One family in Virginia Beach, Virginia, just found out their health plan’s deductible will jump from $800 to $20,000 next year. About 200 miles north, in Maryland, another household learned they’ll pay $500 more monthly to insure their brood in 2026. And thousands of people in Idaho were greeted with insurance rates that’ll cost, on average, $100 more every month.

As shopping season opens for Affordable Care Act plans in some states, customers are confronting staggering costs for their health insurance next year. The extra federal subsidies put in place in 2021 that made coverage more affordable for millions of people will expire at the end of this year unless a gridlocked and idle Congress acts.

With Democratic and Republican lawmakers at an impasse, the federal government shut down on Oct. 1, spurred by the need for an estimated $353 billion over a decade to continue providing enhanced ACA subsidies for roughly 24 million people. Both sides have dug in, with Republicans saying Senate Democrats must vote to reopen the government before they’re willing to negotiate on the ACA’s costs.

If Congress does manage to strike a deal in the coming days or weeks to extend some subsidies, the prices and types of plans available on the online marketplaces could change dramatically, bringing unprecedented uncertainty and upheaval to this year’s open enrollment, which begins in most states on Nov. 1.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, the state-run marketplace, is gaming out strategies should that happen, including the possibility of pausing enrollment so her 200-person team can update the plans to reflect any changes, should Congress pass a new bill on ACA subsidies.

“We will do whatever it takes to make sure we can provide Marylanders with the most affordable health coverage,” Eberle said. “The mechanics of how that gets done, we don’t really know until we figure out what Congress might do.”

“I think everyone realizes that, depending on what happens, we just can’t flip a switch overnight,” she added.

Exchange customers in Maryland can expect to pay, on average, about 35% more next year, even with help from the state, which agreed to offer backup subsidies should the federal government’s discounts expire at the end of this year. Eberle said notices of premium hikes — which assumed the federal subsidies would expire — already were sent to mailboxes and inboxes. One middle-income family of four in the state, for example, will see their monthly premiums go from $916 to $1,427.

People living in most states still use healthcare.gov, the federal marketplace, to enroll in coverage. The Centers for Medicare & Medicaid Services, which oversees the federal exchange, declined to answer questions about how quickly the agency could pivot on any changes Congress may make after sign-ups start.

“CMS does not speculate on potential Congressional action,” Health and Human Services spokesperson Emily Hilliard said in an email.

Like other states that run their own ACA exchanges, California has sent letters to policyholders with information about their 2026 coverage, with costs calculated under the assumption that the subsidies would expire.

But the California exchange team, too, devised backup plans to contact policyholders and revamp its online marketplace if Congress acts before year’s end.

“At no point is it too late,” said Jessica Altman, executive director of Covered California, the state’s exchange. “We are ready to move any mountain we can possibly move to make any changes as quickly as we possibly can.”

It could take about a week to reprogram the site to reflect prices that factor in more generous subsidies, if Congress were to approve them exactly as they currently are, Altman said.

States may also have to update premiums themselves to reflect new rates. Most insurers submitted two sets of premium rates to states this year in case Congress agreed to extend the subsidies.

Right now, many shoppers are seeing the set of higher rates that insurers plan to charge if the subsidies expire.

Insurers say it is necessary to raise premiums without the subsidies because they anticipate healthier, younger people will drop coverage rather than pay more. That would leave insurers with a sicker, older pool of people to cover.

If a subsidy deal is reached, insurers could lower the premiums.

The complications don’t end there.

If Congress passes a subsidy deal after customers have started picking plans, people might see the new prices and want to reconsider the type of coverage for which they already signed up. Enrollees may change plans as long as enrollment is open, through Jan. 15 in most states.

Dozens of insurers offer ACA plans across the country. Those plans range widely in the doctors or medications they cover, as well as how much customers contribute in copays, the fees owed for medical services, and deductibles, the out-of-pocket amount paid before insurers pitch in.

Some people might be willing to pay a higher monthly premium in exchange for a lower deductible. Others, especially those who don’t expect to incur major medical bills, might risk a higher deductible to keep monthly premium payments lower.

In Virginia, some customers are being presented with strikingly high deductibles for next year, said Deepak Madala, the director of Enroll Virginia, which assists people with enrolling in coverage.

He said he’s helping one family in Virginia Beach facing a jump in premium costs from $70 to about $280 a month.

To buy a plan at a similar price, the family, with a household income of about $60,000, would need to look at coverage that carries a deductible of $20,000 or more, he said. Right now, their deductible is $800.

With premiums and deductibles that high, some customers might rethink coverage entirely, he said.

They’re deciding whether “to go without or switch to a plan with a very high deductible,” Madala said of ACA customers’ options.

Pennsylvania’s state-based exchange, which last week started sending out notices detailing 2026 rates, estimates a 102% increase in premiums for its roughly 500,000 customers. About a third of customers are expected to drop coverage, said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority.

The timing of any subsidy deal reached by Congress is most precarious, though, for the roughly 135,000 Idahoans enrolled in ACA coverage.

That’s because their state opened enrollment on Oct. 15, weeks before the rest of the country — and it will end earlier, on Dec. 15.

With ACA enrollees facing average increases of 75% for coverage costs, about 20% are expected to drop out of the marketplace, said Pat Kelly, executive director of Your Health Idaho, the state exchange.

Idaho is prepared to revamp its website if anything changes on the subsidies — a process that could take days — and has “notices ready to go” to inform policyholders of additional savings, Kelly said.

“We would work to do it as quickly as possible, and make sure it is done right,” he said, adding that factors such as the day of the week or proximity to the Thanksgiving holiday could add time.

If Congress waited to act until the federal subsidies expire on Dec. 31 — the date Republican House Speaker Mike Johnson has repeatedly raised as the deadline for a deal — it would be too late for people in Idaho.

“We would run out of open enrollment, and there would not be enough time to make changes,” Kelly said of any congressional deals reached after mid-December.

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

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No es fácil promover la moderación y la disciplina financiera desde las entrañas de un casino.

Pero eso es lo que los empleados estatales de Massachusetts intentan hacer a diario, entre los sonidos y las luces intermitentes de las máquinas tragamonedas.

En el MGM Springfield, al oeste del estado, empleados con remeras verdes se encuentran frente a su pequeña oficina, justo al lado del casino.

Sobre ellos, un cartel dice GameSense, el programa insignia del estado para combatir la ludopatía (adicción al juego). Una pantalla muestra mensajes como “Mantén las apuestas deportivas divertidas. Establece un presupuesto y cúmplelo”.

Los empleados reparten etiquetas para maletas y pañuelos desechables gratuitos para animar a la gente a charlar. Si lo consiguen, entregan a los clientes folletos con el número de teléfono estatal de ayuda para jugadores y su sitio web. Incluso pueden inscribirlos en un programa llamado PlayMyWay, que permite a las personas establecer un presupuesto fijo mensual para sus apuestas.

Fuera de los casinos, GameSense se promociona en redes sociales, aplicaciones y sitios web de apuestas deportivas. Mientras tanto, el Departamento de Salud Pública del estado coloca sus propios mensajes sobre moderación en autobuses y vallas publicitarias.

“Es un gran movimiento de 12 años”, dijo Mark Vander Linden, quien supervisa el programa GameSense en Massachusetts.

El primer casino de Massachusetts abrió sus puertas en 2015 y, a medida que la industria del juego crecía, el estado desarrolló lo que denomina un programa de “juego responsable”, financiado con un impuesto adicional sobre las ganancias de la industria.

Al principio, los reguladores estatales probaron diversas estrategias para educar a los clientes sobre la naturaleza adictiva del juego y sobre sus riesgos financieros.

“Se trataba más bien de asegurar la disponibilidad de folletos que explicaran las probabilidades de cualquier juego”, explicó Vander Linden.

Desde entonces, Massachusetts ha implementado regulaciones adicionales para una industria en auge que ahora incluye las apuestas deportivas generalizadas.

Por ejemplo, no se pueden apostar sobre equipos universitarios de Massachusetts ni jugar con tarjeta de crédito. Todas las empresas de juegos de azar deben permitir a los clientes establecer límites voluntarios e inscribirse en una “lista de autoexclusión voluntaria” que les prohíbe el acceso a casinos o apuestas deportivas durante determinados intervalos de tiempo.

Un mosaico de normas estatales

Algunos estados han establecido límites similares para frenar la ludopatía, pero otros tienen muy pocos. A falta de una política nacional o de una comisión nacional del juego que supervise la industria, cada estado elabora su propio plan.

Un número creciente de investigadores y legisladores en materia de adicciones afirman que es hora de tomar medidas más audaces y unificadas para combatir los trastornos del juego.

Resaltan el auge de la industria del juego desde 2018, cuando la Corte Suprema de Estados Unidos abrió la puerta a que los estados legalizaran las apuestas deportivas y desató una industria agresiva, ahora legal en 39 estados. (Cuarenta y ocho estados han legalizado al menos alguna forma de juego, incluyendo las loterías).

Otros países han avanzado mucho más en la regulación de la industria del juego, y algunos expertos estadounidenses los consideran modelos potenciales.

Por ejemplo, el gobierno de Noruega tiene el monopolio de todas las máquinas tragamonedas, lo que le permite controlar los tipos de juegos que se ofrecen, y cada jugador del país tiene un límite de pérdida de 20.000 coronas (unos $2.000) al mes.

En el Reino Unido, la mayoría de los adultos tienen un límite de apuesta de 5 libras (unos $7) por cada giro en una máquina tragamonedas, y las empresas de juegos de azar están sujetas a un impuesto del 1% que se destina a un fondo para el tratamiento y la prevención de los trastornos del juego.

El año pasado, un informe publicado en la revista médica The Lancet instó a los líderes de salud internacionales a actuar con rapidez en las regulaciones antes de que los trastornos del juego se generalicen y se vuelvan comunes, y mucho más difíciles de detener.

