committee hearing in April. He shared stories of veterans rejected for home loans, elders whose Social Security benefits were reduced, and students denied college loans and federal aid.

“Some of the most vulnerable people are being harassed daily by debt collectors,” White Clay said.

No one is immune from the risk. A high-ranking Indian Health Service official learned during her job’s background check that her credit report contained referred-care debt, the federal report found.

Native Americans face disproportionately high rates of poverty and disease, which researchers link to limited access to health care and the ongoing impact of racist federal policies.

White Clay is among many who say problems with the referred-care program are an example of the U.S. government violating treaties that promised to provide for the health and welfare of tribes in return for their land.

The chairman’s testimony came during a hearing on the Purchased and Referred Care Improvement Act, which would require the Indian Health Service to create a reimbursement process for patients who were wrongfully billed. Committee members approved the bill in November and sent it for consideration by the full House.

A second federal bill, the Protecting Native Americans’ Credit Act, would prevent debt like Hawley’s from affecting patients’ credit scores. The bipartisan bill hadn’t had a hearing by mid-December.

The exact number of people wrongfully billed isn’t clear, but the Indian Health Service has acknowledged it has work to do.

The agency is developing a dashboard to help workers track referrals and to speed up bill processing, spokesperson Brendan White said. It’s also trying to hire more referred-care staff, to address vacancy rates of more than 30%.

Officials say problems with the program also stem from outside health providers that don’t follow the rules.

Melanie Egorin, an assistant secretary at the U.S. Department of Health and Human Services, said at the hearing that the proposed legislation doesn’t include consequences for “bad actors” — health facilities that repeatedly bill patients when they shouldn’t.

“The lack of enforcement is definitely a challenge,” she said.

But tribal leaders warned that penalties could backfire.

White Clay told lawmakers that some clinics already refuse to see patients if the Indian Health Service hasn’t paid for their previous appointments. He’s worried the threat of penalties would lead to more refusals.

If that happens, White Clay said, Crow tribal members who already travel hours to access specialty treatment would have to go even farther.

The Consumer Financial Protection Bureau report found clinics are already refusing to see any referred-care patients due to the program’s payment problems.

The bureau and the Indian Health Service also recently published a letter urging health care providers and debt collectors not to hold patients accountable for program-approved care.

White, the Indian Health Service spokesperson, said the agency recently updated the referred-care forms sent to outside hospitals and clinics to include billing instructions and to stress that patients aren’t liable for any out-of-pocket costs. And he said the staff can help patients get reimbursed if they have already paid for services that were supposed to be covered.

Joe Bryant, an Indian Health Service official who oversees efforts to improve the referral program, said patients can ask credit bureaus to remove debt from their reports if the agency should have covered their bills.

Leaders with the Confederated Tribes of the Colville Reservation in Washington state helped shape the proposed legislation after their citizens were repeatedly harmed by wrongful billing.

Tribal Chairman Jarred-Michael Erickson said problems began in 2017, when a regional Indian Health Service office took over the referred-care program from local staff.

It “created a domino effect of negative outcomes,” Erickson wrote in a letter to Congress.

He said some tribal members whose finances were damaged stopped using the Indian Health Service. Others avoided health care altogether.

Responsibility for the Colville Reservation program transferred back to local staff in 2022. Staffers found the billing process hadn’t been completed for thousands of cases, worth an estimated $24 million in medical care, Erickson told lawmakers.

Workers are making progress on the backlog and they have explained the rules to outside hospitals and clinics, Erickson said. But he said there are still cases of wrongful billing, such as a tribal member who was sent to collections after receiving a $17,000 bill for chemotherapy that the agency was supposed to pay for.

Erickson said the tribe is in the process of taking over its health care facilities instead of having the Indian Health Service run them. He and others who work in Native American health said tribally managed units — which are still funded by the federal agency — tend to have fewer problems with their referred-care programs.

For example, they have more oversight over staff and flexibility to create their own payment tracking systems.

But some Native Americans oppose tribal management because they feel it releases the federal government from its obligations.

Beyond wrongful billing, access to the referred-care program is limited because of underfunding from Congress. The $1 billion budget this year is $9 billion short of the need, according to a committee report by tribal health and government leaders.

Donald Warne, a physician and member of the Oglala Sioux Tribe in South Dakota, called the proposed legislation a “band-aid.” He said the ultimate solution is for Congress to fully fund the Indian Health Service, which would reduce the need for the referred-care program.

Back in Montana, Hawley said she braces for a fight each time she gets a bill that the referral program was supposed to cover.

“I’ve learned not to trust the process,” Hawley said.

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

USE OUR CONTENT

This story can be republished for free (details).

ERWIN, Tenn. — April Boyd texted her husband before she boarded the helicopter.

“So, I don’t want to be dramatic,” she wrote on Sept. 27, “but we are gonna fly and rescue patients from the rooftop of Unicoi hospital.”

Earlier that day, Hurricane Helene roared into the Southern Appalachian Mountains after moving north through Florida and Georgia. The storm prompted a deadly flash flood that tore through Unicoi County in eastern Tennessee, trapping dozens of people on the rooftop of the county hospital.

The fast-moving floodwaters had made earlier rescue attempts by ambulance and boat impossible. Trees, trailers, buildings, caskets, and cars swept past the hospital in murky, brown rapids that overwhelmed the one-story structure with 12 feet of water on all sides.

No one knew how long the hospital’s frame would hold or if the rising water would breach the top of the 20-foot-tall building. Little more than a mile downstream, six people at a plastics plant in Erwin’s industrial park died in the flood.

“I do not feel good about this,” Boyd, a flight nurse for Ballad Health, texted her husband at 1:41 p.m., just before takeoff.

She wrote that she loved him. “If anything goes wrong,” she wanted him to tell her daughters “how much I love them,” too.

Her fears were well-founded.

In 2018, Unicoi County Hospital relocated from higher ground in the heart of Erwin to the southern edge of town, between Interstate 26 and the Nolichucky River. The new hospital was built in a known flood plain, but the facility wasn’t designed to accommodate helicopter landings on its roof. Boyd and her team weren’t sure the roof could bear the weight of their 7,200-pound Eurocopter in good weather, let alone during a flash flood.

“I had a horrible feeling about it,” she said.

By many accounts, the evacuation of 70 people, including 11 patients, by helicopter that day was a stunning success. The hospital was destroyed, but no one died. No one was even physically injured by the ordeal.

Yet, earth scientists, emergency management officials, and others who spoke to KFF Health News describe the narrow escape from Unicoi County Hospital as a cautionary tale. As climate change forces health care leaders and public officials to prepare for severe storms in landlocked parts of the country — where residents haven’t historically paid much attention to hurricane warnings — they must be strategic about both the infrastructure design and the locations selected for new projects, like hospitals.

The Biden administration finalized a rule this year designed to make the construction of such projects that receive funding from the Federal Emergency Management Agency more resilient to flooding. But a review by KFF Health News identified about 20 other Tennessee hospitals already built in, or near, flood plains.

Patrick Sheehan, director of the Tennessee Emergency Management Agency, said past weather patterns can lull people into a false sense of security. But, he added, “past is not always prologue. We’re going to experience novel, new ways of having disasters.”

Historically, the Southern Appalachian Mountains have been the place “where hurricanes go to die,” said Ryan Thigpen, an earth and environmental sciences professor at the University of Kentucky whose research focuses on flooding in the region. But as the Gulf of Mexico becomes warmer and storms, like Helene, that move northward into the mountains carry more moisture, weather events will become more severe.

“It’s apocalyptic,” said Thigpen, of the damage in Erwin. “The next storm may come before they are finished recovering from this. And that’s kind of scary.”

Hospitals in Flood Plains

All week, Michelle Matson had been worried about Unicoi County Hospital in the oncoming storm.

As a district coordinator for the Tennessee Emergency Management Agency, Matson works with local officials to plan for worst-case scenarios.

Leading up to Hurricane Helene, she’d been in regular communication with the county’s emergency management director. The hospital’s vulnerability next to the river kept coming up.

“That was the only place we were worried about,” Matson said.

But concern over the hospital’s location wasn’t new.

In November 2013, Unicoi County Memorial Hospital, which opened in 1953, was acquired by Mountain States Health Alliance on the condition that Mountain States would construct a hospital in Erwin to replace the old one.

Two years later, Mountain States purchased a 45-acre tract of land next to a bend in the Nolichucky River, just off Interstate 26. A hospital system press release at the time explained that due diligence had been conducted to ensure, among other things, that the hospital building would not be in a flood plain. It also presented the location as desirable because it was near the interstate and the landscape would provide “a healing environment by taking advantage of the natural beauty of Unicoi County, with the river running along the east side of the property.”

Dating back decades, though, flood maps published by FEMA put the entire property in a flood plain. The building itself was in a 500-year flood plain (meaning a 0.2% chance of flooding in any given year), while the only road on and off the property was in a 100-year flood plain (meaning a 1% annual risk).

But it wasn’t only FEMA maps that forecast this possibility. In 2001, a report published by Unicoi County marked this land as being in a “flood hazard” area. The report warned of “considerable pressure” to develop flood hazard areas across the county “due to population increase and the need for vacant land.”

The same report acknowledged a history of destructive flooding in the county and the risks it faced being situated along “three major streams,” including the Nolichucky River, which flows northward out of the Blue Ridge Mountains of western North Carolina straight through Erwin.

“If you start looking at the river’s history, there are a number of these notable flood events, and quite a few in the 20th century. They just did not reach this magnitude,” said Philip Prince, a geologist with Appalachian Landslide Consultants. His YouTube videos about mountain flooding during Helene have been viewed hundreds of thousands of times. “People should have been expecting more than they did. But again, we have not seen anything like this.”

Matthew Rice, a former Unicoi County commissioner, served as chair of the Hospital Visioning Committee for the new hospital in 2015. He said some committee members raised questions during the planning process about the location, but he conceded there weren’t many large, flat places to build a hospital in Erwin.

Amid a wave of rural hospital closures across the United States, Erwin residents celebrated when the new hospital opened in 2018. One lawmaker told the Johnson City Press it was “the most modern facility on the planet.”

Alan Levine was CEO of Mountain States Health Alliance during that time and later became the head of Ballad Health, when Mountain States merged with a competing hospital system in 2018 to form the largest state-sanctioned hospital monopoly in the country.

Levine said Mountain States was aware the property carried flood risk but noted that the hospital system added levees to protect the building from river flooding at the recommendation of outside consultants. One levee already existed along the river’s edge. And the hospital itself was deliberately constructed on a high point of the land, at the same elevation as the interstate, Levine said.

“I feel like everything we did when we built it was done the right way,” said Levine, a former health care leader in Louisiana and Florida.

Even so, Matson, who lives in Kingsport, about 45 minutes northwest of Erwin, said some residents were quietly critical of the new hospital’s location.

“We all thought that it was a stupid idea to build a hospital in a flood plain. It’s like, who does that?” Matson said. She said her opinion doesn’t represent an official position of the Tennessee Emergency Management Agency.

But Unicoi isn’t the only Tennessee hospital built in a flood plain. Eight others across the state were built in moderate- or high-risk flood zones, and a dozen other hospitals are situated just outside them, KFF Health News found.

The hospitals at risk span the length of the state, from Memphis on the western edge to Knoxville in the east, and include big-city general hospitals, smaller rural hospitals, and behavioral health facilities.

Some of the hospitals are decades old. Parkridge East Hospital in Chattanooga, for example, was built in the 1970s inside a high-risk flood zone. Others are more recent — like Creekside Behavioral Health in Kingsport. That building, which opened in 2018, straddles high- and moderate-risk flood zones.

Then there are facilities like Pinewood Springs in Columbia. The 60-bed mental health facility, which opened in 2020, is in a low-risk area, but the main road leading in and out of the hospital lies in a high-risk flood area.

