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

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

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

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

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

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

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

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

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

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

By Lauren Sausser and Renuka Rayasam July 17, 2026

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

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

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

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

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

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

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

‘Complex and Convoluted’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More Red Tape Ahead

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

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

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

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

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

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

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

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

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

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

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

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

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

What is hospital financial assistance?

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

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

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

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

How many hospitals use auto-enrollment?

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

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

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

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

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

Who is eligible to be automatically enrolled in financial assistance?

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

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

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

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

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

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

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

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

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

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

When do hospitals screen patients for financial aid?

It depends.

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

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

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

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

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

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

Who pays the bills when patients get free care?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Many Rural Voters Are Prioritizing Health Issues

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

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

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

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

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

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

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

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

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

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

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

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

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

Survey Reflects Angst Over Healthcare

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

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

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

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

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

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

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

Most MAHA Voters Are Also MAGA — But Not All

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

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

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

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

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

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

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

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

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

About the Poll

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

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

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

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

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

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

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

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

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

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

The CBO declined to comment.

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

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

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

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

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

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

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

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

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

Health Benefits Wane for Immigrants

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

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

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

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

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

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

A Few States Try To Fill in the Gaps

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

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

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

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

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

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

By Christine Mai-Duc July 6, 2026

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

100 Nursing Homes at Risk of Dangerous Flooding

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methodology

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

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

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

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

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

Fathom provided guidance and feedback as we developed our analysis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dangers of Aggression

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

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

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

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

A National Campaign

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

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

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

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

A Steady Decline

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

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

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

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

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

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

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

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

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

‘These Pills Have Side Effects’

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

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

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

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

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

Medication Begins

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

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

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

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

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

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

‘She Could Barely Function’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tennessee Health Workers’ Concerns

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Upcoming Execution

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Then the bill came.

The Medical Service

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

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

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

The Bill

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

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

The Billing Problem: What Counts as Care?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Resolution

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

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

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

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

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

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

The Takeaway

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Following the Numbers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s About More Than Recalls

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unified Opposition

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

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

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

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

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

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

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

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

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

State Lawmakers vs. CVS

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

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

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

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

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

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

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

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

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

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

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

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

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

MAPLEWOOD, Mo. — After Missouri voters added abortion protections to the state constitution in 2024, Kelly McCoomb decided to keep her yard sign supporting the measure in the basement of her suburban St. Louis home.

Abortion access is important to McCoomb. She wants her daughter to grow up in a state where the option is available if needed, and the sign was a keepsake from the day Missourians voted to reverse the state’s near-total ban. McCoomb also couldn’t shake the feeling that she’d need to display the sign in her yard again soon.

“I have little faith in our Missouri government,” McCoomb said, sitting on her front porch.

Sure enough, just two years later, the state’s Republican-dominated legislature is asking Missouri voters to overturn the abortion protections they recently supported. The conflicting measures even have the same title: Amendment 3. But while a “yes” vote in 2024 supported adding protections to the state constitution, a “no” vote in 2026 would keep them. McCoomb covered the “YES” on her yard sign with a “NO” made from black duct tape before placing the sign back in her yard.

Voters will weigh in on abortion in Missouri, and three other states, in the November general election. Missouri is also one of two states voting on it for the second time since 2024. Nevada will vote again, too.

The spate of referenda comes after the U.S. Supreme Court overturned federal abortion protections with its 2022 decision in Dobbs v. Jackson Women’s Health Organization, leaving each state to make its own abortion policy. The result has been a patchwork of state rules with varying degrees of bans or limitations, and even a series of “shield laws” in states where abortion remains legal that aim to protect providers from prosecution in states where it’s not.

“I just think there’s a constitutional crisis that’s coming,” said Kristi Hamrick, vice president of media and policy for the anti-abortion organization Students for Life Action.

“Can you have 50 state standards on whether or not a human being is a human being? Can you have 50 state standards on whether human beings have legal protection?” Hamrick said.

Advocacy Groups Work To Clarify Ballot Measures

That patchwork of abortion protections is the reason Nevadans for Reproductive Freedom introduced the 2024 ballot measure to enshrine the state’s law allowing abortions up to 24 weeks after conception into the state constitution, said Denise Lopez, president of the coalition.

The measure received strong support two years ago, with 64% of voters in favor. Nevada law requires two majority votes to enshrine constitutional amendments, so voters will need to support the expanded protection again in November for it to be enacted.

The Nevada ballot measure wouldn’t change the state’s existing law allowing abortions up to 24 weeks after conception. But the proposal would make it more difficult to overturn abortion access, requiring voter approval of any new ban in two elections.

Lopez said Nevadans for Reproductive Freedom has been campaigning to ensure voters are still mobilized.

“Folks care about it,” she said. “They’re seeing what’s happening at the national level, and they want to make sure that whatever’s happening in our neighboring states, like Idaho and Utah, doesn’t happen here in Nevada.”

Idaho, where a ballot measure establishing abortion rights recently qualified to go before voters in November, has one of the strictest abortion bans in the country. Voters will decide whether state statute should allow abortion through fetal viability, the point when a fetus can survive after birth, which is generally considered to be around 24 weeks.

In Utah, abortion is allowed up to 18 weeks while legal challenges to the state’s ban continue.

In Virginia, where abortion is already allowed through two trimesters of pregnancy, until 28 weeks, voters will decide whether to amend their state constitution to codify those rights.

Missouri is the only state voting this year on removing abortion protections already on the books. The measure would repeal the 2024 amendment that guaranteed abortion access through fetal viability in the state and replace it with a ban on abortions with exceptions for medical emergencies, fetal anomalies, and pregnancies resulting from rape or incest. Abortions for rape and incest would have to occur before 12 weeks of pregnancy.

Missouri was the first state to ban abortion after the Dobbs decision in 2022. At that time, abortions had already mostly ceased in the state after three decades of state regulations targeting the practice, including a 72-hour waiting period, minimum dimensions for procedure rooms and hallways in clinics that provide abortions, and a mandate that the clinicians have admitting privileges at nearby hospitals, among others. Only 150 abortions were performed in Missouri in 2021, down from 5,772 in 2011, state records show.

Even though Missouri voters backed the abortion amendment in 2024, it took nearly two years for medication abortions to resume in the state.

A Second Vote Causes Confusion

Margot Riphagen-Dunn, CEO of St. Louis-based Planned Parenthood Great Rivers, said the whiplash of a second statewide vote on abortion mirrors the confusion that patients have experienced about whether abortion is available in the state.

“Chaos is kind of the point here,” Riphagen-Dunn said, “and it is absolutely a tactic that gets in the way of being able to provide.”

The confusion has presented problems for abortion opponents in the state as well.

“I think it’s unfortunate,” said Reagan Barklage, who is a vice president of Students for Life of America and the treasurer of the Missouri Students for Life Ballot Committee. “People need to be very clear on what they’re voting for.”

Barklage said she has had to correct anti-abortion voters while out canvassing to remind them that they are voting “yes” on Amendment 3 this year even though they voted “no” on Amendment 3 last time.

“It is crazy that it ended up being even the same number. I do not think that was intentional, but we’ve got to deal with what we’ve got,” Barklage said, adding, “I hope the pro-choicers kept their yard signs from last time.”

In Maplewood, Missouri, McCoomb said she was happy that her repurposed sign supporting abortion access had been noticed.

“I hope lots of people see and remember to revote,” McCoomb 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.

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

OAK HILL, W.Va. — Each day at New River Health in Oak Hill, Lisa Emery finds disheartening signs of what she describes as a slow-motion repeat of the Hawks Nest Tunnel disaster.

Emery is director of New River’s Breathing Center and chair of the National Coalition of Black Lung and Respiratory Disease Clinics.

The disaster she’s reminded of started in 1930, when construction began on a 3-mile tunnel through Gauley Mountain in West Virginia. Over the course of 18 months, some 3,000 miners, most of them Black, spent long hours drilling through sandstone, engulfed in a cloud of its toxic byproduct, silica dust. More than 750 men died from that exposure.

The risk still exists, and advocates for workers say the government should do more to rein it in.

In April of last year, the Trump administration paused the enforcement of a rule designed to help protect coal miners from an aggressive form of coal workers’ pneumoconiosis, commonly known as black lung disease, the primary cause of which is exposure to silica dust.

(Other occupations at high risk of exposure to silica dust include construction, countertop fabrication, and oil and gas work. The new rule would reduce the permissible limit of exposure in coal mining to the existing level in other industries.)

This April, the Labor Department’s Mine Safety and Health Administration announced an indefinite delay in enforcement of the rule.

Gary Hairston sits on New River Health’s board. For decades, Hairston, a retired coal miner and president of the national Black Lung Association, has been an advocate for miners struggling with the debilitating effects of black lung, including extreme fatigue, an incessant cough, and a sensation of drowning. He regularly lobbies legislators for improved working conditions and black lung benefits. His entreaties, he said, seem to fall on deaf ears. He rarely gets an audience with the legislators themselves.

“I’d just like them to look me in the face,” Hairston said.