Sin embargo, los líderes políticos señalan que Estados Unidos tiene menos interés en la regulación corporativa que muchos otros países, especialmente bajo la administración Trump. Al mismo tiempo, advierten que no hacer nada podría representar una grave amenaza para la salud pública, en especial ahora que las aplicaciones de apuestas deportivas permiten a las personas apostar en cualquier lugar y en cualquier momento.

El temor: más apuestas, más adicción

Incluso antes del “matrimonio” entre los juegos en línea y los teléfonos celulares, los investigadores estimaban que entre el 1% y el 2% de los estadounidenses ya padecían un trastorno del juego, y que un 8% adicional corría el riesgo de desarrollarlo.

Algunos políticos estadounidenses temen que el problema solo empeore.

“La sofisticación y complejidad de las apuestas se han vuelto abrumadoras”, declaró el senador Richard Blumenthal (demócrata de Connecticut). “Y por eso necesitamos protecciones que permitan a las personas decir que no”.

Blumenthal ha copatrocinado el Safe Bet Act (la Ley de Apuestas Seguras), una legislación que impondría normas federales a las empresas de apuestas deportivas.

El proyecto de ley propone la prohibición de la publicidad de juegos de azar durante eventos deportivos en vivo, controles obligatorios de asequibilidad para clientes con grandes gastos, límites a los programas de membresía VIP, la prohibición del uso de la inteligencia artificial para marketing y la creación de una base de datos nacional de “autoexclusión”, entre otras normas.

“Los estados no pueden proteger a sus consumidores de las ofertas excesivas y abusivas, y a veces de los anuncios engañosos”, declaró Blumenthal. “Simplemente no tienen los recursos ni la jurisdicción”.

La industria del juego se opone firmemente a esta ley. Las normas federales serían una bofetada para los reguladores estatales, afirmó Joe Maloney, vocero de la American Gaming Association.

“Tienen el potencial de, primero, usurpar drásticamente la autoridad de los estados y, segundo, congelar la industria”, afirmó.

El juego responsable y la salud pública

Las nuevas regulaciones también son innecesarias, afirmó Maloney. La industria reconoce que el juego es adictivo para algunas personas, explicó, por lo que desarrolló una iniciativa de divulgación y concientización conocida como “juego responsable”.

Esto incluye mensajes en autobuses y carteles que advierten a la gente que deje de jugar cuando ya no sea divertido y les recuerdan que las probabilidades de ganar son muy bajas.

“Hay mensajes muy directos, como: ‘Aquí perderás dinero’”, dijo Maloney.

Agregó que su grupo industrial no recopila datos sobre si tales medidas reducen las tasas de adicción. Sin embargo, afirmó que las restricciones al juego no son la solución.

“Si de repente se empieza a elegir entre lo legal y lo prohibido, se está alejando a los apostadores del mercado legal y llevándolos al ilegal”, afirmó Maloney.

Los líderes de salud pública argumentan que el modelo de “juego responsable” de la industria no funciona.

“Se necesita regulación cuando la industria ha demostrado incapacidad y falta de voluntad para autocontrolarse”, afirmó Harry Levant, director de políticas de juego del Instituto de Defensa de la Salud Pública de la Facultad de Derecho de la Universidad de Northeastern en Boston.

Una de las razones por las que el enfoque de la industria es “ética y científicamente defectuoso” es que atribuye toda la culpa y la responsabilidad a las personas con un trastorno del juego, afirmó Levant. “No se puede decir a una persona que lucha contra la adicción: ‘Bueno, simplemente deja de hacerlo’”.

Levant aborda el tema desde su experiencia personal. Se está recuperando de una adicción al juego. Ex abogado, fue condenado en 2015 por robar dinero de sus clientes para financiar su adicción al juego. Desde entonces, no solo se ha convertido en un defensor de regulaciones más estrictas, sino que también es un terapeuta especializado en adicciones.

La American Gambling Association (AGA) afirmó apoyar el tratamiento de los trastornos del juego y ayudar a financiar algunos servicios de derivación y tratamiento a través de impuestos estatales. Sin embargo, Levant calificó esto como “el equivalente moral de que las grandes tabacaleras digan: ‘Hagamos lo que queramos con nuestros cigarrillos, siempre y cuando paguemos la quimioterapia y los cuidados paliativos'”.

En cambio, Levant aboga por un enfoque de salud pública que ayude a prevenir la adicción de raíz. Esto significa limitar la publicidad, y los tipos y la frecuencia de las apuestas, para todos, no solo para quienes ya tienen problemas.

Para defender su postura, Levant abre su computadora y muestra un anuncio corporativo producido por Simplebet, filial de DraftKings.

En el video, la compañía presume de conseguir que más gente apueste en deportes mediante las llamadas microapuestas durante los partidos en directo. “Impulsamos la participación de los aficionados convirtiendo cada momento de cada partido en una oportunidad para apostar. Automático, algorítmico, impulsado por el aprendizaje automático y la IA”, dice la voz en off.

Ese es el tipo de participación constante que fomenta la adicción, afirmó Levant. (Contactados por KFF Health News y NPR, DraftKings declinó hacer comentarios y, en su lugar, envió un enlace a su programa de “juego responsable”).

Legisladores quieren actuar ya

Algunos de estos mecanismos de juego se verían limitados por la Ley de Apuestas Seguras, que Levant y sus colegas del Instituto de Defensa de la Salud Pública ayudaron a redactar.

Pero si la legislación no se aprueba en el actual Congreso, reacio a las regulaciones, los estados deberán tomar medidas contundentes por su cuenta, afirmó Levant.

La Legislatura de Massachusetts está considerando actualmente la “Ley de Salud del Apostador” (Bettor Health Act), que impondría normas adicionales a las empresas de apuestas deportivas.

“El objetivo no es eliminar por completo las apuestas”, dijo

La representante estatal de Massachusetts, la demócrata Lindsay Sabadosa, copatrocinadora del proyecto de ley, dijo: “Es para detener los peores excesos de las apuestas deportivas en línea”.

El proyecto de ley de Massachusetts incluye componentes de la legislación federal, como los controles de asequibilidad obligatorios. Estos limitarían la cantidad de dinero que algunos jugadores pueden perder. Los controles de asequibilidad se basan en un programa piloto del Reino Unido.

“Si solo te permiten tomar dos copas, sabemos que no te vas a emborrachar, ¿verdad?”, dijo Sabadosa. “Si solo te permiten apostar $100 al día porque es una cantidad asequible, no te arruinarás. Podrás pagar el alquiler”.

La Ley de Salud del Apostador también prohibiría las apuestas “prop”, que son apuestas realizadas durante un partido en vivo, como quién marca el primer tiro en baloncesto o quién conecta el primer jonrón en béisbol.

Sin embargo, los ingresos fiscales estatales provenientes de las apuestas deportivas ascendieron a $2.800 millones en 2024, una fuente de financiación muy útil para los presupuestos estatales con dificultades. Debido a este posible impulso, Levant teme que los gobiernos estatales eviten una mayor regulación.

Los estados podrían incluso verse tentados por la promesa de ingresos adicionales provenientes de nuevos tipos de juegos de azar, como el “iGaming”. Se refiere a las versiones en línea de la ruleta, el blackjack y otros juegos de casino, disponibles a cualquier hora, desde la comodidad del hogar.

Actualmente, el iGaming es legal en siete estados, pero la legislación pendiente en otros estados, incluido Massachusetts, podría expandir sus mercados.

“Comprendemos lo difícil que es para los estados equilibrar sus presupuestos en el actual entorno político”, declaró Levant, “pero están empezando a reconocer que la solución a ese problema no es seguir impulsando un producto conocido por ser adictivo”.

Este artículo forma parte de una colaboración entre NPR y New England Public Media.

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

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El cierre del gobierno federal continúa, trabado por el desacuerdo en el Congreso sobre el costo del seguro médico de 22 millones de personas que tienen planes adquiridos en los mercados establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Mientras tanto, un nuevo informe muestra que más de 154 millones de personas con cobertura médica a través de sus empleos enfrentan fuertes aumentos de precios. Y, concluye la investigación, la situación podría empeorar.

Según una encuesta anual de empleadores publicada el 22 de octubre por KFF, las primas de los seguros médicos que ofrecen los empleadores aumentaron 6% en 2025, alcanzando un promedio de $26.993 al año para una cobertura familiar.

Es la primera vez en dos décadas que el costo de asegurar a una familia de cuatro personas aumenta 6% o más durante tres años consecutivos, según los datos de KFF.

En los últimos cinco años, la prima promedio por cobertura familiar ha aumentado un 26%, en comparación con un alza del 29% en los salarios de los trabajadores y casi un 24% en la inflación. Hoy, el seguro médico para una familia cuesta más o menos lo mismo que comprar un Toyota Corolla híbrido nuevo.

La prima promedio anual para un plan individual proporcionado por los empleadores subió un 5%, alcanzando los $9.325, casi $3.000 más que en 2016, según la encuesta.

“Nos preocupa que los costos de salud sigan subiendo”, dijo Eric Trump, encargado del área contable de Steve Reiff Inc., una pequeña empresa en South Whitley, Indiana, especializada en el arenado y la pintura de maquinaria pesada.

Trump, quien no tiene relación con el presidente Donald Trump, comentó que los costos de los planes médicos que ofrece la empresa subieron un 8% para el año fiscal 2026, más o menos lo mismo que en los últimos años.

Los trabajadores de Reiff pagan aproximadamente el 50% del costo de su cobertura médica. Cerca de la mitad de los 20 empleados rechazaron el seguro porque obtienen la cobertura a través de un familiar o prefieren no tener cobertura, explicó. “No podemos hacer mucho; no tenemos suficientes empleados para distribuir el costo”.

La mayoría de las personas que acceden al seguro médico a través del trabajo contribuyen al pago de sus primas. Este año, el trabajador promedio aportó $1.440 por cobertura individual y $6.850 por cobertura familiar.

