One of the world’s biggest genetic databases comprises DNA data donated over the years by more than a million retired military service members. It’s part of a project run by the Department of Veterans Affairs.

The initiative, dubbed the Million Veteran Program, is a “crown jewel of the country,” said David Shulkin, a physician who served as VA secretary during the first Trump administration. Data from the project has contributed to research on the genetics of anxiety and peripheral artery disease, for instance, and has resulted in hundreds of published papers. Researchers say the repository has the potential to help answer health questions not only specific to veterans — like who is most vulnerable to post-service mental health issues, or why they seem more prone to cancer — but also relevant to the nation as a whole.

“When the VA does research, it helps veterans, but it helps all Americans,” Shulkin said in an interview.  

Researchers now say they fear the program is in limbo, jeopardizing the years of work it took to gather the veterans’ genetic data and other information, like surveys and blood samples.

“There’s sort of this cone of silence,” said Amy Justice, a Yale epidemiologist with a VA appointment as a staff physician. “We’ve got to make sure this survives.”

Genetic data is enormously complex, and analyzing it requires vast computing power that VA doesn’t possess. Instead, it has relied on a partnership with the Energy Department, which provides its supercomputers for research purposes.

In late April, VA Secretary Doug Collins disclosed to Sen. Richard Blumenthal, the top Democrat on the Senate Veterans’ Affairs Committee, that agreements authorizing use of the computers for the genomics project remained unsigned, with some expiring in September, according to materials shared with KFF Health News by congressional Democrats.

Spokespeople for the two agencies did not reply to multiple requests for comment. Other current and former employees within the agencies — who asked not to be identified, for fear of reprisal from the Trump administration — said they don’t know whether the critical agreements will be renewed.

One researcher called computing “a key ingredient” to major advances in health research, such as the discovery of new drugs.

The agreement with the Energy Department “should be extended for the next 10 years,” the researcher said.

The uncertainty has caused “incremental” damage, Justice said, pointing to some Million Veteran Program grants that have lapsed. As the year progresses, she predicted, “people are going to be feeling it a lot.”

Because of their military experience, maintaining veterans’ health poses different challenges compared with caring for civilians. The program’s examinations of genetic and clinical data allow researchers to investigate questions that have bedeviled veterans for years. As examples, Shulkin cited “how we might be able to better diagnose earlier and start thinking about effective treatments for these toxic exposures” — such as to burn pits used to dispose of trash at military outposts overseas — as well as predispositions to post-traumatic stress disorder.

“The rest of the research community isn’t likely to focus specifically” on veterans, he said. The VA community, however, has delivered discoveries of importance to the world: Three VA researchers have won Nobel Prizes, and the agency created the first pacemaker. Its efforts also helped ignite the boom in GLP-1 weight loss drugs.

Yet turbulence has been felt throughout VA’s research enterprise. Like other government scientific agencies, it’s been buffeted by layoffs, contract cuts, and canceled research.

“There are planned trials that have not started, there are ongoing trials that have been stopped, and there are trials that have fallen apart due to staff layoffs — yes or no?” said Sen. Patty Murray (D-Wash.), pressing Collins in a May hearing of the Senate Veterans’ Affairs Committee.

The agency, which has a budget of roughly $1 billion for its research arm this fiscal year, has slashed infrastructure that supports scientific inquiry, according to documents shared with KFF Health News by Senate Democrats on the Veterans’ Affairs Committee. It has canceled at least 37 research-related contracts, including for genomic sequencing and for library and biostatistics services. The department has separately canceled four contracts for cancer registries for veterans, creating potential gaps in the nation’s statistics.

Job worries also consume many scientists at the VA.

According to agency estimates in May, about 4,000 of its workers are on term limits, with contracts that expire after certain periods. Many of these individuals worked not only for the VA’s research groups but also with clinical teams or local medical centers.

When the new leaders first entered the agency, they instituted a hiring freeze, current and former VA researchers told KFF Health News. That prevented the agency’s research offices from renewing contracts for their scientists and support staff, which in previous years had frequently been a pro forma step. Some of those individuals who had been around for decades haven’t been rehired, one former researcher told KFF Health News.

The freeze and the uncertainty around it led to people simply departing the agency, a current VA researcher said.

The losses, the individual said, include some people who “had years of experience and expertise that can’t be replaced.”

Preserving jobs — or some jobs — has been a congressional focus. In May, after inquiries from Sen. Jerry Moran, the Republican who chairs the Veterans’ Affairs Committee, about staffing for agency research and the Million Veteran Program, Collins wrote in a letter that he was extending the terms of research employees for 90 days and developing exemptions to the hiring freeze for the genomics project and other research initiatives.

Holding jobs is one thing — doing them is another. In June, at the annual research meeting of AcademyHealth — an organization of researchers, policymakers, and others who study how U.S. health care is delivered — some VA researchers were unable to deliver a presentation touching on psychedelics and mental health disparities and another on discrimination against LGBTQ+ patients, Aaron Carroll, the organization’s president, told KFF Health News.

At that conference, reflecting a trend across the federal government, researchers from the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality also dropped out of presenting. “This drop in federal participation is deeply concerning, not only for our community of researchers and practitioners but for the public, who rely on transparency, collaboration, and evidence-based policy grounded in rigorous science,” Carroll said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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

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Rehab hospitals that help people recover from major surgeries and injuries have become a highly lucrative slice of the health care business. But federal data and inspection reports show that some run by the dominant company, Encompass Health Corp., and other for-profit corporations have had rare but serious incidents of patient harm and perform below average on two key safety measures tracked by Medicare.

Yet even when inspections reveal grave cases of injury, federal health officials do not inform consumers or impose fines the way they do for nursing homes. And Medicare doesn’t provide easy-to-understand five-star ratings as it does for general hospitals.

In the most serious problems documented by regulators, rehab hospital errors involved patient deaths.

In Encompass Health’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak during construction at the facility.

At its hospital in Jackson, Tennessee, a patient, 68, was found dead overnight, lying on the floor in a “pool of blood” after an alarm that was supposed to alert nurses that he had gotten out of bed had been turned off.

In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the wrong drug, one of 26 medication errors the hospital made over six months. He died two days later at another hospital.

“I can still see Fred laying in the bed as they shut each little machine off,” said his widow, Susan Roufs. “They clicked four of them, and then the love of my life was gone.”

Encompass, which owns 168 hospitals and admitted 248,000 patients last year, has led the transformation of this niche industry. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits as the places where the majority of annual patient admissions occur, a KFF Health News and New York Times analysis found. A third of all admissions were to Encompass hospitals. Such facilities are required to provide three hours of therapy a day, five days a week.

Across the nation, there are now nearly 400 stand-alone rehab hospitals, the bulk of which are for-profit. These hospitals collectively generate profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency.

At the same time, the number of small, specialized units within acute care hospitals — where most rehab used to be provided — has dwindled. There are now around 800 of those, and most are nonprofits.

In its latest annual report, Encompass, which is publicly traded, reported an 11% net profit in 2024, earning $597 million last year on revenues of $5.4 billion.

Federal data on the performance of about 1,100 of the rehab facilities show Encompass tends to be better at helping most patients return home and remain there. In a two-year period ending in September 2023, Medicare rated 233 rehab facilities as performing better than the national rate for this major metric, called “discharge to community.” Most rehabs with better community discharge rates are for-profit, and Encompass owns 79 of them.

But data from Medicare also reveals Encompass owns many of the rehabs with worse rates of potentially preventable, unplanned readmissions to general hospitals. Medicare evaluates how often patients are rehospitalized for conditions that might have been averted with proper care, including infections, bedsores, dehydration, and kidney failures.

Encompass accounts for about 1 in 7 rehab facilities nationally, but owned 34 of the 41 inpatient rehab facilities that Medicare rated as having statistically significantly worse rates of potentially preventable readmissions for discharged patients. (Overall, rates of readmission after discharge ranged from 7% to 12%, with a median of 9%.)

And it owned 28 of the 87 rehab facilities — 65 of which were for-profit — that had worse rates of potentially preventable readmissions to general hospitals during patient stays. (The median for these kinds of readmissions was 5%, and rates for individual rehabs ranged from 3% to 9%.)

Patrick Darby, the executive vice president and general counsel of Encompass, strongly defended the company’s record in written responses to questions. He dismissed Medicare’s readmissions ratings of “better,” “worse,” and “no different than the national rate” as “a crude scoring measure” and said “performance is so similar across the board.” He called the violations found during health inspections “rare occurrences” that “do not support an inference of widespread quality concerns.”

“The simplest and most accurate reason for EHC’s success is that our hospitals provide superior care to patients,” he said, referring to Encompass by its corporate initials.

Chih-Ying Li, an associate professor of occupational therapy at the University of Texas Medical Branch at Galveston School of Health Professions, said in an interview that a research study she conducted found the profit status of a rehab facility was the only characteristic associated with higher unplanned readmissions.

“The finding is pretty robust,” she said. “It’s not like huge, huge differences, but there are differences.”

Alarming Mistakes

VanBibber was admitted to Encompass’ Huntington hospital in 2021 for therapy to strengthen her lungs. At the time, the hospital was undergoing a $3 million expansion, and state regulators had warned the company that areas of the hospital occupied by patients had to be isolated from the construction “using airtight barriers,” according to a health inspection report.

In her room, which was about 66 feet from the construction zone, she began having trouble breathing, the report said. When she told the staff, they ignored her and shut her door, according to a lawsuit brought by her estate. Staff members eventually noticed that she was “lethargic and gasping for air,” and called 911.

When the emergency medical squad arrived, the carbon monoxide detectors they wore sounded. By that time, VanBibber’s blood oxygen levels were dangerously low, the inspection report said. She died three days later from respiratory failure and carbon monoxide poisoning, according to the inspection report and the lawsuit. A plumber had been using a gas-powered saw in the construction area, but there were no carbon monoxide detectors in the hallways, the report said.

In court papers, Encompass and its construction contractors denied negligence for VanBibber’s death. The case is pending.

Inspectors determined Encompass failed to maintain a safe environment for all patients during construction and didn’t properly evaluate other patients for signs of poisoning, the report said.

Since 2021, the federal Centers for Medicare and Medicaid Services, or CMS, which oversees health inspections, has found that 10 Encompass hospitals, including the one that cared for VanBibber, had immediate jeopardy violations, federal records show. Such violations — like the ones that Medicare also found in connection with the deaths of Roufs and the patient who fell after leaving his bed — mean a hospital’s failure to comply with federal rules has put patients at risk for serious injury, serious harm, serious impairment, or death.

Darby, the general counsel for Encompass, said the company regretted any clinical problems and had promptly addressed all such findings to the satisfaction of inspectors. He said Encompass that has an “excellent compliance record,” including superior results from its accreditation agency, and that its overall number of health citations was tiny given how many hospitals Encompass owns and how many patients it treats.

Six other corporate-operated for-profit hospitals were also cited, while none of the 31 stand-alone nonprofit rehab hospitals received such violations from 2021 to 2024. (Inspection reports for general hospitals do not systematically specify in which part of the building a violation occurred, so rehab unit violations cannot be identified.)

An alert called a bed alarm was at the root of immediate jeopardies at Encompass hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The devices are pressure- and motion-sensitive and emit a sound and display a light to alert staff members that someone at a high risk of falls has left his or her bed.

In its Morgantown hospital, a nurse technician discovered a patient face down on the floor with a large gash on her head after a defective alarm did not go off, an inspection report said. After she died, the nurse told inspectors: “We are having a lot of problems with the bed alarms.”