Gary Hairston, president of the Black Lung Association, says his lobbying of legislators for improved working conditions and black lung benefits for coal miners seems to fall on deaf ears. (Taylor Sisk for KFF Health News)

Evidence from just-released research underscores the urgency of his appeals for a safer work environment.

In August, the National Institute for Occupational Safety and Health, an agency within the federal Centers for Disease Control and Prevention, released a report on the results of testing conducted over the past five years on miners in central Appalachia — eastern Kentucky, southwestern Virginia, and West Virginia — with 25 or more years underground. Almost 1 in 3 tested positive for black lung disease, the highest rate in nearly 50 years.

The rate in 2018, the last time the agency reported results, was 1 in 5. The lowest reported rate, in 1999, was less than 1 in 10.

“We knew this would happen,” said Sam Petsonk, a West Virginia attorney who has represented thousands of miners in the region. “It’s surprising to me that they only found one in three.”

Silica Dangers

Exposure to silica has increased as more-accessible coal seams are depleted, requiring mining operations to probe deeper, often through sandstone. The stone breaks into sharp particles that are 100 times smaller than a grain of sand and, according to National Institute for Occupational Safety and Health research, are some 20 times more toxic than coal dust. Trapped in lung tissue, those particles can cause a debilitating, sometimes fatal condition.

Kenny Thompson, a retired West Virginia miner who now lives in Richmond, Kentucky, was employed in the mines for 22 years. He would sometimes cut into four feet of sandstone to reach a coal seam.

“You ate a lot of dust,” Thompson recalled. It induced nausea. It took a toll.

In October 2025, he had his left lung removed. Post-surgery, he was in a coma for three months; he flatlined three times, he said. “They were about to really give up on me.”

He had to relearn to walk and to talk. Trekking to the mailbox still leaves him winded, lightheaded, and blurry-eyed.

The new silica rule would cut the allowable level of silica dust in half, thereby meeting the standard of other industries. Miner advocates laud the fact that it would require operators to deploy engineering controls, such as improved ventilation systems and water sprays.

But the National Mining Association and other industry trade groups argue that reaching and maintaining compliance would also require supplementing those controls with workforce measures, such as requiring personal protection equipment and rotating miners from particularly dusty areas. Many miners, and their advocates, say such measures are impractical — because respirators can impede breathing, can limit vision, and often malfunction, and because smaller mines don’t have enough workers to support rotating schedules.

In April 2025, the 8th U.S. Circuit Court of Appeals granted an emergency stay of the rule to give operators more time to comply.

In May of this year, the Labor Department sent the White House Office of Management and Budget a request to gather information on the proposed rule. And in July, the department’s regulatory agenda included a new notice of proposed rulemaking, indicating its intent to amend the rule.

The department’s Mine Safety and Health Administration “recognizes it has a clear duty under the law to impose stricter silica standards,” said Petsonk, the attorney representing coal miners. “They’re failing to provide that measure of protection to American coal miners, so they’re going through bureaucratic motions to make it seem like they’re doing something, when, in fact, they’re just perpetuating an illegal and lethal status quo.”

The Labor Department declined to comment on ongoing rulemaking or litigation.

“We knew this would happen,” West Virginia attorney Sam Petsonk says of a recently released report showing that the black lung rate for coal miners in central Appalachia is at a nearly 50-year high. (Taylor Sisk for KFF Health News)

‘It’s On the Books’

The rule is, in fact, in effect, said Chris Williamson, head of the Mine Safety and Health Administration in the Biden administration — it’s just not being enforced. He and his team filed a legal brief in the closing days of the administration defending the rule.

“It’s on the books,” Williamson said, adding that the Mine Safety and Health Act prohibits weakening existing protections for miners. “I’m just genuinely curious,” he said. “I want to know how they can address the issues that the industry’s raised without weakening protections for miners.”

Meanwhile, younger miners, with a decade or less in the mines, are being diagnosed with advanced stages of black lung. New River Health’s Emery said the youngest person her clinic had diagnosed with complicated black lung was 30. He’d worked underground for 10 years.

This is no longer just your “papaw’s disease,” she said. “It’s your husband’s disease. It’s your son’s disease.” (More than 90% of coal miners are men.)

With families to support, Emery said, “what do these guys do when they’re disabled in their 30s?”

Lisa Emery is director of the New River Health Breathing Center in West Virginia and chair of the National Coalition of Black Lung and Respiratory Disease Clinics. She says the youngest person her clinic has diagnosed with complicated black lung was 30. (Taylor Sisk for KFF Health News)

She told of a man who sat in her office with his wife, describing his symptoms. As he spoke, he began to cry. His wife was taken aback. “‘I didn’t know it was that bad,’” Emery recalled her saying. “And he said: ‘That’s why I haven’t fixed the deck. I haven’t fixed the deck because I can’t breathe, and I’m just so tired.’”

Thompson can relate. “For 22 years, you’re used to getting up, putting your boots on every day, and going to work,” he said. “I’d been in great health shape and 160 pounds. And here I am now, I don’t work at all and I’m 115 pounds.”

Still, he recognizes what the job afforded.

“You know, it put my girls through college,” he said. “And to me, as a dad, that was the best reward that I can give them, to move forward in life, to be successful at what they chose to be and not work like a dog like I had to.”

President Donald Trump said in an April 2025 executive order: “Our Nation’s beautiful clean coal resources will be critical to meeting the rise in electricity demand due to the resurgence of domestic manufacturing and the construction of artificial intelligence data processing centers.”

Six months later, the Energy Department announced a $625 million investment to “expand and reinvigorate America’s coal industry.”

Should the administration announce a weaker rule, it would be “an unconscionable crime against American coal miners,” Petsonk said. “But I fear that’s going to happen.”

In June, Hairston spoke at a reception for a photo exhibit titled “Entirely Preventable: The Toxic Legacy of Silica Dust From Hawks Nest to Black Lung.”

“It seems like coal miners, we’re just a number,” he said. “Just a number.”

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

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

The San Vicente de Paúl Nursing Home in the South Bronx hasn’t admitted a patient since December 2024. ArchCare, which operates the facility, has reduced its capacity from 120 available beds to 53 and plans to shrink it further.

Another ArchCare nursing home, on Staten Island, has shut down a full floor. North of the city, in Dutchess County, its Ferncliff Nursing Home has contracted from 309 available beds to 196.

The eight nursing homes owned by ArchCare, a nonprofit that provides eldercare through the Archdiocese of New York, have 269 fewer usable beds than they did 18 months ago, a nearly 12% decline, creating waiting lists for patients seeking long-term care.

Across New York state, 24 nursing homes have closed since 2020, resulting in a loss of more than 3,000 licensed beds, according to LeadingAge New York, which represents nonprofit senior living organizations.

That mirrors a national trend. In 2015, the Centers for Medicare & Medicaid Services certified 15,648 nursing facilities. A decade later, that number had fallen by more than 900.

With the oldest baby boomers turning 80 this year, an age when the need for long-term care climbs sharply, researchers are sounding alarms. Will there be enough nursing home beds for a rapidly graying nation?

“We’re seeing a serious problem and it’s heading in the wrong direction,” said David Grabowski, a health policy researcher at Harvard Medical School. He is an author of a study in JAMA Internal Medicine that found a 5% decrease in national nursing home capacity from 2019 to 2024. “As you look at the demographics, this is only going to get worse, maybe a lot worse,” he said, especially given looming Trump administration policies on immigration and Medicaid financing.

The reasons for the shrinkage?

ArchCare blames inadequate state reimbursement for Medicaid, a perennial industry complaint. The primary payer for nursing home care, Medicaid provides less than the daily cost of care, said Clif Porter, chief executive of the American Health Care Association, an industry trade group.

“Before the pandemic and inflation, the losses were sustainable,” said Jason Hutchens, ArchCare’s chief operating officer. More recently, he said, “we were running at an unsustainable loss — we had no choice.”

Nursing homes, most of them for-profit, try to compensate by attracting short-stay patients covered by Medicare, which pays higher rates than Medicaid. When they can’t, “unless you’re extremely rapacious or extremely efficient, you’re not going to make it,” said Vincent Mor, a health services researcher at the Brown University School of Public Health who is an author of an article, published in the New England Journal of Medicine, raising concerns about reduced capacity. “The numbers don’t add up.”

Staff shortages, which have plagued nursing homes for decades, have also caused contractions and closures. Nursing home aides work stressful, low-paying jobs with historically high turnover rates. Their median hourly wage last year was $20.67, according to federal data compiled by PHI, a research and advocacy group for direct care workers. Although pay has risen over the past decade, about 40% of nursing home aides rely on some form of public assistance, such as Medicaid or the Supplemental Nutrition Assistance Program, PHI reported.

The number of nursing home aides has rebounded from the covid pandemic, according to PHI, but fewer are working than in 2015. And while hiring and retention have improved, Porter said, “there’s still a significant gap between demand, especially future demand, and where the workforce currently is.”

National occupancy rates, which fell sharply during the pandemic, have returned to a more typical 80%.

That figure can be misleading; it doesn’t mean 1 bed in 5 sit empty, awaiting a patient. Occupancy counts state-licensed beds, but the more meaningful number is operating beds — how many are actually available depending on a facility’s staffing and other factors.