Con el tiempo, muchos trabajadores han tenido que asumir deducibles más altos —el monto que deben pagar de su bolsillo por servicios médicos antes de que su seguro comience a cubrir los costos—. Más de un tercio de los trabajadores asegurados están inscritos en planes con un deducible de $2.000 o más por persona. Según el informe, la proporción de trabajadores con un plan de este tipo ha aumentado un 32% en los últimos cinco años y un 77% en la última década.

Los crecientes costos de los medicamentos y las hospitalizaciones suelen destacarse como las principales causas del incremento en el precio de los seguros médicos, y ninguno de estos factores muestra señales de disminuir.

“Los primeros informes indican que los costos seguirán en alza en 2026, lo que podría provocar aumentos aún más elevados en las primas, a menos que los empleadores y las aseguradoras encuentren formas de compensar estos costos mediante cambios en los beneficios, el reparto de gastos o el diseño de los planes”, señala la encuesta de KFF.

Una de las cuestiones que más preocupa a los empleadores es el alto precio de los medicamentos GLP-1 para bajar de peso, que cada vez más empresas cubren. Los precios elevados, junto con la alta demanda, han llevado a algunas compañías a restringir o eliminar la cobertura de estos medicamentos.

“Las grandes empresas saben que estos nuevos medicamentos para bajar de peso, muy costosos, son un beneficio importante para sus trabajadores, pero su precio a menudo supera las previsiones”, afirmó en un comunicado de prensa Gary Claxton, autor del estudio y vicepresidente senior de KFF.

“No es una sorpresa que algunas compañías estén reconsiderando el acceso a los medicamentos para bajar de peso”, agregó.

Los empleadores suelen responder al aumento de los costos de salud trasladando parte de esos gastos a sus trabajadores, pero no está claro cuánto más ellos pueden resistir económicamente. La encuesta mostró que casi la mitad de las grandes empresas dijeron que sus empleados están “bastante” o “muy” preocupados por cuánto les toca pagar de su propio bolsillo.

Aunque el aumento en el precio de los seguros pagados por las empresas ha superado la inflación general, la cuestión ha recibido poca atención en el Congreso en los últimos meses.

Para ayudar a financiar la ampliación de los recortes fiscales, la ley tributaria y de gasto público del presidente Trump reduce en miles de millones de dólares el monto que el gobierno destina a Medicaid, el programa de seguro de salud federal y estatal que cubre a 70 millones de personas de bajos ingresos y con discapacidades. Los analistas presupuestarios del Congreso pronostican que estos recortes harán que millones de personas pierdan su cobertura médica a lo largo de la próxima década.

El gobierno federal está cerrado desde el 1 de octubre, ya que los demócratas se niegan a aprobar un nuevo presupuesto federal a menos que los republicanos acepten prorrogar los subsidios que ayudan a unas 22 millones de personas a adquirir cobertura de salud a través de los mercados de ACA.

Sin la intervención del Congreso, estos subsidios (también llamados créditos fiscales) expirarán y las primas se duplicarán para muchos consumidores a partir de enero.

El informe de KFF se basa en una encuesta realizada este año a 1.862 empleadores públicos no federales y privados, seleccionados al azar, con 10 o más trabajadores.

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

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It isn’t easy to promote moderation and financial discipline from the bowels of a casino.

But that’s what Massachusetts state workers try to do every day, amid the clanging bells and flashing lights of the slot machines.

At the MGM Springfield in western Massachusetts, workers wearing green polos stand outside their small office, right off the casino floor.

Above them, a sign reads “GameSense,” the state’s signature program to curb problem gambling. A mounted screen cycles through messages such as “Keep sports betting fun. Set a budget and stick to it.”

The workers hand out free luggage tags and travel-size tissues to encourage people to stop and chat. If they succeed, they give customers brochures displaying the state’s gambling helpline number and website. They can even enroll them in a program called “PlayMyWay,” which allows customers to set monthly spending limits on how much they gamble.

Outside the casinos, GameSense is marketed on social media and on sports betting apps and websites. Meanwhile, the state’s Department of Public Health puts its own moderation messages on buses and billboards.

“That’s a big movement in 12 years,” said Mark Vander Linden, who oversees the GameSense program in Massachusetts.

Massachusetts’ first casino opened in 2015, and as the gaming industry grew, the state developed what it calls a “responsible gaming” program, funded by a surtax on gambling industry profits.

At first, state regulators tried various strategies to educate customers about the addictive nature of gambling, as well as the financial risks.

“It was much more about making sure that there are brochures that are available that explained the odds of whatever game it was,” Vander Linden said.

Since then, Massachusetts has put in place additional regulations on a booming industry that now includes widespread sports betting. For example, there’s no betting on Massachusetts college teams, and no gambling by credit card. All gambling companies must allow customers to set voluntary limits and sign up for a “voluntary self-exclusion list” that bans them from casinos or sports betting over various time intervals.

A Patchwork of State Policies

Some states have set similar limits to curb problem gambling, but others have very few. In the absence of a nationwide policy, or a national gambling commission to oversee the industry, each state is on its own. 

A growing number of addiction researchers and policymakers say it’s time to take bolder — and more unified — steps to combat gambling disorders. They point to the explosion of the gaming industry since 2018, when the U.S. Supreme Court opened the door for states to legalize sports betting and unleashed an aggressive industry, now legal in 39 states. (Forty-eight states have legalized at least some form of gambling, including lotteries.)

Compared with the U.S., several other countries have gone much further in regulating the gambling industry, and some experts in the U.S. are looking to them as potential models.

For example, Norway’s government has a monopoly on all slot machines so it can control the types of games offered, and every gambler in the country is limited to losing 20,000 kroner (about $2,000) a month.

In the United Kingdom, most adults are limited to betting 5 pounds (about $7) on every spin on a slot machine, and gambling companies are subject to a 1% levy that goes into a fund for treatment and prevention of gambling disorders.

Last year, a report published in the medical journal The Lancet called on international health leaders to act quickly on regulations before gambling disorders become widespread and common — and that much harder to stop.

But policy leaders point out that the U.S. has less appetite for corporate regulation than many other countries, especially under the Trump administration. At the same time, they warn that doing nothing could pose a serious public health threat, especially now that sports betting apps allow people to gamble anywhere and anytime.

Fears That More Gambling Means More Addiction

Even before the marriage of online gaming and cellphones, researchers had estimated 1% to 2% of Americans already had a gambling disorder, and an additional 8% of people were at risk of developing one.

Some U.S. politicians fear the problem will only get worse.

“The sophistication and complexity of betting has become staggering,” said Democratic U.S. Sen. Richard Blumenthal of Connecticut. “And that’s why we need protections that will enable an individual to say no.”

Blumenthal has cosponsored the SAFE Bet Act, legislation that would impose federal standards on sports betting companies.

The bill proposes a ban on gambling ads during live sporting events, mandatory “affordability checks” for high-spending customers, limits on VIP membership schemes, a ban on artificial intelligence tracking for marketing, and the creation of a national “self-exclusion” database, among other rules.

“States are unable to protect their consumers from the excessive and abusive offers, and sometimes misleading pitches,” Blumenthal said. “They simply don’t have the resources or the jurisdiction.”

The gambling industry is strongly opposed to the SAFE Bet Act. Federal standards would be a “slap in the face” to state regulators, said Joe Maloney, a spokesperson for the American Gaming Association.

“You have the potential to just dramatically, one, usurp the states’ authority and then, two, freeze the industry in place,” he said.

‘Responsible Gaming’ Versus the Public Health Approach

New regulations are also unnecessary, Maloney said. The industry acknowledges that gambling is addictive for some people, he said, which is why it developed an outreach/awareness initiative known as “responsible gaming.”

That includes messages on buses and billboards warning people to stop playing when it’s no longer fun and reminding them the odds of winning are very low.

“There’s very direct messages, such as, ‘You will lose money here,’” Maloney said.

He said his industry group does not collect data on whether such measures reduce addiction rates. But he said gambling restrictions are not the answer.

“If you suddenly start to pick and choose what can be legal or banned, you’re driving bettors out of the legal market and into the illegal market,” Maloney said.

Public health leaders argue that the industry’s “responsible gaming” model doesn’t work.

“You need regulation when the industry has shown an inability and unwillingness to police itself,” said Harry Levant, director of gambling policy for the Public Health Advocacy Institute at the Northeastern University School of Law in Boston.

One reason the industry’s approach is “ethically and scientifically flawed” is that it puts all the blame and responsibility on individuals with a gambling disorder, Levant said. “You can’t say to a person who is struggling with addiction, ‘Well, just don’t do that anymore.’”

Levant comes to the issue from personal experience. He is in recovery from a gambling addiction. A former lawyer, Levant was convicted in 2015 for stealing clients’ money to fund his betting habit. Since then, he not only has become an advocate for stronger regulations but also is a trained addiction therapist.

The American Gaming Association said it supports treatment for gambling disorders and helps pay for some referral and treatment services through state taxes. But Levant called that “the moral equivalent of Big Tobacco saying, ‘Let us do whatever we want for our cigarettes, as long as we pay for chemotherapy and hospice.’”

Instead, Levant advocates for a public health approach that would help prevent addiction from the get-go. That means putting limits on marketing and on the types, and frequency, of gambling — for everyone, not just those already in trouble.

To make his case, Levant opens his laptop and pulls up a corporate infomercial produced by Simplebet, a DraftKings subsidiary.

In the video, the company boasts about getting more people to gamble on sports through what’s called microbetting during live games. “We drive fan engagement by making every moment of every game a betting opportunity. Automatic, algorithmic, powered by machine learning and AI,” the voiceover said.

That’s the kind of constant engagement that promotes addiction, Levant said. (Contacted by KFF Health News and NPR, DraftKings declined to comment, instead sending a link to its “responsible gaming” program.)