Medicare is not authorized by law to fine rehab hospitals for safety rule violations, even ones involving deaths uncovered during inspections, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000.

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used because of its draconian consequences.

“Termination is typically a last resort after working with the provider to come back into compliance,” Catherine Howden, a CMS spokesperson, said in an email.

As a result, because there’s no graduated penalty, even the most serious — and rare — immediate jeopardy violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems.

“Only having a nuclear weapon has really hurt patient safety,” said Michael Millenson, a medical quality advocate.

One immediate jeopardy incident did result in a punishment, but only because the hospital was in California, which allows its health department to issue penalties. Encompass’ Bakersfield hospital paid a $75,000 fine last year for failing to control the blood sugar of a patient who died after her heart stopped.

Rapid Growth and a Troubled History

Encompass has accelerated its expansion in recent years and now operates in 38 states and Puerto Rico. It plans to open 17 more hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the end of 2027, according to its latest report.

It frequently moves into new markets by persuading local nonprofit hospitals to shutter their rehab units in exchange for an equity stake in a newly built Encompass hospital, company executives have told investors.

The president of Encompass, Mark Tarr, calls it a “win-win proposition”: The local hospitals can use their emptied space for a more lucrative line of service and Encompass gets a “jump start” into a new market, with partner hospitals often referring patients.

Tarr, who was paid $9.3 million in compensation last year, told investors that Encompass requires that the existing hospitals sign a noncompete deal. Sixty-seven Encompass hospitals are joint ventures, mostly with nonprofit hospitals as investors, according to the company’s June financial filing, the most recent available.

Darby said the company’s profits allow it to build hospitals in areas that lack intensive inpatient rehabilitation and improve existing hospitals. “High-quality patient care is not only consistent with shareholder return, but quality and shareholder return are in fact critical to one another,” he said.

The success of Encompass is particularly notable given that it barely survived what experts said was one of the largest modern accounting scandals in 2003.

The Securities and Exchange Commission charged that the company, then known as HealthSouth, overstated earnings by $2.7 billion to meet Wall Street analyst quarterly expectations, leading to the ouster of its founder and directors. In 2004, the company agreed to pay the government $325 million to settle Medicare fraud allegations without admitting wrongdoing. Darby credited the company’s new leaders for obtaining a $2.9 billion judgment on behalf of shareholders against the company’s founder.

The company changed its name to Encompass in 2018 after acquiring Encompass Home Health and Hospice. In 2019, the Justice Department announced the company had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed patients to get higher Medicare reimbursements, and admitted patients who were too sick to benefit from therapy. The company denied any wrongdoing, blaming independent physicians who worked at its hospitals. Darby said Encompass settled the case only to “avoid more years of expense and disruption.” He said the Justice Department never filed a lawsuit despite years of investigation.

Medication Harms

Rehab hospital inspection reports are not posted on Care Compare, Medicare’s online search tool for consumers. KFF Health News had to sue CMS under the Freedom of Information Act to obtain all its inspection reports for rehab hospitals. In contrast, Care Compare publishes all nursing home inspection reports and assigns each facility a star rating for its adherence to health and safety rules.

So people now choosing a rehab hospital would not know that at the Encompass hospital in Sioux Falls, South Dakota, in 2021, a nurse accidentally gave Roufs a blood pressure drug called hydralazine instead of hydroxyzine, his prescribed anti-anxiety medication, according to an inspection report. Roufs went into cardiac arrest. This type of error, called a “look-alike/sound-alike,” is one hospitals and staff members are supposed to be especially alert to.

Months before, an internal safety committee had identified a trend of medication errors, including when a nurse accidentally gave a patient 10 times the prescribed amount of insulin, sending him to the hospital, the inspection report said. The nurse had misread four units as 40. Since Roufs’s death, inspectors have faulted the hospital six times for various lapses, most recently in April 2024 for improper wound care.

An Encompass hospital in Texarkana, Texas, misused antipsychotic medications to pacify patients, resulting in an immediate jeopardy finding from CMS, the report said. And the company’s hospital in Erie, Pennsylvania, was issued an immediate jeopardy violation for not keeping track of medication orders in 2023, when a patient had a cardiac arrest after not receiving all of his drugs, according to the inspection report.

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues.

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities, according to a CMS spokesperson.

Deadly Bedsores

The family of Paul Webb Jr., 74, claimed in a lawsuit that the Encompass hospital in Erie left Webb unattended in a wheelchair for hours at a time, putting pressure on his tailbone, in 2021. His medical records, provided to reporters by the family, list a sitting tolerance of one hour.

Webb — who had been originally hospitalized after a brain bleed, a type of stroke — developed skin damage known as a pressure sore, or bedsore, on his bottom, the lawsuit said. The suit said the sore worsened after he was sent to a nursing home, which the family is also suing, then home, and he died later that year. In his final weeks, Webb was unable to stand, sit, or move much because of the injury, the lawsuit said.

In court papers, Encompass and the nursing home denied negligence, as Encompass has in some other pending and closed lawsuits that accused it of failing to prevent pressure sores because nurses and aides failed to regularly reposition patients, or notice and treat emerging sores. Darby said Webb’s death occurred three months after his Encompass stay and was not related to his care at Encompass. He said no hospital with long-term patients could prevent every new or worsening pressure sore, but that Encompass’ rates were similar to the 1% national average.

One of Webb’s sons, Darel Webb, recalled a warning given to the family as they left an appointment their father had with wound specialists: A doctor brought up Christopher Reeve, the actor who played Superman in movies in the 1970s and 1980s.

“He goes, ‘Remember, Superman was paralyzed from falling off the horse, but he died from a bedsore,’” he said.

Jordan Rau has been writing about hospital safety since 2008. Irena Hwang is a New York Times data reporter who uses computational tools to uncover hidden stories and illuminate the news.

METHODOLOGY

To examine the medical rehabilitation hospital industry, we obtained and analyzed a database of inspection reports of freestanding rehabilitation hospitals from the federal Centers for Medicare & Medicaid Services, or CMS. We also obtained inspection reports from several states through public records requests.

We analyzed inpatient rehabilitation facility characteristics and patient volume data contained in hospital data files from the Rand Corp., a nonprofit research organization. This dataset compiles cost reports all hospitals submit each year to CMS. For each facility for the years 2012 to 2023, we categorized annual discharges by facility type (freestanding rehabilitation hospital or unit within an acute care hospital); facility ownership status (for-profit, nonprofit, or government); and which hospitals were owned by Encompass Health under its current or prior name, HealthSouth.

Financial information about Encompass Health was obtained from the company’s Securities and Exchange Commission disclosure filings.

We examined the readmission rates for all inpatient rehabilitation facilities that CMS publishes in its quality data. CMS evaluates the frequency with which Medicare patients were readmitted for potentially preventable reasons to an acute care hospital during their rehab stay. Separately, CMS also evaluates the frequency of potentially preventable readmissions to an acute care hospital within 30 days of discharge from rehab. We also examined the rate of successful return to home or community. Figures for all three metrics were available for about 1,100 of the roughly 1,200 rehab facilities in the CMS data. The most recent readmission data covered Medicare discharges from October 2021 through September 2023.

We examined nursing home penalties from the last three years from CMS’ data on nursing homes.

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

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Rehabilitation therapy can be a godsend after hospitalization for a stroke, a fall, an accident, a joint replacement, a severe burn, or a spinal cord injury, among other conditions. Physical, occupational, and speech therapy are offered in a variety of settings, including at hospitals, nursing homes, clinics, and at home. It’s crucial to identify a high-quality, safe option with professionals experienced in treating your condition.

What kinds of rehab therapy might I need?

Physical therapy helps patients improve their strength, stability, and movement and reduce pain, usually through targeted exercises. Some physical therapists specialize in neurological, cardiovascular, or orthopedic issues. There are also geriatric and pediatric specialists. Occupational therapy focuses on specific activities (referred to as “occupations”), often ones that require fine motor skills, like brushing teeth, cutting food with a knife, and getting dressed. Speech and language therapy help people communicate. Some patients may need respiratory therapy if they have trouble breathing or need to be weaned from a ventilator.

Will insurance cover rehab?

Medicare, health insurers, workers’ compensation, and Medicaid plans in some states cover rehab therapy, but plans may refuse to pay for certain settings and may limit the amount of therapy you receive. Some insurers may require preauthorization, and some may terminate coverage if you’re not improving. Private insurers often place annual limits on outpatient therapy. Traditional Medicare is generally the least restrictive, while private Medicare Advantage plans may monitor progress closely and limit where patients can obtain therapy.

Should I seek inpatient rehabilitation?

Patients who still need nursing or a doctor’s care but can tolerate three hours of therapy five days a week may qualify for admission to a specialized rehab hospital or to a unit within a general hospital. Patients usually need at least two of the main types of rehab therapy: physical, occupational, or speech. Stays average around 12 days.

How do I choose?

Look for a place that is skilled in treating people with your diagnosis; many inpatient hospitals list specialties on their websites. People with complex or severe medical conditions may want a rehab hospital connected to an academic medical center at the vanguard of new treatments, even if it’s a plane ride away.

“You’ll see youngish patients with these life-changing, fairly catastrophic injuries,” like spinal cord damage, travel to another state for treatment, said Cheri Blauwet, chief medical officer of Spaulding Rehabilitation in Boston, one of 15 hospitals the federal government has praised for cutting-edge work.

But there are advantages in selecting a hospital close to family and friends who can help after you are discharged. Therapists can help train at-home caregivers.

How do I find rehab hospitals?

The discharge planner or caseworker at the acute care hospital should provide options. You can search for inpatient rehabilitation facilities by location or name through Medicare’s Care Compare website. There you can see how many patients the rehab hospital has treated with your condition — the more the better. You can search by specialty through the American Medical Rehabilitation Providers Association, a trade group that lists its members.

Find out what specialized technologies a hospital has, like driving simulators — a car or truck that enable a patient to practice getting in and out of a vehicle — or a kitchen table with utensils to practice making a meal.

How can I be confident a rehab hospital is reliable?

It’s not easy: Medicare doesn’t analyze staffing levels or post on its website results of safety inspections as it does for nursing homes. You can ask your state public health agency or the hospital to provide inspection reports for the last three years. Such reports can be technical, but you should get the gist. If the report says an “immediate jeopardy” was called, that means inspectors identified safety problems that put patients in danger.

The rate of patients readmitted to a general hospital for a potentially preventable reason is a key safety measure. Overall, for-profit rehabs have higher readmission rates than nonprofits do, but there are some with lower readmission rates and some with higher ones. You may not have a nearby choice: There are fewer than 400 rehab hospitals, and most general hospitals don’t have a rehab unit.

You can find a hospital’s readmission rates under Care Compare’s quality section. Rates lower than the national average are better.

Another measure of quality is how often patients are functional enough to go home after finishing rehab rather than to a nursing home, hospital, or health care institution. That measure is called “discharge to community” and is listed under Care Compare’s quality section. Rates higher than the national average are better.

Look for reviews of the hospital on Yelp and other sites. Ask if the patient will see the same therapist most days or a rotating cast of characters. Ask if the therapists have board certifications earned after intensive training to treat a patient’s particular condition.

Visit if possible, and don’t look only at the rooms in the hospital where therapy exercises take place. Injuries often occur in the 21 hours when a patient is not in therapy, but in his or her room or another part of the building. Infections, falls, bedsores, and medication errors are risks. If possible, observe whether nurses promptly respond to call lights, seem overloaded with too many patients, or are apathetically playing on their phones. Ask current patients and their family members if they are satisfied with the care.