To identify these hospitals, KFF Health News looked for licensed facilities in or near areas that, according to FEMA, have either a high flood risk (with a 1-in-100 chance of flooding in any given year) or moderate risk (a 1-in-500 chance in any given year).

But FEMA’s maps likely underestimate the true flood risk, researchers and government watchdogs agree, because they’re largely outdated and don’t account for current or future conditions, including more frequent and more intense storms and flooding associated with climate change.

Those maps are updated on an ongoing but slow and piecemeal basis. Meanwhile, the federal regulation finalized this year to expand areas considered at risk for current and future flooding also sets more stringent building standards for critical infrastructure projects located in 100-year flood plains and funded by federal taxpayers.

The rule became effective on Sept. 9, less than three weeks before Hurricane Helene ravaged the Southern Appalachians, but it is unclear whether the incoming Trump administration will preserve it.

After he took office in 2017, President Donald Trump revoked federal flood protection standards set up under the Obama administration. Karoline Leavitt, a spokesperson for the incoming Trump administration, did not respond to emailed questions for this article.

An ‘Antiquated and Broken’ System

On Sept. 24, three days before the hospital evacuation, the National Hurricane Center issued the first of several warnings predicting significant river flooding and landslides in the Southern Appalachians. Two days before the flood in Erwin, a satellite office of the National Weather Service in Morristown, Tennessee, predicted “life-threatening flash flooding” near the Tennessee-North Carolina state line.

The warnings kept coming. The National Weather Service in upstate South Carolina forecast on Sept. 26, a Thursday, that Helene would amount to one of the region’s most significant weather events “in the modern era.”

“I don’t think people knew what that meant,” said Prince, the geologist. “We just didn’t have a precedent.”

Ballad Health didn’t anticipate that Unicoi would flood during the storm, Levine said, even though a hazard vulnerability assessment conducted annually for the hospital identifies external flooding as the second-highest risk facing Unicoi County Hospital, behind only a civil disturbance. The same 2024 assessment rated the hospital’s preparedness for a flood as a “3” or “low,” the worst possible score.

But a document outlining the hospital’s emergency alert procedures makes no mention of flood risk. If anything, hospital leaders said they were anticipating a surge of patients during Hurricane Helene if Erwin and the surrounding area experienced widespread power outages.

“There was no conversation I had with anybody, anywhere about the risk of flooding before Friday morning,” Levine said.

The day before, Jennifer Harrah, the hospital’s administrator, had called a meeting to discuss the storm. Sean Ochsenbein, an emergency medicine physician and the hospital’s chief medical officer, recalled that the group gathered “just to kind of circle the wagons, make sure everybody was on the same page.”

Later that day, Harrah spoke to Unicoi County’s emergency management director. But “let me be very clear,” Ochsenbein said. “Nobody gave us — as Ballad or our hospital — any kind of indication that we would have floodwaters.”

And yet little more than 24 hours after their planning meeting, both Harrah and Ochsenbein were stranded on the hospital roof, literally praying to God for their rescue.

“I called my husband, and I called my sons,” Harrah said. “I told them that I loved them.”

One reason the impact of the storm seemed to catch people off guard was a disconnect between the strong warnings issued by the federal agencies and the low expectations that many people in the region, including Ballad Health leaders, had of the potential flood risk.

It was sunny outside when people were evacuated from the hospital roof, Thigpen pointed out. It had rained about 5 inches in Erwin over several days, but that was nothing compared with places in the North Carolina mountains that received more than 20 inches over the same period. Rainfall at those higher altitudes eventually drained into the rivers and streams that ultimately destroyed places like Erwin.

But residents in Unicoi County had no clue what was coming their way, Thigpen said, because there weren’t river gauges upstream to sound alarms about dangerous water levels.

“I think that our warning systems are antiquated and broken,” he said. “These people in Erwin have seen floods — and a lot of big floods — and it’s never been anywhere close to this.”

Tennessee state climatologist Andrew Joyner is one of several experts now calling for more river gauges to monitor water levels and a network of weather stations in every county designed to collect live precipitation data.

Thirty-eight states already operate similar systems, he said, estimating that setting up and staffing weather stations across Tennessee would cost less than $4 million in the first year.

But the state has failed to act before. Following a catastrophic flood in Waverly, Tennessee, that killed 20 people and destroyed hundreds of homes and businesses in 2021, the Tennessee General Assembly denied a $200 million request to relocate 14 public schools across the state that had been deemed vulnerable to future flooding.

‘Might Not Make It Back’

On the morning of the flood, Matson had stood with the county’s emergency management director behind Unicoi County Hospital and watched the rising river. “We both had this, like, sick feeling in our stomach that said we’ve got to evacuate,” she remembered. “I said to him, worse comes to worst, we evacuate, nothing happens. Just blame it on me.”

They made the call to start moving patients out of the hospital just before 9:45 a.m. Less than 30 minutes later, the river had breached its banks, cutting a new channel in front of the hospital and eliminating access to the only road on or off the property.

When an ambulance evacuation became untenable, the Tennessee Emergency Management Agency called in swift-water teams, specially designed to rescue people in turbulent waters. But the flash flood had become so violent and the river was so full of debris that the boats couldn’t safely carry patients away. Meanwhile, dangerous wind conditions prevented helicopters located to the east or west from immediately flying that morning to rescue everyone by air.

“To be honest, I really thought we may not make it back” from the rescue mission, Boyd, the flight nurse, said.

When the wind started to die down that afternoon, Virginia State Police deployed two helicopters to rescue patients. Eventually, three Black Hawk helicopters from the Tennessee National Guard assisted in the effort. Pilots were required to make multiple round trips between the hospital and the local high school to evacuate four or five people at a time who had been stranded by the flood. Some patients stranded in boats near the hospital were hoisted into helicopters, while those who were stranded on the roof were either carried onto the aircraft or climbed aboard while the helicopters lightly touched down on their skids.

As the afternoon wore on and the evacuation was nearing its completion, pilot Jeff Bush with the Virginia State Police said he learned that the hospital building was weakening. They weren’t sure how much longer it would hold.

“It was intense,” he said. “The fact that the building is still standing is, I think, kind of amazing.”

Ballad Health evacuated two other hospitals and one nursing home by ambulance within 24 hours of the flood in Erwin, but none of those sustained damage. Meanwhile, what’s left of Unicoi County Hospital stands next to the Nolichucky in a field of mud and displaced river rocks.

For now, Ballad Health has opened a temporary urgent care center and plans to establish an emergency department at the site of the former Unicoi County Memorial Hospital in downtown Erwin.

Levine said Ballad Health will eventually rebuild a full-service hospital, but he estimated the project would cost $50 million, roughly twice as much as it did in 2018. It remains unclear where it would be built.

Probably not in a flood plain, Levine said. “I would avoid it if I could.”

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.

USE OUR CONTENT

This story can be republished for free (details).

When George Lai of Portland, Oregon, took his toddler son to a pediatrician last summer for a checkup, the doctor noticed a little splinter in the child’s palm. “He must have gotten it between the front door and the car,” Lai later recalled, and the child wasn’t complaining. The doctor grabbed a pair of forceps — aka tweezers — and pulled out the splinter in “a second,” Lai said. That brief tug was transformed into a surgical billing code: Current Procedural Terminology (CPT) code 10120, “incision and removal of a foreign body, subcutaneous” — at a cost of $414.

“This was ridiculous,” Lai said. “There was no scalpel.” He was so angry that he went back to the office to speak with the manager, who told him the coding was correct because tweezers could make an incision to open the skin.

When Helene Schilders of Seattle went to her dermatologist for her annual skin check this year, she mentioned her clothing was irritating a skin tag she had. The doctor froze the tag with liquid nitrogen. “It was squirt, squirt. That’s it,” Schilders told me. She was “floored” by an explanation of benefits that said the simple treatment had been billed as $469 for surgery.

Assuming the bill was a mistake, she called the doctor’s office and was told that surgery had indeed occurred — because the skin was broken in the process. Hence surgical CPT code 17110, “destruction of 1-14 benign lesions.”

Schilders complained to her insurer, who provided a document informing her that “surgery is classified as something entering the body, such as a Q-tip entering the ear canal or a scalpel during surgery.”

Huh? “I have had surgery, and this is not it,” Schilders said.

In common vernacular, “surgery” evokes images of physicians and nurses leaning over an operating table, gowned and masked, as they address a problem deep in the body. Removing an appendix or a tumor. Replacing a knee. Clipping a leaking aneurysm in the brain. It most probably involves a scalpel or specialized instruments and surgical skill.

More and more minor interventions, however, have been rebranded and billed as surgery, for profit. These tiny interventions don’t yield huge bills — in the hundreds rather than the thousands of dollars — but, cumulatively, they likely add up to tens if not hundreds of millions of dollars for doctors and hospitals annually. The surprise bills often catch patients off guard. And they must pay up if they haven’t met their insurance deductible. Even if they have, “surgery” generally requires a coinsurance payment, while an office visit doesn’t.

“There’s more pressure to make money, and the idea is you can charge more if it’s a surgical procedure,” said Sabrina Corlette, founder and co-director of Georgetown University’s Center on Health Insurance Reforms. “The payer should be reviewing this and saying this is run-of-the-mill. But there’s not a lot of incentive to do that.”

Corlette surmised that the codes employed in the instances mentioned above were intended for rare, complicated cases in which the removal of a splinter or a skin lesion — or 14 of them — required special skills or time. But the codes’ use has ballooned, covering the complicated and the commonplace. The use of code 17110 billed from doctors’ offices has gone up 62% from 2013 (1,739,708) to 2022 (2,817,190).

The blizzard of surgeries-in-name-only is a symptom of a system that has long valued procedures far more than intellectual work in its payments to medical providers. That merits rethinking, and there are some hints that the incoming presidential administration might be interested in doing so.

The current payment calculation system has its origins in the late 1980s, when a team led by an economist at Harvard University’s public health school, William Hsiao, created what’s called the Resource Based Relative Value Scale, or RBRVS, to rationalize Medicare’s payments to doctors. It allocated reimbursement using a formula that included physician work, practice expenses, and malpractice expenses. It concluded “that the work per unit time (a measure of intensity) for invasive services is about three times that of evaluation/management.”

In other words, it enshrined the notion that “invasive services” — procedures or surgery — were by far the most valuable.

An American Medical Association committee that includes physicians from an array of specialties periodically suggests updates to those codes (and federal regulators accept them, in many years, over 90% of the time). Since surgeons are overrepresented on the committee, the valuation of anything defined as an operation has only increased, giving billers the incentive to classify even the most mundane interventions as surgery.

Experts of all political stripes have spent years critiquing the process — it’s common sense that the fox (physicians) should not be guarding the henhouse (payments). President-elect Donald Trump’s pick for Health and Human Services secretary, Robert F. Kennedy Jr., has signaled that he might rethink that approach, according to the health-industry publication Stat. Kennedy has not outlined an actual plan to replace the current process, but he is reportedly exploring if the Centers for Medicare & Medicaid Services, a government agency, could do it instead.

Absent reform, on it goes.

Anthony Norton of Puyallup, Washington, took his 3-year-old daughter to a doctor this year because she had a bothersome plantar wart on her foot. The doctor applied a chemical ointment to the wart in the office every two weeks and covered it with a Band-Aid. When the child arrived for a third visit, Norton was informed he had an outstanding balance of $465 (in addition to the $25 office visit copay already paid) because the application was “surgery.” CPT code 17110 again.

“It made no sense,” Norton later recalled. The billing office assured him it was surgery, he said, “because the ointment penetrates the skin.”

Norton wondered: “When you extrapolate that, is putting on Neosporin or calamine surgery, too?”

We are now in an era in which a neurologist spending 40 minutes with a patient to tease out a diagnosis can be paid less for that time than a dermatologist spending a few seconds squirting a dollop of liquid nitrogen onto the skin.