Lawmakers Want To ‘Stop the Worst Excesses’ Before the Next Gambling Trend

Some of those gambling mechanisms would be limited by the SAFE Bet Act, which Levant and his colleagues at the Public Health Advocacy Institute helped write.

But if the legislation doesn’t get through the current regulation-averse Congress, then states need to take strong action on their own, Levant said.

The Massachusetts Legislature is currently considering the “Bettor Health Act,” which would impose additional rules on sports betting companies.

“The goal is not to stop gambling entirely,” said Massachusetts state Rep. Lindsay Sabadosa, a cosponsor of the bill. “It’s to stop the worst excesses of online sports betting.”

The Massachusetts bill includes components of the federal legislation, such as mandatory “affordability checks.” Those would cap how much money some gamblers can lose. Affordability checks are modeled on a pilot program in the United Kingdom.

“If you’re only allowed to have two drinks, we know that you’re not going to get drunk, right?” Sabadosa said. “If you’re only allowed to gamble $100 a day because that’s an affordable amount, you’re not going to go broke. You’re still going to be able to pay the rent.”

The Bettor Health Act would also ban “prop” bets, which are wagers placed during a live game, such as who makes the first shot in basketball, or who hits the first home run in baseball.

But state tax revenue from sports betting rose to $2.8 billion in 2024 — a welcome source of funding for struggling state budgets. Because of that potential boost, Levant fears that state legislatures will shy away from further regulation.

States may even be tempted by the promise of additional revenue from new types of gambling, such as “iGaming.” That refers to online versions of roulette, blackjack, and other casino-style games, playable at any hour, from the comfort of home.

IGaming is currently legal in seven states, but pending legislation in other states, including Massachusetts, could expand its markets.

“We have empathy for how hard it is for states to balance their budgets in this current political environment,” Levant said, “but states are starting to recognize that the answer to that problem is not to further push a known addictive product.”

This article is part of a partnership with NPR and New England Public Media.

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

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Listen: Health care has been at the heart of the federal government’s shutdown. KFF Health News chief Washington correspondent Julie Rovner appeared on WAMU’s Oct. 22 “Health Hub” to explain the health care compromises some lawmakers want before they will agree to reopen the government.

Affordable Care Act tax credits are at the heart of one of the longest government shutdowns in U.S. history. The impact is starting to be felt by families and federal employees. Food assistance programs could run out of money at the end of the month. And federal health agencies such as the Centers for Disease Control and Prevention have faced layoffs.

KFF Health News chief Washington correspondent Julie Rovner appeared on WAMU’s Oct. 22 “Health Hub” to discuss the possible compromises that could reopen the government.

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

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

Health programs are feeling the pinch of the ongoing government shutdown. Funding for the Supplemental Nutrition Assistance Program, or SNAP, and the food program for women, infants, and children, WIC, is likely to run out in November, and cuts at the Centers for Disease Control and Prevention are keeping the agency from carrying out some of its primary public health functions.

Meanwhile, the Trump administration’s immigration crackdown is also leading to health consequences, and the Department of Homeland Security is trying to bolster its medical staff to cope with the large number of people in its custody.

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

Panelists Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories.

Among the takeaways from this week’s episode:

• As the federal shutdown continues, some are facing the startling possibility that their SNAP and WIC benefits soon will be cut off. Lawmakers remain in a stalemate over renewing the enhanced Affordable Care Act subsidies that are set to expire, and the roughly 24 million people with such plans — about 90% of whom benefit from the subsidies — are starting to learn what they will owe next year without them.
• With a key weekly government report on morbidity and mortality halted amid the shutdown, the New England Journal of Medicine and the Center for Infectious Disease Research and Policy announced they will team up to publish public health alerts. While others are stepping in to fill the gap left by the Trump administration’s pullback from public health, the federal government’s data and ability to access information are not easily replaced.
• It’s unclear whether the Trump administration’s plan to make in vitro fertilization more accessible will yield a substantial improvement in access to fertility treatments. Some employers already offer supplemental IVF benefits, and so far there are few details, such as how generous the Trump proposal would require coverage to be.

Also this week, Rovner interviews KFF Health News’ Katheryn Houghton, who wrote the latest “Bill of the Month” feature, about a broken elbow and a nearly six-figure bill.

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

Julie Rovner: ProPublica’s “The Shadow President,” by Andy Kroll.

Shefali Luthra: The 19th’s “More People Are Freezing Their Eggs — But Most Will Never Use Them,” by Shalini Kathuria Narang, Rewire News Group.

Alice Miranda Ollstein: Brown University’s “New Study: AI Chatbots Systematically Violate Mental Health Ethics Standards.”

Rachel Roubein: The Washington Post’s “Errors in New Medicare Plan Portal Mislead Seniors on Coverage,” by Dan Diamond and Akilah Johnson.

Also mentioned in this week’s podcast:

• Politico’s “ICE Is Hiring Dozens of Health Workers as Lawsuits, Deaths in Custody Mount,” by Alice Miranda Ollstein and Ruth Reader.
• The 19th’s “ICE Keeps Detaining Pregnant Immigrants — Against Federal Policy,” by Shefali Luthra and Mel Leonor Barclay.
• The Associated Press’ “Anti-Science Bills Hit Statehouses, Stripping Away Public Health Protections Built Over A Century,” by Michelle R. Smith and Laura Ungar.

Credits Francis Ying 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.

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This summer, the state of Louisiana texted just over 13,000 people enrolled in its Medicaid program with a link to a website where they could confirm their incomes.

The texts were part of a pilot run to test technology the Trump administration says will make it easier for some Medicaid enrollees to prove they meet new requirements — working, studying, job training, or volunteering at least 80 hours a month — set to take effect in just over a year.

But only 894 people completed the quarterly wage check, or just under 7% of enrollees who got the text, according to Drew Maranto, undersecretary for the Louisiana Department of Health.

“We’re hoping to get more to opt in,” Maranto said. “We plan to raise awareness.”

The clock is ticking for officials in 42 states — excluding those that did not expand Medicaid at all — and Washington, D.C., to figure out how to verify that an estimated 18.5 million Medicaid enrollees meet rules included in President Donald Trump’s tax and spending law. They have until the end of next year, and federal officials are giving those jurisdictions a total of $200 million to do so.

The policy change is one of several to free up money for Trump’s priorities, such as increased border security and tax breaks that mainly benefit the wealthy.

The nonpartisan Congressional Budget Office has said the work rules will be the main reason millions of people won’t be able to access health insurance over the next decade. It estimates changes to the Medicaid program will result in 10 million fewer Americans covered by 2034 — more than half of them because of the eligibility rules.

For now, state officials, health policy researchers, and consumer advocates are watching the pilot program in Louisiana and another in Arizona. Mehmet Oz, director of the Centers for Medicare & Medicaid Services, has touted those test-drives and said they will allow people to verify their incomes “within seven minutes.”

“There have been efforts to do this in the past, but they haven’t been able to achieve what we can achieve because we have technologies now,” said Oz, during a television appearance in August.

Brian Blase, the president of the conservative Paragon Health Institute and a key architect of Medicaid changes in the new law, has chimed in, saying during a recent radio appearance that with today’s artificial intelligence “people should be able to seamlessly enter how they are spending their time.”

KFF Health News found scant evidence to support such claims. Federal and state officials have offered little insight into what new technology the two pilots have tested. They do say, however, that it connects directly with the websites of Medicaid enrollees’ payroll providers, rather than using artificial intelligence to draw conclusions about their activities.

Oz said the Trump administration’s efforts started “as soon as the bill was signed” in July. But work on the pilot programs began under the Biden administration.

And Medicaid is a state-federal program: The federal government contributes most of the funds, but it is up to the states to administer them, not the federal government.

“Oz can say, ‘Oh no, we’re going to fix this. We’re going to do this.’ Well, they don’t actually run the program,” said Joan Alker, a health policy researcher at Georgetown’s Center for Children and Families.

Officials have also offered few details about the pilots’ effectiveness in assisting enrollees in Medicaid or other public benefit programs.

The shortage of information has some state officials and health policy researchers worried that the Trump administration lacks viable solutions to help states implement the work rules. As a result, they say, people with a legal right to Medicaid benefits could lose access to them.

“What actually keeps me up at night is the fear that members that are eligible for Medicaid and are trying to get health care services would fall through the cracks and lose coverage,” said Emma Sandoe, Oregon’s Medicaid director.

Officials involved in the Louisiana and Arizona projects declined to answer many specific questions about their efforts, instead directing KFF Health News to federal officials.

Spokespeople for Arizona’s Medicaid and Economic Security departments — Johnny Córdoba and Brett Bezio, respectively — did not share data on how many people participated in the state’s pilot test nor describe the outcome. They said the pilot had been used to verify eligibility only for the federal Supplemental Nutrition Assistance Program, a smaller program than Medicaid.

The Community Food Bank of Southern Arizona, a nonprofit that helps people sign up for such SNAP benefits, hadn’t heard of the pilot program.

State officials and health policy researchers said neither pilot program could confirm whether a person meets other qualifying activities — such as community service — or any of the numerous exemptions. The tools being tested can verify only income.

Andrew Nixon, director of communications for the U.S. Department of Health and Human Services, which oversees Oz’s agency, wrote in a statement that the digital tools officials aim to share with states “are largely under development.”

One person doing that development is Michael Burstein, a software engineer who, until recently, worked at the U.S. Digital Service, which later became known as the Department of Government Efficiency.

As the U.S. Digital Service was turned into DOGE, Burstein and other staffers left and started a nonprofit called Digital Public Works to finish supporting the technology to make it easier for people to verify their incomes for Medicaid enrollment.

But without permission from state officials, Burstein would not describe the tool in development, aside from saying that it’s mobile-first, can quickly verify income for a new or returning client, “and we’re pretty happy with it.”

The state agencies that manage benefit programs, such as Medicaid and SNAP, are understaffed, and they use different eligibility systems, many of which need updating, which makes improving them “a challenging task,” he said.