What if I can’t handle three hours of therapy a day?

A nursing home that provides rehab might be appropriate for patients who don’t need the supervision of a doctor but aren’t ready to go home. The facilities generally provide round-the-clock nursing care. The amount of rehab varies based on the patient. There are more than 14,500 skilled nursing facilities in the United States, 12 times as many as hospitals offering rehab, so a nursing home may be the only option near you.

You can look for them through Medicare’s Care Compare website. (Read our previous guide to finding a good, well-staffed home to know how to assess the overall staffing.)

What if patients are too frail even for a nursing home?

They might need a long-term care hospital. Those specialize in patients who are in comas, on ventilators, and have acute medical conditions that require the presence of a physician. Patients stay at least four weeks, and some are there for months. Care Compare helps you search. There are fewer than 350 such hospitals.

I’m strong enough to go home. How do I receive therapy?

Many rehab hospitals offer outpatient therapy. You also can go to a clinic, or a therapist can come to you. You can hire a home health agency or find a therapist who takes your insurance and makes house calls. Your doctor or hospital may give you referrals. On Care Compare, home health agencies list whether they offer physical, occupational, or speech therapy. You can search for board-certified therapists on the American Physical Therapy Association’s website.

While undergoing rehab, patients sometimes move from hospital to nursing facility to home, often at the insistence of their insurers. Alice Bell, a senior specialist at the APTA, said patients should try to limit the number of transitions, for their own safety.

“Every time a patient moves from one setting to another,” she said, “they’re in a higher risk zone.”

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

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On his way to an Ultimate Fighting Championship event, Health and Human Services Secretary Robert F. Kennedy Jr. stopped by the home of podcaster Gary Brecka. The two spent time in a hyperbaric oxygen chamber and tried some intravenous nutrition drips that Brecka, a self-avowed longevity and wellness maven, sells and promotes on his show, “The Ultimate Human.”

Then the podcast taping started, and Kennedy — who was also on the mic — took aim at Big Pharma’s influence on federal health policy.

“We have a sick-care system in our country, and the etiology ultimately of all that disease is corruption,” Kennedy said before the show cut away to an ad for vitamin chips. “And it’s the capture of these agencies by the industries they are supposed to regulate.”

While Kennedy lambastes federal agencies he says are overly influenced by the pharmaceutical industry, he and some other figures of the “Make America Healthy Again,” or MAHA, movement — such as siblings Calley and Casey Means, Robert Malone, and Peter McCullough — have their own financial ties to a vast and largely unregulated $6.3 trillion global wellness industry they also support and promote.

Kennedy and those four advisers — three of whom have been tapped for official government roles — earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a KFF Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS.

The total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data isn’t publicly available.

The Means siblings have launched wellness companies that have raised more than $99 million from investors, according to company news releases as well as information from Clay, a customer research data company, and Tracxn, an information technology firm that provides access to a database of companies, funding rounds, and investor information.

“Secretary Kennedy, and all HHS officials, fully comply with all ethics and financial disclosure laws,” agency spokesperson Emily Hilliard said in an email. “Any attempt to suggest impropriety is reckless and politically motivated.”

Some public health leaders and ethicists say the financial ties raise red flags, with the potential for personal profits to shape decision-making at the highest levels of federal health agencies.

“It’s becoming completely corrupted,” said Arthur Caplan, founding head of the medical ethics division at New York University’s Grossman School of Medicine. “You shouldn’t have a vested interest in making recommendations on wellness or supplements or health. It opens the door to all kinds of shenanigans. Big Wellness is no different than Big Pharma. They’re a well-organized political force.”

Unlike any other previous administration, President Donald Trump’s administration has elevated anti-vaccine and wellness leaders to positions at HHS from which they can steer federal policy. Adherents to the MAHA movement say the change is long overdue, arguing that previous administrations haven’t devoted sufficient attention to the potential harms of traditional medical approaches.

Critics including health policy leaders and physicians say they worry the revamped HHS and its agencies are now harming public health. For example, they point to a recent Kennedy decision to remove and replace all the members of a vaccine advisory group, a move the American Medical Association criticized as lacking transparency and proper vetting. Two of Kennedy’s newly named panel members — Malone and Martin Kulldorff — previously earned money as paid experts in vaccine lawsuits against Merck, as first reported by Reuters and the life-sciences news outlet BioSpace.

Calley Means, who has criticized the recommended U.S. vaccine schedule for youths and has no medical training, is a special government employee and a top health adviser to Kennedy. He also co-founded the wellness company Truemed.

The company enables people to spend pretax dollars from Flexible Spending Accounts and Health Savings Accounts to pay for wellness products, health food, and SoulCycle classes.

Truemed’s website says it can provide customers with a “Letter of Medical Necessity” for the items.

The IRS has warned consumers about companies that misrepresent wellness items like food as FSA-eligible when they are not, in fact, permitted medical expenses.

The IRS did not respond to questions about the status of that policy under the Trump administration.

In 2024, when Kennedy was running for president as an independent, he promoted Means’ company on his own podcast. Means also promoted his close connection with Kennedy last year on podcasts and on Instagram while also using social media to advance Truemed. And while working for the public as a special government employee since March, Means has used social and new media to promote podcasters who make money selling wellness products, to criticize specific pharmaceutical drugs, and to tout the wellness book he co-wrote, “Good Energy,” according to a KFF Health News review of social media posts and podcasts.

Means has also used podcasts and social media to rail against new injectable weight loss drugs. The Trump administration in April decided not to finalize a rule that would have allowed Medicaid and Medicare to cover the injectable drugs, putting them out of reach for millions of potential users.

Hilliard, the HHS spokesperson, didn’t respond to questions about whether Means, as a Kennedy adviser, has recused himself from decisions that could affect his business. Neither HHS nor the White House responded to requests to speak with him.

His sister, Casey Means, is Trump’s pick for surgeon general and was also an adviser to Kennedy during his 2024 presidential run. She co-founded Levels, a company valued at $300 million in 2022 that promotes glucose monitoring for nondiabetic, healthy individuals. Consumers pay $199 for a one-month supply of continuous glucose monitors.

She has used social media to call for public policy that would encourage blood sugar monitoring for healthy individuals, saying “tips to stabilize glucose should be on every billboard in America.” Research has found little evidence that such monitoring provides health benefits for people without diabetes.

Her company stands to benefit under the Trump administration. Kennedy said in April that he was considering a regulatory framework for federal health programs’ coverage of injectable weight loss drugs that would first require patients to try glucose monitoring or other options.

“And if they don’t work, then you would be entitled to the drug,” he told CBS News.

Casey Means isn’t a practicing doctor and doesn’t hold an active medical license, according to records from the Oregon Medical Board. And, as an online influencer, she “failed to disclose that she could profit” from sales of products she recommends, according to The Associated Press.

HHS spokesperson Hilliard didn’t answer questions about whether Casey Means would recuse herself from working on anything that would directly benefit her company, or why she didn’t disclose that she could profit from sales of products she recommends. HHS didn’t respond to questions about Means’ ties to Kennedy or agency support for glucose monitoring, nor did the agency respond to a request to speak directly to the Trump surgeon general pick.

Outside Advisers

McCullough, a former cardiac doctor who has financial ties to the wellness industry, has been part of Kennedy’s circle of informal advisers, according to people close to the secretary. He also has enough sway with some GOP lawmakers that they’ve had him testify before Congress. In May, he told a Senate subcommittee that mRNA covid-19 vaccines can lead to deaths that have been underreported. But the FDA says the covid vaccines are safe, with fewer than 1 in 200,000 vaccinated individuals experiencing a severe allergic reaction or heart problems like myocarditis or pericarditis.

He profits from his anti-covid-vaccine message. McCullough devised a protocol he says helps people detox from covid mRNA shots, selling the products through The Wellness Co. McCullough is the company’s chief scientific officer, draws a partial salary, and holds an equity stake.

For $89.99, consumers can purchase Ultimate Spike Detox supplements containing nattokinase, an enzyme from fermented soybeans. A two-month supply of Spike Support supplements sells on Amazon for about $62. More than 900 bottles have sold in the past month.

McCullough didn’t respond to an email seeking comment. HHS also didn’t respond to questions about his relationship with Kennedy.

Some health policy leaders and doctors say the financial connections federal health officials and advisers have to the wellness industry raise concerns.

“It’s exactly the problem RFK has taken up with the FDA, saying it’s too beholden to pharma,” said Pieter Cohen, an associate professor of medicine at Harvard University.

“When you’re in bed with supplement manufacturers, you are creating the same kinds of conflicts of interest, whether or not you directly profit,” he said. “You should be independently advocating for public health, not cheerleading for any particular industry.”

The wellness sector includes personal care, weight loss, health, nutrition, and wellness tourism.

Its lobbying influence is markedly smaller than the lobbying reach of pharmaceutical companies, according to OpenSecrets, a research organization that tracks money in U.S. politics. The nutritional and dietary supplements industry spent about $3.7 million on lobbying in 2024, for example, compared with the $387 million the pharmaceutical industry spent the same year.

It’s also gotten far less scrutiny. The industry is a growing political force with its own lobbyists, celebrities, and industry-backed advocacy groups, and research shows that public interest in wellness has grown since the pandemic. Eighty-four percent of U.S. consumers say wellness is a “top” or “important” priority, according to a survey released this year by McKinsey & Co.

Unlike with Big Pharma, there’s scant regulation of the industry. Companies can sell supplements and other products without notifying the FDA, and there’s little oversight by the Federal Trade Commission of their product claims.

“The wellness industry profiteers by undermining and creating distrust in science and regulated products,” said Andrea Love, an immunologist and microbiologist who founded ImmunoLogic, a science and health education organization. “They are messaging that the government and Big Pharma are hiding information and treatments or cures to keep us weak and vulnerable.”

Ethics and Disclosures

People on both sides of the issue say the industry has found its captain in Kennedy, an anti-vaccine activist with deep ties to the MAHA and wellness movements.

He has profited by referring people to law firms that are suing over alleged vaccine injury. For example, he gets a fee for referring potential clients to a Los Angeles personal injury firm, according to a January ethics statement to HHS and his financial disclosures. One of his adult sons works at the personal injury law firm.

When his nomination to the HHS secretary post was under consideration, Kennedy indicated in his ethics disclosure that he intended to continue profiting from lawsuits over Gardasil, a Merck vaccine that protects against HPV. After Democrats raised concerns with the financial relationship, he told Congress he would divest his interest and sign over the financial stake to one of his adult sons.

Federal ethics rules bar government employees from participating in matters in which they, their spouse, or their minor child has a financial stake. It doesn’t include adult children such as Kennedy’s sons.

“There are a lot of loopholes, and that is one of them,” said Cynthia Brown, senior ethics counsel at the Citizens for Responsibility and Ethics in Washington, a watchdog organization focused on U.S. government ethics and accountability. “It certainly is an appearance problem. Even if it’s not a technical violation, it is an ethical problem in terms of influence.”

Some lawmakers and ethics leaders weren’t mollified by Kennedy’s planned divestiture. Sen. Elizabeth Warren (D-Mass.) called on Kennedy to agree to a four-year, post-employment ban on accepting any compensation from lawsuits involving any entity regulated by HHS.