That number is usually lower and, in many cases, sinking. The American Health Care Association reported in 2024 that almost half of nursing homes were limiting admissions and 57% had waiting lists for new residents.

It’s possible, of course, that they also face financial losses because of lower demand. “Nursing homes close because people don’t want to go to nursing homes,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care, an advocacy group. “The quality is so low that people avoid them like the plague.”

Last year, Medicare inspectors found at least one quality violation serious enough to harm or jeopardize residents in 27% of nursing homes, according to an analysis by KFF, a health information nonprofit.

In recent decades alternatives emerged that diverted patients from nursing homes. About a million older adults currently live in assisted living facilities. And among Medicaid recipients, the ongoing policy shift called “rebalancing” has enabled more people to receive services at home (where most want to be) rather than in nursing homes.

In 1988, only 10% of Medicaid expenditures for long-term services went to home- or community-based services; the rest paid for institutional care. By 2020, more than 60% of expenditures funded home and community care, said Priya Chidambaram, a KFF senior policy manager specializing in Medicaid, citing a staff analysis.

How big a problem these trends pose depends partly on geography. The decline in the number of nursing homes in rural locations — about 10% from 2015 to 2025 — was much greater than the national drop of about 6%.

“It’s more difficult to staff a rural nursing home,” Chidambaram said. “Labor pools are smaller, and it’s hard to get people to take lower-paid or part-time jobs if they have to travel long distances.”

Bed shortages are also creating bottlenecks at hospitals. Where nursing home capacity declined, Grabowski’s team found, patients stayed in hospitals longer because they couldn’t locate posthospital care. They often had to travel farther to find facilities. “It gums up the entire system,” Grabowski said.

On two fronts, Trump administration policies could make matters worse, experts said. Revoking legal status for certain immigrant groups has worsened staffing shortages.

So far, “we’re not seeing significant impact across the country,” Porter said. But the effects are being felt in specific locations, including Florida, New York, and Massachusetts, he confirmed. With further revocations and deportations, “a lot fewer older adults are going to have caregivers,” Grabowski said.

The administration’s more than $900 billion in cuts to Medicaid over a decade are also expected to exact a toll. As states grapple with reduced funding, analysts expect home and community services to take a greater initial hit than institutional care. But that could increase pressure on nursing homes if patients who lose home care turn to institutions instead.

Less of these services “means more nursing home entry,” Grabowski said.

As policy ideas circulate — with calls for better data tracking, special visas for immigrant health workers, and targeted grants for nursing homes serving high-cost populations — researchers, advocates, and families are waiting to see what unfolds.

“So much of this is speculative,” Chidambaram said. “We don’t know what states will decide. We don’t know how the market will react. We’re in new territory here.”

The New Old Age is produced through a partnership with The New York Times.

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

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

Mason Henderson with his mother, Tabitha Lowe, in November during a visit to New York, where Henderson was participating in a clinical trial to treat his brain cancer. Henderson died in May after a two-year battle with the disease. (Jerry Lowe)

Eighteen months after his initial diagnosis, chemotherapy hadn’t slowed 21-year-old Mason Henderson’s rare brain tumor, which had spread to his spinal fluid. So he left his home in southeastern Texas to spend three weeks in a clinical trial in New York City.

But that failed, too, leaving a murky path for Henderson, whose cancer was so rare the World Health Organization had only given it a name in 2021. So early this year, Henderson’s doctors, evaluating his tumor’s deep genetic language, turned to a drug made by Merck and AstraZeneca called Lynparza.

It was not the standard of care for Henderson’s condition — there wasn’t really any standard, which is not unusual for rare cancers. And Henderson’s insurance would not pay for it, despite the careful justification given by the two specialists treating him.

“They have no guidelines for his cancer,” Henderson’s mother, Tabitha Lowe, said in a March interview with KFF Health News. “They’re discriminating against him because his cancer is so rare.”

Tabitha Lowe and her son Mason Henderson. Lowe spent six weeks trying to get an $8,700-a-month drug for her son that the family’s pharmacy benefit manager wouldn’t cover. (Tabitha Lowe)

Every year, tens of thousands of people — representing about a quarter of all U.S. cancers — are diagnosed with tumors that differ enough from frequently identified ones to be called rare. In determining whether to reimburse treatment for such ailments, insurers turn to Food and Drug Administration labels and expert guidelines.

But these rare afflictions often lack targeted, FDA-approved treatment options, even though in many cases, molecular tests offered by diagnostic companies and university labs can provide a strong suggestion of what will work.

“Insurance coverage routinely trails behind what genomic testing reveals about a patient’s cancer and what the science supports,” said Olivier Elemento, director of Weill Cornell Medicine’s Englander Institute for Precision Medicine.

Henderson’s neuro-oncologists, Jacob Mandel of the Baylor College of Medicine and Jessica Schulte of NYU Langone Health, decided to try Lynparza, also known by the generic name olaparib, in combination with chemotherapy. There wasn’t a wealth of evidence behind the drug but there was a “biologically reasonable” assumption it would help, Schulte said, because cells in tumors like Henderson’s have a flaw that drugs like Lynparza can target. Providers in several previous cases had seen brain cancers like Henderson’s respond well to the drug.

“In general, we try to base our treatment decisions on large patient studies” involving hundreds of patients, Schulte said. But large clinical trials will probably never be conducted for a cancer as rare as Henderson’s.

Schulte, who specializes in brain cancers in young adults, sees only a few of Henderson’s type each year, she said.

Mandel prescribed the drug on Jan. 16. Liviniti, Henderson’s pharmacy benefit manager, responded with a quick refusal on Jan. 30. Two weeks later, the company sent an explanation: “Lynparza is not approved for the diagnosis provided.” Out-of-pocket, the drug would cost about $8,700 per month, Lowe said. Liviniti did not respond to phone calls seeking comment.

Before his diagnosis, Henderson was a healthy, athletic young man with a big heart, faith in Jesus, and a tight group of friends, his mother said. At Evadale High School, north of Beaumont, Texas, Henderson played baseball and football and was homecoming king in 2022. After graduating, he worked at the local paper mill, spending his free time hunting, fishing, and exploring the woods on an all-terrain vehicle. He wanted to be a police officer, Lowe said.

Henderson was 20 on March 15, 2024, when his brother Gunner found him at the top of the stairs in the family home with his head in his hands. “He was in the post-seizure state,” Lowe said. “He couldn’t talk. Was crying. Trying to hug me. Could not communicate.”

At an emergency room in Beaumont, an MRI revealed a large tumor. He was transferred to Baylor St. Luke’s Medical Center in Houston and diagnosed with a form of brain cancer called diffuse hemispheric glioma (H3-G34 mutant).

Surgery a few days later cut out 90% of the tumor, but brain cancers are almost impossible to remove entirely, because of the delicacy of the tissue they’re embedded in, Schulte said.

After 16 months of radiation and chemotherapy, a September 2025 scan showed the cancer had spread to his spinal cord, a condition called leptomeningeal disease that usually proves fatal within a few months. Mandel contacted Schulte about a clinical trial she was leading. It consisted of 11 days of brutal craniospinal irradiation, which left Henderson exhausted. When it was over, the cancer was still there.

“The family was wonderful,” Schulte recalled. “They were trusting in their team, but they asked appropriate questions to make sure that we were thinking about Mason as a person.”

Coverage Refused

Lynparza, approved by the FDA in 2014 for ovarian cancer, works by interfering with tumor cells’ ability to multiply. After Liviniti, the pharmacy benefit manager, refused coverage for Henderson, his family turned to Jefferson County. Henderson’s stepfather, Jerry Lowe, flies helicopters for the county sheriff’s office.

The county, which had the final say on reimbursement because it pays claims directly for its employees’ family health coverage, also refused. When Henderson’s family appealed, the county review board authorized an independent medical reviewer to look at the case. The nonspecialist supported the board’s finding and recommended another drug, but Henderson’s doctors disagreed. The board didn’t respond to a request for comment.

AstraZeneca had also turned down the family’s request for a donation of the drug. By then it was March, six weeks after Lynparza was prescribed.

Cancers that start in the brain are unusual — only about 25,000 cases are diagnosed in the U.S. each year, compared with 320,000 breast cancers and 229,000 lung cancers. Only a few hundred people each year, mostly young adults, are diagnosed with Henderson’s type, according to Schulte.

Treatment options for diffuse hemispheric glioma are few; brain cancers in general are often excluded from clinical trials. They represent a relatively small market for a pharmaceutical company. Testing drugs against them is risky, because of the brain’s sensitivity, and difficult because the drug must pass through the tightly packed cell walls lining the blood vessels, known as the blood-brain barrier.

Patients like Henderson often struggle to get medications that are prescribed off-label based on recent scientific findings. (Tabitha Lowe)

Still, drugmakers are increasingly homing in on narrower and potentially more accurate drug targets as science reveals more of cancer’s remarkable molecular diversity.