The $200 million in start-up costs the federal government has earmarked for systems to track work requirements equals roughly four times what it cost to administer Georgia’s Medicaid work requirement program alone.

That state, which has the nation’s only active work requirement program, called Georgia Pathways to Coverage, in September was granted a temporary extension, despite a recent report from a federal watchdog saying it hadn’t received enough federal oversight. A complicated sign-up process has kept enrollment in the program far below Georgia’s own projections.

Trump’s tax and spending law allows states to ask for extra time — until the end of 2028 — to start enforcing the rules, but only with the approval of HHS Secretary Robert F. Kennedy Jr. It also allows counties with high unemployment rates to be exempted, but states must apply for that exemption.

Even with an app that states can use to prove people are eligible for Medicaid, enrollees would still need to know that app existed and how to use it — neither of which is a given, Alker said. There is also no guarantee they’d have reliable cell service or internet access. As KFF Health News has reported, millions of Americans live in rural areas without reliable internet.

Private vendors also have been working on such apps, said Jennifer Wagner, who researches Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. Wagner said she has seen several vendors demonstrate products they plan to pitch to states for the work rules. Many are limited in scope, she said, like those in the pilot tests.

“Nobody has a magical solution that’ll make sure eligible people don’t lose coverage,” she said.

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

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Mary Catherine Johnson is a retired small-business owner from outside Rochester, New York. She voted for Donald Trump three times.

Lexy Mealing, who used to work in a physician’s office, is from Long Island. She’s a Democrat.

But the women share a common bond. They both survived breast cancer.

And when the American Cancer Society Cancer Action Network organized its annual citizen lobby day in Washington last month, Johnson and Mealing were among the more than 500 volunteers pushing Congress to keep cancer research and support for cancer patients at the top of the nation’s health care agenda.

The day is something of a ritual for groups like the cancer organization.

This year, it came as Democrats and Republicans in Washington slid toward a budget impasse that shut down the federal government. But these volunteers transcended their political differences and found common ground.

“Not one person here discussed if you’re a Democrat, if you’re a Republican,” said Mealing, one of 27 volunteers in the New York delegation. “Cancer doesn’t care.”

Every one of the volunteer lobbyists had been touched in some way by the deadly disease, which is expected to kill more than 600,000 people in the U.S. this year.

Johnson said each of her mother’s 10 siblings died from cancer, as did a lifelong friend who died at age 57, leaving behind his wife and two young daughters.

Like many of the New York volunteers, Johnson also said she’s worried about the state of politics today.

“I think we’re probably the most divided that we’ve ever been,” she said. “That scares me. Scares me for my grandchildren.”

Katie Martin, a cancer volunteer from outside Buffalo, also worries. She and her daughter recently drove past political protesters screaming at one another on the street.

 “My daughter is silent and then starts asking, ‘What is this?’ And I don’t know how to explain it, because it doesn’t even make sense to me,” she said. “It’s very heartbreaking.”

Mealing said she can barely watch the news these days. “A lot of Americans are very stressed out. There’s a lot of things going on.”

Americans are indeed split over many issues — immigration, guns, President Trump. But helping people with cancer and other serious illnesses retains broad bipartisan support, polls show.

In one recent survey, 7 in 10 voters said it’s very important for the federal government to fund medical research. That included majorities of Democrats and Republicans.

“It’s rare in today’s environment to see numbers like that,” said Jarrett Lewis, a Republican pollster who conducted the survey for patient groups. “But almost everybody in this country knows somebody who’s had cancer.”

Similarly, a recent KFF poll found that three-quarters of U.S. adults, including most Republicans who align with the Make America Great Again, or MAGA, movement, want Congress to extend subsidies that help Americans buy health insurance through Affordable Care Act marketplaces.

These subsidies, which are critical to people with chronic illnesses such as cancer, are among the main sticking points in the current budget impasse in Congress.

As the cancer volunteers gathered in a conference hotel in Washington, they focused on their shared agenda: increasing funding for cancer research, retaining insurance subsidies, and expanding access to cancer screening.

“We may not see eye to eye politically. We might not even see eye to eye in social circumstances,” said Martin, the Buffalo-area volunteer. “But we can see beyond those differences because we’re here for one cause.”

The state delegations practiced the pitches they would make to their members of Congress. They ran through the personal stories they would share. And they swapped tips for how to deal with resistant staff and how to ask for a photo with a lawmaker.

On the morning of their lobby day, they reconvened in a cavernous ballroom, decked out in matching blue polo shirts and armed with red information folders to leave at each office they would visit.

They got a pep talk from a pair of college basketball coaches. Then they headed across town to Capitol Hill.

The army of volunteers — from every state in the country — hit 484 of the 535 Senate and House offices.

Not every visit was an unqualified victory. Many Republican lawmakers object to extending the insurance subsidies, arguing they’re too costly.

But lawmakers from both parties have backed increased research funding and support for more cancer screening.

And the New Yorkers felt good about the day. “It was amazing,” Mealing said as the day wrapped up. “You could just feel the sense of, ‘Everybody stronger together.’”

When evening came, the volunteers met on the National Mall for a candlelight vigil. It was raining. Bagpipes played.

Around a pond near the Lincoln Memorial, some 10,000 tea lights glimmered in little paper bags. Each luminary had a name on it — a life touched by cancer.

John Manna, another New Yorker, is a self-described Reagan Republican whose father died from lung cancer. He reflected on the lessons this day could offer a divided nation.

“Talk to people,” he said. “Get to know each other as people, and then you can understand somebody’s positions.  We have little disagreements, but, you know, we don’t attack each other. We talk and discuss it.”

Manna said he would be back next year.

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

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WASHINGTON — Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, as originally envisioned, is quickly becoming a quaint idea.

Rather, states should submit applications that “rebuild and reshape” how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at Washington, D.C.’s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors’ office staffers and state health agency leaders — some from as far away as Hawaii.

“This isn’t a backfill of operating budgets,” said Sutton, CMS’ innovation director. “We’ve been really clear on that.”

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Donald Trump’s massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by $137 billion over 10 years. Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill’s financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency’s leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It’s “what I would call incumbents versus insurgents in the rural space,” said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

Applications are due Nov. 5. The money will be awarded to states by the end of the year and distributed over five years.

Half of the $50 billion will be divided equally among all states with an approved application; the other half will go to states that win points. Of the second half, $12.5 billion will be allotted based on a formula that calculates each state’s rurality. The remaining $12.5 billion will go to states that score well on initiatives and policies that mirror the Trump administration’s “Make America Healthy Again” objectives.

The application identifies specific policy goals such as implementing the Presidential Fitness Test and restrictions to food assistance, as well as broader investment strategies around remote care services, data infrastructure, and consumer-facing technology tools, which CMS identified as “symptom checkers and AI chatbots.”

In September, after CMS officials released the application, Republican members of Congress from states with Democratic governors called for fairness, concerned their states might direct the money to urban areas. In a letter to Oz and Health and Human Services Secretary Robert F. Kennedy Jr., they said the money “will serve as a lifeline for rural and at-risk hospitals in our communities that are already struggling to keep their doors open.”

Smaller hospitals fear they will get “a tiny little slice” of each state’s share, said Emily Felder, who leads the health care practice at Brownstein Hyatt Farber Schreck, a law firm whose clients include rural hospital systems.

“There’s a lot of frustration,” Felder said.

But Kinsley, who was previously North Carolina’s secretary of health and human services, said using this money only to shore up a balance sheet “is really just throwing good money after bad.” In contrast, he said, insurgents such as technology-driven startups can offer new strategies.

One of those companies vying for funding is Homeward Health, a Silicon Valley-based company that contracts with Medicare managed care insurers. Using artificial intelligence analytics, Homeward helps patients get care in their home and with local providers.

The company manages the health of 100,000 rural Michigan patients enrolled in insurance, said Homeward co-founder and chief executive Jennifer Schneider. The company was a sponsor for the Watergate summit. It also has ongoing meetings with Oz and his team, Schneider said.

“They’re doing their job, and they’re talking to a lot of people in the ecosystem and really eager to learn from those of us that have been in the system,” Schneider said. “We’re one of many in that position.”

KFF Health News requested an interview with Alina Czekai, director of the newly created Office of Rural Health Transformation. CMS spokesperson Alexx Pons said the agency was “unable to accommodate facilitation of any interview.”

Instead, CMS provided an emailed statement from Oz saying the program “will help states and communities reimagine what’s possible for rural healthcare.”

Brock Slabach, chief operations officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics, said the money would best be used to help pay for transformation that isn’t “sexy” or “revolutionary.”

“If what we end up with is we have a wearable for every rural patient, I don’t think that’s transformational,” Slabach said, referring to digital health monitors such as fitness-tracking watches.

Slabach, a onetime small-hospital chief executive and an unofficial adviser to hundreds of rural facilities nationwide, named a few ideas for the money — including paying for capital improvements such as electronic health records or equipment, loan repayment programs to aid workforce development, and creating “SWAT” teams that rescue rural hospitals on the brink of closure.

More than 150 rural hospitals have closed nationwide since 2010 — a statistic cited by CMS’ Sutton that is well known among industry watchers. The Sheps Center at the University of North Carolina, which compiles the closure data, also released a guide to help states calculate how rural they are for their applications.

State applications will be reviewed by a panel, with some reviewers from within the government but others outside it, said Kate Sapra, acting deputy director of the Office of Rural Health Transformation, speaking at the Watergate.

“We will train them in the scoring criteria,” Sapra said, adding that the panelists will not be coming from “your state” and will need to fill out conflict-of-interest forms. A portion of money each state gets will be reevaluated annually based on the progress it makes on its goals and priorities, according to CMS.

States are creating stakeholder groups, asking for public comment, and working with their health agencies. Some, such as Mississippi and New Mexico, are hiring consultants.