Lai was so angry at being charged more than $400 to pull that splinter out of his child’s hand that he went on a crusade, returning to the dermatologist’s office when his calls were ignored, accusing it of fraud and threatening to complain to his insurer. Only then, he said, did the doctor’s office waive the surgical charge — and kick him and his family out of the practice.

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.

USE OUR CONTENT

This story can be republished for free (details).

The Host Julie Rovner KFF Health News @jrovner 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 shooting death of UnitedHealthcare CEO Brian Thompson on the streets of New York City prompted a surprising wave of sympathy for the perpetrator, rather than the victim, from Americans who say they have been wronged by their health insurers. It remains to be seen whether backlash from the killing will result in a more serious conversation about what ails the health care system.

Meanwhile, in some of his first extended interviews since the election, President-elect Donald Trump continued to be noncommittal about his plans for health care in general and the Affordable Care Act in particular.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The killing of UnitedHealthcare’s chief executive has amplified simmering anger and distrust over the nation’s health care system. Many people are upset about the cost of care, limitations of coverage, gaps in access — and much more. While Democratic policymakers have pushed in recent years to insure as many Americans as possible, insurance coverage is only part of the equation in resolving the system’s ills.
• There’s not much time left for this Congress. Still on the agenda is passing funding for some health priorities. Extending telehealth access, for instance, is a small but key issue for which lawmakers will need to find money to offset the cost of an expensive program. And cultural issues continue to play a role, with the House passing a defense spending package this week that would cut coverage for gender-affirming care for minor dependents of those in the armed forces.
• And Trump’s recent interviews with NBC News’ “Meet the Press” and Time magazine offered little clarity on his health care plans. He referred to making changes to the ACA and not making changes to abortion pill availability — but it is clear that such issues are not among his top concerns and that policies will depend largely on the personnel within the health agencies.

Also this week, Rovner interviews Francis Collins, who was the director of the National Institutes of Health and a science adviser to President Joe Biden.

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

Julie Rovner: KFF’s “Medicare Spending was 27% More for People Who Disenrolled From Medicare Advantage Than for Similar People in Traditional Medicare,” by Jeannie Fuglesten Biniek, Alex Cottrill, Nolan Sroczynski, and Tricia Neuman. 

Alice Miranda Ollstein: CNN’s “Most Women in the US Aren’t Accessing Family Planning Services, Even as Abortion Restrictions Grow,” by Deidre McPhillips. 

Sandhya Raman: Stat’s “Spending Less, Living Longer: What the U.S. Can Learn From Portugal’s Innovative Health System,” by Usha Lee McFarling. 

Rachel Cohrs Zhang: ProPublica’s “‘Eat What You Kill,’” by J. David McSwane.

Also mentioned in this week’s podcast:

• NBC News’ “Read the Full Transcript: President-Elect Donald Trump Interviewed by ‘Meet the Press’ Moderator Kristen Welker.”
• Time magazine’s “Donald Trump: 2024 TIME Person of the Year,” by Eric Cortellessa.
• Politico’s “How Trump’s Transition Could End Up Hamstringing His Agenda,” by Alice Miranda Ollstein.
• KFF Health News’ “Federal Judge Halts Dreamers’ Brand-New Access to ACA Enrollment in 19 States,” by Julie Appleby.

Credits Taylor Cook Audio producer Lonnie Ro Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

Eloisa Mendoza ha pasado 18 años ayudando a personas que no dominan el inglés a comprender documentos legales complejos. Los guía en medio de eventos estresantes, repletos de denso papeleo, como solicitudes de ciudadanía, divorcios y traducciones de actas de nacimiento.

Mendoza trabaja en Elko, Nevada, una región remota en el noreste del estado. Su labor se ha vuelto cada vez más importante a medida que la población latina de la ciudad ha crecido a aproximadamente el 26%. El porcentaje de personas de 5 años o más que hablan un idioma distinto al inglés en casa aumentó al 18% en 2022, y el español es el idioma hablado en casi el 15% de los hogares.

A pesar de la creciente demanda para que los gobiernos rurales locales se comuniquen con los residentes en idiomas distintos al inglés, los legisladores estatales en Nevada excluyeron a los condados más pequeños de una ley estatal de acceso lingüístico que se promulgó recientemente. Más gobiernos estatales y locales han implementado medidas similares en los últimos años, pero están concentradas en su mayoría en jurisdicciones urbanas o suburbanas.

Aunque la América rural es en su mayoría blanca no hispana y angloparlante, se ha vuelto rápidamente más diversa.

Sin embargo, implementar leyes estatales y locales de acceso lingüístico es un desafío, según investigadores, dado que los estándares pueden variar entre agencias estatales y localidades, lo que dificulta garantizar asistencia de alta calidad a los que hablan idiomas diferentes al inglés.

No proporcionar acceso lingüístico a quienes lo necesitan no solo constituye una violación de los derechos civiles protegidos por el Título VI de la Ley de Derechos Civiles, sino que también puede generar preocupaciones de salud y seguridad pública, dijo Jake Hofstetter, analista de políticas del Migration Policy Institute, un grupo de investigación enfocado en política migratoria.

Aunque el acceso lingüístico es una protección federal, 11 estados y Washington, D.C., han creado políticas amplias dirigidas a sus poblaciones. Algunos estados tienen leyes específicas para sectores como la educación o la atención médica. Otras leyes de acceso lingüístico se han establecido en ciudades como Austin, en Texas; Philadelphia, en Pennsylvania; y Portland, en Maine.

En el apogeo de la pandemia de covid-19, los gobiernos estatales y locales que no tenían sistemas sólidos de acceso lingüístico tuvieron dificultades para comunicar información pública vital a comunidades diversas. Un análisis de la información sobre covid publicada en los sitios web de los departamentos de salud de las 10 ciudades más pobladas del país encontró que no se proporcionaba completamente en español.

La población blanca no hispana en las áreas rurales del país disminuyó en aproximadamente 2 millones entre 2010 y 2020, según un análisis de la Escuela de Políticas Públicas Carsey de la Universidad de New Hampshire. El porcentaje de personas pertenecientes a minorías raciales o étnicas en áreas rurales aumentó del 20% en 2010 al 24% en 2020, siendo los hispanos el grupo más grande.

En 2021, 25 millones de personas de 5 años o más en Estados Unidos tenían un dominio limitado del inglés, de los cuales casi dos tercios eran hispanos, según KFF. Nevada es uno de los nueve estados donde al menos el 10% de la población tiene un dominio limitado del inglés.

Según una encuesta de 2023 realizada por KFF y Los Angeles Times, alrededor del 31% de las personas con dominio limitado del inglés enfrentaron barreras lingüísticas al intentar acceder a servicios de salud.

Una cuarta parte tuvo dificultades para solicitar ayuda del gobierno para alimentos, vivienda o cobertura médica. Además, los inmigrantes que no hablan bien inglés tuvieron el doble de probabilidades de no tener seguro médico en comparación con aquellos que dominan el idioma, y presentaron peores resultados de salud.

Desde que terminó la emergencia por la pandemia, Hofstetter ha observado un número significativo de políticas estatales que abordan el acceso lingüístico, pero no muchas políticas locales enfocadas en áreas rurales.

El experto señaló que la ley más reciente de Nevada sobre acceso lingüístico, aprobada en 2023, es única porque identifica específicamente y requiere que los condados más poblados del estado —Clark y Washoe— creen e implementen planes de acceso lingüístico. Otra ley aprobada ese mismo año destinó $25 millones a las agencias para implementar dichos planes.

El senador estatal demócrata Edgar Flores, quien representa una parte del condado de Clark y fue coautor de la ley más reciente sobre idiomas, indicó que los legisladores han enfrentado resistencia de las agencias estatales en varios intentos por fortalecer los requisitos para proporcionar información y documentos en otros idiomas. Según Flores, los funcionarios citan recursos y personal limitados.

“Creo que, desafortunadamente, nuestras jurisdicciones rurales ya están increíblemente limitadas en recursos y, en el momento de esta solicitud, había preocupación de que no estuvieran en condiciones de cumplir con los requisitos”, dijo Flores. “Esa es la realidad”.

Flores indicó que, aunque algunas agencias y jurisdicciones habían creado planes de acceso lingüístico en años anteriores, los legisladores descubrieron que no siempre se implementaban ni se hacían cumplir. Por esta razón, decidieron centrarse primero en los dos condados más grandes del estado mientras trabajan para expandir las políticas a “todos los códigos postales y todas las agencias”.

“Tenemos personas de todas partes que ahora han hecho de Nevada su hogar”, dijo Flores. “Tenemos una obligación con ellos”.

Las personas que viven en áreas rurales pueden beneficiarse de una red de recursos de agencias estatales que prestan servicios en sus condados o de programas locales que deben abordar el acceso lingüístico debido al financiamiento federal.

Pero Hofstetter señaló que existen brechas en el marco de protecciones federales, estatales y locales a nivel nacional.

El grado en que los gobiernos locales ofrecen comunicaciones en idiomas distintos al inglés varía por varias razones, incluida la aplicación de las protecciones de derechos civiles. Esa aplicación depende de quejas de derechos civiles, que a menudo deben ser presentadas por residentes que pueden no conocer sus derechos relacionados con el acceso lingüístico, dijo Hofstetter.

Los miembros de la comunidad también pueden enfrentar resistencia de los líderes locales a la expansión del acceso a servicios e información en otros idiomas.

En 2018, Mendoza apoyó la idea de ofrecer boletas en inglés y español en el condado de Elko. Los comisionados del condado, tres de los cuales aún están en la junta, votaron unánimemente para recomendar al secretario del condado retrasar la oferta de boletas bilingües tanto como fuera posible después de cuestionar los datos demográficos del censo, y alegar que no tenían fondos para traducir las boletas.

Tener acceso a boletas en su idioma preferido ayuda a los votantes a comprender mejor las iniciativas que los afectan, muchas de las cuales están relacionadas con la salud, como una pregunta en la boleta del 5 de noviembre que pedía a los votantes opinar sobre si consagrar el derecho al aborto en la constitución estatal. La medida fue aprobada con el 64% de los votantes a favor y necesita ser aprobada nuevamente en 2026 para implementarse.

La Legislatura de Nevada se reunirá nuevamente en febrero, y Flores dijo estar seguro de que habrá al menos un proyecto de ley sobre acceso lingüístico. Hofstetter anticipa más normas estatales y locales sobre el tema en los próximos años.

“Imagino que eso incluirá algunas áreas rurales”, concluyó.

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.

USE OUR CONTENT

This story can be republished for free (details).

A former Montana health department staffer who described himself as the lead author of legislation to scrutinize nonprofit hospitals’ charitable acts said new rules implementing the bill amounted to a hospital “wish list” and that the state needs to go back to the drawing board.

The Montana Department of Public Health and Human Services recently adopted the rules outlining how the state will collect data on nonprofit hospitals’ charitable acts with the goal of eventually creating giving standards. That could include benchmarks, such as how much financial aid hospitals must provide patients.

The state’s rules come more than four years after a legislative audit found shortcomings in the health department’s oversight and more than a year after Republican Gov. Greg Gianforte signed the law.

The aim is to fill in national oversight gaps that make it hard to weigh whether hospitals do enough for patients and their communities to earn their tax-exempt status as charitable organizations.

Brenton Craggs, a former regulatory affairs coordinator for the health department who said he was the initial architect of the 2023 oversight law, said the state’s plan caters to the Montana Hospital Association.

“This is basically a wish list of demands from the hospital association,” Craggs said. “They wanted us to be bound to federal standards.”

The biggest red flag, Craggs said, is that the state’s rules allow hospitals with operating losses an exemption from Montana’s eventual community benefit and financial assistance standards.

“Almost every, if not every, single nonprofit hospital in the state will have operating losses during their fiscal years,” Craggs said.

He also said the state should ensure hospitals can’t count unpaid bills they submitted to debt collectors as part of uncompensated care they list as a benefit. As is, Craggs said, a hospital can claim that loss “while simultaneously financially ruining the patient.”