Under guidance issued in 2022, the FDA has approved nine drugs to be used for patients whose tumors have specific mutations, regardless of the organ where the cancer first appeared. These “tissue agnostic” drugs are still a tiny minority, but as genome sequencing becomes more common — growing numbers of oncologists order it for patients — insurers will have to keep up, Weill Cornell’s Elemento said.

Several U.S. research groups are hosting clinical experiments known as “basket trials,” in which mostly late-stage cancer patients are put on drug combinations based on tumor genetics, rather than the organ of origin.

The American Society of Clinical Oncology has recruited more than 3,000 patients into one of the biggest efforts, the Targeting Agent and Profiling Utilization Registry, or TAPUR, which began in 2016. It provides off-label treatments at no cost to advanced-staged cancer patients at more than 270 U.S. oncology practices.

About half the participants have benefited, and in rare cases the treatment kept patients alive for a year or more or seemingly cured them, said Richard Schilsky, the program’s founder and its principal investigator until recently. The results have led to changes in several treatment guidelines, he said, and a change in guidelines “usually is sufficient to create a pathway to reimbursement by insurance.”

Research has uncovered “quite a few” cases in which Lynparza was effective against a variety of tumor types, Schilsky said. But like many clinical trials, TAPUR excludes patients with primary brain tumors — like Henderson’s.

Oncologists disagree on how broadly genetics discoveries will transform cancer diagnosis. Cancers are currently identified as breast, colon, lung, etc., because those are the cells that pathologists see when diagnosing a tumor, said Razelle Kurzrock, the associate director of clinical research at the Medical College of Wisconsin Cancer Center.

But that’s a “mistake of history,” she said. “You’re making the diagnosis based on the pathologist’s view of the surface of the cell rather than what’s actually driving the cancer.”

A Dutch father and son invented the first light microscope to peer at cells around 1590. The Human Genome Project finished in 2003. If genome-enabled next-generation sequencing, now used for molecular tumor scans, had come before the light microscope, “no one would look at organ of origin,” she said.

Kurzrock leads I-PREDICT, a clinical trial in which every patient gets individualized cancer therapy based on DNA, RNA, and protein patterns in their tumor. Instead of getting drug combination A or B, “in our trial everyone gets a different set of drugs,” she said. Physicians can instead use standard therapies, she said, and their patients are the study controls.

Other oncologists see limitations to purely genetic diagnosis. Certain cancer centers advertise by saying, “‘We’ll sequence your tumor better than anyone else, and therefore you’ll live longer and do better if you come here,’” said Kathy Miller, a professor of oncology at Indiana University. “But the evidence doesn’t support those claims right now.”

‘I Wouldn’t Give Up’

In Henderson’s case, the problem was never diagnosis; Baylor clinicians identified his cancer type quickly. But its rarity and location made the tumor hard to fight, and the lack of financial help made it even harder.

On March 8, Tabitha Lowe went on Facebook, LinkedIn, and Instagram with photos of her son and descriptions of his plight. She tagged AstraZeneca, Liviniti, and the county board that had denied his reimbursement. “Rare cancer patients are denied treatment simply because their cancers are rare,” she wrote in one of the posts, which were shared hundreds of times.

“I hated to take this route, but when it comes to my kids there’s nothing I won’t do,” she told KFF Health News. “I’ve cried, I’ve stressed out, but I wouldn’t give up.”

Tabitha Lowe took to Facebook to try to get her son Mason Henderson access to the brain cancer treatment his doctors sought for him. (Tabitha Lowe)

The next day, AstraZeneca’s patient assistance program, which had turned down her request for the drug two weeks earlier, emailed her with good news: A bottle of 60 Lynparza pills had been shipped to her pharmacy. Company spokesperson Tara Parsell said patient confidentiality prevented her from commenting on its actions.

Lowe’s six-week battle had paid off. Now, “it’s in God’s hands,” she said in an April interview. By mid-April, however, Henderson could no longer walk. Then came issues with his speech. “It all happened so fast.”

On May 4, in the family’s living room, where his bed had been moved, Henderson died, after taking the drug for nearly two months. Hundreds attended his memorial service; their cars made a procession seven minutes long.

The family has created a college scholarship in Henderson’s name for graduates of the local high school. An online campaign and bass fishing tournament had raised nearly $24,000 by September. Willie Robertson of Duck Dynasty, professional pickleballer Tyson McGuffin, and pro fisherman Hank Parker donated items for a raffle. Country singer Mark Chestnutt sent two signed guitars, Lowe said.

“Faster treatment would have been better,” although it’s hard to know whether it would have extended Henderson’s life, NYU’s Schulte said.

“I will always wonder,” Lowe said in a phone interview this summer. “Cancer don’t pause while the paperwork’s in progress.”

“There’s something especially painful thinking about how much time I spent fighting healthcare instead of being with Mason,” she added. “I was forced to become a PBM, insurer, research expert, all while trying to be his mother.”

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

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

BOISE, Idaho — Joshua and Ashley Durham run a family medicine practice, and for the first time in their lives, they have no health insurance.

When the Durhams began their practice at the end of 2023 — he as a primary care physician and she as a pharmacist who handles the billing — the couple bought coverage for themselves and their two kids on the Affordable Care Act marketplace. But they said their monthly premiums for a similar health plan for this year rose several hundred dollars to nearly $1,600.

They decided to pay out-of-pocket for their medical expenses instead, leaning on $50,000 they had set aside in a health savings account over several years.

“It’s nerve-racking,” said Joshua Durham, 47. “It just takes, you know, one little accident, and then you got a big fat bill.”

The healthcare industry traditionally has more of its workforce on medical insurance than many other fields. Nationwide, 7% of all healthcare workers were uninsured in 2024, compared with 11% of all adults under 65, according to a KFF analysis of the most recent American Community Survey data. And doctors were especially unlikely to forgo health insurance, with just 2% uninsured.

But even healthcare workers are feeling the pinch as health insurance costs rise each year, with employers expecting that costs will jump an additional 8.2% for 2027.

The Republican-led Congress also opted last year not to renew Affordable Care Act marketplace credits enacted during the covid pandemic. While subsidies remain in place for people with low incomes, the pandemic-era credits helped reduce many consumers’ premium payments, especially those working in small businesses such as independent medical practices. Nearly half of marketplace enrollees worked for small businesses or were self-employed in 2024; some of the most common occupations included chiropractic care and dentistry.

Jack Dillon, executive director of the Association for Independent Medicine, which represents 4,000 physician-led practices, said premium increases have become untenable for small businesses, whether employers seek coverage through the marketplace or directly from insurers.

“The cost has become so astronomical,” Dillon said. “You’re looking at it and saying, ‘What’s the value?’”

As health insurance continues to become less affordable, Dillon said, more healthcare employers may seek alternatives to their standard coverage, such as providing higher hourly wages or providing only minimal plans.

The number of people without insurance in the U.S. is expected to increase by roughly 15 million over 10 years because of the expiration of the expanded ACA subsidies and $1.1 trillion in estimated cuts resulting from President Donald Trump’s signature One Big Beautiful Bill Act, according to the Congressional Budget Office.

Healthier people are the most likely to opt out of insurance. That leaves insurance covering a smaller pool of people who tend to be sicker and need more expensive care. So insurers raise prices to cover the remaining enrollees, which fuels even higher premium costs.

‘Healthcare Is a Business’

Samantha LeGault, a nurse practitioner at a health clinic in Boise, said her employer-offered plan’s premium payment rose from $700 to $1,500 a month this year to insure herself, her husband, and four of their kids. LeGault has Crohn’s disease and two of their daughters also have medical conditions, so she said her family has no choice but to continue to pay for that health coverage.

But she decided to skip dental insurance to save money, and she prioritizes dental visits for her children over herself.

She had already struggled to set aside retirement savings and had switched her children from a private school they liked to public school to cut down on costs. Then the new health insurance costs tightened her budget even more. She estimated that about one-fifth of her income now goes toward her monthly premium payments.

“I know how the clinics work, that I am an expensive patient,” LeGault said. “At the end of the day, healthcare is a business in the United States.”

Samantha LeGault, a nurse practitioner for a health clinic in Boise, says her medical insurance premium costs rose from $700 to $1,500 a month this year to cover her, her husband, and four of their kids. She has Crohn’s disease, and two of her daughters also have medical conditions. She continues to pay for health coverage but opted to skip dental insurance to reduce their monthly expenses. (Hayat Norimine/KFF Health News)

The Durhams have three other employees in their practice. Two of them receive health insurance through their spouses, Ashley Durham said. The Durhams said they pay $420 monthly toward their physician assistant’s premiums.

As a primary care physician, Joshua Durham said he doesn’t need regular doctor visits, because he can diagnose and treat himself — and, if needed, the rest of his family, though he acknowledged that’s frowned upon. The American Medical Association’s code of ethics generally discourages doctors from treating themselves or relatives but makes exceptions for emergency situations or short-term, minor problems. Ashley Durham said she’s filled prescriptions for her family.

Arthur Caplan, a bioethicist and professor emeritus at New York University’s Grossman School of Medicine, said that as more people are “turning toward relatives because they can’t access or easily see a regular doctor,” it may make sense to revisit that aspect of the code of ethics.