In Montana, a collection of health providers and associations proposed a list of ideas for the cash, including creating a loan repayment fund for rural clinicians to try to ease worker shortages.

“It’s one-time money, and it’s a little bit of money,” said David Mark, a doctor who is the CEO of One Health, which has clinics dotted across eastern Montana and Wyoming. A state could receive a minimum of $100 million a year for five years if all 50 states have applications approved.

“How do you accomplish goals of a health care system transformation with an infusion of money like that?” Mark said.

Neither Montana nor Wyoming — vast, rural states — sent leaders to the Watergate summit, according to a copy of the attendees list. In the afternoon, attendees could rotate among planning tables and meet with corporate sponsors such as the electronic health records behemoth Epic and the emergency services company Global Medical Response.

Wyoming Department of Health Deputy Director Franz Fuchs confirmed his state did not send representatives to the event, because they were “stretched with other commitments.” Montana, Wyoming, and other states submitted an optional letter of intent signaling they will apply for the funds. CMS did not respond to questions about how many and which states have submitted letters.

During the Watergate event, hints of brewing competition among states began to surface.

“I think Arkansas’ application is going to be better than yours,” seasoned political adviser Jack Sisson said with a smile during a morning panel.

The audience laughed. Sisson, who recently left his job as health adviser for Arkansas Gov. Sarah Sanders, had interrupted Michael Hendrix, policy adviser to another Republican governor, Tennessee’s Bill Lee.

“See, this is the kind of friendly competition that CMS is hoping for,” Hendrix said. He grinned, thanked Sisson, and added, “I look forward to us both winning.”

KFF Health News Montana correspondent Katheryn Houghton contributed to this report.

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

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

Democrats and Republicans are both facing potential political consequences in their continuing standoff over federal government funding. Republicans are likely to face a voter backlash if they refuse to agree to Democrats’ demands that they renew additional tax credits for Affordable Care Act marketplace plans, since the majority of those facing premium hikes live in GOP-dominated states. For their part, Democrats are worried that Republicans will violate the terms of any potential spending deal.

At the same time, the Trump administration is using the shutdown to try to lay off thousands of federal workers, including those performing key public health roles at the Centers for Disease Control and Prevention.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Lauren Weber of The Washington Post.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• As the federal government shutdown drags on, there has been little progress toward a deal on government spending — or on the expiring ACA marketplace subsidies Democrats are fighting to renew. Potential subsidy compromises could, for instance, implement a minimal premium in place of $0 premiums, to reduce enrollment fraud, as Republicans want.
• A federal judge halted the Trump administration’s latest layoffs of federal workers amid questions about the layoffs’ legality. The administration in particular dealt a heavy blow this round to the CDC, an agency that has been battered by staff reductions, policy shifts, and even violence.
• New reporting shows the Trump administration explored the feasibility of tracing abortion pill residue in wastewater, following up on an anti-abortion claim that the drugs may be contaminating the water supply. Yet advocates could have an ulterior motive: developing the ability to trace use of the pill to further crack down on abortions.
• And President Donald Trump unveiled a deal with a second drugmaker, AstraZeneca, that allows the company to avoid tariffs in exchange for building a new U.S. facility. But as with the first deal, it’s unclear how much money the agreement will save patients.

Also this week, Rovner interviews health insurance analyst Louise Norris of Medicareresources.org about the Medicare open enrollment period, which began Oct. 15.

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

Julie Rovner: Politico’s “RFK Jr.’s Got Advice for Pregnant Women. There’s Limited Data To Support It,” by Alice Miranda Ollstein.

Anna Edney: The New York Times’ “The Drug That Took Away More Than Her Appetite,” by Maia Szalavitz.

Joanne Kenen: Mother Jones’ “From Medicine to Mysticism: The Radicalization of Florida’s Top Doc,” by Kiera Butler and Julianne McShane.

Lauren Weber: KFF Health News’ “Senators Press Deloitte, Other Contractors on Errors in Medicaid Eligibility Systems,” by Rachana Pradhan and Samantha Liss.

Also mentioned in this week’s podcast:

• The Washington Post’s “She Left the Medical Mainstream and Rose To Be RFK Jr.’s Surgeon General Pick,” by Lauren Weber and Rachel Roubein.
• The Bulwark’s “There’s Something Weirdly Familiar About This New GOP Argument,” by Jonathan Cohn.
• Politico’s “4 GOP Ideas for an Obamacare Subsidies Compromise,” by Benjamin Guggenheim.
• The New York Times’ “The E.P.A. Followed Up on an Unusual Request About Abortion Pills,” by Caroline Kitchener and Coral Davenport.
• Bloomberg News’ “WHO Warns Against Three India-Made Cough Syrups After Child Deaths,” by Satviki Sanjay.

Credits Francis Ying 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.

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Este verano, durante una cena con su mejor amiga, Jacki Barden habló de un tema incómodo: la posibilidad de morir sola.

“No tengo hijos, ni esposo, ni hermanos”, recordó haber dicho Barden. “¿Quién va a sostener mi mano cuando muera?”.

Barden, de 75 años, nunca tuvo hijos. Vive sola en el oeste de Massachusetts desde que su esposo falleció en 2003. “Llega un momento en la vida en el que ya no vas para arriba, sino que empiezas a bajar”, me dijo. “Y empiezas a pensar cómo será el final”.

Esto es algo que se preguntan muchos adultos mayores que viven solos, una población que ya supera las 16 millones de personas y que sigue creciendo. Muchos cuentan con familiares o amigos. Pero otros no tienen ni pareja ni hijos; sus parientes viven lejos o están distanciados de los pocos familiares que les quedan. Algunos han perdido, por la edad o por enfermedades, a amigos muy queridos.

Más de 15 millones de personas mayores de 55 años no tienen cónyuge ni hijos biológicos; casi 2 millones no tienen ningún familiar.

Otros adultos mayores han quedado aislados porque están enfermos, débiles o tienen alguna discapacidad. Casi 1 de cada 5 tiene poco o ningún contacto con otras personas. Y las investigaciones muestran que el aislamiento se vuelve todavía más común a medida que se acerca la muerte.

¿Quién estará con estas personas que envejecen solas cuando lleguen al final de sus vidas? ¿Cuántas de ellas morirán sin tener a su lado a alguien conocido o querido?

Lamentablemente, no lo sabemos: las encuestas nacionales no dicen quién acompaña a los adultos mayores cuando mueren. Pero morir en soledad es una preocupación creciente, ya que cada vez más personas llegan a la vejez sin pareja, después de enviudar o divorciarse, o permanecen solteras o sin hijos, según demógrafos, investigadores y médicos especializados en la atención a adultos mayores.

“Siempre hemos tenido pacientes que estaban prácticamente solos cuando llegaban al final de la vida”, dijo Jairon Johnson, director médico de cuidados paliativos y del hospicio de Presbyterian Healthcare Services, el sistema de salud más grande de Nuevo México. “Pero antes no era tan habitual como ahora”.

Durante la pandemia de covid-19, las familias no podían entrar ni a los hospitales ni a las residencias de ancianos cuando fallecían sus parientes más grandes. Fue el período en que se prestó más atención a las consecuencias potencialmente graves de que una persona muriera en soledad. Pero desde entonces la cuestión ha desaparecido en gran medida del radar.

A muchos, incluidos profesionales de la salud, la posibilidad de morir sin que nadie los acompañe les provoca un sentimiento de abandono. “No me imagino lo que ha de ser, además de estar con una enfermedad terminal, pensar: ‘me estoy muriendo y no tengo a nadie’”, dijo Sarah Cross, profesora asistente de medicina paliativa en la Emory University School of Medicine.

Según la investigación de Cross, hoy la mayoría de las personas mueren en su casa. Pero aunque muchos hospitales tienen programas llamados ‘Nadie muere solo’, donde hay voluntarios que acompañan a los pacientes en sus últimos días, no existen servicios similares para los que mueren en su hogar.

Alison Butler, de 65 años, es doula de final de vida y vive en el área de Washington, D.C. Acompaña a las personas y a sus seres queridos durante el proceso de morir. También ha vivido sola durante 20 años. En una larga conversación, Butler admitió que siente la idea de morir sola como una forma de rechazo. Contuvo las lágrimas al hablar de la posibilidad de sentir que su vida “no le importa ni le importó verdaderamente” a nadie.

La falta de personas de confianza que puedan ayudar a adultos con enfermedades terminales también puede llevar a que se abandonen y disminuya su bienestar. La mayoría de los adultos mayores no tiene los recursos económicos para pagar una residencia asistida o ayuda en casa si ya no pueden hacer las compras, bañarse, vestirse o moverse por sus propios medios dentro de su hogar.

Economistas y expertos en políticas públicas advierten que los recortes por casi $1.000 millones a Medicaid, que prevé la ley fiscal y de gasto del presidente Donald Trump, que los republicanos llaman One Big Beautiful Bill Act, probablemente agravarán las dificultades para acceder a los cuidados adecuados.

Medicare, el programa federal de seguro médico para personas mayores, por lo general no cubre servicios a domicilio. La fuente principal de ese tipo de ayuda para quienes no tienen recursos económicos es Medicaid. Pero los estados podrían verse obligados a eliminar los programas de cuidados en el hogar financiados por Medicaid a medida que disminuye la financiación federal.

“Me da mucho miedo lo que pueda pasar”, dijo Bree Johnston, geriatra y directora de cuidados paliativos en Skagit Regional Health, en el noroeste del estado de Washington. Ella está convencida de que más adultos mayores con enfermedades terminales que viven solos acabarán muriendo en hospitales porque no tendrán acceso a servicios esenciales.

“Los hospitales no suelen ser el lugar más humano para morir”, dijo Johnston.

Aunque los cuidados paliativos en el hogar son una alternativa cubierta por Medicare, con frecuencia no resulta suficiente para los adultos mayores con enfermedades terminales que viven solos. (Los cuidados paliativos están dirigidos a personas con una expectativa de vida de seis meses o menos).