Katy Mack, a spokesperson for the Montana Hospital Association, said parts of the oversight as proposed in the law and rulemaking process weren’t workable with federal law, accounting practices, or the sustainability of rural hospitals.

“Hospitals are not opposed to reasonable and informed oversight,” Mack said. “Hospitals are opposed to one-size-fits-all rules that force them to divert resources from priorities identified by their community.”

Craggs’ rebuke reflects a nationwide tension between states’ seeking to put checks on nonprofit hospitals and pushback from those hospitals. The debate centers on whether nonprofit hospitals give back their fair share.

Nonprofit hospitals must report “community benefits” they provide, such as services offered at a loss or free health screenings. But federal law doesn’t specify what qualifies or how much to give. Hospitals report their giving inconsistently and, in some cases, count something that’s good for business as a benefit.

Montana is among the latest states trying to define what should count as a benefit. Hospitals lobbied against cumbersome oversight from the start.

In the health department’s notice that it had adopted the rules in September, state officials said the 2023 law ultimately restricted the reports it could require nonprofits to submit.

The law also required the state’s definitions of, and standards for, community benefits to align with federal standards “wherever possible.” The agency’s adoption notice said that, while it would try to stick to those standards, the department recognized that it “may not always be possible.”

Health policy analysts have said stopping at federal standards would be meaningless.

“The whole point of the state-level policy is to improve upon what the federal government has not done,” said Christopher Whaley, a health economist at Brown University who studies the business of health care. “If a state is saying we have to follow what the federal government does, then they’re just going to end up in the same exact place.”

Craggs, who now works as an attorney for the Montana Office of Public Instruction, filed a letter opposing the state’s rules during the public comment period before they were adopted. KFF Health News obtained that letter through a records request for the public comments regarding the rulemaking.

In an interview, Craggs said he was the health department’s lead on the oversight legislation and that he was removed from that work after he publicly pushed back against changes the association had proposed during a Jan. 25, 2023, legislative hearing.

Jon Ebelt, a health department spokesperson, said the agency didn’t want to comment. He said the state’s notice of its adoption of the rules stands on its own.

According to state lobbying reports, the oversight bill was among the association’s watched legislation for the 2023 session. The organization ultimately supported the bill after lawmakers made amendments.

Republican Rep. Bob Keenan, the bill’s sponsor, said some of the changes were “draconian.” But Keenan said he ultimately supported the policy as amended because he knew it was the result of long negotiations with the association. Lawmakers could make future changes, he said.

Craggs said the state’s oversight goal was to create standards that worked across hospitals, big and small. Instead, he said, the state’s exemptions give hospitals an easy out and the agency is kicking the can down the road on creating standards.

Montana missed the law’s July deadline to set standards and the health department has been vague about what shape those standards could take. Officials have said they need to compile years of data to set fair benchmarks and that they’ll begin establishing standards in 2026.

Craggs said past reports of hospital data are already available for officials to begin setting those standards. But he added the data the state plans to collect from hospitals has too many gaps to offer meaningful oversight.

In the adoption notice, the state said it must balance interests. It said the department will also take action if it appears any hospitals abuse their exemption from giving standards.

“Many critical access hospitals and rural emergency hospitals operate on very thin margins in remote, rural, and/or frontier areas,” the notice said.

The agency said hospitals with losses still must meet federal rules.

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

USE OUR CONTENT

This story can be republished for free (details).

Eloisa Mendoza has spent 18 years helping people who aren’t fluent in English navigate complex legal documents. She guides them through stressful events and accompanying dense paperwork, such as citizenship applications, divorces, and birth certificate translations.

Mendoza works in Elko, Nevada, situated in a remote region in the state’s northeastern corner. Her work has become increasingly important as the town’s Hispanic or Latino population has grown to about 26%. The share of people age 5 or older who speak a language other than English at home increased to 18% as of 2022, while Spanish is the language spoken in nearly 15% of households.

Despite rising demand for local rural governments to communicate with residents in languages other than English, state lawmakers in Nevada left out smaller counties from a recently enacted statewide language-access law. More state and local governments have enacted similar measures during the past few years, but they’re mostly concentrated in urban or suburban jurisdictions.

Rural America is largely white and predominantly English-speaking but has rapidly grown more diverse. Implementing state and local language-access laws, however, is a challenge, researchers say, given standards can vary across state agencies and localities, making it difficult to ensure high-quality assistance is provided to speakers of various non-English languages. Not providing language access to people who need it is not only a violation of civil rights protected by Title VI of the Civil Rights Act, but it also can create public health and safety concerns, said Jake Hofstetter, a policy analyst for the Migration Policy Institute, a think tank focused on immigration policy and research.

While language access is a federal protection, 11 states and Washington, D.C., have created broad policies targeted to their populations. And some states have laws targeting specific sectors, such as education or health care. Other language-access laws have taken root in such municipalities as Austin, Texas; Philadelphia; and Portland, Maine.

At the height of the covid-19 pandemic, state and local governments lacking strong language-access systems struggled to communicate vital public health information to diverse communities. An analysis of covid information posted on health department websites of the 10 most populous U.S. cities found it was not fully provided in Spanish.

The number of white residents in rural parts of the nation decreased by about 2 million from 2010 to 2020, according to an analysis by the Carsey School of Public Policy at the University of New Hampshire. And the percentage of people who are members of a racial or ethnic minority living in rural areas increased from 20% in 2010 to 24% in 2020, with the largest share being Hispanic.

As of 2021, 25 million people age 5 or older in the U.S. had limited English proficiency, of whom nearly two-thirds were Hispanic, according to KFF, a health information nonprofit that includes KFF Health News. Nevada is one of nine states where at least 10% of people have limited English proficiency.

According to a 2023 KFF-Los Angeles Times survey of immigrants, about 31% with limited English proficiency said they faced language barriers when trying to access health care. A quarter said they struggled to apply for government financial help with food, housing, or health coverage. And immigrants limited in their ability to speak English were twice as likely to be uninsured as immigrants who were proficient in English, and they had worse health outcomes.

Since the pandemic emergency ended, Hofstetter has seen a significant number of state policies addressing language access, he said, but he doesn’t see many local policies that focus on the issue in rural areas.

Hofstetter said Nevada’s most recent law on language access, approved in 2023, is unique in that it specifically identifies and requires the state’s most populous counties — Clark and Washoe — to create and implement language-access plans. A separate bill, also approved last year, appropriated $25 million to agencies for implementing language access plans.

Democratic state Sen. Edgar Flores, who represents part of Clark County and was a cosponsor on the most recent language-access law, said lawmakers have faced pushback from state agencies for various attempts at strengthening requirements to provide information and documents in languages other than English. He said officials cite limited staffing and funding.

“I think, unfortunately, our rural jurisdictions are already incredibly limited with resources and, at the time of this request, there was a concern that they were not in a position to meet the requirements,” Flores said. “That’s the bottom line.”

He said that while some agencies and jurisdictions had created language-access plans in past years, legislators found they were not always implemented and enforced. For this reason, Flores said, lawmakers decided it would be better to focus on the state’s two largest counties first while they work toward expanding policies to “every ZIP code, every agency.”

“We have folks from all walks of life who have now made Nevada their home,” Flores said. “We have an obligation to them.”

People living in rural areas may still benefit from a patchwork of resources through state agencies that provide services in their counties or local programs that are required to address language access because of federal funding.

But gaps in the framework of federal, state, and local protections exist nationwide, Hofstetter said.

The degree to which local governments offer communications in languages other than English varies for several reasons, including enforcement of civil rights protections. That enforcement relies on civil rights complaints, which often must be filed by residents who may not know their rights related to language access, Hofstetter said.

Community members may also face resistance from local leaders on expanding access to services and information in other languages. In 2018, Mendoza supported offering ballots in Elko County in Spanish as well as English. County commissioners, three of whom are still on the board, unanimously voted to recommend the county clerk delay offering bilingual ballots as long as possible after questioning census demographic data and stating they didn’t have funding to translate the ballots.

Having access to ballots in their preferred language helps voters better understand initiatives affecting them, many of which are health-related, such as a Nov. 5 ballot question that asked voters to weigh in on whether to enshrine a right to abortion within the state’s constitution. The measure passed with 64% of voters in favor and needs to be approved once more in 2026 to be implemented.

The Nevada Legislature convenes again in February, and Flores said he’s certain there will be at least one language-access bill. Hofstetter said he anticipates more state and local policies addressing the issue within the next few years.

“I would imagine that that’s going to include some rural areas,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

La disponibilidad de vacunas seguras y eficaces contra covid a menos de un año del inicio de la pandemia marcó un hito en los tres siglos de historia de la vacunación: comenzaba, aparentemente, una era de protección contra las enfermedades infecciosas.

Sin embargo, una reacción generalizada contra las intervenciones del estado en la salud pública permitió que el presidente electo Donald Trump nombrara a Robert F. Kennedy, el más conocido activista antivacunas del país como máximo responsable del área de Salud.

Ahora, expertos afirman que una confluencia de factores podría causar el resurgimiento de epidemias mortales de enfermedades como el sarampión, la tos ferina y la meningitis, o incluso de polio.

 “La cantidad de cosas que empezarán a desmoronarse es abrumadora”, dijo James Hodge, experto en derecho de salud pública en el Colegio de Derecho Sandra Day O’Connor de la Universidad Estatal de Arizona. “Vamos a experimentar un cambio crítico en la legislación y las políticas sobre vacunas”.

“Estas políticas harán que América vuelva a enfermarse”, afirmó Lawrence Gostin, profesor de derecho de la salud pública en la Universidad de Georgetown.

Los legisladores estatales que cuestionan la seguridad de las vacunas están preparados para presentar proyectos de ley que debiliten los requisitos de vacunación para ir a la escuela, o los eliminen por completo, señaló Northe Saunders, quien monitorea la legislación relacionada con vacunas para la SAFE Communities Coalition.

Incluso los estados que mantengan los requisitos que hoy existen podrán ser afectados por las decisiones que tome un Congreso controlado por los republicanos, Kennedy y el ex miembro de la Cámara Dave Weldon, en caso de que sean confirmados para dirigir el Departamento de Salud y Servicios Humanos (HHS) y los Centros para el Control y Prevención de Enfermedades (CDC), respectivamente.

Ambos —Kennedy como activista, Weldon como médico y congresista desde 1995 hasta 2009, y protagonista de documentales antivacunas desde entonces— han respaldado teorías ya desacreditadas que culpan a las vacunas del autismo y otras enfermedades crónicas. Los dos han acusado a los CDC de ocultar las pruebas que confirmarían sus postulados, a pesar de las docenas de estudios científicos de prestigio que demuestran lo contrario.

El equipo de Kennedy no respondió a los pedidos de comentarios o entrevistas.

En noviembre, Robert F. Kennedy Jr. declaró a NPR: “No vamos a quitarle las vacunas a nadie”.

Todavía no está claro hasta qué punto el nuevo gobierno buscaría desalentar la vacunación, pero si los niveles de inmunización caen bastante, las enfermedades y muertes prevenibles por vacunas podrían dispararse.

“Es una fantasía pensar que podemos reducir las tasas de vacunación y la inmunidad colectiva en Estados Unidos sin sufrir la reaparición de estas enfermedades”, dijo Gregory Poland, co-director de la Atria Academy of Science & Medicine. “Uno de cada 3,000 niños que desarrolla sarampión va a morir. No hay tratamiento para evitarlo. Van a morir”.

En noviembre de 2019, una epidemia de sarampión causó la muerte de 80 niños en Samoa. En esa oportunidad, Kennedy escribió al primer ministro de ese país afirmando falsamente que la vacuna contra el sarampión probablemente estaba causando esas muertes.

Scott Gottlieb, que fue el primer comisionado de la Administración de Drogas y Alimentos (FDA) bajo la administración Trump, declaró en CNBC el 29 de noviembre que Kennedy “va a costar vidas en este país” si sabotea la vacunación.