Out-of-Pocket Expenses

Healthcare workers with less advanced medical certifications than the Durhams often don’t have the option of treating themselves or family members — or don’t have savings to fall back on for healthcare expenses. And many healthcare professionals, such as Jill Kordick, a 64-year-old retired healthcare executive in Norwalk, Iowa, aren’t willing to go without the safety net of insurance.

In her work, Kordick saw hospitalizations become financially devastating for patients, so she said she would never opt out of health insurance — even for just the 16 months before she’d become eligible for Medicare at age 65.

Last year, she qualified for the enhanced Affordable Care Act tax credits, allowing her to pay $75 a month for health coverage. Her premiums rose to $800 a month this year when those subsidies expired.

Because she has a $10,000 deductible, she put off going to the doctor for weeks when she had a sinus infection this year, until it ultimately evolved into an ear infection. She said she regularly rethinks, and sometimes returns, nonessential groceries in her shopping cart. And she keeps her house’s thermostat at 80 degrees in the summer to cut down on air conditioning costs.

Kordick said healthcare is a universal struggle in this country, regardless of how familiar patients are with the industry. “It’s disheartening that it’s as broken and fragmented as it is,” she said.

The Durhams have seen the impact of unaffordable healthcare on their patients. They said they try to lend some leeway to patients when they can — a luxury they have, operating their own practice. In one case, Ashley Durham said, she wrote off $1,160 in bills for a single father whose son didn’t have health insurance rather than send their bills to a collection agency.

“It’s hard, because as a human I want to help them out,” she said. “At the same time, we need revenue for our office.”

Joshua Durham is more nervous about going uninsured than his wife. As a child, he witnessed his parents struggling to pay medical bills for their family of nine in south-central Idaho. Durham recalled that his dad, who was a carpenter, helped build a surgeon’s house to pay for an operation.

Today, Durham also sometimes exchanges work for care. He said he gets free eye exams from an uninsured optometrist and offers him free primary care.

He worries about a worst-case scenario: a car crash, a sports injury, a serious diagnosis.

“Do I have pancreatic cancer today?” Durham said wryly.

So far, the couple has paid around $9,000 total for expenses out of their health savings account this year, including physical therapy to help with the thoracic outlet syndrome that affects Durham’s neck and shoulder, mental health appointments, and contact lenses. The expenses were higher than the Durhams anticipated. But it was still less than what their monthly premiums would have cost them.

Their decision has paid off, Joshua Durham said. At least for now.

The Durhams used the Affordable Care Act marketplace for health insurance for their family of four last year. This year, they chose to pay out-of-pocket for care instead when the cost of their premium payments jumped. (Hayat Norimine/KFF Health News)

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

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

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

Paul Nestadt is about as steeped in suicide prevention as a person can be.

He treats suicidal patients as a psychiatrist, has co-authored scores of research papers on how and why people kill themselves, and teaches graduate courses on the subject.

But he’ll be the first to admit: “I can’t tell you which of my patients is likely to die by suicide in the next six months.”

Almost nobody can.

Research shows predictions of who will be suicidal are only slightly better than a coin toss. And they haven’t improved over 50 years.

But that doesn’t make Nestadt hopeless. Instead, it pushes him to pursue interventions that don’t require pinpointing people at risk.

Chief among them: making it harder for people to carry out the act of killing themselves.

“Instead of asking every doctor to figure out which patient will die by suicide and locking that patient up, it might be that we need to make sure there aren’t loaded guns available,” Nestadt said.

In an ongoing series, KFF Health News is examining approaches to suicide prevention that expand beyond providing people at risk with medication and therapy. Although those are lifesaving measures, many clinicians, researchers, and people who have lost loved ones to suicide agree that more is needed. The challenge is that when it comes to firearms, broad policy approaches quickly become constitutionally complicated and politically polarizing.

Research shows that limiting access to lethal means is one of the most promising approaches to save lives. It can involve erecting barriers on buildings and bridges to prevent people from jumping, as well as decreasing the number of pills someone can buy or be prescribed at once.

And reducing access to guns.

“That’s the one that will save the most lives,” said Nestadt, medical director at the Johns Hopkins Center for Suicide Prevention.

It may also be the most difficult to achieve.

More than 28,000 people killed themselves with a gun last year, representing more than half of all suicide deaths in the U.S., according to preliminary federal data. Even as overall suicide rates have dipped recently, gun suicides have hit record highs for five years in a row.

Most Gun Deaths in the U.S. Are Suicides

From 2021 to 2025, suicide deaths by gun hit record highs each year, even as homicides by gun decreased.

Source: <a href="https://wonder.cdc.gov/&quot; target="_blank" style="color:#0071ce">CDC WONDER</a> <br> Note: 2025 data is provisional. The following ICD-10 codes identify firearm death types: X93-95 (homicide), X72-X74 (suicide), W32-34, Y22-24, and Y35.0 (other, which includes accident, legal intervention, and undetermined). <br> Credit: Aneri Pattani/KFF Health News

Many of the deaths are among middle-aged white men and veterans, two groups that have had high suicide rates for years. But more recently, gun suicides have risen among women and among some Black and Latino men. Researchers say a surge in first-time gun buyers during the covid pandemic underscores the need for prevention efforts that can be applied widely.

Some people assume it’s futile to restrict access to bridges, pills, or guns. The thinking goes: Those who want to kill themselves will simply find another way.

But research refutes that. Creating barriers for one method doesn’t typically push people to another.

Suicide risk can surge quickly, with people spending less than an hour or even five minutes between deciding to die and acting on it. Anything that delays such action — for example, having to unlock a safe to access a gun — gives them time to reconsider or for someone to intervene.

A Sharp Rise in Gun Suicides Among Black Women

White women had the highest rates of gun suicides by women in 2015 and 2024, but among women of other races and ethnicities, the increase was faster and steeper over that time.

Source: <a href="https://publichealth.jhu.edu/sites/default/files/2026-07/2024-CGVS-gun-violence-in-the-united-states.pdf?nvep=&hmac=&emci=8288e977-1e8c-f111-b337-000d3a1558ce&emdi=ea000000-0000-0000-0000-000000000001&ceid=&quot; style="color:#0071ce">The Firearm Mortality Epidemic: Examining the U.S. Data From 2024, Johns Hopkins Center for Gun Violence Solutions</a> <br> Note: Rates represent gun suicide deaths per 100,000 people. <br> Credit: Aneri Pattani/KFF Health News

However, in the U.S., discussion around guns — even in the context of a traditionally bipartisan topic such as suicide prevention — is a political lightning rod. Mentions of background checks, waiting periods, or red flag laws often send people running to their respective corners. Gun owners and the firearm industry say many of the policies suicide prevention advocates seek threaten their Second Amendment rights, and many policymakers see the topic as a nonstarter.

President Donald Trump has been a strong ally of gun owners. His administration has rolled back dozens of firearms regulations and rescinded a previous surgeon general’s warning that called gun violence a public health crisis. It has also revoked grants focused on addressing community gun violence and cut federal staff working on the issue.

The White House did not respond to specific questions about how these actions may affect the nation’s high rate of gun suicides or what it’s doing to prevent such deaths. But spokesperson Lauren Bis said in a statement that “President Trump is committed to Making America Healthy Again and that includes mental health.” She pointed to the administration’s support for developing psychedelic treatments for mental illness and an announcement of $52.5 million in grants for veteran suicide prevention.

The Limits of Red Flag Laws

One gun policy that has gained some traction, despite pushback, is the extreme risk protection order, more commonly known as a red flag law.

Adopted in some form in 22 states and the District of Columbia, these laws allow judges to temporarily remove a person’s guns when evidence suggests they pose a danger to themself or others.

Although such laws are often passed in the wake of mass shootings, research suggests they’re more effective at preventing suicide.

Still, they require identifying someone at risk.

Someone like Dorothy Paugh’s dad.

In 1965, when Paugh was a young girl, her dad lost his job. He was distressed, not knowing how he’d support his wife and five children, Paugh said. He reviewed his life insurance policy, told his wife where he kept important documents, and bought a handgun.

“If my mom had been able to get an extreme risk protection order or if Dad’s best friend had asked to hold his gun for a while, maybe my dad would not have shot himself. He might have lived,” Paugh said.

Decades later, Paugh advocated for a red flag law in Maryland and sat in the legislative gallery when the measure was passed.

She believes the law is saving lives.

Studies across other states show that for every 10 to 20 guns removed under red flag laws, one suicide is averted, saving a life.

But Paugh also recognizes the law’s limitations.

“It wouldn’t have saved my son,” she said.

Dorothy Paugh’s father died by suicide in 1965. She lost her 25-year-old son, Peter, shown in the photo, to suicide in 2012. Both men shot themselves. Paugh has since become an advocate for gun policies that have been shown to reduce suicide deaths, such as red flag laws and mandatory waiting periods before completing a gun purchase. (C. Allen Paugh)

Her 25-year-old son, Peter, fatally shot himself in 2012. He’d recently bought a house with his girlfriend and hosted a birthday celebration for his brother. He’d purchased a gift ahead of Mother’s Day — five novels by Charles Dickens, Paugh’s favorite author — that Paugh received after his death.