“It would be insufficient for RFK Jr. to only divest his interest in the Gardasil case while leaving the window open to profit from other anti-vax lawsuits, including future cases he could bring after leaving office,” she said in a statement.

Kennedy also made money on the MAHA name by applying in September to register it as a trademark. He transferred trademark ownership to a limited liability company led by friend and MAHA ally Del Bigtree after making about $100,000 off the phrase, according to his financial disclosure.

HHS’ Hilliard didn’t answer questions about whether Kennedy had signed over his interest in fees from legal referrals to his son, the money he made by registering MAHA as a trademark, or whether he agreed with Warren’s request that upon leaving office he accept a four-year ban on accepting money from lawsuits involving entities regulated by HHS.

Bigtree is executive director of the Informed Consent Action Network, or ICAN, an anti-vaccination group. He was communications director for Kennedy’s failed presidential campaign, and as an informal adviser to the secretary he helped vet candidates for HHS jobs. Bigtree’s salary at the nonprofit was $234,000 for the 2023 fiscal year, according to documents filed with the IRS. ICAN paid $6 million in legal fees to Siri & Glimstad in 2023. The firm’s managing partner, Aaron Siri, focuses on vaccine injury. He has been Kennedy’s personal lawyer and adviser, and also helped vet candidates for the secretary.

Brown, an ethics counselor, said the transfer and ongoing advisory relationship could raise questions about who is influencing Kennedy. Bigtree, at a Politico event in February, called on Kennedy to recruit scientists to HHS who believe vaccines cause autism, for example. One of Kennedy’s early actions at HHS was the launch of a study on the causes of autism.

ICAN didn’t respond to an email seeking comment. HHS also didn’t respond to questions about Kennedy’s transfer of the MAHA trademark to Bigtree.

“This is the type of Washington wheeling and dealing that raises questions about integrity in government,” Brown said. “If it was trademarked before he became a public official, there may be no law broken. But by transferring it to someone he knows, it illustrates the constant trickle of influence among those in power.”

Past administrations have faced similar criticism over health regulators’ ties to Big Pharma. Alex Azar, who led HHS during the previous Trump administration, worked for drugmaker Eli Lilly before entering public office. Robert Califf, FDA commissioner during the Biden administration, was a consultant to drug companies.

Scott Gottlieb, who was FDA commissioner from 2017 to 2019 and an adviser to Trump’s presidential campaign, stepped down to join the board of the drugmaker Pfizer.

“Big Pharma is well off. But, in general, financial conflicts don’t depend on how much the organizations are spending,” said Zeke Emanuel, a bioethicist who served on a covid advisory board under President Joe Biden. “The question is, is there a reasonable concern that financial or other concerns are affecting their judgment?”

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

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Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, industry leaders often also warn of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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

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

As he had wanted, President Donald Trump signed his big budget bill into a big budget law in a White House ceremony on July 4, cementing, among other things, billions of dollars in cuts to health programs such as Medicaid. The new law will also reshape rules for the Affordable Care Act, Medicare, and other health programs. 

Meanwhile, the threat of layoffs continues to hang over the heads of employees at the Department of Health and Human Services, and funding for health-related contracts and grants remains stalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Rachel Roubein of The Washington Post, and Tami Luhby of CNN.

Panelists Rachel Cohrs Zhang Bloomberg News @rachelcohrs Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories. Tami Luhby CNN @Luhby Read Tami's stories.

Among the takeaways from this week’s episode:

• As details of Trump’s tax and domestic policy law come into focus, it’s clear that many immigrants in the country legally stand to lose government benefits, especially health coverage. While the GOP described the legislation as targeting “illegal immigrants,” the law as written bars many individuals living here with the government’s permission — including refugees and victims of domestic abuse and trafficking — from signing up for Medicaid, receiving Affordable Care Act marketplace subsidies, and more.
• Other aspects of Trump’s priority-laden law received extra attention following its hastened passage. In an unusually political move, the Social Security Administration touted to beneficiaries the law’s cuts to taxes on Social Security benefits — which is neither what the law does nor what a federal agency traditionally does when Congress passes a law.
• This week, the Supreme Court issued a decision from its shadow docket supporting the Trump administration’s ability to lay off federal workers using only his executive authority. That opinion is the latest curve on this year’s employment roller coaster for government employees, suggesting many people could soon lose their jobs.
• In health agency news, public health groups are suing the Trump administration over the withdrawn recommendations on covid-19 vaccines — as insurers and others in the health industry sort out how to handle a federal shift in immunization recommendations. And HHS Secretary Robert F. Kennedy Jr. canceled a meeting of the U.S. Preventive Services Task Force. The abrupt cancellation suggests Kennedy could soon remake the panel, as he did last month with the panel on vaccines.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, who reported the latest KFF Health News’ “Bill of the Month” feature, about some very expensive childhood immunizations. If you have a medical bill that’s exorbitant, baffling, or confusing, send it to us here.

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 England Journal of Medicine’s “The Corporatization of U.S. Health Care — A New Perspective Series,” by Debra Malina, et al.

Rachel Roubein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and JoNel Aleccia.

Rachel Cohrs Zhang: The Wall Street Journal’s “Prosecutors Question Doctors About UnitedHealth’s Medicare Billing Practices,” by Christopher Weaver and Anna Wilde Mathews.

Tami Luhby: The Washington Post’s “A New D.C. Hospital Grapples With Too Many Patients and Too Few Nurses,” by Jenna Portnoy.

Also mentioned in this week’s podcast:

• The Washington Post’s “Inside Operation Gold Rush, Largest Health Care Fraud Bust in U.S. History,” by Dan Diamond and Lauren Weber.
• KFF Health News’ “World’s Premier Cancer Institute Faces Crippling Cuts and Chaos,” by Rachana Pradhan and Arthur Allen.
• Stat’s “Inside the Staff Exodus and Tanking Morale That Threaten Makary’s FDA,” by Lizzy Lawrence.
• The New York Times Magazine’s “Inside the Collapse of the F.D.A.,” by Jeneen Interlandi.
• CNN’s “Social Security Administration Praises Trump’s Agenda Bill in Widely Sent Out Statement,” by Shania Shelton and Tami Luhby.

click to open the transcript Transcript: Digesting Trump’s Big Budget Law

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 10, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Tami Luhby of CNN. 

Tami Luhby: Hello. 

Rovner: And Rachel Roubein of The Washington Post. 

Rachel Roubein: Hey, everyone. 

Rovner: Later in this episode, we’ll have my interview with my colleague Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month,” about some very expensive immunizations that shouldn’t have been. So two Julies and two Rachels this week — we will work hard to keep it all straight. On to the news. 

We’re going to start this week with President [Donald] Trump’s big budget reconciliation bill, which he signed, as was his desire, on July Fourth. To paraphrase one analyst, for a tax cut energy border enforcement bill, it sure has a lot of health care provisions in it. If you’re a regular podcast listener, you’ll know it represents the biggest cutback of federal safety net programs ever, and in particular the biggest cuts to the Medicaid health program since that program’s inception 59 years and 11 months ago. But while we’ve talked about Medicaid work requirements and state provider taxes at some length — you can go back to last week or the week before’s podcast if you want to hear that — I wanted to talk about a few things this week that are now law and haven’t gotten as much attention. 

First, the cutback to coverage for legal immigrants. We know that the House-passed efforts to punish states that use their own funds to cover undocumented people were axed by the Senate parliamentarian, but there are also lots of cutbacks not just to Medicaid eligibility but also to the Affordable Care Act eligibility and even Medicare for people who are here legally. Is this something Republicans think is going to be popular, to go after legal immigrants, not just people who are here undocumented? 

Luhby: Well, the way that they’re describing it is they’re describing it as illegal immigrants. So they did that with the tax provisions as well as in the health insurance provisions. But actually, as you say, it basically bars legal immigrants, including refugees, asylees, people who are victims of domestic violence or sex or labor trafficking. They can no longer sign up for Medicaid, Affordable Care Act subsidies, SNAP [the Supplemental Nutrition Assistance Program], or food stamps, and Medicare actually as well. So yes, it’s actually taking away benefits from legal immigrants. But as we know, this is a hot-button topic for the Republicans, so they’re able to say that they’re cutting back on waste, fraud, and abuse. 

Rovner: This was a big fight in the 1990s when they did the welfare reform bill, which is when I think some of these limits first went into effect, and it was a huge to-do about rolling back eligibility for, as you say, people who are here legally. This time it feels like it was just kind of an afterthought. 

Luhby: Well, there were so many provisions in this bill. I think it was difficult for both lawmakers and journalists to cover everything. So there was coverage about this. I wrote a story after the House bill, and there were other stories about it. But when you have so many other changes happening in the bill with, as you say, work requirements, provider taxes, eligibility restrictions, and so many other things, it’s hard, I guess, for people and lawmakers to highlight everything. 

Rovner: And it did happen really fast, at least by congressional standards. I don’t think anybody thought that they were really going to get this done and to the president by July Fourth. I’m still kind of wrapping my head around that. Well, the bill, now law, also caps federal loans for those attending medical school at $200,000, which sounds like a lot except that the average medical student’s loan balance when they finish med school is more than $260,000 if you count their undergraduate loans, too. Is the idea here that medical schools are just going to lower their tuition? And has anything like this ever happened before? I don’t remember seeing this. This is the federal government trying to force down tuition? Or force not-rich people to not be able to go to medical school? 

Luhby: That is another thing that has actually not been covered widely in the bill, which is surprising, is the House version actually had much more draconian changes to the student loan program. The Senate bill did not adopt all of them, but it did adopt caps on graduate as well as professional programs, including the medical school as well as parent PLUS [Parent Loan for Undergraduate Students] programs. So yes, the other option will be for students to seek out private loans. I think part of the issue was distancing the federal government from the student loan program. Again, the Senate bill was not as harsh as the House bill, but it will force people, as you say, to either choose not to go, to have to rely more on friends and family, or to rely on private loans that have fewer benefits. 

Rovner: I want to underscore something Tami just said. This is not just aimed at medical students. It’s aimed at medical students and law students, and basically it’s the student loan program writ large. But it’s going to have a particular impact at a time we know that we’re facing a doctor shortage. It’s either going to make it harder for some people to go to medical school or they think they’re going to force medical schools to lower their tuition, which feels unlikely, but we’ll have to see how that one plays out. Well, finally, one thing that was not in this bill — elimination of taxes on Social Security, something that the president promised when he was running for office. That’s because Congress can’t amend Social Security in budget reconciliation. They wrote that into law decades ago. But that didn’t stop the Trump administration from sending every Social Security and Medicare recipient an email taking credit for ending Social Security taxation. Tami, you wrote about this. What the heck was this? 

Luhby: Yeah, let me clarify also. It’s ending taxation on Social Security benefits, not on Social Security, not the payroll taxes that we all pay. But this was one of the president’s big promises that he was going to end the taxation on tips, overtime, and Social Security benefits. He did accomplish temporary ending of taxation on a certain amount of tips and overtime compensation, but as you said, they can’t do Social Security benefits. So what they did was they did a temporary enhanced standard deduction for senior citizens at $6,000 for four years from 2025 to 2028, through 2028. And the Social Security Administration quickly sent out a message heralding the great accomplishment that seniors will be paying more, and the government has kind of straddled the line between saying that this is a cut on Social Security benefits or at least promises made, promises kept. 