La nominación de Kennedy valida y consagra la desconfianza pública en los programas de salud del gobierno, asegura Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia.

“La idea de que se considere para ocupar un puesto tan importante hace que la gente piense que sabe de lo que habla”, dijo Offit. “Y él apela a generar desconfianza, a la idea de que ‘hay cosas que no ves, datos que no presentan, que yo voy a averiguar para que realmente puedas tomar una decisión informada’”.

Qué quieren los grupos antivacunas

Hodge ha elaborado una lista de 20 acciones que la administración podría llevar a cabo para debilitar los programas nacionales de vacunación, desde difundir información errónea hasta retrasar las aprobaciones de la FDA sobre vacunas. O retirar el apoyo del Departamento de Justicia a las leyes de vacunación que buscan impugnar grupos como Children’s Health Defense, que Kennedy fundó y dirigió antes de postularse para la presidencia.

Kennedy podría eliminar el Comité Asesor sobre Prácticas de Inmunización de los CDC, cuyas recomendaciones sobre el uso de una vacuna determinan si el gobierno la financia a través del programa Vacunas para Niños, que se creó hace 30 años y ofrece inmunizaciones gratuitas a más de la mitad de los niños del país.

Otra opción es que Kennedy coloque en el comité a aliados suyos que se oponen a nuevas vacunas y, al menos en teoría, retire las recomendaciones para vacunas como la triple viral (sarampión, paperas y rubéola), que se usa desde hace 53 años y cuya anulación es uno de los principales objetivos del movimiento antivacunas.

Mientras tanto, siempre hay amenazas de enfermedades infecciosas. Pero en lugar de prepararse para enfrentarlas, como haría una administración entrante común, Kennedy ha amenazado con reestructurar las agencias federales de salud. En una conferencia de Children’s Health Defense en noviembre, en Georgia, declaró que, cuando asuma el cargo, les dará “un respiro a las enfermedades infecciosas” para ocuparse de las afecciones crónicas.

El virus H5N1, o gripe aviar, podría estallar y convertirse en una nueva pandemia. No solo se ha propagado entre el ganado sino que ha infectado por lo menos a 55 personas. El dengue, que se transmite por mosquitos, es otra de las enfermedades que aumenta en el país.

Las enfermedades tradicionales de la infancia también están manifestándose con mayor frecuencia, en parte debido a la baja en la vacunación. Este año hubieron 16 brotes de sarampión —el 89% de los casos en personas no vacunadas— y la epidemia de tos ferina fue la peor desde 2012.

“Así es como estamos empezando”, dijo Peter Hotez, pediatra y virólogo del Baylor College of Medicine. “Y a esta situación se suma el nombramiento a la cabeza del HHS de uno de los activistas antivacunas más contundente y visible, lo que me provoca mucha preocupación”.

Los precios de las acciones de las compañías farmacéuticas con grandes portfolios de vacunas se han desplomado desde la designación de Kennedy. Incluso antes de la victoria de Trump, la escasez de vacunas y el escepticismo habían hecho caer la demanda de las más nuevas, como las vacunas contra el Virus Respiratorio Sincitial (VSR) y el herpes zóster de GSK.

Kennedy tiene varias maneras para retrasar o directamente detener el lanzamiento de nuevas vacunas. También para reducir las ventas de vacunas existentes. Por ejemplo, puede exigir estudios adicionales después que las vacunas ya están en el mercado o difundir estudios que sugieren posibles riesgos de seguridad, aunque esa afirmación sea errónea o no esté comprobada.

Kennedy, quien ha apoyado teorías conspirativas como que el VIH no causa el sida y que los pesticidas provocan disforia de género, declaró a NPR que existen “enormes déficits” en la investigación sobre la seguridad de las vacunas. “Nos aseguraremos de que esos estudios científicos se realicen y de que las personas puedan tomar decisiones informadas”, dijo.

El nombramiento de Kennedy “es un mal pronóstico para el desarrollo de nuevas vacunas y la aplicación de las que están actualmente disponibles”, dijo Stanley Plotkin, quien desarrolló la vacuna contra la rubéola en la década de 1960 y ahora es consultor de la industria de vacunas. “El desarrollo de vacunas requiere millones de dólares. A menos que haya perspectivas de obtener beneficios, las empresas comerciales no van a interesarse en invertir en esas investigaciones”, reflexionó.

Los defensores de las vacunas, que disponen de menos recursos que los grupos antivacunas, mucho mejor financiados, consideran que será muy difícil la batalla para defender la necesidad de la inmunización en los tribunales, las legislaturas y la opinión  pública. Las personas rara vez valoran la ausencia de una enfermedad erradicada, lo que dificulta promover las vacunas, incluso cuando son altamente efectivas.

Una situación muy grave

“Para mucha gente, RFK Jr. era motivo de burla, pero él está absolutamente decidido, habla totalmente en serio”, afirmó Ernst. “Tiene mucho poder, dinero y una vasta red de padres antivacunas que aparecerán en cualquier momento”. Nada similar ha ocurrido en los grupos a favor de las vacunas, dijo Ernst.

El 22 de octubre pasado, cuando una junta sanitaria de Idaho votó a favor de dejar de suministrar vacunas contra covid en seis condados, no había defensores de las vacunas en la reunión. “Ni siquiera sabíamos que esa discusión estaba en el orden del día”, aseguró Ernst. “La movilización por nuestra parte siempre está más retrasada. Pero no me rindo”, concluyó.

Este giro multifacético e impredecible ha sido desconcertante para Walter Orenstein, quien como jefe de la división de inmunización de los CDC entre 1988 y 2004 convenció a los estados de que endurecieran los requisitos de vacunación escolares para luchar contra los brotes de sarampión.

“La gente no entiende el concepto de protección comunitaria y, si lo entiende, no parece importarle”, afirmó Orenstein. Como epidemiólogo de los CDC en la India, Orenstein fue testigo de algunos de los últimos casos de viruela en la década de 1970. También atendió con frecuencia a niños con meningitis causada por la bacteria H. influenzae tipo B, una enfermedad que ha desaparecido casi totalmente gracias a una vacuna introducida en 1987.

“Yo era muy ingenuo”, dijo. “Pensaba que la vacunación contra covid consolidaría la aceptación de las vacunas, pero sucedió todo lo contrario”.

Los legisladores que se oponen a las vacunas podrían presentar leyes para eliminar los requisitos de acceso a la escuela en casi todos los estados, explicó Saunders.

En Texas se ha presentado un proyecto de ley de estas características, donde lo que se conoce como el movimiento de elección de vacunas ha estado creciendo desde 2015 y se intensificó durante la pandemia, fusionándose con los grupos de defensa de los derechos de los padres y grupos antigubernamentales opuestos a medidas como las vacunas obligatorias y el uso de máscaras.

“El genio ya está fuera de la botella y no se puede volver a meter”, dijo Rekha Lakshmanan, directora de estrategia de Immunization Partnership en Texas. “Se ha convertido en un problema con muchos ángulos con el que tenemos que lidiar”, agregó.

En el último año escolar completo, más de 100.000 alumnos de las escuelas públicas de Texas fueron eximidos de aplicarse una o más vacunas, dijo Lakshmanan, y se cree que muchos de los 600.000 niños en el estado que reciben su educación en sus casas tampoco están vacunados.

Los planes del presidente electo Donald Trump, que se propone eliminar las protecciones del servicio civil de los trabajadores federales, podrían ser la mayor amenaza para las políticas de vacunación existentes. Una decisión de ese tipo pondría en peligro a los empleados de las agencias federales de salud cuyo trabajo diario es prepararse para luchar contra las enfermedades y epidemias.

“Si se desmantela el aparato administrativo del estado el impacto en la salud pública será a largo plazo y grave”, dijo Dorit Reiss, profesora de la Facultad de Derecho Hastings de la Universidad de California.

El multimillonario Elon Musk, una persona con gran influencia sobre el presidente electo, planea recortes de gastos que también se consideran una amenaza.

“Dañar las funciones más importantes de la FDA, es como matar a la gallina de los huevos de oro, tanto para nuestra salud como para la economía”, afirmó Jesse Goodman, director del Center on Medical Product Access, Safety and Stewardship de la Universidad de Georgetown y ex director científico de la FDA.

“Sería exactamente lo contrario de lo que Kennedy dice que quiere, que son productos médicos seguros. Si en la agencia carecemos de científicos y clínicos calificados e independientes, el riesgo de que los estadounidenses tengan alimentos y medicamentos inseguros se incrementa.”

Los brotes de enfermedades prevenibles con vacunas podrían ser alarmantes, pero ¿serían suficientes para impulsar de nuevo las tasas de  vacunación? Ernst, de Voices for Vaccines, no está convencido.

“Ya estamos teniendo brotes. Tendrían que pasar años antes de que murieran suficientes niños como para que la gente dijera: ‘Supongo que el sarampión es algo realmente peligroso’”, afirmó. “La muerte de un niño no será suficiente. La historia que contarán será: ‘A ese niño le pasaba algo. A mi hijo no le puede pasar’”.

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.

USE OUR CONTENT

This story can be republished for free (details).

KINGSPORT, Tenn. — Jerry Qualls had a heart attack in 2022 and was rushed by ambulance to Holston Valley Medical Center, where he was hospitalized for a week and kept alive by a ventilator and blood pump, according to his medical records.

His wife, Katherine Qualls, said his doctors offered little hope. In an interview and a written complaint to the Tennessee government, she said doctors at Holston Valley told her that her husband would not qualify for a heart transplant and shouldn’t be expected to recover.

Defiant, she insisted he be transferred hours away to a hospital in Nashville. Within days of leaving Holston Valley, Jerry Qualls was awake and sitting upright, his wife said, and he ultimately received a lifesaving heart transplant.

“How many families don’t know how to get a transfer and their loved one dies?” Katherine Qualls wrote in her complaint to the state. “My husband would have been dead within a few days if I didn’t get him out when I did.”

Holston Valley Medical Center is a flagship of Ballad Health, a 20-hospital system in northeastern Tennessee and southwestern Virginia that is the only option for hospital care in a large swath of Appalachia. Ballad formed six years ago when lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. The merger created the largest state-sanctioned hospital monopoly in the nation.

Since then, Ballad has largely kept those hospitals open. But the monopoly has also fallen short of about three-fourths of the quality-of-care goals set by the states over the last three fiscal years, including failing to meet state benchmarks on infections, mortality, emergency room speed, and patient satisfaction, according to annual reports from the Tennessee Department of Health and Ballad itself.

Some local residents have become wary, afraid, or unwilling to seek care at Ballad hospitals and must drive over an hour to reach other options, according to written complaints to the Tennessee government and state lawmakers, public hearing testimony, and KFF Health News interviews conducted over the past year with patients, family members, local leaders, and some officials who once publicly supported the monopoly, including a former government consultant and one state lawmaker. Many of those who submitted complaints or were interviewed allege that paper-thin staffing at Ballad hospitals and ERs is the root cause of the monopoly’s quality-of-care woes.

In a two-hour interview vigorously defending the company, Ballad Health CEO Alan Levine said the hospitals are rapidly recovering from a quality-of-care slump caused by covid-19 and a subsequent rise in nursing turnover and staff shortages. These issues affected hospitals nationwide, Levine said, and were not related to the Ballad merger or the monopoly it created.

Levine declined to discuss specific complaints from patients. But he said that each of the complaints referenced in this article took issue with medical decisions made by doctors in Ballad hospitals — not “any policy or practice at Ballad.”

“I can understand if the patients, if the wife, was upset about the medical decisions they made if it turned out to be wrong,” Levine said. “But that has nothing to do with the merger, OK? That’s a completely different issue, and it happens in hospitals all over the country.”

In the interview with KFF Health News and in the days that followed, Levine flexed considerable connections to officials in the Tennessee government. As Levine spoke in a boardroom at Ballad’s hilltop headquarters, he was flanked by three local mayors who voiced support for the hospitals and said complaints came from a vocal minority of their constituents. Days later, Levine got two Tennessee state agency directors and a former state health commissioner to provide emails or text messages supporting statements he made during the interview.