Unlike in her father’s case, Paugh said, no one saw warning signs for Peter. “I did not know that my son was suicidal. I didn’t have a clue,” she said. Even if a red flag law existed then, she wouldn’t have thought to use it.

The people most vulnerable to firearm suicide usually aren’t identified as such by family members or clinicians, said Michael Anestis, a clinical psychologist and the executive director of the New Jersey Gun Violence Research Center.

Studies have shown that among people who die by suicide, those who used guns were less likely to have sought mental health care in the past. And most veterans and service members who die by gun suicide never tell anyone about their suicidal thoughts in the months leading to their death.

That’s why red flag laws are just a first step in suicide prevention, Anestis said. They target specific individuals at high risk — the aspect that makes such laws more politically palatable — but they do not apply to the many other people who are quietly suicidal.

Paugh’s son, Peter, fatally shot himself in 2012. Paugh says she didn’t see warning signs that he was suicidal. Peter is pictured here hiking the Appalachian Trail in 2009. (Dorothy Paugh)

Lessons From Road Safety

Nestadt, the Johns Hopkins psychiatrist, said the nation needs to approach suicide prevention the way it approaches car accidents.

“You’re not trying to figure out who’s at risk of an accident” by testing people’s reaction time or cataloging who gets into fender benders, Nestadt said.

Instead, governments implemented speed limits, passed seat belt laws, and required auto manufacturers to install air bags and shatter-resistant windshields. The crash death rate declined significantly.

Applying a similar strategy to suicide might involve requiring permits and background checks to buy a gun, as well as instituting waiting periods before completing the purchase.

One study found that enacting a permit-to-purchase law in Connecticut was associated with a roughly 15% decrease in gun suicide rates, while repealing such a law in Missouri was linked to a 16% increase in firearm suicide rates.

Most Suicides in America Involve a Gun

Suicide deaths by gun have been increasing for several years, even as suicides by suffocation — the second most common method — have been decreasing.

Source: <a href="https://wonder.cdc.gov/mcd-icd10-provisional.html&quot; target="_blank" style="color:#0071ce">CDC WONDER</a> <br> Note: 2025 data is provisional. "All other methods combined" includes cut/pierce, drowning, fall, fire/flame, other land transport, other, and unspecified. <br> Credit: Aneri Pattani/KFF Health News

About three dozen states have enacted laws requiring owners to lock up their guns in homes where children live, a practice shown to reduce youth suicides. That’s an issue of particular importance, with gun suicide rates increasing 245% among Black youths and 98% among Latino youths since 2014.

Anestis said laws requiring permits and safe storage can also reduce homicides and other gun injuries.

Those types of violence not only hurt people directly but also increase their risk of suicide. Research suggests people who are exposed to gun violence in their community experience trauma and become habituated to the idea of injury or death. That “double whammy” makes them more likely to kill themselves, Anestis said.

Responsibility, Rights, and Saving Lives

Gun owners and firearm trade associations generally oppose universal measures, such as requiring permits and waiting periods. They prefer education campaigns that teach people how to recognize warning signs, talk about mental health, and safely store guns — initiatives that place responsibility on individuals.

The National Shooting Sports Foundation, which represents the firearms industry, has partnered with the American Foundation for Suicide Prevention to create flyers and brochures to be posted in gun shops.

“Our purpose is to provide educational materials to the firearm-owning community on how to help prevent suicide and save lives,” Bill Brassard, the NSSF’s senior director of suicide prevention initiatives, said in a statement.

The National Rifle Association said policies focused on guns miss deeper concerns that make someone suicidal, such as mental illness.

“Suicide is a serious issue that deserves serious solutions focused on the underlying causes, not on political efforts to restrict the rights of law-abiding Americans,” NRA spokesperson Justin Davis said in a statement. “A truly dangerous individual needs to be incapacitated, not just deprived of one particular means of harm.”

Some initiatives have managed to bring together unlikely bedfellows — gun store owners, public health experts, and even libraries — to provide free locks to secure firearms at home, identify locations that will temporarily store someone’s guns while they’re in crisis, and educate people on how to avoid selling guns to someone who is suicidal.

Those efforts give Paugh hope and fuel her passion to continue advocating for better mental health care, open conversations about suicide, and policies that decrease access to guns.

“It’s not a cure-all,” Paugh said of those policies. But “it does save lives.”

Having lost a parent and a child, she knows how valuable that can be.

“If you’re that one person or that person’s family, it’s all the difference in the world,” 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.

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

When the FDA was deciding whether to approve the drug Tavneos several years ago to treat a set of rare autoimmune diseases, agency experts argued that would be a mistake, according to FDA records.

One problem cited: The manufacturer had provided only “limited safety data.”

As it often does, the FDA in 2021 approved the drug with a proviso: It required the manufacturer to conduct an additional years-long safety study once the drug was on the market.

Today, like many similar “postmarket” studies mandated by the FDA, that additional study is delayed, according to a federal database. As of last fall, only 21 of the planned 300 patients had been enrolled, the FDA said in an April letter and regulatory posting.

Meanwhile, the FDA has identified dozens of cases of liver damage “possibly” or “probably causally associated” with the drug. That was one of the potential side effects the postmarket study was meant to evaluate.

Tavneos illustrates the perils of the FDA’s approach to many drugs and medical devices — and the frequent lapses in follow-through.

A KFF Health News analysis of Food and Drug Administration data found hundreds of postmarket studies listed as delayed. In some cases, the work was delayed by more than a decade or the manufacturer was still developing a plan for the study.

As a result of delays, patients, doctors, and others could be left in a fog about the risks and benefits of the drugs or devices, even as they stake their money, their health, or their lives on the products.

Postmarket study requirements “have often proven toothless,” said cardiologist Sanket Dhruva, an associate professor of medicine at the University of California-San Francisco who has published related research.

The FDA’s reliance on postmarket studies reflects a balancing act.

Making new treatments available faster can save or improve lives, especially when patients with grim prognoses and no good options have little to lose. The full risks and benefits may be revealed only over the long term, and when therapies are used by far more people than even large clinical trials enroll.

But relying on post-approval studies to resolve questions risks exposing patients to products that do more harm than good. Whoever is paying the bills — patients, insurance companies, employers, or government health programs such as Medicare and Medicaid — can end up wasting money and rewarding manufacturers for useless or risky products.

“Doctors rely on this evidence, patients rely on this evidence, and if that evidence is not there, it’s going to lead to a lot of uncertainty,” Dhruva said.

Trump administration policy changes designed to hasten drugs through FDA review could leave more riding on postmarket studies, medical researchers say.

For example, in February, FDA leaders announced that “the default requirement” for agency approvals will be one clinical trial instead of two.

Reducing pre-approval testing “will inevitably put a lot of pressure on the post-approval system,” said Aaron Kesselheim, a professor at Harvard Medical School who has analyzed postmarket studies.

FDA officials said the new policy would “substantially reduce costs” for manufacturers and “speed drugs to market.” Writing in The New England Journal of Medicine, they denied the change would compromise safety or efficacy, saying that “erroneous conclusions may be reached even with two, three, or four studies.”

In response to questions for this article, a spokesperson for the Department of Health and Human Services, which includes the FDA, said postmarket studies can experience delays for legitimate reasons. “Assessing the significance of any delay requires a case-specific review,” said the spokesperson, Emily Hilliard.

The fact that a study is delayed “should not be treated as evidence that a product has an unresolved safety or effectiveness issue,” Hilliard said.

Amgen, the company that makes Tavneos, is still working on the postmarket research the FDA mandated, company spokesperson Alison Chartan said, adding, “We remain committed to completing this important study.”

Amgen’s headquarters in Thousand Oaks, California, in May 2023. (Mario Tama/Getty Images)

Behind Schedule

An FDA database downloaded by KFF Health News in August tracks the progress of postmarket studies that makers of drugs or biologics — such as vaccines and gene therapies — were required to perform or promised to perform.

The database showed almost 600 were running behind schedule.

Of those, more than 250 originally had final reports due before July 31, 2026 — the date that, according to an FDA webpage, the database last had been updated.

About a third of ongoing studies were listed as delayed.

In some cases, the FDA has granted extensions. In others, it has denied them. And in rare instances, the products were discontinued before the studies ran their course.

Postmarket studies can involve clinical trials or other analyses of patient data. They can look at safety or efficacy. A product can be the subject of more than one postmarket study.

The nearly 600 delayed studies involved almost 350 products, KFF Health News found.

The FDA has defined delayed as behind the original schedule. That can mean off track or overdue.

As of August, other FDA databases tracking medical devices listed dozens of postmarket studies as behind schedule.

Products included:

The CustomFlex Artificial Iris, a prosthesis implanted in the eye in place of damaged, defective, or congenitally missing irises. The protocol for a study in children was accepted in 2019, the database said. The study was meant to follow patients for five years. According to an FDA page downloaded in August, zero patients were enrolled.