So no, there were two issues with that email that was sent out. One, it wasn’t quite accurate. That definitively did not cut income taxes on Social Security benefits. But the other thing is there was a lot of question that typically agencies don’t send out laudatory emails based on congressional actions. So there was some concern in some circles of the politicization of Social Security and of the agency. So I will be actually hopefully writing a story on that to clarify. We wrote a story, as you said, last week to clarify it, but hopefully I’ll have another one coming soon. 

Rovner: Yeah, good, because I know people are confused. And I should point out that the original tax on Social Security benefits was implemented to shore up the Medicare trust fund. So if you take it away, you’ll put Medicare in financial trouble. 

Moving on, federal courts have already stepped in to block at least one provision of the brand-new budget law, the one-year ban on Medicaid funding to Planned Parenthood that would prevent even those clinics that don’t do abortions from getting funding for non-abortion services like family planning and cancer screenings. Planned Parenthood argued that the provision violates their free-speech rights for supporting abortion, but this is far from the last word on this provision, right? 

Roubein: As you said, there was the lawsuit. This has been a big political fight for years and years and years. And what they ended up doing in the bill is it’s one year — right? — for Planned Parenthood. And so this is something that I think Planned Parenthood has said would impact roughly one-third of its nearly 600 clinics. I think the organization, their numbers are that roughly one-third of its nearly 600 clinics could close if this provision went into effect. 

Rovner: And this was just, I think, a two-week block so they can have another hearing so this can continue, but this is the first time that — as long as Congress has been trying to defund Planned Parenthood, this is really the first time they’ve managed to actually do it, even though it wasn’t for as long as I think that the House bill had. So we’ll see if this ultimately gets through or not. 

Well, we also heard from the Supreme Court this week. While the court may be technically out for the year, it’s still pumping out decisions on the so-called shadow docket. This week the court ruled that President Trump can so lay off thousands of federal workers by executive order — or did it? Tami, you wrote about this decision. What does it actually mean for these people who work for federal agencies and are afraid of losing their jobs? 

Luhby: Well, they’re very concerned right now. The court case is still ongoing. The Supreme Court lifted the block that a lower court had had. So as we know, there are agencies that had these RIF, being reduction in force, plans and reorganization plans, and several heads of agencies have said that they’re only in a holding pattern, because they’re going to adhere to the courts’ and judges’ rulings, so now they’re free to do that. And HHS [the Department of Health and Human Services] emailed me back to say that they have a plan and that they plan to proceed, and other agencies are expected to proceed. So The Washington Post actually had a really good story talking to various federal workers who are now very concerned that they were going to start actually losing their jobs. Federal workers have been in a holding pattern for months now, being put on administrative leave, being let go, being reinstated, temporarily reinstated, back on administrative leave. So they’ve really been through a roller coaster, and it’s not necessarily over yet for them, but it does seem like many folks may be losing their jobs soon. 

Rovner: Yeah. Wow. 

Roubein: The Department of Health and Human Services RIFs that came down April 1 was about roughly 10,000 people. Now, as Tami said, there were, for instance — I tend to focus on the FDA [Food and Drug Administration] — there were some people in departments that were brought back, but it’s hard to get actual numbers on how many that is. But there have been a lot of people that were on admin leave through June 2 who have just kind of continued to be on admin leave and be in sort of this limbo since April 1. 

Rovner: Wow. It’s amazing that any work is getting done. We’re going to get to HHS in a second. We’ve got one more court case. Public health groups led by the American Academy of Pediatrics sued HHS Secretary Robert F. Kennedy Jr. over his decision to withdraw the recommendations for covid vaccines. Rachel, this is just one part of an effort by some of these groups to effectively substitute their own recommendations for those of the now mostly anti-vax government Advisory Committee on Immunization Practices, right? 

Cohrs Zhang: Right. I think what we’ve seen here is kind of the first example of a policy challenge by some of these public health groups. There certainly were lawsuits related to the reductions in force that felt a little bigger-picture, and again, we’ve seen this playing out at the Supreme Court. But this is a specific challenge that Secretary Kennedy’s decision to unilaterally change vaccine recommendations for healthy children and pregnant women was arbitrary and capricious. They pointed out some different policies across different subagencies that seemed to conflict, and the fact that it was announced in a social media video, and that they ignored the advice of expert advisers, which is kind of the structure that Congress set up for these recommendations to happen. So I think it will be a really important litmus test for whether lawsuits are going to be an effective tool for some of these outside groups concerned about some of these policy changes to slow down or stop some of the changes they’re most worried about at HHS. 

Rovner: And we’re seeing, I know, I think both of you have written about some of these groups wanting to, basically, since they’re saying they can no longer trust the government immunization advisory panel, they want to put out their own recommendations and work with insurance companies to cover things that — based on some of these groups instead. It’s fracturing the way things are done, right? 

Cohrs Zhang: Right. It’s true, and insurance policies are based on all sorts of different things. It’s not like there’s one kind of rule. And I think we’re really testing the boundaries and kind of figuring out that there’s a lot of variability here, and I think there’s a lot of uncertainty, especially going to next year. Generally, insurance plans are kind of set for what they’re going to cover this year, but some of the language in general policies kind of leaves a gray area. If this expert advisory panel that RFK Jr. has fired all the members and put in new members, if they start taking votes that are changing recommendations for previous vaccines that the government has recommended, I think it really throws a lot of coverage into question, and we know that even small copays can discourage people from getting vaccines. And there are these other government programs that provide vaccines for low-income children that are also in question if this panel continues to take votes on existing vaccines in addition to new ones. So I think there is just going to be tough decisions by the insurance industry as to where they’re going to look for these recommendations. 

Rovner: And of course, overlaying all of this is the fact that we learned this week that measles cases are now at a three-decade high and likely to continue to spread. It’s summer, and kids are going to camp and other group activities, and families are traveling. And Rachel R., you wanted to add something. 

Roubein: Oh, yeah. Just on this effort to kind of create this parallel system of recommending, potentially distributing, vaccines. It really marks an escalation of concern from public health experts. My colleague Lena Sun and I dug into it a little bit, and as the other Rachel mentioned, insurance was one of the biggest questions we got from people. But there are other things that they’re mobilizing a little bit behind the scenes on, which is like discussing: Could groups order vaccines directly from manufacturers? Could they give greater weight to recommendations from medical associations like the American Academy of Pediatrics, etc.? So I’ve talked to people who I know are spending a lot of time on this each day. And yeah, like you said, there are a lot of questions how this kind of creates potentially tension and a fractured environment at the same time. 

Rovner: Speaking of Secretary Kennedy and his personal takeover of HHS advisory committees, just days after the Supreme Court ruled for the Biden administration that members of the U.S. Preventive Services Task Force don’t have to be confirmed by the Senate, because they are under the direct authority of the HHS secretary, HHS Secretary Kennedy took that to heart and yesterday canceled a meeting of the group scheduled for today, without stating a reason. Is this a prelude to doing to the U.S. Preventive Health Services Task Force what he’s already done to the immunization panel, basically fire them all and replace them with handpicked people? 

Luhby: That’s the main concern. We don’t know yet. He hasn’t done that yet. That is what folks are very concerned about. And I spoke yesterday to Dr. Aaron Carroll, who’s also the CEO of AcademyHealth and a big public health expert, and he had some very strong words and was very concerned about it, saying, again, that the task force is roughly 40 years old and it’s worked across both Republican and Democratic administrations. It’s a trusted source of science-based guidance. And his concern is that if Secretary Kennedy again removes everybody who’s on it now and puts in more his own people that the process could be either actually undermined and considered partisan or ideological, or at least viewed that way, which will also cause problems and a lack of trust. 

Rovner: Yeah, we will have to see how that goes. Well, meanwhile, within HHS, as we’ve already mentioned, things aren’t going great. My KFF Health News colleagues Rachana Pradhan and Arthur Allen have a pretty devastating piece about chaos at the National Cancer Institute, where lifesaving research is being held up in the wake of cuts and funding freezes. Things apparently aren’t much better over at the Food and Drug Administration. Both The New York Times and Stat have in-depth stories this week — and we will link to all of these stories — about the agency’s growing inability to get its required work done, between layoffs and buyouts and people just plain quitting or retiring because of the political interference. Rachel R., you covered the FDA. Is this what you’re hearing, too? 

Roubein: Yeah, I would say these stories track with what I’ve been hearing. A lot of this comes back to, which I think the New York Times story also led with, a tweet from Kennedy before the election saying the FDA is going to change, people who work there should pack their bags, preserve their records. And that caused a lot of concern from career officials. And they were wondering: Is he going to make good on this pledge to cut staff? And the FDA saw, under the RIF, it was like 3,500. Again, we don’t know exactly the number that’s been brought back, but from what I’ve heard from officials inside the agency, there’s been a lot of concern and confusion. 

Additionally, if you look at the leadership of the agency, like the center directors who are career officials, almost all of them have turned over, whether it’s deciding to leave on their own, whether it’s Peter Marks, who was the top vaccine regulator, being pushed out, or Brian King, who was the tobacco center leader, also being pushed out. So you can sort of see how that leadership has revolved and changed among top career officials, and not just the political posts. 

Rovner: And I know we talk about this pretty much every week, but it continues to be news. HHS is not just cutting staff. It’s sitting on money that’s supposed to be going out the door to recipients of grants and contracts. And it’s looking increasingly like the plan is to run out the clock to the end of the fiscal year at the end of September by not spending money that Congress has appropriated and President Trump has signed into law. At some point this is going to come to a head in court, I imagine. 

Cohrs Zhang: Yeah, the other Rachel’s colleagues at The Washington Post had a great story about how that is the plan, to test Congress’ authority and appropriations power. And right now, I think Congress has talked about this week a rescissions package, which allows them to rescind the money that was initially appropriated. So I think that this is an interesting dynamic to watch as to whether they simply won’t spend money that’s appropriated and then later ask Congress to rescind it. So it is kind of a strange setup, but again, I think it is important to note that there will be different dynamics on appropriations this cycle, given that now Congress is through the One Beautiful Bill and Republican leadership has a little bit more practice. And so I think these appropriations conversations will be different this year. So definitely one to watch. 

Rovner: Yeah, and I want to mention that rescissions bill, because it includes rescissions for a lot of international aid, including PEPFAR [President’s Emergency Plan for AIDS Relief], and we’re seeing it passed the House by one vote. I think everything that passes the House now passes by one vote. But the Senate has been kind of slow-walking it. There’s a deadline of July 18 for when the administration sends up a rescission package. Congress has 45 days to act on it, and those 45 days end on July 18. Now, it looks like the Senate isn’t going to just sort of put it on the floor and try to pass what the House did but they’re going to amend it, which would, of course, have to send it back to the House. Are they trying to run the clock out here without actually saying to the president, No, we don’t want you to not spend this money that we already told you to spend? 

Cohrs Zhang: I don’t know if we can read their minds. Deliberation takes time. Maybe it’s deliberate. I don’t know. I don’t think we’re in a position to say that yet. 

Luhby: There are a lot of concerns with the bill, on both sides, but one thing that — this is supposed to be the beginning of the great cuts that DOGE, the Department of Government Efficiency, Elon Musk’s former program that was going to cut a trillion dollars from the federal deficit. And one thing that’s being mentioned is the fact that if they can’t get this pretty small rescissions package through, what does it mean for the rest of these potential spending cuts that they want to implement? 