Logan Grant, executive director of the Tennessee Health Facilities Commission, which processes complaints against hospitals for the state, said in a statement prompted by Levine that Ballad hospitals are “not an outlier in terms of substantiated survey findings.”

Joe Grandy, the mayor of Tennessee’s Washington County, where Ballad is headquartered, said most residents consider the quality of care in the area “about as good as it gets.”

Brenda Getaz certainly doesn’t.

Getaz, 76, who spent three decades as a hospital official specializing in quality standards before retiring to Washington County, said she plans to move to Atlanta if state governments do not take action to fix Ballad in the coming year. Getaz said local medical professionals she trusts have urged her to move away so she does not have to rely on Ballad for care.

“I’m frightened to be taken to a Ballad facility,” she said.

Glimpses of Government Concern

The Tennessee Department of Health, which has the most direct oversight over Ballad Health, over the past year has declined multiple interview requests to discuss the hospital monopoly. Department emails reviewed by KFF Health News, some of which were obtained through public record requests, offer glimpses of concern inside the agency.

Emails show the health department has attempted to hold Ballad more accountable for its quality of care in closed-door negotiations and is investigating Holston Valley’s treatment of a recent heart patient after receiving detailed complaints from his family. In a 2023 email, Tennessee Health Commissioner Ralph Alvarado reacted to a news story about low job satisfaction among Ballad nurses by writing: “Ouch. … What are they doing to address this?”

In another email from the same year, Alvarado praised an informal report submitted at a public hearing that concluded Ballad’s monopoly had caused more harm than good. The report was written by Wally Hankwitz, a retired health care executive who once led a physician management company in Kingsport. The report levied pages of criticism against Ballad’s “sub-par” performance and called for the monopoly to end.

“THIS communication from the COPA hearing is particularly good,” the health commissioner wrote to some of his staff. “Totally based on data. I would almost like to hear Ballad’s response to this.”

When asked to respond to the Hankwitz report, Levine said it was “full of errors” and that “no credible institution would pay attention to it.”

Despite concerns, Tennessee and Virginia have each year determined that the benefits of the Ballad monopoly outweigh any negative impacts, issuing stamps of approval that allow the monopoly to continue. This has occurred, at least in part, because both states grade Ballad against scoring rubrics that do not prioritize quality of care.

Larry Fitzgerald, a retired Tennessee consultant who monitored the monopoly for the state for more than five years and always gave Ballad high marks, said in an interview that his hands were tied by the state’s lenient grading system, which allowed Ballad to succeed on paper even when it failed to meet the state’s quality-of-care goals.

Fitzgerald said he is unconvinced that the state-sanctioned monopoly had prevented any hospital closures and said the merger had “probably not” benefited local residents overall.

When asked where he would get medical attention if he lived in northeastern Tennessee or southwestern Virginia, Fitzgerald immediately responded, “I’m not going to a Ballad hospital.”

In his interview, Levine alleged Fitzgerald had “basically defrauded the state” by not raising these criticisms of Ballad in his public reports on the monopoly and said it was “irresponsible” and “obscene” to express his concerns about quality of care after retiring.

‘Horror Stories’ From Ballad Patients

Tennessee House member Bud Hulsey, a Republican from Kingsport, wrote in a 2023 letter to the state health department that he “was an avid supporter of the merger” that created Ballad but since then had become “concerned” and “saddened” by the state of the local hospitals.

In a recent interview, Hulsey said that while his family has received excellent care from Ballad, his constituents have told him “horror stories” for years.

“I had people call me from the waiting room after they’ve sat there for 12 or 14 hours,” Hulsey said. “The scales have far more complaints on them than accolades.”

Others have soured on the monopoly, too. Joe Macione, who for years was on the board of Wellmont Health System, one of the rival companies that became Ballad, once publicly advocated for the merger.

In an interview, Macione said state leaders should have admitted years ago that the monopoly was a mistake.

“It has not worked,” said Macione, 87. “All my family knows that, if I have the time, I want to go to a highly graded hospital, either in Asheville or Knoxville.”

Ballad Health was created in 2018 after Tennessee and Virginia officials waived federal anti-monopoly laws and approved the nation’s biggest hospital merger, based on what’s called a Certificate of Public Advantage, or COPA, agreement. Ballad is now the only option for hospital care for most of the approximately 1.1 million people in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

In the years since, there have been multiple signs of discontent with and within Ballad hospitals. In 2019, protesters gathered daily for eight months outside Holston Valley to oppose the closure of the neonatal intensive care unit and the downgrading of a trauma center. (Ballad has said the NICU closure was necessary and benefited patients, and a study published this year said the trauma changes saved lives.)

In 2020, Bristol Regional Medical Center CEO Greg Neal resigned after it was discovered he made the initial incision in a heart surgery despite not being a doctor, according to Tennessee state records. (Levine said in his interview that the resignation shows Ballad is holding employees accountable.)

In 2022, 14 cardiologists signed a letter warning of “severe limitations” in the Bristol Regional cardiac catheterization lab that were affecting patient safety and delaying procedures for weeks or months. (Ballad said in a letter to the Tennessee government that it worked with the cardiologists, who it said were partly to blame, to make the lab more efficient.)

In 2023, Ballad Health was ranked last among 200 large health care organizations in an analysis of nurse satisfaction published by an MIT business magazine. (Levine dismissed this analysis as unscientific.) This year, the Federal Trade Commission cited Ballad as a cautionary tale while opposing a similar hospital merger under consideration in Indiana, and a longtime Kingsport doctor took a parting shot at Ballad in his obituary. (Ballad declined to comment on either topic.)

And in August, the widow of a Tennessee sheriff filed a lawsuit alleging that Ballad caused her husband’s death and intentionally understaffed hospitals “to save money.” Brenda Tester, the wife of Johnson County Sheriff Eddie Tester, alleged in that lawsuit that Ballad put her husband on blood thinners and then gave him an unnecessary liver biopsy, causing “life ending internal blood loss” that led to “his cardiac arrest and ultimately his sudden death.”

Ballad has yet to respond to the Tester lawsuit in court. Levine said in his interview that the doctors who treated the sheriff were not employed by Ballad but merely contracted to work in its hospitals.

Some of Ballad’s most determined critics are family members of Anton Maki Jr., a former Holston Valley doctor who returned to the hospital as a patient in February. The family has filed complaints with multiple Tennessee agencies and the federal government and provided emails to KFF Health News showing that Tennessee is investigating Maki’s case.

In an interview and in those complaints, Maki’s family members allege Holston Valley gave Maki improper treatment, even though his symptoms and lab tests made it obvious that he was having a serious heart attack that required urgent attention.

The improper care did “permanent damage” to Maki’s heart, the family’s complaints allege. That damage required him to have a permanent mechanical heart pump surgically implanted at a non-Ballad hospital, said one of his daughters, Alexandra Maki, who is a surgeon in Kentucky. She said her father died after a fall three months later while still in a weakened state.

Alexandra Maki said that her father had been alarmed by the Ballad monopoly for years but that she didn’t fully appreciate his warnings until she witnessed his care at Holston Valley firsthand.

“I filed these complaints because it is my duty as a doctor to report what I saw,” Alexandra Maki said. “That was not care. It is a facade of a hospital. It is a well-oiled death machine.”

KFF Health News reporter Samantha Liss contributed to this article.

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.

USE OUR CONTENT

This story can be republished for free (details).

The availability of safe, effective covid vaccines less than a year into the pandemic marked a high point in the 300-year history of vaccination, seemingly heralding an age of protection against infectious diseases.

Now, after backlash against public health interventions culminated in President-elect Donald Trump’s nominating Robert F. Kennedy Jr., the country’s best-known anti-vaccine activist, as its top health official, infectious disease and public health experts and vaccine advocates say a confluence of factors could cause renewed, deadly epidemics of measles, whooping cough, and meningitis, or even polio.

“The litany of things that will start to topple is profound,” said James Hodge, a public health law expert at Arizona State University’s Sandra Day O’Connor College of Law. “We’re going to experience a seminal change in vaccine law and policy.”

“He’ll make America sick again,” said Lawrence Gostin, a professor of public health law at Georgetown University.

State legislators who question vaccine safety are poised to introduce bills to weaken school-entry vaccine requirements or do away with them altogether, said Northe Saunders, who tracks vaccine-related legislation for the SAFE Communities Coalition, a group supporting pro-vaccine legislation and lawmakers.

Even states that keep existing requirements will be vulnerable to decisions made by a Republican-controlled Congress as well as by Kennedy and former House member Dave Weldon, should they be confirmed to lead the Department of Health and Human Services and the Centers for Disease Control and Prevention, respectively.

Both men — Kennedy as an activist, Weldon as a medical doctor and congressman from 1995 to 2009— have endorsed debunked theories blaming vaccines for autism and other chronic diseases. (Weldon has been featured in anti-vaccine films in the years since he left Congress.) Both have accused the CDC of covering up evidence this was so, despite dozens of reputable scientific studies to the contrary.

Kennedy’s staff did not respond to requests for comment. Karoline Leavitt, the Trump campaign’s national press secretary, did not respond to requests for comment or interviews with Kennedy or Weldon.

Kennedy recently told NPR that “we’re not going to take vaccines away from anybody.”

It’s unclear how far the administration would go to discourage vaccination, but if levels drop enough, vaccine-preventable illnesses and deaths might soar.

“It is a fantasy to think we can lower vaccination rates and herd immunity in the U.S. and not suffer recurrence of these diseases,” said Gregory Poland, co-director of the Atria Academy of Science & Medicine. “One in 3,000 kids who gets measles is going to die. There’s no treatment for it. They are going to die.”

During a November 2019 measles epidemic that killed 80 children in Samoa, Kennedy wrote to the country’s prime minister falsely claiming that the measles vaccine was probably causing the deaths. Scott Gottlieb, who was Trump’s first FDA commissioner, said on CNBC on Nov. 29 that Kennedy “will cost lives in this country” if he undercuts vaccination.

Kennedy’s nomination validates and enshrines public mistrust of government health programs, said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

“The notion that he’d even be considered for that position makes people think he knows what he’s talking about,” Offit said. “He appeals to lessened trust, the idea that ‘There are things you don’t see, data they don’t present, that I’m going to find out so you can really make an informed decision.’”

Targets of Anti-Vaccine Groups

Hodge has compiled a list of 20 actions the administration could take to weaken national vaccination programs, from spreading misinformation to delaying FDA vaccine approvals to dropping Department of Justice support for vaccine laws challenged by groups like Children’s Health Defense, which Kennedy founded and led before campaigning for president.

Kennedy could also cripple the National Vaccine Injury Compensation Program, which Congress created in 1986 to take care of children believed harmed by vaccines — while partially protecting vaccine makers from lawsuits.

Before the law passed, the threat of lawsuits had shrunk the number of companies making vaccines in the United States — from 26 in 1967 to 17 in 1980 — and the remaining pertussis vaccine producers were threatening to stop making it. The vaccine injury program “played an integral role in keeping manufacturers in the business,” Poland said.

Kennedy could abolish the CDC’s Advisory Committee on Immunization Practices, whose recommendation for using a vaccine determines whether the government pays for it through the 30-year-old Vaccines for Children program, which makes free immunizations available to more than half the children in the United States. Alternatively, Kennedy could stack the committee with allies who oppose new vaccines, and could, in theory at least, withdraw recommendations for vaccines like the 53-year-old measles-mumps-rubella shot, a favorite target of the anti-vaccine movement.

Meanwhile, infectious disease threats are on the rise or on the horizon. Instead of preparing, as a typical incoming administration might, Kennedy has threatened to shake up the federal health agencies. Once in office, he’ll “give infectious disease a break” to focus on chronic ailments, he said at a Children’s Health Defense conference last month in Georgia.