Barbara Fant of Clinical Research Consultants, to whom the FDA’s 2018 letter approving the product was addressed, said the rarity of an eye disease called aniridia poses challenges for post-approval studies. The German manufacturer, the U.S. distributor, and Clinical Research Consultants are working with the FDA to identify alternative ways to fulfill the postmarket requirements, Fant said.

“Confirming the long-term safety of the device remains a top priority for both the study team and FDA,” Fant said.

Paxlovid, a treatment for covid. A study to assess its safety in pregnant women was originally to be completed by the end of 2024, the FDA database said. “The trial completion and final report milestones were missed,” the database said.

Pfizer, the manufacturer, is working with the FDA and remains committed to “submitting results as soon as practicable,” Pfizer spokesperson Jerica Pitts said.

The Scandinavian Total Ankle Replacement system. The device and the original protocol for the clinical trial were approved in 2009. The study was meant to include a minimum of 500 subjects, the database said, but the actual number enrolled was 142. Almost half those patients had one or more adverse events, with dozens of “reoperations,” “revisions,” or “removals,” the database said.

Rachel Colloff and Cristina Pasquino — spokespeople for Enovis, which markets STAR Ankle — did not respond to multiple inquiries. Jenny Braga, a spokesperson for Stryker, which previously sold the product, did not answer questions about the postmarket study.

Oxaydo (originally named Oxecta), a form of the potentially addictive opioid painkiller oxycodone touted as designed to deter abuse. When the FDA approved it in 2011, it required the manufacturer, part of Pfizer, to conduct a postmarket study to assess whether it reduces “misuse and abuse, and their consequences: overdose, death and addiction.” The final report was originally scheduled to be submitted in 2016.

The FDA database listing the study as delayed said the agency “issued a failure to respond letter” in 2022.

Today the issue may be all but moot.  

Control of the product passed from company to company over the years until 2023, when Acura Pharmaceuticals said in a Securities and Exchange Commission filing that patents on Oxaydo would begin expiring that year and it didn’t intend to continue marketing the drug.

According to another FDA database, Oxaydo has been discontinued.

The FDA has enforcement powers and uses them “where appropriate,” HHS’ Hilliard said. She did not provide requested details, and she did not answer questions about the studies listed above.

Delay Can Pay

For manufacturers, delay can pay, Harvard’s Kesselheim said. While postmarket studies are ongoing, companies can continue to sell the products.

“Medicare and Medicaid spent more than $18 billion from 2018 to 2021 for accelerated approval drugs with incomplete confirmatory trials past their original planned completion dates,” the HHS Office of Inspector General estimated in 2022.

The FDA can demand postmarket studies for a variety of reasons, including to address concerns that arise after a product has been approved. Some look at uses not covered by the original approval, and some are meant to shed light on serious risks that are already known.

In April, when it approved Foundayo, a weight loss drug made by Eli Lilly, the FDA required the company to conduct additional research to assess a variety of concerns, including “retained gastric contents,” “major adverse cardiovascular events,” and “drug-induced liver injury,” as well as effects of exposure during pregnancy, such as “major congenital malformations,” “spontaneous abortions,” and “stillbirths.”

The FDA said it approved the drug under the new Commissioner’s National Priority Voucher program, intended for products that “address critical national health priorities.” The program strives for an “ultra-fast” review, the FDA has said — one to two months, instead of six months or more with other expedited pathways.

“Postmarketing requirements and enhanced safety monitoring are a routine part of the FDA’s approach to evaluating newly approved medicines,” Eli Lilly spokesperson Kristiane Silva Bello said, “including ongoing monitoring in areas identified during clinical development.”

‘False Hope’

The FDA waded into a world of uncertainty in 2016 when it granted accelerated approval to a drug for Duchenne muscular dystrophy, a degenerative disease that primarily affects boys, disabling them at a young age and ultimately killing them.

Agency scientists had found that the drug, Exondys 51, was unproven and argued against greenlighting it.

Ellis Unger, then a senior drug evaluation official at the FDA, wrote in an internal memo that “thousands of patients and their families would be given false hope in exchange for hardship and risk.”

The manufacturer, Sarepta Therapeutics, conceded the uncertainty. “A clinical benefit of EXONDYS 51 has not been established,” it said when the drug, also known by the generic name eteplirsen, was approved.

The drug, the first FDA-approved treatment for Duchenne muscular dystrophy, targeted a subset of patients with the disease.

The FDA required Sarepta to conduct further studies and warned that it could withdraw approval if postmarket trials failed to verify a clinical benefit or were “not conducted with due diligence.”

Unger issued a warning of his own: “FDA has not succeeded in withdrawing the marketing of a single drug for lack of verification of clinical benefit following accelerated approval. The reality is that if eteplirsen is given accelerated approval, it is highly likely to remain on the market indefinitely, irrespective of whether or not efficacy is verified.”

Sarepta was originally required to submit a final report on a postmarket study by a May 2021 deadline, according to an FDA database and a 2016 FDA letter to the company.

Almost a decade after the drug was approved, and more than five years after that deadline, the study was listed in an FDA database as delayed.

“The final report milestone was missed, because the sponsor requested milestone extensions due to study delays,”  the database said.

Meanwhile, in 2022 the website Pharmaceutical Technology ranked Exondys 51 as the second-most expensive drug in the U.S., at an annual cost of $750,000 to $1.5 million.

Last year, the drug generated $538 million in sales for Sarepta, according to a company presentation to investors.

Sarepta found it difficult to recruit patients for the postmarket clinical trial, company spokesperson Tracy Sorrentino said. The target population is small, patients were hesitant to enroll, and Sarepta was competing with other clinical trials for participants, Sorrentino said.

The study has been fully enrolled since 2023, Sorrentino said, and the company plans to provide an initial look at the data late this year.

‘Manipulated’

Amgen is the maker of the drug Tavneos. (Hannah Yoon/Bloomberg via Getty Images)

Amgen has cited similar challenges, even as Tavneos generated $459 million in global sales last year.

When an approved treatment is available, patients may be reluctant to enroll in a study in which they could be given a placebo, Amgen’s Chartan said.

The clinical trial was originally supposed to be done by the end of 2030. As of July 24, just 49 patients had been enrolled, Chartan said.

The FDA has said the study was to include 300 patients, and each patient enrolled must be followed for five years, said Hilliard, the HHS spokesperson.

Tavneos was approved to treat severe cases of a group of diseases — known by the shorthand ANCA-associated vasculitis — in which, as the Cleveland Clinic explains, the immune system inflicts potentially fatal damage on blood vessels and organs. 

“As of January 2026, estimated real-world exposure” to Tavneos “exceeds 25,000 patient-years globally, consisting of over 6,500 in the United States and 19,000 abroad,” Amgen has said. (For context, one patient taking a drug for five years would amount to five “patient-years.”)

A clinical trial sponsored by ChemoCentryx to secure approval of Tavneos failed to prove it was effective, the FDA now alleges. Instead of disclosing that outcome to the FDA, company personnel “manipulated” the results, the FDA alleged in an April letter to Amgen.

Amgen, the parent company of ChemoCentryx, has denied the results were manipulated and has said the data “remain valid.”

Nonetheless, the European Union recently revoked its approval of Tavneos.

The FDA is trying to pull Tavneos from the market, and Amgen is fighting that effort.

The company has a lot riding on the outcome. Tavneos can cost more than $220,000 per year, according to the drug discount website GoodRx, and when Amgen acquired ChemoCentryx in 2022 for $3.7 billion, Tavneos was the only drug ChemoCentryx had brought to market.

In a June letter to the FDA, Amgen said the benefits of Tavneos outweigh the risks.

The FDA disagrees.

The FDA “can no longer conclude that there is, or has ever been, a valid demonstration of substantial evidence of effectiveness for TAVNEOS,” the agency wrote.

Citing 76 cases of DILI — drug-induced liver injury — the agency said it was “increasingly concerned about the safety profile of TAVNEOS.” Without proof of effectiveness, at least for its approved use, “the drug’s benefits cannot outweigh its known risks,” the FDA wrote.

Data reporter Maia Rosenfeld 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.

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

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.

Reports from a top artificial intelligence company that it stopped several attempted uses of its product that could assist in manufacturing a bioweapon caught the attention of lawmakers in Washington this week. But it is still unclear whether or when Congress will act to regulate the fast-moving industry — and the House has left town until after Election Day.

Meanwhile, with many voters expressing anger over the rising cost of healthcare, President Donald Trump is proposing to send $500 checks to some people enrolled in Affordable Care Act insurance plans before the election. But even if those checks materialize, in most cases they will be smaller than the increases many policyholders have already seen.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Tami Luhby CNN @Luhby Read Tami's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• Anxieties about AI reached a fever pitch this week, with a few leading developers calling to slow the pace of innovation amid troubling reports about AI’s progress and use, including reported attempts to misuse AI for biological warfare. Meanwhile, the Trump administration is pressing to incorporate AI into healthcare.
• Federal lawmakers are exploring changes to the independent arbitration system created by the No Surprises Act, which took effect in 2022. While the law has cut down on patient exposure to surprise out-of-network medical bills in emergencies, the system has resulted in far larger paydays than anticipated for many doctors — which, in turn, has prompted a sizable increase in coverage costs, including for employers.
• Some cities and states are suing to block implementation of the latest public charge rules from the Trump administration, arguing they could have a chilling effect for some who are entitled to public benefits, such as the eligible children of immigrants. They allege that could leave cities and states on the hook and harm local economies.
• Abortion opponents are claiming victory as the Environmental Protection Agency moves to test water for remnants of abortion pills, among other chemicals and drugs. California’s attorney general is wrapping up a lawsuit against two nonprofits offering what they describe as abortion pill reversals, despite a lack of evidence the method works or is safe. And the family of a Texas woman who died after being denied an abortion is suing her doctors and the state’s attorney general, Ken Paxton.