Rovner: Yeah, I’m surprised that it’s July and that this hasn’t all come to a head yet, but we will see. Well, finally this week, a segment I’m calling “Important Stuff We Missed While We Were All Too Busy Covering the Budget Bill.” First up is an actual big case of health care fraud being prosecuted by the Trump Justice Department. Well, the Trump administration got to announce it. It was actually an investigation first started by the Biden administration, first uncovered by a group of accountable care organizations who noticed an unusual number of urinary catheters being ordered for their patients, but not by them, and first written about in early 2024 by your colleagues at The Post, Rachel R., including our podcast panelist Lauren Weber. This is a pretty impressive prosecution, even by Medicare standards. It’s a $10.6 billion fraud scheme that involved all kinds of fraudulent medical equipment charges. I wonder if we can expect more like this or if we think this is a one-off that the Biden administration started. Do we know anything about the Trump administration’s pursuit of Medicare fraud? 

Roubein: As you mentioned, this is something my colleagues Dan Diamond and Lauren Weber have been covering really closely. I just kind of wanted to lay out a number that I thought was really stark when reading the piece, which was that companies collectively submitted fraudulent claims to Medicare for more than 1 billion urinary catheters. And my colleagues talked to someone at HHS inspector general’s office about this, and he said that he didn’t even know if the United States has the ability to manufacture 1 billion catheters in such a short time. So I thought that was pretty stark. I don’t know exactly what the next big investigation is going to be, but I think the piece kind of lays out how they want to try and catch things before money goes out the door. 

Rovner: Yeah, I think that for a long time they tried to catch fraud sort of after the fact and recoup, and now I think at least there’s an effort — there was an effort under the Biden administration and I think the first Trump administration — to try and be a little bit more proactive about Medicare fraud. 

Cohrs Zhang: There is now. I was just going to say that during public appearances, CMS [Centers for Medicare & Medicaid Services] Administrator Mehmet Oz has talked about having a quote-unquote “war room” with fraud at CMS. I think it is very much under the DOGE ethos that’s taken over the agencies. So again, who’s to say what’s next? But I think there are some good targets out there that they’re definitely spending energy on. 

Rovner: All right, well, also last month the Trump administration announced a deal negotiated with major insurers to maybe back off of the overuse of prior authorization. That’s where insurance claims get denied before care prescribed by a doctor is delivered. Now, this is not just not a new issue. It dates back to the end of the last century during the fight over something called the Patient’s Bill of Rights, which was eventually folded into the Affordable Care Act. And yet here we are 15 years after that, still fighting about insurance companies second-guessing doctors. Why is this still a thing? 

Luhby: Well, it is one way that insurance companies are able to control costs, which is what they’re being slammed for now. And of course it is more in the news now after the murder of UnitedHealth’s Brian Thompson last December, which we saw actually a lot of people on social media — they didn’t quite say he got what he deserved, but it really— 

Rovner: Some of them did. 

Luhby: Yeah. It unleashed the fury that people have had and maybe some have been storing up, but it really showed that this is a huge issue. So on earnings calls, we’ve seen before, but particularly after, insurers saying that they’re going to do more to try to streamline prior authorization and have it affect patients less and doctors less. And this was this combined effort that they announced, and interestingly announced before the administration did, which I thought was notable. But we’ll see. We’ve seen these announcements and efforts before. So we’ll have to be on top of whether it actually happens. 

Cohrs Zhang: It does seem like a microcosm of some of these larger problems with the American health care system. Like you said, this has been going on for a century, and honestly it’s— 

Rovner: Well, not for a century. Since the 1990s. 

Cohrs Zhang: Sure. Yeah, since the last century I guess, but since the ’90s. But honestly, some practices are still using fax machines. There are different requirements for every single insurer, which I think is part of the problem that they’re trying to address here, that it’s hard for physicians to manage all of these different requirements for these different companies as they’re trying to care for patients, and also just trying to get everybody into the new century in terms of technology and making sure everything’s electronic. It seems like really basic stuff, but it just hasn’t happened yet. So it fits into this larger model that we’ve seen from the Trump administration HHS so far where they want voluntary cooperation from companies, and they prefer that to regulation, but have seemed to leave the door open to regulation if these things don’t work out as promised. 

Rovner: And of course some of it is too much new technology, because we’ve seen both The Wall Street Journal and Stat have written at length about UnitedHealthcare using AI to do some of these prior authorization decisions so that — it used to be they would complain because it was a nurse instead of a doctor who would look at these requests. Now it’s a computer program looking at these requests, which makes some people unhappy. Tami, you want to add something. 

Luhby: And just talking about technology, though, one thing that is interesting that they’re pushing is real-time decisions. So it will be interesting to see, and it could really benefit both patients and doctors if they’re in there, in the visit, and the doctor puts in the procedure or drug or whatever and immediately gets back like, Yes, we’ll approve, or No, we won’t, to give the doctor and the patient time to discuss alternatives. So that would be an interesting technological advance if that happens. 

Rovner: As usual, technology cuts both ways in health care, as everything else. All right, well, that is this week’s news. Now we will play my “Bill of the Month” interview with Julie Appleby, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back. 

Appleby: Thanks for having me. 

Rovner: So this month’s patient — or patients, plural — are a bunch of kids in Texas whose parents took them to make sure all their shots were up to date, particularly because, as we’ve talked about at length on the podcast, Texas is at the center of a pretty big measles outbreak this year. Tell us who the family is and what kind of care they got. 

Appleby: Well, this is the Nguyen family, and they’re living in Texas because Mr. Nguyen is a postdoc fellow in public health and infectious disease, interestingly enough, at the University of Texas Medical Branch in Galveston. And so he was very concerned about the measles outbreak. His 4-year-old son had had the first dose of the measles vaccine when he was much younger, because that’s when you get it, but he needed a second dose. So he took his family to a primary care clinic at UTMB, and he asked, Hey, they need a checkup — will their vaccines be covered? And he was assured that they would. So they went in. His 4-year-old son had several shots. He had three shots, actually, but he had one that we’re writing about here. It was the measles, mumps, rubella, and chickenpox is also called varicella vaccine, and he also had a couple of other shots. So they got all those. His daughters had already been vaccinated for measles, so they got different vaccinations. And then they all went home, and they thought everything was fine. 

Rovner: Now, they have insurance, but they still got a big bill. How big was it, and why weren’t the shots covered? Isn’t that required under the Affordable Care Act? 

Appleby: Yes, and yes, they got a very big bill. Altogether, all three kids, because he’s got 11-year-old twin daughters and his 4-year-old son, their bills came close to $5,000, but we were mainly focusing on his son’s bill. So his son’s bill was $2,500 approximately for the office visits and the three shots. And of that, the MMRV vaccine, the measles vaccine was $1,422, plus $161 to administer it. And yes, the Affordable Care Act does require that preventive care be covered without a copay, and these vaccinations would be considered preventive care. However, Mr. Nguyen’s family is covered under a separate policy he bought for his wife and kids, and it’s basically a short-term travel medical insurance type of policy. And those short-term policies do not have to meet the rules of the Affordable Care Act. And this one it did not. It did not cover preventive care like vaccinations. 

Rovner: So he has student insurance, right? Because he’s technically a student? 

Appleby: He’s technically a student. He does have insurance through his job, because he is working, actually, at UTMB, but it was very expensive to add his wife and family. And this plan was a lot less expensive to cover them for the entire year separately. 

Rovner: So even before the Affordable Care Act, the federal government created a program called Vaccines for Children that was intended to make sure that people who don’t have insurance coverage for vaccines can get their kids immunized, too. Why didn’t that kick in? 

Appleby: Yeah, the Vaccines for Children Program was started after a big epidemic in 1989 to 1991 where there were many, many cases and many, many deaths. And they found out that, a lot of these kids, that cost was the factor. Even some of them that had insurance, cost was just a factor. So this program was set up. It does cover kids who are either underinsured for vaccines or uninsured, and it covers them pretty much for free, like a little $13 administration fee. But in this case, UTMB said that there were several errors that occurred, and one of the errors happened when he was at the office and they entered his insurance information incorrectly. So it did not pick up that it was one of these short-term plans that doesn’t cover vaccinations. Otherwise, UTMB told me that they would have looked to the Vaccines for Children Program, but in this case that was one of the mistakes. His insurance was entered incorrectly, so they didn’t even check. They didn’t even check if he would qualify for the Vaccines for Children Program. 

Rovner: So what eventually happened with this bill? 

Appleby: So he asked for some relief from UTMB, and they initially gave him a 50% discount for being a self-paid patient, basically an uninsured patient. And the bill was still pretty hefty. It was still $1,266, of which the vaccine was $711. But after we contacted UTMB, they looked into it a little bit further and discovered a couple things. One, that he should have qualified for the Vaccines for Children Program, which they hadn’t entered in correctly. And two, that they had updated their chargemaster, which is a list of prices, several months earlier, and had mistakenly entered some of the vaccine prices, according to UTMB, at much higher levels than they should have been, so he kind of got hit with a double whammy. So at the end of the day, what they did was they waived all the vaccine costs for him, and he just ended up paying about $200 for the child’s office visit. And a similar thing happened with his daughters, who had also received other vaccinations. 

Rovner: So what’s the takeaway here? It sounds like the family did exactly what they thought they should have. They had insurance, they were told that it would be covered, and yet they still got socked with this enormous bill. 

Appleby: Yeah, they did do pretty much everything. I think one thing that experts always tell us is that you should always check with your insurer before you go in for some kind of elective thing, just to double-check. And in this case, they would’ve told him, Hey, vaccinations are not covered. So that’s always a good idea. He also did the right thing by asking for a self-paid discount. And if you’re in a situation where you need vaccines for yourself or your kids and you are uninsured, check to see if they qualify for some kind of government program, through a public health agency or the Vaccines for Children Program, or some other low-cost method of getting those vaccinations. 

Rovner: Yeah, because vaccines should be available for not-prohibitive costs, right? Isn’t that the goal here? 

Appleby: That is the goal here, especially during a measles outbreak. That does seem like this guy was trying to do all the right things and take care of his family and did get hit with a series of mistakes that led to this large bill. 

Rovner: And if all else fails, you can write to us. Julie Appleby, thank you so much. 

Appleby: Thank you. 

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Rachel Z., why don’t you go first this week? 

Cohrs Zhang: OK, yeah. My story was from The Wall Street Journal, and it was a follow-on to some of the reporting we discussed earlier. The headline is “Prosecutors Question Doctors About UnitedHealth’s Medicare Billing Practices,” by Christopher Weaver and Anna Wilde Mathews. And it’s just a discussion and kind of illuminating some of the details of where federal investigators are looking into some of their investigations into UnitedHealth. And it really seems that they’re looking into billing codes and what sorts of incentives or pressure that doctors faced to put certain billing codes on patients’ files. And I just thought it was a really great piece of reporting. And it’s hard to report on federal investigations, and they got some people on the record here. So just as a piece of craft, I really admired it. 

Rovner: It is — and we should be talking more about the investigation to UnitedHealth. And we will. I promise. Tami. 

Luhby: Well, I have a good piece that I looked at from Jenna Portnoy of The Washington Post. It’s headlined, “A New D.C. Hospital Grapples With Too Many Patients and Too Few Nurses.” And the show has discussed the impact of the Big Beautiful Bill on hospitals and how they could, may be struggling in the future from Medicaid cuts. But here we have a hospital that opened in April in D.C. This is an in-depth story about Cedar Hill Regional Medical Center GW Health and how it was immediately inundated with too many patients and too few staffers, particularly nurses. Portnoy explains the challenges of running a hospital in a low-income area when there’s a nursing shortage. One great example that she gave was that the chief operating officer is cleaning beds. 