The H5N1 virus, or bird flu, that has spread through cattle herds and infected at least 55 people could erupt in a new pandemic, and other threats like mosquito-borne dengue fever are rising in the U.S.

Traditional childhood diseases are also making their presence felt, in part because of neglected vaccination. The U.S. has seen 16 measles outbreaks this year — 89% of cases are in unvaccinated people — and a whooping cough epidemic is the worst since 2012.

“So that’s how we’re starting out,” said Peter Hotez, a pediatrician and virologist at the Baylor College of Medicine. “Then you throw into the mix one of the most outspoken and visible anti-vaccine activists at the head of HHS, and that gives me a lot of concern.”

The share prices of drug companies with big vaccine portfolios have plunged since Kennedy’s nomination. Even before Trump’s victory, vaccine exhaustion and skepticism had driven down demand for newer vaccines like GSK’s RSV and shingles shots.

Kennedy has ample options to slow or stop new vaccine releases or to slow sales of existing vaccines — for example, by requiring additional post-market studies or by highlighting questionable studies that suggest safety risks.

Kennedy, who has embraced conspiracy theories such as that HIV does not cause AIDS and that pesticides cause gender dysphoria, told NPR there are “huge deficits” in vaccine safety research. “We’re going to make sure those scientific studies are done and that people can make informed choices,” he said.

Kennedy’s nomination “bodes ill for the development of new vaccines and the use of currently available vaccines,” said Stanley Plotkin, a vaccine industry consultant and inventor of the rubella vaccine in the 1960s. “Vaccine development requires millions of dollars. Unless there is prospect of profit, commercial companies are not going to do it.”

Vaccine advocates, with less money on hand than the better-funded anti-vaccine advocates, see an uphill battle to defend vaccination in courts, legislatures, and the public square. People are rarely inclined to celebrate the absence of a conquered illness, making vaccines a hard sell even when they are working well.

While many wealthy people, including potion and supplement peddlers, have funded the anti-vaccine movement, “there hasn’t been an appetite from science-friendly people to give that kind of money to our side,” said Karen Ernst, director of Voices for Vaccines.

‘He’s Serious as Hell’

“RFK Jr. was a punch line for a lot of people, but he’s serious as hell,” Ernst said. “He has a lot of power, money, and a vast network of anti-vaccine parents who’ll show up at a moment’s notice.” That’s not been the case with groups like hers, Ernst said.

On Oct. 22, when an Idaho health board voted to stop providing covid vaccines in six counties, there were no vaccine advocates at the meeting. “We didn’t even know it was on the agenda,” Ernst said. “Mobilization on our side is always lagging. But I’m not giving up.”

The kaleidoscopic change has been jarring for Walter Orenstein, who persuaded states to tighten school mandates to fight measles outbreaks as head of the CDC’s immunization division from 1988 to 2004.

“People don’t understand the concept of community protection, and if they do they don’t seem to care,” said Orenstein, who saw some of the last cases of smallpox as a CDC epidemiologist in India in the 1970s, and frequently cared for children with meningitis caused by H. influenzae type B bacteria, a disease that has mostly disappeared because of a vaccine introduced in 1987.

“I was so naïve,” he said. “I thought that covid would solidify acceptance of vaccines, but it was the opposite.”

Lawmakers opposed to vaccines could introduce legislation to remove school-entry requirements in nearly every state, Saunders said. One bill to do this has been introduced in Texas, where what’s known as the vaccine choice movement has been growing since 2015 and took off during the pandemic, fusing with parents’ rights and anti-government groups opposed to measures like mandatory shots and masking.

“The genie is out of the bottle, and you can’t put it back in,” said Rekha Lakshmanan, chief strategy officer at the Immunization Partnership in Texas. “It’s become this multiheaded thing that we’re having to reckon with.”

In the last full school year, more than 100,000 Texas public school students were exempted from one or more vaccinations, she said, and many of the 600,000 homeschooled Texas kids are also thought to be unvaccinated.

In Louisiana, the state surgeon general distributed a form letter to hospitals exempting medical professionals from flu vaccination, claiming the vaccine is unlikely to work and has “real and well established” risks. Research on flu vaccination refutes both claims.

The biggest threat to existing vaccination policies could be plans by the Trump administration to remove civil service protections for federal workers. That jeopardizes workers at federal health agencies whose day-to-day jobs are to prepare for and fight diseases and epidemics. “If you overturn the administrative state, the impact on public health will be long-term and serious,” said Dorit Reiss, a professor at the University of California’s Hastings College of Law.

Billionaire Elon Musk, who has the ear of the incoming president, imagines cost-cutting plans that are also seen as a threat.

“If you damage the core functions of the FDA, it’s like killing the goose that laid the golden egg, both for our health and for the economy,” said Jesse Goodman, the director of the Center on Medical Product Access, Safety and Stewardship at Georgetown University and a former chief science officer at the FDA. “It would be the exact opposite of what Kennedy is saying he wants, which is safe medical products. If we don’t have independent skilled scientists and clinicians at the agency, there’s an increased risk Americans will have unsafe foods and medicine.”

Outbreaks of vaccine-preventable illness could be alarming, but would they be enough to boost vaccination again? Ernst of Voices for Vaccines isn’t sure.

“We’re already having outbreaks. It would take years before enough children died before people said, ‘I guess measles is a bad thing,’” she said. “One kid won’t be enough. The story they’ll tell is, ‘There was something wrong with that kid. It can’t happen to my kid.’”

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.

USE OUR CONTENT

This story can be republished for free (details).

It seems no one is taking covid-19 seriously anymore, said Mollee Loveland, a nursing home aide who lives outside Pittsburgh.

Loveland has seen patients and coworkers at the nursing home where she works die from the viral disease.

Now she has a new worry: bringing home the coronavirus and unwittingly infecting her infant daughter, Maya, born in May.

Loveland’s maternity leave ended in late June, when Maya wasn’t yet 2 months old. Infants cannot be vaccinated against covid until they are 6 months old. Children younger than that suffer the highest rates of hospitalization of any age group except people 75 or older.

Between her patients’ complex medical needs and their close proximity to one another, covid continues to pose a grave threat to Loveland’s nursing home — and to the 15,000 other certified nursing homes in the U.S. where some 1.2 million people live.

Despite this risk, a CDC report published in April found that just 4 in 10 nursing home residents in the U.S. received an updated covid vaccine in the winter of 2023-24. The analysis drew on data from Oct. 16, 2023, through Feb. 11, 2024, and was conducted by the Centers for Disease Control and Prevention.

The CDC report also revealed that during January’s covid peak, the rate of hospitalizations among nursing home residents was more than eight times that of all U.S. adults, age 70 and older.

Billing Complexities and Patient Skepticism

Last winter’s low vaccination rate was partly driven by the end of the federal government’s paying for administering the shots, said Rajeev Kumar, a Chicago-based geriatrician.

While the vaccines remain free to patients, clinicians must now bill each person’s insurer separately. That makes vaccinating an entire nursing home more logistically complicated, Kumar said.

Kumar is president of the Post-Acute and Long-Term Care Medical Association, which represents clinicians who work in nursing homes and similar settings, such as post-acute care, assisted living, and hospice facilities.

“The challenges of navigating through that process and arranging vaccinations, making sure that somebody gets to bill for services and collect money, that’s what has become a little bit more tedious,” he said.

In April, after the study was released, the CDC recommended that adults 65 and older get an additional dose of an updated vaccine if it’s been more than four months since their last dose. That means most nursing home patients who have had only one shot in fall or winter are not considered up to date on the covid vaccines.

Kumar and his colleagues are encountering more skepticism of the covid vaccines, compared with their rollout.

“The long-term care population is a microcosm of what’s happening across the country and, unfortunately, covid vaccine reluctance remains persistent throughout the general public. It’s our most significant challenge,” according to an emailed statement from David Gifford, chief medical officer at AHCA/NCAL, which represents both for-profit and nonprofit nursing homes.

Nursing aide Loveland also has observed doubts and misinformation cropping up among patients at her job: “It’s the Facebook rabbit hole.”

But there are ways to push back against bad information, and states show wide variation in the proportion of nursing home residents who got vaccinated last winter.

For example, in both North and South Dakota, more than 55% of residents at nursing homes that reported data have gotten an updated covid vaccine this fall. Nationally, that share is 32%.

Building Trust Through Relationships

One major medical system operating in the Dakotas, Sanford Health, has managed more than two dozen nursing homes since a 2019 merger with the long-term care chain Good Samaritan Society.

In some of these nursing homes more than 70% of residents were vaccinated last fall and winter — at one Sanford facility in Canton, South Dakota, the rate exceeded 90%.

Sanford achieved this by leveraging the size of the health system to make delivering vaccines more efficient, said Jeremy Cauwels, Sanford’s chief medical officer. He also credited a close working relationship with a South Dakota-based pharmacy chain, Lewis Drug.

But the most crucial factor was that many of Sanford’s nursing home patients are cared for by doctors who are also employed by the health system. At most Sanford’s North and South Dakota nursing homes, these clinicians provide on-site primary care, meaning patients don’t have to leave the facilities to see doctors.

These employed doctors have been critical in persuading patients to stay up to date on their covid shots, Cauwels said. For example, a medical director who worked at the Good Samaritan nursing home in Canton was a long-serving physician with close ties to that community.

“An appropriate one-on-one conversation with someone who cares about you and has a history of doing so in the past, for us, has resulted in much better numbers than other places have been able to get to nationally,” said Cauwels, who added that Sanford still needs to work on reaching more patients.

Sanford’s success shows the onus of getting patients vaccinated extends beyond nursing homes, said Jodi Eyigor, director of nursing home quality and public policy for LeadingAge, which represents nonprofit nursing homes. She said primary care providers, hospitalists, pharmacists, and other health care stakeholders need to step up.

“What conversations have occurred before they walked into a nursing home’s doors, between them and their doctors? Because they’re probably seeing their doctors quite frequently before they come into the nursing home,” said Eyigor, who noted these other clinicians are also regulated by Medicare, the federal health insurance program for adults 65 and older.

Critics: Shot Uptake Linked to Residents’ Dissatisfaction

Nursing homes are required to educate patients — as well as staff — about the importance of the covid vaccines. Industry critics contend that one-on-one conversations, based on trusted relationships with clinicians, are the least that nursing homes should do.

But many facilities don’t seem to be doing even that, according to Richard Mollot, executive director of the Long Term Care Community Coalition, a watchdog group that monitors nursing homes. A 40% recent vaccination rate is inexcusable, he said, given the danger the virus poses to people who live in nursing homes.

A study from the Journal of Health Economics estimates that from the start of the pandemic through Aug. 15, 2021, 21% of covid deaths in the U.S. were among people living in nursing homes.

Mollot said that the alarmingly low covid vaccination rate is a symptom of larger issues throughout the industry. He hears from patients’ families about poor food quality and a general apathy that some nursing homes have toward residents’ concerns. He also cites high rates of staff turnover and substandard, even dangerous, care.

These problems intensified in the years since the start of the covid pandemic, Mollot said, causing extensive stress throughout the industry.

“That has resulted in much lower care, much more disrespectful interactions between residents and staff, and there’s just that lack of trust,” he added.

Loveland, the nursing aide outside Pittsburgh, also thinks the industry has fundamental problems when it comes to daily interactions between workers and residents. She said the managers at her job often ignore patients’ concerns.

“I feel like if the facilities did more with the patients, they would get more respect from the patients,” she said.

That means that when administrators announced it was time for residents to get one of the newest covid vaccines this year, Loveland said, residents often simply ignored the message, even if it meant putting their own health at risk.

This article is from a partnership that includes 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.

USE OUR CONTENT

This story can be republished for free (details).

Covid’s rampage through the country’s nursing homes killed more than 172,000 residents and spurred the biggest industry reform in decades: a mandate that homes employ a minimum number of nurses.