Por un lado, este servicio está subutilizado: menos de la mitad de los adultos mayores de 85 años lo aprovechan. Por otro lado, “mucha gente cree, erróneamente, que las agencias de hogares van a proporcionar personal de apoyo en el hogar y ayudar con todos esos problemas funcionales que surgen al final de la vida”, explicó Ashwin Kotwal, profesor asociado de medicina en la división de geriatría de la Escuela de medicina de la University of California-San Francisco School of Medicine.

Pero en realidad, esas agencias ofrecen atención intermitente y dependen en gran medida de familiares que puedan ayudar con actividades como el baño o la alimentación. Algunas agencias ni siquiera aceptan a personas que no tengan cuidadores, señaló Kotwal.

Y entonces quedan los hospitales. Si el adulto mayor está consciente, el personal puede hablar con él sobre sus prioridades y ayudarlo a tomar decisiones médicas importantes, explicó Paul DeSandre, jefe de cuidados paliativos y de apoyo en el Grady Health System en Atlanta.

Si la persona está desorientada o inconsciente, lo cual es frecuente, el personal intenta identificar a alguien que pueda contar lo que el paciente hubiera querido al final de su vida y posiblemente actuar como su representante legal. La mayoría de los estados tiene leyes que designan representantes predeterminados, generalmente familiares, para quienes no han elegido uno con anticipación.

Si no se encuentra a nadie, el hospital acude a la Corte para solicitar la tutela legal, y el paciente se convierte en pupilo del estado, que asume la responsabilidad legal de las decisiones sobre el final de su vida.

En los casos más extremos, cuando nadie responde, una persona que muere sola puede ser clasificada como “no reclamada” y enterrada en una fosa común. Esto también es cada vez más habitual, según el libro “The Unclaimed: Abandonment and Hope in the City of Angels” (Los no reclamados: abandono y esperanza en la Ciudad de los Ángeles), publicado el año pasado.

La doctora Shoshana Ungerleider fundó End Well, una organización dedicada a mejorar las experiencias del final de la vida. Ella propuso identificar desde temprano a las personas mayores que viven solas y están gravemente enfermas, y ofrecerles un apoyo más amplio. Recomendó mantenerse en contacto con ellas regularmente mediante llamadas, videollamadas o mensajes de texto.

Y recordó que no todos los adultos mayores tienen las mismas prioridades al final de la vida. Cada uno es distinto.

Barden, la viuda en Massachusetts, por ejemplo, se ha centrado en prepararse con anticipación: ya tiene organizados todas las cuestiones legales y financieras, y también sus asuntos funerarios.

“He sido muy afortunada en la vida. Hay que mirar hacia atrás y estar agradecidos por lo bueno, en lugar de enfocarnos en lo malo”, me dijo. Sobre imaginar su muerte, comentó: “Será lo que tenga que ser. No tenemos control sobre esas cosas. Supongo que me gustaría que alguien estuviera conmigo, pero no sé cómo será eso”.

Algunas personas quieren morir como vivieron: solas. Una de ellas es Elva Roy, de 80 años, fundadora de Age-Friendly Arlington, en Texas, quien, después de divorciarse dos veces, ha vivido sola durante 30 años.

Cuando hablé con ella, me dijo que había reflexionado mucho sobre morir sola y que estaba considerando la opción de una muerte médicamente asistida, quizá en Suiza, si llegaba a tener una enfermedad terminal. Es una forma de mantener el sentido de control e independencia que la ha sostenido durante su vida como adulta mayor soltera.

“Sinceramente, no quiero que haya alguien a mi lado si estoy demacrada, débil o enferma”, dijo Roy. “No me reconfortaría tener a alguien ahí tomándome la mano, limpiándome la frente o viéndome sufrir. Me siento realmente bien con la posibilidad de morir sola”.

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

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“It’s going to be the biggest infusion of federal dollars into rural health care in American history.”

Robert F. Kennedy Jr. on Sept. 4, 2025, in a Senate hearing

At a September Senate hearing, Health and Human Services Secretary Robert F. Kennedy Jr. boasted about a rural health initiative within  President Donald Trump’s “One Big Beautiful Bill Act.”

“It’s going to be the biggest infusion of federal dollars into rural health care in American history,” Kennedy said, responding to criticism from Sen. Bernie Sanders (I-Vt.). Sanders said the law would harm patients and rural hospitals.

Kennedy was referring to the law’s five-year, $50 billion Rural Health Transformation Program, HHS spokesperson Emily Hilliard said. GOP lawmakers have made similar claims about the program.

The fund was added to the bill at the last minute to secure support from Republican lawmakers who represent rural states. Some were concerned about how the bill’s Medicaid cuts would harm rural America, where more than 150 hospitals have stopped offering inpatient services or been shuttered completely since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

“The transformation fund was really talked about in the context of saving rural hospitals that would be facing these significant Medicaid cuts,” said Carrie Cochran-McClain, chief policy officer at the National Rural Health Association. Medicaid is the joint state-federal health insurance program that primarily covers low-income people and those with disabilities.

So is Kennedy right in his description of the rural health fund as a historic cash infusion, or does it fail to acknowledge critical context?

The Rural Health Transformation Program

Trump’s tax and spending law is expected to reduce federal Medicaid spending in rural areas by at least $137 billion by 2034, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. The Congressional Budget Office predicts the law will increase the overall number of uninsured patients by 10 million by 2034.

Rural health facilities disproportionately rely on Medicaid reimbursement to stay afloat. In 2023, 40.6% of children and 18.3% of adults under age 65 from rural areas and small towns were enrolled in Medicaid, according to the Center for Children and Families at Georgetown University. In metro areas, the rates were 38.2% and 16.3%, respectively.

The Trump administration argues that rural hospitals cannot rely on “legacy” funding sources like Medicaid and Medicare due to the programs’ reimbursement structure, which ties payments to the number of services provided, a model that’s not financially sustainable for rural facilities with typically low patient volumes.

“Distinct from these other programs, the Rural Health Transformation Program is designed to provide a flexible source of investment” to promote innovation, efficiency, and sustainability, the White House wrote in a memo.

Here’s how it works. States can propose projects spearheaded by state agencies, health care providers, consultants, and vendors aimed at various purposes, such as improving technology, access to care, and workforce recruitment.

States can use only 15% of their transformation program funding for provider payments and can direct money to non-rural areas, according to KFF.

Half of the $50 billion will be evenly divided among states whose applications are approved — regardless of their rural and overall populations — according to the “Notice of Funding Opportunity” for the program.

The other half will be awarded based on “the transformative possibilities” of states’ grant proposals; how much they’ve committed to aligning their health policies with the Trump administration’s; and data on their rural population, rural health facilities, uncompensated care, and other measurements.

The application deadline is Nov. 5.

The Big Picture

Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, said the rural health community is excited about the innovations the new program might foster, but he’d “love for it to happen in the absence of these cuts that are going to devastate our rural health system.”

“It’s not going to fill the hole,” Meit said.

KFF estimates that the rural health fund’s five-year, $50 billion investment is a little over a third of the expected loss of federal funding in rural areas that will be spread over 10 years. According to that analysis, Medicaid cuts over that period would tally at least $137 billion in rural areas.

That number doesn’t account for other reductions stemming from the same law, such as cuts to the ACA Marketplaces or the health system revenue loss expected from an increase in the number of people without insurance. 

These factors are important to note because the rural health program is a temporary initiative, while reductions in federal spending are long-term.  

Another issue is the difference in the program’s spirit. The rural health fund is focused on transforming the rural health care system — not providing continued funding to keep facilities open or making up for lost Medicaid funds. Even if the money triggers successful innovations, there are doubts that those will happen in time to prevent rural health facilities from closing.

“There’s a real misperception that somehow these funds are going to be able to save rural America or save rural hospitals,” Cochran-McClain said.

Joseph Antos, a health policy expert and senior fellow emeritus at the conservative-leaning American Enterprise Institute, said Kennedy’s comment is something “politicians say when they want to ignore the rest of the policies.”

“What they wanted was to say that they were creating a new program,” Antos said. “Well, this is a very inefficient way to distribute a relatively very small amount of money to hospitals that will incur much larger bad debt over the coming years, thanks to the cuts in Medicaid.”

One Caveat

Experts said that when viewed outside of mandatory programs like Medicare and Medicaid, the $50 billion rural health fund does appear to be unrivaled, especially for a limited, five-year program.

Several mentioned the Hill-Burton Act as another program that significantly boosted rural health care. The law provided loans and grants that modernized or built 6,800 health facilities, many of which were in rural areas, from 1946 to 1997, according to the Health Resources and Services Administration.

Incomplete funding data makes it difficult to account for inflation, said Kelsey Moran, an assistant professor and health economist at the University of Miami.

But she estimated that, during the life of the program, it spent $47 billion in 2024 dollars when using the Consumer Price Index, or $109 billion when using the CPI’s medical care index. The medical index has a higher inflation rate because health prices have risen more than overall prices.

Our Ruling 

Kennedy said the rural health fund is “going to be the biggest infusion of federal dollars into rural health care in American history.”

The statement contains an element of truth because the new program could be the most significant one-time investment in rural health funding.

But it ignores critical facts and context that create a different impression.

Federal contributions to rural areas from Medicaid and Medicare easily dwarf this program’s $50 billion mark. The new fund offers states flexibility in how they can allocate resources, meaning there’s no guarantee that all the new funding will go to rural Americans’ health care. The program comes at the same time rural areas are expected to lose far more from Medicaid cuts and an increase in uninsured patients than what the rural health fund infusion can backfill.

Experts say the rural health fund’s cash infusion is canceled out by other parts of Trump’s tax and spending law that call for cuts and policy changes.

We rate this statement Mostly False.