One issue that’s particularly notable from a health perspective is that the hospital had to turn away ambulances five times between mid-April and the end of June because its ER was full or because it had equipment failures. And one thing that she brought up, which is interesting, is that the hospital is trying to educate local residents about when one needs to visit an ER versus an urgent care center, to help lighten the hospital’s load. So it’s a good read and very illuminating. 

Rovner: It is, and it’s a brand-new hospital in a very underserved part of D.C. Really good story. Rachel R. 

Roubein: My extra credit this week is by The Associated Press. The headline is “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and JoNel Aleccia. The story is about Secretary Kennedy praising a company that delivers meals directly to the homes of Medicaid and Medicare enrollees, and he thanks this company, called Mom’s Meals, for sending taxpayer-funded meals without additives to the homes of sick and elderly Americans. The Associated Press reviewed the menu, the ingredients, and the nutrition labels, and also spoke to experts. And what the reporters found is that the company offers these heat-and-eat, ultraprocessed foods that Kennedy kind of routinely criticizes for making people sick. Marion Nestle, who’s a longtime nutrition researcher, told the AP that she felt like there are other companies that would be able to produce better, healthier products, but they, of course, do cost more. Mom’s Meals, the company, when AP asked them about it, said that their meals don’t include some ingredients that Kennedy has railed against, like synthetic dyes, for instance. 

Rovner: Oh, that’s something. It’s a really good story. All right, well, for the second week in a row, my extra credit this week is from a medical journal. This week it’s a new series being launched by the New England Journal of Medicine called “The Corporatization of U.S. Health Care.” It’s pretty nerdy, but I feel like the continuing march towards more and more of health care being consolidated under the control and direction of for-profit entities is at the heart of a lot of our system’s dysfunction. Which is not to suggest the business shouldn’t play a role in our health care system, even a large role, just that if we’re really going to go in this direction, maybe we should do it with an end goal in mind rather than just letting it happen. It’s a really good introduction to the subject. I’m looking forward to reading the rest of this series, both nerdy and really, really important if you want to understand health policy. 

OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Tami? 

Luhby: I’m at cnn.com. 

Rovner: There you go. Rachel R. 

Roubein: My Bluesky is @rachelroubein, my X is @rachel_roubein, and you can always catch me on email or LinkedIn. 

Rovner: And Rachel Z. 

Cohrs Zhang: I’m spending a lot of time on LinkedIn these days and on X, @rachelcohrs. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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As a postpartum doula, Dawn Oliver does her best work in the middle of the night.

During a typical shift, she shows up at her clients’ home at 10 p.m. She answers questions they may have about basic infant care and keeps an eye out for signs of postpartum depression.

After bedtime, she may feed the baby a bottle or wake the mother to breastfeed. She soothes the infant back to sleep. Sometimes, she prepares meals for the family in a Crock-Pot or empties the dishwasher.

She leaves the following morning and returns, often nightly, for two or three weeks in a row.

“I’m certified to do all of it,” said Oliver, of Hardeeville, South Carolina, who runs Compassionate Care Doula Services. It takes a village to raise a child, as the adage goes, but “the village is not what it used to be,” Oliver said.

Doulas are trained to offer critical support for families — before delivery, during childbirth, and in those daunting early days when parents are desperate for sleep and infants still wake up around the clock. While doulas typically don’t hold a medical or nursing degree, research shows they can improve health outcomes and reduce racial health disparities.

Yet their services remain out of reach for many families. Oliver charges $45 an hour overnight, and health insurance plans often don’t cover her fees. That’s partly why business “ebbs and flows,” Oliver said. Sometimes, she’s fully booked for months. Other times, she goes several weeks without a client.

That may soon change.

Two bipartisan bills, introduced in separate chambers of the South Carolina General Assembly, would require both Medicaid, which pays for more than half of all births in the state, and private insurers to cover the cost of doula services for patients who choose to use one.

South Carolina isn’t an outlier. Even as states brace for significant reductions in federal Medicaid funding over the next decade, legislatures across the country continue to pass laws that grant doula access to Medicaid beneficiaries. Some state laws already require private health insurers to do the same. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana, and Montana, have passed laws to facilitate Medicaid coverage of doula services.

All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so.

Notably, these coverage requirements align with one of the goals of Project 2025, whose “Mandate for Leadership” report, published in 2023 by the conservative Heritage Foundation, offered a blueprint for President Donald Trump’s second term. The document calls for increasing access to doulas “for all women whether they are giving birth in a traditional hospital, through midwifery, or at home,” citing concerns about maternal mortality and postpartum depression, which may be “worsened by poor birth experiences.” The report also recommends that federal money not be used to train doctors, nurses, or doulas to perform abortions.

The Heritage Foundation did not respond to an interview request.

Meanwhile, the idea that doulas can benefit babies, parents, and state Medicaid budgets by reducing costly cesarean sections and preterm birth complications is supported by a growing body of research and is gaining traction among conservatives.

A study published last year in the American Journal of Public Health found that women enrolled in Medicaid who used a doula faced a 47% lower risk of delivering by C-section and a 29% lower risk of preterm birth. They were also 46% more likely to attend a postpartum checkup.

“Why wouldn’t you want somebody to avail themselves of that type of care?” said Republican state Rep. Tommy Pope, who co-sponsored the doula reimbursement bill in the South Carolina House of Representatives. “I don’t see any reason we shouldn’t be doing that.”

Pope said his daughter-in-law gave birth with the assistance of a doula. “It opened my eyes to the positive aspects,” he said.

Amy Chen, a senior attorney with the National Health Law Program, which tracks doula reimbursement legislation around the country as part of its Doula Medicaid Project, said lawmakers tend to support these efforts when they have a personal connection to the issue.

“It’s something that a lot of people resonate with,” Chen said, “even if they, themselves, have never been pregnant.”

Conservative lawmakers who endorse state-level abortion bans, she said, often vote in favor of measures that support pregnancy, motherhood, and infant health, all of which these doula reimbursement bills are intended to do.

Some Republicans feel as if “they have to come out in favor of that,” Chen said.

Health care research also suggests that Black patients, who suffer significantly higher maternal and infant mortality rates than white patients, may particularly benefit from doula care. In 2022, Black infants in South Carolina were more than twice as likely to die from all causes before their 1st birthday as white infants.

That holds true for women in rural parts of the country where labor and delivery services have either closed or never existed.

That’s why Montana lawmakers passed a doula reimbursement bill this year — to narrow health care gaps for rural and Indigenous communities. To that end, in 2023, the state enacted a bill that requires Medicaid to reimburse midwives for home births.

Montana state Sen. Mike Yakawich, a Republican who backed the Democratic-sponsored doula reimbursement bill, said pregnant women should have someone to call outside of a hospital, where health care services can be costly and intimidating.

“What help can we provide for moms who are expecting? My feeling is, it’s never enough,” Yakawich said.

Britney WolfVoice lives on the Northern Cheyenne Indian Reservation in southeastern Montana, about two hours from the closest birthing hospital. In early July, she was seven months pregnant with her fourth child, a son, and said she planned to have a doula by her side for the second time in the delivery room. During WolfVoice’s previous pregnancy, an Indigenous doula named Misty Pipe brought cedar oil and spray into the delivery room, rubbed WolfVoice’s back through contractions, and helped ensure WolfVoice’s husband was the first person their daughter saw.

“Being in a hospital, I felt heard for the very first time,” WolfVoice said. “I just can’t explain it any better than I felt at home. She was my safe place.”

Pipe said hospitals are still associated with the government forcibly removing children from Native American homes as a consequence of colonization. Her goal is to help give people a voice during their pregnancy and delivery.

Most of her clients can’t afford to pay for doula services out-of-pocket, Pipe said, so she doesn’t charge anything for her birth services, balancing her role as a doula with her day job at a post office.

“If a mom is vulnerable, she could miss a prenatal appointment or go alone, or I can take time off of work and take her myself,” Pipe said. “No mom should have to birth in fear.”

The new state law will allow her to get paid for her work as a doula for the first time.

In some states that have enacted such laws, initial participation by doulas was low because Medicaid reimbursement rates weren’t high enough. Nationally, doula reimbursement rates are improving, Chen said.

For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client.

But Chen said it is unclear how federal Medicaid cuts might affect the fate of these state laws.

Some states that haven’t passed doula reimbursement bills, including South Carolina, might be hesitant to do so in this environment, she said. “It’s just a really uncertain time.”

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Kelli Reardon undergoes an MRI twice a year to screen for breast cancer, a measure she said she must take to protect her health. Her mother died of the disease at age 48, putting Reardon at higher risk, and Reardon has dense breast tissue, which makes it harder to detect a growth through a mammogram.

When Reardon moved from Alabama to North Carolina, she had little choice but to switch from having the screening done at an imaging center to having it done at a hospital.

Then she saw how much higher the charges were. At first, Reardon thought it was an error: “They made a mistake with billing,” she said. “They accidentally added a zero.”

It wasn’t a mistake.

In this installment of InvestigateTV and KFF Health News’ “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, and Jamie Grey, director of investigations, explore how the type of medical facility where a patient seeks care can affect the cost of that care — particularly when that facility is a hospital.

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

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Nicole Silva’s 4-year-old daughter was headed to a relative’s house near the southern Colorado town of La Jara when a vehicle T-boned the car she was riding in. A cascade of ambulance rides ensued — a ground ambulance to a local hospital, an air ambulance to Denver, and another ground ambulance to Children’s Hospital Colorado.

Silva’s daughter was on Medicaid, which was supposed to cover the cost of the ambulances. But one of the three ambulance companies, Northglenn Ambulance, a public company since acquired by a private one, sent Silva’s bill to a debt collector. It was for $2,181.60, which grew to more than $3,000 with court fees and interest, court records show. The preschool teacher couldn’t pay, and the collector garnished Silva’s wages.

“It put us so behind on bills — our house payment, electric, phone bills, food for the kids,” said Silva, whose daughter recovered fully from the 2015 crash. “It took away from everything.”

Some state legislators are looking to curb bills like the one she received — surprise bills for ground ambulance rides.

When an ambulance company charges more than an insurer is willing to pay, patients can be left with a big bill they probably had no choice in.

States are trying to fill a gap left by the federal No Surprises Act, which covers air ambulances but not ground services, including ambulances that travel by road and water. This year, Utah and North Dakota joined 18 other states that have passed protections against surprise billing for such rides.

Those protections often include setting a minimum for insurers to pay out if someone they cover needs a ride. But the sticking point is where to set that bar. Legislation in Colorado and Montana stalled this year because policymakers worried that forcing insurers to pay more would lead to higher health coverage costs for everyone.

Surprise ambulance bills are one piece of a health care system that systematically saddles Americans with medical debt, straining their finances, preventing them from accessing care, and increasing racial disparities, as KFF Health News has reported.

“If people are hesitating to call the ambulance because they’re worried about putting a huge financial burden on their family, it means we’re going to get stroke victims who don’t get to the hospital on time,” said Patricia Kelmar, who directs health care campaigns at PIRG, a national consumer advocacy group. “It means that person who’s worried it might be a heart attack won’t call.”

The No Surprises Act, signed into law by President Donald Trump in 2020, says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network. Like doctors or hospitals, ambulance companies can contract with insurers, making them in-network. Those that don’t remain out-of-network.

But unlike when making an appointment with a doctor or planning a surgery, a patient generally can’t choose the ambulance company that will respond to their 911 call. This means they can get hit with large out-of-network bills.