But with President-elect Donald Trump’s return to the White House, the industry is ramping up pressure to kill that requirement before it takes effect, leaving thousands of residents in homes too short-staffed to provide proper care.

The nursing home industry has been marshaling opposition for months among congressional Republicans — and some Democrats — to overrule the Biden administration’s mandate. Two industry groups, the American Health Care Association and LeadingAge, have sued to overturn the regulation, and 20 Republican state attorneys general have filed their own challenge.

Consumer advocates, industry officials and independent researchers agree that the incoming administration is likely to rescind the rule, given the first Trump administration’s “patients over paperwork” campaign to remove “unnecessary, obsolete, or excessively burdensome health regulations on hospitals and other healthcare providers.” Among other things, Trump aided the industry by easing fines against homes that had been cited for poor care.

“The Trump administration has proven itself really eager to reverse overreaching regulations,” said Linda Couch, senior vice president for policy and advocacy at LeadingAge, which represents nonprofit elder care providers. “We think it’s got a pretty good chance of being repealed, and hope so.”

Issued in April, the staffing regulation requires nursing homes to have registered nurses on-site around the clock — something that the industry has endorsed — and to maintain minimum numbers of nurses and aides. Four in 5 homes would have to increase staffing. The requirements would be phased in, starting in May 2026.

Even before the election, many experts and activists had doubts that the rule would be effectively enforced, given the poor results in states that have imposed their own minimums. In New York, California, Rhode Island, and Massachusetts — states with the most robust requirements — many homes remain below the legal staffing levels. Governors have given many homes reprieves, and other homes have found that paying penalties costs less than the increase in payroll for additional staff.

The federal government estimates the average annual cost over a decade to meet the Biden mandate would be $4.3 billion a year, a 2% increase in expenses, though the changes do not include increases in federal Medicare or Medicaid payments.

“Staffing is everything in terms of nursing-home quality,” said R. Tamara Konetzka, a professor of public health sciences at the University of Chicago.

While the rule’s effectiveness was uncertain, she worried that repealing it would send the wrong message. “We would be losing that signal that nursing homes should try really hard to improve their staffing,” she said.

Advocate groups for nursing home residents, who had criticized the Biden administration rule for not requiring even higher staffing levels, have since pivoted and are trying to protect it.

“We’re hoping the president-elect will come in and take a look at the science and data behind it and see this really is a modest reform,” said Sam Brooks, the director for public policy for the National Consumer Voice for Quality Long-Term Care, a Washington, D.C.-based nonprofit. “We’d be devastated to see it fall.”

The Trump transition team did not respond to a request for comment. The Department of Health and Human Services did not respond to requests for comment, but in a court filing it argued that nursing homes should be able to reach the required staffing levels.

“There is more than enough time to identify, train and hire additional staff,” the Biden administration wrote.

The quality of care in the nation’s 15,000 nursing homes and the lack of adequate staffing for their 1.2 million residents has been a concern for decades. Inspection reports continue to find homes leaving residents lying in their own feces, suffering severe bedsores and falls, contracting infections, choking on food while unattended, or ending up back in a hospital for preventable reasons. Some nursing homes overuse psychotropic medications to pacify residents because they do not have enough workers to attend to them.

Leslie Frane, executive vice president of the SEIU, the Service Employees International Union, which represents health care workers, said in a statement that “far too many nursing home owners will not do the right thing and invest in workers without oversight and binding regulation.”

The nursing home industry says many homes cannot afford to increase their workforces, and that, even if they could, there is a scarcity of trained nurses, and not enough people willing to work as aides for an average $19 an hour. A registered nurse earns $40 an hour on average in a nursing home, less than what they could make at a hospital, according to the Bureau of Labor Statistics.

The Biden administration noted in its court filing it was planning to spend $75 million to recruit and train more workers, and that there were more than 100,000 workers who left nursing homes during the pandemic and could be lured back if salaries and working conditions were better.

How many nursing homes could afford the increased cost remains a mystery because of weaknesses in the government’s requirements for financial transparency. About half of homes lose money, according to their reports to Medicare, but some nursing home owners grow rich through clandestine maneuvers to siphon profits into their own pockets.

Last month, owners of Centers Health Care, one of New York state’s largest nursing home chains, agreed to pay $45 million to settle allegations by Attorney General Letitia James that they diverted $83 million intended for resident care to themselves during the pandemic.

Maryellen Mooney, a spokesperson for the Centers Health Care chain, which denied the allegations, said in a statement that Centers was “committed to fully implementing the settlement terms, including a significant investment in resident care.”

About three-quarters of nursing homes are for-profit. The industry, though, highlights the most sympathetic examples: rural nonprofit nursing homes like Kimball County Manor & Assisted Living in Kimball, Nebraska. Its staffing levels for registered nurses are 40% below what the new rule would require, federal data shows.

Sarah Stull, Kimball’s administrator, said recruitment had always been challenging and that temporary nursing staffing agencies charged more than double what she paid her own staff.

“We had to pay $65 for a nurse aide during covid, and that’s insane,” she said.

The government estimated that about a fourth of the nation’s nursing homes would be eligible to apply for hardship exemptions if there were a documented shortage of nurses and aides in their communities compared with the national average.

But Nate Schema, the chief executive of the Good Samaritan Society, which runs 133 nonprofit homes mainly in the rural Midwest, estimated that only seven would be likely to qualify for a hardship waiver.

“Philosophically, they sound great,” he said. “But in practicality and how they’re put together, they won’t do much for us.”

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.

USE OUR CONTENT

This story can be republished for free (details).

When Hurricane Helene struck in late September, it flooded the largest IV fluid factory in the United States. The Baxter International facility in western North Carolina had been producing 1.5 million IV bags a day, 60 percent of the nation’s supply. The company immediately began rationing its products, and the shortage sent ripples through the health-care industry.

IV saline and fluids with carbohydrates are used regularly in hospitals and other clinical settings, both for hydration and to deliver medications. The shortage has left facilities scrambling to figure out the best use of the IV fluid bags they have.

But some hospital administrators see an opportunity in the IV fluid shortage to question standard practices. “There has been increasing literature over the last 10 to 20 years that indicates maybe you don’t need to use as much,” said Sam Elgawly, chief of resource stewardship at Inova, a health system in the D.C. area. “And this accelerated our sort of innovation and testing of that idea.”

Elgawly said he’s keeping one question front of mind: “How often are we actually giving it more than we need to, where we just keep it going because a patient’s in the hospital?”

He told KFF Health News that across the system IV fluid usage has dropped 55 percent since early October.

Hospitals such as those in the Inova system are using different ways to conserve, including giving some medications intravenously but without a dedicated IV fluid bag, known as “pushing” the medication.

“You don’t even need a bag at all. You just give the medication without the bag,” he said.

Simpler conservation measures could become common after the shortage abates, said Vince Green, chief medical officer for Pipeline Health, a small hospital system in the Los Angeles area that serves mainly people on Medicare and Medicaid. Green said medical staffers are encouraging patients to drink Gatorade or water instead of defaulting to IVs for hydration.

And medical staff make sure to use up the entire bag before starting another.

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

The North Carolina factory has reopened and is producing some IV fluid products, but it’s not up to prehurricane production levels. Some hospital administrators are anticipating dealing with the shortage through the end of the year.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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.

USE OUR CONTENT

This story can be republished for free (details).

The Host Julie Rovner KFF Health News @jrovner 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.

Public health, one of the more misunderstood concepts in the health world, is about the health of entire populations, rather than individuals. As a result, public health is closely tied to things like the environment, nutrition, and safety.

One commonality among many of President-elect Donald Trump’s picks to manage federal health agencies is their distrust of the nation’s public health system. With major concerns such as bird flu looming, that sentiment could translate into efforts to undermine those of public health workers.

To illuminate the importance and nuances of public health — and recognizing that public health is best explained at the local level — KFF Health News has partnered with Civic News Company to launch a project called Healthbeat.

In this special episode of KFF Health News’ “What the Health?”, chief Washington correspondent Julie Rovner is joined by KFF Health News public health correspondent and Healthbeat national reporter Amy Maxmen, Healthbeat editor-in-chief Charlene Pacenti, and Healthbeat New York City reporter Eliza Fawcett.

Panelists Amy Maxmen KFF Health News and Healthbeat Read Amy's stories. Charlene Pacenti Healthbeat Read Charlene's bio. Eliza Fawcett Healthbeat Read Eliza's stories.

Among the takeaways from this week’s episode:

• The covid-19 pandemic revealed the need for a deeper understanding of public health — a data-driven field devoted to the health and well-being of populations. Some of the biggest public health issues of the moment include childhood vaccination rates, and long covid and post-traumatic stress disorder cases among health care workers.
• Bird flu is top of mind for many in public health. While the virus has been around for decades, its transmissibility to cattle is new, and that concerning characteristic emerged in the United States. The outbreak was not contained when it was first observed in a handful of states, and now the question is whether the virus mutates to enable human-to-human transmission — a trait that could make bird flu the next pandemic.
• Many in the public health community are wary of the possibility that Trump and his administration’s officials could gut funding and policies that support the nation’s health — and even non-health policies can hold consequences for health care. For instance, anti-immigration measures could drain the health workforce; many immigrants work as home health aides, nursing home staffers, and more.

Mentioned in this week’s podcast:

• KFF Health News’ “Exclusive: Emails Reveal How Health Departments Struggle To Track Human Cases of Bird Flu,” by Amy Maxmen.
• Healthbeat’s “Georgia Facing Numerous Crises, but Board of Public Health Hasn’t Met Since May,” by Rebecca Grapevine.
• Healthbeat’s “New Yorkers, Meet Your Local Epidemiologist,” by Charlene Pacenti.

Credits Lonnie Ro Audio producer Taylor Cook Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

The current Affordable Care Act open enrollment season is the first big test of new federal guardrails against fraud.

The rules aim to head off unauthorized ACA plan enrollments or switches by rogue agents and entities looking to make money via enrollment commissions. Such sign-ups triggered more than 274,000 consumer complaints through August this year.

But some health insurance experts fear the new rules could slow consumer sign-ups and reduce the number who sign up for 2025 coverage. In most states, ACA open enrollment started Nov. 1 and extends through Jan. 15.

Regulators “really have this tightrope to walk,” said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University.

The Centers for Medicare and Medicaid Services, for example, now requires that certain policy adjustments — those in which the agent is not “affiliated” with the existing plan — have more restrictions, such as mandating a three-way call between the agent or broker, the consumer and healthcare.gov.

In August, CMS also barred two of about a dozen private sector online enrollment platforms from connecting with healthcare.gov. And it suspended 850 agents suspected of possibly being involved in these activities, although some were reinstated.

Federal regulators said in mid-October that casework associated with consumer complaints had fallen by almost a third in recent weeks.

Still, CMS’s actions inadvertently could slow the enrollment process.

Given that phone lines for healthcare.gov already get busy — especially in mid-December — Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers, said consumers should “hit the ground running.”

Meanwhile, reports are emerging that fraudsters are already figuring out workarounds for CMS’s antifraud protections, Nolan said.

For its part, CMS said it has “ramped up support operations” at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight. CMS officials expect “minimal wait times,” Wu added.

The problem of unauthorized switches is not new but took off during last year’s open enrollment.

Brokers generally blamed much of the problem on the ease with which agents could access ACA information in the federal marketplace. Though federal regulators have worked to tighten that access, they stopped short of instituting what Nolan and some other agents say is needed: two-factor authentication.

For consumers, unauthorized switches can cause a host of problems, from higher deductibles to new networks that do not include their physicians or hospitals, or even tax bills if those unauthorized policies came with premium credits for which they did not qualify.

But they also posed a political liability for the Biden administration, a blemish amid two years of record ACA enrollment. Democrats want more oversight and punishment of rogue agents, while Republicans say fraud was fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire at the end of 2025, will be decided by Congress next year.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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.

USE OUR CONTENT

This story can be republished for free (details).