Our Sources

“Watch: Sanders, RFK Jr. Get Into Testy Exchange Over COVID Vaccine, CDC Director’s Firing,” CBS News, Sept. 4, 2025.

“$50B Rural Health ‘Slush Fund’ Faces Questions, Skepticism,” KFF Health News, July 21, 2025.

“Rural Hospital Closures,” Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, accessed Sept. 15, 2025.

“Senate GOP Mulls Shielding Rural Hospitals From Medicaid Cuts,” Roll Call, June 20, 2025.

“Key Takeaways From CMS’s Rural Health Funding Announcement,” KFF, Sept. 23, 2025.

“Estimated Budgetary Effects of Public Law 119-21, To Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline,” Congressional Budget Office, July 21, 2025.

“Medicaid’s Role in Small Towns and Rural Areas,” Georgetown University Center for Children and Families, Jan. 15, 2025.

“MEMORANDUM Re: The One Big Beautiful Bill is a Historic Investment in Rural Healthcare,” The White House, undated.

Notice of Funding Opportunity for the Rural Health Transformation Program, government document published on Sept. 15, 2025.

“The Federal Budget in Fiscal Year 2023: An Infographic,” Congressional Budget Office, March 5, 2024.

“The Federal Budget in Fiscal Year 2024: An Infographic,” Congressional Budget Office, March 20, 2025.

“Hill-Burton Facilities Compliance,” HRSA, accessed Sept. 16, 2025.

“Hospital Charity Care & The Hill-Burton Act,” working paper by Kelsey Moran updated on Sept. 15, 2025.

Phone interview with Matthew Fiedler, a senior fellow in economic studies at the Center on Health Policy at The Brookings Institution, Sept. 24, 2025.

Phone interview with Gbenga Ajilore, chief economist, and Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, Sept. 24, 2025.

Phone interview with Larry Levitt, executive vice president for health policy at KFF, Sept. 24, 2025.

Phone interview with Joseph Antos, a health policy expert and senior fellow emeritus at the American Enterprise Institute, Sept. 23, 2025.

Phone interview with Carrie Cochran-McClain, chief policy officer at the National Rural Health Association, Sept. 17, 2025.

Phone interview with Kelsey Moran, assistant professor in the Department of Health Management and Policy at the University of Miami, Sept. 15, 2025.

Phone interview with Alana Knudson, director of the NORC Walsh Center for Rural Health Analysis at the University of Chicago, Sept. 12, 2025.

Phone interview with Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, Sept. 11, 2025.

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

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COLUMBUS, Miss. — April Hines has battled with her weight since she was a teenager.

But in the past couple of years, she’s fallen from 600 pounds to 385, and her blood pressure and blood sugar levels are down, too. “I’m not as fatigued as I used to be, and I’ve been able to go back to church,” she said.

Hines, 46, credits her weight loss to Trulicity, part of a new class of expensive weight loss drugs known as GLP-1s, and her Medicaid coverage for it. “It’s a blessing,” she said.

In a state where the obesity rate ranks among the highest in the country, many health providers were thrilled when Mississippi Medicaid in 2023 began covering GLP-1s for people 12 and older. Only 13 states cover the drugs for Medicaid enrollees for obesity, and Mississippi’s Medicaid program typically has some of the sparsest benefits and strictest eligibility rules.

Hines is one of relatively few enrollees to have used the new Medicaid benefit, which weight loss doctors in the state say has been hindered by national drug shortages, the state’s prior authorization process for the drugs, and a lack of marketing. Just 2% of adults on Mississippi Medicaid who meet the weight-related criteria had been prescribed a GLP-1 as of December 2024, according to a report to the state’s Medicaid Drug Utilization Review Board.

“It’s a little sad to have so many people out there not benefiting,” said William Rosenblatt, a family doctor in Columbus who treats Hines. “These drugs get to the root cause of so many health conditions.”

Already-scarce Medicaid coverage of the highly touted weight loss drugs could become more limited, with federal Medicaid funding cuts expected in the wake of the massive tax-and-spending bill President Donald Trump signed into law in July. The Congressional Budget Office estimated that the law would reduce Medicaid spending by about $911 billion over a decade.

“The law is going to create fairly intense pressure on states not to expand benefits,” said Michael Kolber, a partner in the health consulting firm Manatt. That may be especially true for these drugs, which often cost around $1,000 a month and could be used by a large percentage of Medicaid recipients, he said.

GLP-1s, which have been used for years to treat Type 2 diabetes, have gained widespread attention as a way to lose weight and reduce obesity-related conditions and their long-term costs.

But states may remain reluctant to offer the expensive drugs for obesity, because Medicaid recipients frequently churn on and off the coverage as their income changes. And because the drugs’ health benefits may take years to materialize — such as averting a future heart attack — the long-term financial advantages could accrue to other insurers.

Even ahead of the federal cuts, which will largely take effect in 2027, states are already feeling the pinch. North Carolina’s Medicaid program dropped its coverage of the drugs this month, citing their high cost.

Coverage for the weight loss drugs presents a dilemma for the Trump administration, which has identified as priorities attacking chronic health conditions and reducing federal spending. Health and Human Services Secretary Robert F. Kennedy Jr. has downplayed the need for the drugs and said more emphasis should be placed on eating better and exercising more.

In 2024, the Biden administration proposed that Medicare and Medicaid cover weight loss drugs to help tackle obesity as a public health crisis. In April, the Trump administration revoked the Biden-era proposal, saying the programs would not cover GLP-1 drugs for weight loss.

But in August, The Washington Post reported the Trump administration was considering a five-year pilot program for Medicare and Medicaid to cover the drugs after all. No details have been released. Asked for comment on the report, Centers for Medicare & Medicaid Services spokesman Alexx Pons told KFF Health News that all decisions go through a cost-benefit review.

Meanwhile, the Trump administration has included the GLP-1 drugs Ozempic, Wegovy, and Rybelsus on its list of 15 medicines that will be subject to price negotiations with pharmaceutical manufacturers under its Medicare Part D program, a system created during the Biden administration amid opposition from Republicans. The results of those negotiations are expected to be announced this fall.

Most private insurers don’t cover GLP-1s for weight loss, which can make the drugs unaffordable for those paying out of pocket.

Further analysis provided to Mississippi’s Medicaid drug review board shows that, in the first 15 months the drugs were covered, only about 2,900 Medicaid enrollees age 12 or older started treatment. Nearly 90% of them were female, and many had high blood pressure and high cholesterol.

The analysis also found most enrollees using the drugs lived in the southern, central, or northern parts of Mississippi — not along the Mississippi Delta on the western side of the state, where obesity rates are highest, at nearly 50%.

About 40% of adults in Mississippi are obese, just one percentage point behind top-ranked West Virginia, according to federal data.

Mississippi Medicaid spokesman Matt Westerfield told KFF Health News that the state spent $12 million in the first 15 months, providing the weight loss drugs to 2,200 adult members. He said the state approved the new drugs on the logic that treating obesity would improve enrollees’ health and eventually could lead to cost savings by reducing diseases caused by obesity.

Westerfield said that while utilization has been below the state’s projections, such treatment decisions are up to patients and their doctors. He said the state has been “raising awareness” of the drugs among health care providers, but he declined to comment further.

Rosenblatt, who works for Baptist Medical Group, part of a large regional health system, said some doctors have less incentive to prescribe the medicine, because the state doesn’t pay them to counsel patients about necessary dietary changes when taking the new drugs.

He called the drugs “game changers,” adding that he has seen patients lose 50 pounds or more within a few months of starting the drugs and no longer need medications for diabetes or other conditions.

A New England Journal of Medicine study published in 2021 found participants receiving GLP-1 drugs were more likely to show significant, sustained weight loss compared with those getting a placebo.

Other recent studies have shown the drugs help people with obesity lower their high blood pressure and reduce their odds of heart attacks or strokes.

Mississippi is one of 10 states that have not expanded Medicaid eligibility under the 2010 Affordable Care Act to everyone with an income under 138% of federal poverty level, or $21,597 this year.

In Mississippi, Medicaid does not cover adults without dependent children. Parents qualify only if their income is below 22% of the federal poverty level, or $5,863 for a family of three this year.

The state’s prior authorization process requires doctors to document to the state that patients meet certain obesity levels and that a treatment plan is in place. Doctors must demonstrate that enrollees are losing weight every six months to renew their prescription.

At the Hattiesburg Clinic — a large, multi-specialty group with a location in Hattiesburg, Mississippi — Virginia Crawford, a physician who specializes in obesity, said she was surprised so few patients are getting the drugs. A year ago, there were shortages of the drugs that could have curtailed physicians prescribing them. And she said the state’s prior authorization requirements for the drug could discourage primary care doctors. Many common medications do not require progress reports or even prior authorization.

“We need to make patients more aware that this option is available for them,” she said.

Lauren Scott, 40, of Laurel, Mississippi, said that with the help of Medicaid coverage, she lost nearly 100 pounds taking Wegovy.

“It’s just been amazing,” she said of how the drug drastically cut her appetite. “I remember going to Outback with my husband, and we got the onion ring appetizer and 16-ounce ribeye and salad with extra ranch dressing. I had some onion rings and started on the salad and realized I could not eat any more of this.”

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

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Cremation has become Americans’ most popular choice for the postmortem treatment of their bodies. But the process involves burning fossil fuels, which may release toxic gases. “The New Old Age” columnist Paula Span appeared on WAMU’S Oct. 8 “Health Hub” to explain some of the more environmentally friendly alternatives.

Green burials are gaining popularity as an affordable, eco-friendly alternative to traditional funerals. They avoid toxic embalming chemicals, steel caskets, and concrete vaults, letting a body naturally decompose. Methods range from the elaborate — like “human composting” and water cremation — to a simple pine box.

“The New Old Age” columnist Paula Span appeared on WAMU’s Oct. 8 “Health Hub” to talk about the environmental and economic motivations behind these alternatives to conventional burials.

Jackson Sinnenberg contributed to this report.

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

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