Federal lawmakers punted on including ground ambulances, in part because of the variety of business models — from private companies to volunteer fire departments — and a lack of data on how much rides cost.

Instead, Congress created an advisory committee that issued recommendations last year. Its overarching conclusion — that patients shouldn’t be stuck in the crossfire between providers and payers — was not controversial or partisan. In Colorado, a measure aimed at expanding protections from surprise ambulance bills got a unanimous thumbs-up in both legislative chambers.

Colorado had previously passed a law protecting people from surprise bills from private ambulance companies. This new measure was aimed at providing similar protections against bills from public ambulance services and for transfers between hospitals.

“We knew it had bipartisan support, but there are some people that vote no on everything,” said a pleasantly surprised Karen McCormick, a Democratic state representative.

A less pleasant surprise came later, when Gov. Jared Polis, who is also a Democrat, vetoed it, citing the fear of rising premiums.

States can do only so much on this issue, because state laws apply only to state-regulated health plans. That leaves out a lot of workers. According to a 2024 national survey by KFF, a health information nonprofit that includes KFF Health News, 63% of people who work for private employers and get health insurance through their jobs have self-funded plans, which aren’t state-regulated.

“It’s why we need a federal ambulance protection law, even if we passed 50 state laws,” Kelmar said.

According to data from the Colorado secretary of state’s office, the only lobbying groups registered as “opposing” the bill were Anthem and UnitedHealth Group, plus UnitedHealth subsidiaries Optum and UnitedHealthcare.

As soon as the legislative session ended in May, Kevin McFatridge, executive director of the Colorado Association of Health Plans, a trade group representing health insurance companies in the state, sent a letter to the governor requesting a veto, with an estimate that the legislation would result in premiums rising 0.4%.

The Colorado bill said local governments — such as cities, counties, or special districts — would set rates.

“We are in a much better place by not having local entities set their own rates,” McFatridge told KFF Health News. “That’s almost like the fox managing the henhouse.”

Jack Hoadley, an emeritus research professor with Georgetown University’s McCourt School of Public Policy, said it isn’t clear whether state laws approved elsewhere are raising premiums, or if so by how much. Hoadley said Washington state is expected to come out with an impact analysis of its law in a couple of years.

The national trade association for insurance companies declined to provide a comment for this article. Instead, AHIP forwarded letters that its leaders submitted to lawmakers in Ohio, West Virginia, and North Dakota this year opposing measures in each state to set base ambulance rates. AHIP leadership described the proposals as inflated, government-mandated pricing that would reduce insurers’ chance to negotiate fair prices. Ultimately, the association warned, the proposed minimums would increase health care costs.

In Montana, legislators were considering a minimum reimbursement for ground ambulances of 400% of what Medicare pays, or at a set local rate if one exists. The proposal was sponsored by two Republicans and backed by ambulance companies. Health insurers successfully lobbied against it, arguing that the price was too steep.

Sarah Clerget, a lobbyist representing AHIP, told Montana lawmakers in a legislative hearing that it’s already hard to get ambulance companies to go in-network with insurers, “because folks are going to need ambulance care regardless of whether their insurance company will cover it.” She said the state’s proposal would leave those paying for health coverage with the burden of the new price.

“None of us like our insurance rates to move,” Republican state Sen. Mark Noland said during a legislative meeting as a committee tabled the bill. He equated the proposed minimum to a mandate that could lead to people having to pay more for health coverage for an important but nonetheless niche service.

Colorado’s governor was similarly focused on premiums. Polis said in his veto letter that the legislation would have raised premiums between 73 cents and $2.15 per member per month.

“I agree that filling this gap in enforcement is crucial to saving people money on health care,” he wrote. “However, those cost savings are outweighed in my view by the premium increases.”

Isabel Cruz, policy director at the Colorado Consumer Health Initiative, which supported the bill, said that even if premiums did rise, Coloradans might be OK with the change. After all, she said, they’d be trading the threat of a big ambulance bill for the price of half a cup of coffee per month.

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In Connecticut, construction workers in the Local 478 union who complete addiction treatment are connected with a recovery coach who checks in daily, attends recovery meetings with them, and helps them navigate the return to work for a year.

In Pennsylvania, doctors applying for credentials at Geisinger hospitals are not required to answer intrusive questions about mental health care they’ve received, reducing the stigma around clinicians seeking treatment.

The workplace is the new ground zero for addressing mental health. That means companies — employees and supervisors alike — must confront crises, from addiction to suicide. The two seemingly unrelated advances in Connecticut and Pennsylvania have one common factor: They grew out of the work of a little known federal agency called the National Institute for Occupational Safety and Health.

It’s one of the key federal agencies leading workplace mental health efforts, from decreasing alarmingly high rates of suicide among construction workers to addressing burnout and depression among health care workers.

But after gaining considerable traction during the covid-19 pandemic, that work is now imperiled. The Trump administration has fired a majority of NIOSH staffers and is proposing severe reductions to its budget.

Private industry and nonprofits may be able to fill some of the gap, but they can’t match the federal government’s resources. And some companies may not prioritize worker well-being above profits.

About 60% of employees worldwide say their job is the chief factor affecting their mental health. Research suggests workplace stress causes about 120,000 deaths and accounts for up to 8% of health costs in the U.S. each year.

“Workplace mental health is one of the most underappreciated yet critical areas we could intervene on,” said Thomas Cunningham, a former senior behavioral scientist at NIOSH who took a buyout this year. “We were just starting to get some strong support from all the players involved,” he said. “This administration has blown that apart.”

NIOSH, established in 1970 by the same law that created the better-known Occupational Safety and Health Administration, is charged with producing research that informs workplace safety regulations. It’s best known for monitoring black lung disease in coal miners and for testing masks, like the N95s used during the pandemic.

As part of the mass firing of federal workers this spring, NIOSH was slated to lose upward of 900 employees. After pushback from legislators — primarily over coal miner and first responder safety — the administration reinstated 328. It’s not clear if any rehired workers focus on mental health initiatives.

At least two lawsuits challenging the firings are winding through the courts. Meanwhile, hundreds of NIOSH employees remain on administrative leave, unable to work.

Emily Hilliard, a press secretary for the Department of Health and Human Services, asserted in a statement that “the nation’s critical public health functions remain intact and effective,” including support for coal miners and firefighters through NIOSH. “Improving the mental health of American workers remains a key priority for HHS, and that work is ongoing,” she wrote.

She did not answer specific questions from KFF Health News about whether any reinstated NIOSH employees lead mental health efforts or who is continuing such work.

Reducing Suicides and Addiction in Construction and Mining

Over 5,000 construction workers die by suicide annually — five times the number who die from work-related injuries. Miners suffer high rates too. And nearly a fifth of workers in both industries have a substance use disorder, double the rate among all U.S. workers.

Kyle Zimmer recognized these issues as early as 2010. That’s when he started a members’ assistance program for the International Union of Operating Engineers Local 478 in Connecticut. He hired a licensed clinician on retainer and developed partnerships with local treatment facilities.

At first, workers pushed back, said Zimmer, who recently retired after 25 years in the union, many as director of health and safety.

Their perception was, “If I speak up about this issue, I’m going to be blackballed from the industry,” he said.

But slowly, that changed — with NIOSH’s help, Zimmer said.

The agency developed an approach to worker safety called Total Worker Health, which identifies physical and mental health as critical to occupational safety. It also shifts the focus from how individuals can keep themselves safe to how policies and environments can be changed to keep them safe.

Over decades, the concept spread from research journals and universities to industry conferences, unions, and eventually workers, Zimmer said. People began accepting that mental health was an occupational safety issue, he said. That paved the way for NIOSH’s Miner Health Program to develop resources on addiction and for Zimmer to establish the recovery coaching program in Connecticut.

“We have beat that stigma down by a lot,” Zimmer said.

Other countries have made more progress on mental health at work, said Sally Spencer-Thomas, co-chair of the International Association for Suicide Prevention’s workplace special interest group. But with the growth of the Total Worker Health approach, a 2022 surgeon general report on the topic, and increasing research, the U.S. appeared to finally be catching up. The recent cuts to NIOSH suggest “we’re kind of losing our footing,” she said.

Last year, Natalie Schwatka, an assistant professor at the Colorado School of Public Health’s Center for Health, Work & Environment, received a five-year NIOSH grant to build a toolkit to help leaders in labor-intensive industries, such as construction and mining, strengthen worker safety and mental health.

While many companies connect people to treatment, few focus on preventing mental illness, Schwatka said. NIOSH funding “allows us to do innovative things that maybe industry wouldn’t necessarily start.”

Her team planned to test the toolkit with eight construction companies in the coming years. But with few NIOSH employees left to process annual renewals, the funds could stop flowing anytime.

The consequence of losing such research is not confined to academia, Zimmer said. “Workers’ health and safety is very much in jeopardy.”

Health Care Sector Braces for Fallout From NIOSH Cuts

For a long time, clinicians have had troubling rates of addiction and suicide risk. Just after the height of the pandemic, a NIOSH survey found nearly half of health workers reported feeling burned out and nearly half intended to look for a new job. The agency declared a mental health crisis in that workforce.

NIOSH received $20 million through the American Rescue Plan Act to create a national campaign to improve the mental health of health workers.

The results included a step-by-step guide for hospital leaders to improve systems to support their employees, as well as tips and suggested language for leaders to discuss well-being and for workers to advocate for better policies.

Cunningham, the behavioral scientist who left NIOSH this year, helped lead the effort. He said the goal was to move beyond asking health workers to be resilient or develop meditation skills.

“We’re not saying resilience is bad, but we’re trying to emphasize that’s not the first thing we need to focus on,” he said.

Instead, NIOSH suggested eliminating intrusive questions about mental health that weren’t relevant to keeping patients safe from hospital credentialing forms and offering workers more input on how their schedules are made.

The agency partnered on this work with the Dr. Lorna Breen Heroes’ Foundation, named after an emergency medicine doctor who died by suicide during the pandemic. The foundation extended the campaign by helping health systems in four states implement pieces of the guide and learn from one another.

Foundation leaders recently appeared on Capitol Hill with Noah Wyle, who plays an emergency physician on the TV series “The Pitt,” to advocate for renewed federal funding for this work.

Corey Feist, foundation CEO and co-founder, said renewing that funding to NIOSH is crucial to get this guide out to all hospitals.

Without those resources, “it’s just going to really delay this transformation of health care that needs to happen,” he said.

Who Can Fill the Gap?

TJ Lyons, a multidecade construction industry safety professional who has worked at big-name companies such as Gilbane, Turner, and DPR Construction, is confident that workplace mental health will remain a priority despite the NIOSH cuts.

General contractors and project owners have been incorporating budget lines for mental health support for years, he said, sharing an example of a $1 billion project that included a mental health clinician on call for four hours several days a week. Workers would make appointments to sit in their pickup trucks during lunch breaks and talk to her, he said.

Now when these big companies subcontract with smaller firms, they often ask if the subcontractors provide mental health support for workers, Lyons said.

But others are skeptical that industry can replace NIOSH efforts.

Several workplace safety experts said smaller companies lack the means to commission research studies and larger companies may not share the results publicly, as a federal agency would. Nor would they have the same credibility.

“Private industry is going to provide what the people paying them want to provide,” said a NIOSH employee and member of the American Federation of Government Employees union, currently on administrative leave, who was granted anonymity for fear of professional retaliation.

Without federal attention on workplace mental health, “people may leave the workforce,” she said. “Workers may die.”

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

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