Also this week, Rovner interviews Sabrina Corlette of the Georgetown University Center for Health Insurance Reforms, discussing some potential short-term fixes to the nation’s health system.

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

Julie Rovner: KJZZ Phoenix’s “Data Shows DES Failed To Complete Most SNAP Eligibility Interviews, Resulting in Massive Cuts,” by Camryn Sanchez.

Tami Luhby: The Washington Post’s “What ‘Ferritin Face’ Means — And How To Tell If You May Be Iron-Deficient,” by Erica Sloan.  

Anna Edney: Bloomberg News’ “Patients Who Fight Health Insurance Denials Often Win,” by John Tozzi, Tanaz Meghjani, and Ike Swetlitz.

Alice Miranda Ollstein: KFF Health News’ “Indigenous Groups Are Exempt From Medicaid Work Rules, but Native Hawaiians Aren’t,” by Ashley Mizuo.

Also mentioned in this week’s podcast:

• Science’s “‘Chilling’ Warning or Overreaction? AI Bioweapons Report Divides Experts,” by Jocelyn Kaiser.
• The New York Times’ “U.S. Health Officials Move Quickly To Deploy Medical A.I. Despite Concerns,” by Christina Jewett.
• Roll Call’s “Surprise Billing Dispute Process In ‘Crisis,’ Groups Say,” by Ariel Cohen.
• KFF Health News’ “A Generation of Kids Suffer as Trump Destabilizes Immigrant Families,” by Claudia Boyd-Barrett.
• Politico’s “Abortion Opponents Claim ‘Tremendous Victory’ as EPA Tests Water for Abortion Pills,” by Miranda Willson, Alice Miranda Ollstein, Ariel Wittenberg.
• Politico’s “Free Speech or False Advertising? California Judge To Rule on ‘Abortion Pill Reversal’ Claims,” by Rachel Bluth and Alice Miranda Ollstein.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

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

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

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

The scenario often unfolds like this: Medical researchers investigate a frequently used drug and report that it’s less effective for older patients than previously thought, or that its risks outweigh its benefits in older adults. More studies follow, confirming those findings.

After a few years, medical associations revise their guidelines, warning that the drug in question should be avoided or at least prescribed more selectively. It might be added to the Beers Criteria, an influential list of potentially inappropriate medications for older patients, published by the American Geriatrics Society.

If the drug’s role is preventive, the U.S. Preventive Services Task Force, an independent expert panel, may weigh in with cautions. The FDA may issue “black box” warnings about concerning side effects.

After a few more years, researchers look at broad national data to see whether use of this drug declined. Often, the answer is: Yes, but not enough. Sometimes, though, use didn’t decline much at all or actually increased.

“Medications are like barnacles,” said Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the U.S. Deprescribing Research Network. “They’re easy to start, but they can be hard to stop.”

This medical inertia partly reflects the time lag involved in disseminating findings. “Clinicians have a million things they need to know and attend to, and information may take a while to get to them,” Steinman said.

But it also reflects the way “clinicians and patients get used to treating conditions in certain ways,” he said. “They become ingrained habits.” Finding alternative approaches is challenging, so “it’s easy to go with what you know.”

Recent studies of three medications or classes of drugs widely used among older Americans illustrate the problem.

The Drawbacks of Benzodiazepines

Scientists began raising alarms about benzodiazepines more than 20 years ago. Prescribed for insomnia and anxiety, “they offer prompt relief,” said Mark Olfson, a psychiatrist and epidemiologist at Columbia University.

The problem? Benzodiazepines (including Valium, Xanax, and Ativan) and the related “Z” drugs (Ambien, Lunesta) “may impair balance, coordination, and cognition that can translate into falls and fractures and motor vehicle accidents,” Olfson said. In patients also taking opioids for pain, benzodiazepines can cause overdoses.

Moreover, “once you’ve taken them for a period of time, you develop a dependence,” Olfson added. “When you come off them, you may develop withdrawal symptoms.”

So what’s happened to benzo use among older adults, who are more sensitive to these effects? In a recent examination of prescribing trends, published in the Annals of Internal Medicine, Olfson and his team reported progress. Among people 65 and older, the rate of patients filling prescriptions for benzos dropped to 11.5% in 2024, from about 14% in 2015.

But that decline has stalled since 2020, perhaps related to the covid-19 pandemic. Moreover, prescribed use actually rose among those over 75, from 12% in 2020 to about 13% four years later. Dispensing through pharmacies in long-term care facilities more than doubled. And about a third of users were taking the drug for longer than six months, increasing the likelihood of dependence. “It’s worrisome,” Olfson said.

But he cautioned that patients shouldn’t stop benzodiazepines suddenly or on their own, which can provoke withdrawal. “It requires supervised tapering” with a medical professional, he said. “It takes many weeks.”

Overprescribing Antibiotics

For years, the standard treatment for diverticulitis, the inflammation or infection of small pouches that form in the colon, was antibiotics, primarily fluoroquinolones (like Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin).

“It was unquestioned,” said Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system. “Antibiotics are safe and effective, great, lifesaving drugs, so the mindset was: When in doubt, use them.”

But in 2015, the American Gastroenterological Association recommended against routinely prescribing antibiotics for “uncomplicated” diverticulitis, which represents a great majority of cases. Other medical groups followed suit.

Clinical trials had shown that, for this condition, antibiotics had little or no effect on mortality, the need for surgery, complications, or recurrences. “They hadn’t improved anything,” Sutton said.

And as with any drug, “there are downsides, unintended consequences,” he said. “Side effects from antibiotics account for a substantial amount of emergency room visits” for symptoms like nausea, vomiting, and diarrhea. Antibiotics heighten the risk of the virulent C. difficile infection, too.

Plus, “the more you use antibiotics, the less they work in the future,” Sutton said. The World Health Organization has deemed antimicrobial resistance “a major global health threat.”

So Sutton and his colleagues, studying treatment in 70,000 visits to 120 VA facilities, expected to see antibiotic use for uncomplicated diverticulitis decline over 10 years.

Instead, they reported recently in the Annals of Internal Medicine that antibiotic prescriptions remained nearly universal at 97% of visits, guidelines or no guidelines. The patients would most likely have done as well with a few days of Tylenol and a clear liquid diet.

Antibiotic overuse remains common for other conditions of later life, too, including the kind of urinary tract infections that cause no troublesome symptoms and upper respiratory infections that are typically viral, not bacterial.

In such cases, when a doctor prescribes an antibiotic, “I’d encourage patients to say, ‘Please explain the rationale for doing this,’” Sutton said. “If they don’t, it’s OK to press pause.”

When Aspirin Isn’t the Answer

Aspirin is different. Because it’s cheap and sold over the counter, anybody can start taking it on their own — and millions of older Americans do, thinking it will help prevent cardiac problems.

For people who’ve already had a heart attack, stroke, or cardiac intervention like a stent or bypass surgery, daily low-dose aspirin for “secondary prevention” does lower the odds of another event, studies have demonstrated.

But for “primary prevention” in people who haven’t had one, the guidelines changed in 2019, when the American College of Cardiology and the American Heart Association recommended against aspirin for this purpose in those 70 or older. The U.S. Preventive Services Task Force went further, warning against aspirin for primary prevention starting at age 60.

Large clinical trials had shown scant benefit for aspirin as a primary prevention measure, but there were harms, notably gastrointestinal bleeding. “As we age, the risks of bleeding go up,” said Timothy Anderson, an internist at the University of Pittsburgh who co-directs its Prescribing Wisely Lab. More rarely, but more seriously, aspirin can cause bleeding in the brain.

In a JAMA study published last year, Anderson and his co-author found the message was getting through: Aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had dropped substantially from 2011 to 2023. But more than a third of those 70 or older were still taking it.

Some caveats: A subgroup of older adults with high risk factors for cardiovascular disease may benefit from aspirin for primary prevention. And, confusingly, some evidence suggests that older patients already taking aspirin face a higher risk of cardiovascular disease if they discontinue it.

“Step 1 is a conversation with your primary care physician” about aspirin, Anderson said. “‘Is this still right for me as I get older?’”

Older patients taking aspirin, many without any medical guidance, “are interested in reducing their risk of heart attack and stroke,” he said. “They’re trying to be proactive and healthy.” But with blood pressure medications and statins for cholesterol, “we have better strategies than aspirin for that.”

The New Old Age is produced through a partnership with The New York Times.

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

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