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The national 911 emergency response system is in the midst of its own code red.

The lack of federal funding to upgrade aging 911 systems has created significant disparities in state emergency response services, with older operations plagued by outages and longer response times.

Last month, for instance, Massachusetts was hit with a statewide 911 outage that lasted about two hours — making it at least the eighth state with a service interruption in the United States this year. The outage was blamed on a safety feature that was supposed to provide protection against cyberattacks and hacking. But it was just one more such episode in the headlines.

More than three-quarters of call centers experienced outages in the past year, based on the latest Pulse of 9-1-1 Survey by the National Emergency Number Association and Carbyne, which makes public safety technology products.

In Congress, lawmakers have looked at ways to pay to modernize 911 systems by using revenue from the Federal Communications Commission — specifically, revenue that comes from the FCC’s auctioning of the rights to transmit signals over specific bands of the electromagnetic spectrum. There’s a catch: The Senate in March 2023 let the FCC’s authority to auction spectrum bands lapse.

Lawmakers have floated proposals, but final plans are in limbo. For example, legislation sponsored by Rep. Cathy McMorris Rodgers (R-Wash.) would renew the auction authority until September 2026 and provide almost $15 billion in grants from auction proceeds for upgrading 911 systems. The bill unanimously passed the House Energy and Commerce Committee in May 2023.

With funding attempts in Congress stalled, states and localities are taking a piecemeal approach — tapping general funds or other resources to modernize operations. Florida, Illinois, Montana and Oklahoma passed legislation in 2023 to advance or fund next-generation 911 systems, according to the National Conference of State Legislatures.

Most of the country’s roughly 6,000 call centers were built using analog rather than digital technologies. Next-generation 911 systems are more resilient, with better backups in case of an outage, advocates say. They allow callers to share photos and videos or text messages, and they also improve location accuracy.

But upgrades by states, cities and counties are spotty — generally happening in jurisdictions with deeper pockets. Proponents say billions of dollars in federal funding is urgently needed to ease disparities and build a stronger national emergency response system.

“Now there are haves and have-nots,” said Jonathan Gilad, vice president of government affairs at NENA, which represents 911 first responders. “Next-generation 911 shouldn’t be for people who happen to have an emergency in a good location.”

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Statement from Assistant Secretary for Public Affairs Jeff Nesbit on HHS Secretary Becerra Testing Positive for COVID-19

The first time Tammy and Jordan Myers held their twins, the premature babies were so fragile that their tiny faces were mostly covered by oxygen masks and tubing. Their little hands rested gently on Tammy’s chest as the machines keeping them alive in a neonatal intensive care unit in Grand Rapids, Michigan, beeped and hummed around them.

It was an incredible moment, but also a terrifying one. A court had just denied the Myers’ parental rights to the twins, who were born via surrogate using embryos made from Jordan’s sperm and Tammy’s eggs. (Tammy’s eggs had been frozen before she underwent treatment for breast cancer.)

“In the early hours of their lives, we had no lifesaving medical decision-making power for their care,” Tammy Myers told lawmakers at a Michigan Senate committee hearing in March.

Instead, the state’s surrogacy restrictions required the Myers to legally adopt their biological twins, Eames and Ellison.

“Despite finally being granted legal parenthood of our twins almost two years after they were born, our wounds from this situation remain raw, casting a long shadow over the cherished memories that we missed,” Myers told lawmakers, her voice catching.

Until this spring, Michigan was the only state that had a broad criminal ban on surrogacy. Many families say that ban left them in legal limbo: They were compelled to leave the state to have children; find strangers on Facebook who would carry their child; or, like the Myers, be forced to legally adopt their own biological children.

Gov. Gretchen Whitmer of Michigan signed legislation in April repealing the 1988 criminal ban, legalizing surrogacy contracts and compensated surrogacy after more than three decades. But the legalization is raising fears among conservatives and religious groups, who echo Pope Francis’ concerns that surrogacy exploits women and makes children “the basis of a commercial contract.”

As reproductive technology advanced in recent decades, most states passed laws permitting and regulating surrogacy. But Michigan did not, said Courtney Joslin, a professor at the University of California-Davis School of Law who specializes in family law. Still, those restrictions didn’t prevent Michiganders from having children via surrogacy.

“Criminal bans, or even civil bans, don’t end the practice,” Joslin said. “People are still engaged in surrogacy, and it’s becoming more clear that the effect of a ban is just to leave the parties without any protection. And that includes the person acting as a surrogate.”

In 2009, a couple in western Michigan had to surrender custody of twins after their surrogate decided to keep the babies. The surrogate claimed that she hadn’t been aware of an arrest and a mental health issue in the intended mother’s past. In 2013, a surrogate from Connecticut fled to Michigan to give birth, knowing state law would give her parental rights. She and the intended parents had disagreed over whether to terminate the pregnancy following the discovery of major fetal abnormalities.

The Myers family, however, thought they would be able to avoid any protracted legal fights. They had the full support of their surrogate, Lauren Vermilye, a stranger who’d volunteered to be their surrogate after seeing Tammy’s posts on Facebook. Yet even with Vermilye and her husband, Jonathan, saying that the twins belonged to the Myers, Michigan judges denied the Myers’ request for a prebirth order giving them parental rights.

“As a devoted family already raising our kind, inclusive and gentle-hearted 8-year-old daughter, Corryn, we were forced to prove our worthiness through invasive psychological testing, home visits, and endless meetings to discuss our parenting plan to prove that we were fit to raise our twins, Eames and Ellison,” Tammy Myers told lawmakers in March.

Opponents of Michigan’s repeal of its surrogacy ban distinguish altruistic surrogacy — in which the surrogate mother does not receive any compensation, including for her medical and legal expenses — from a contract for a child.

Legislators in Michigan’s House of Representatives passed bills late last year to allow courts to recognize and enforce surrogacy contracts. These bills allowed parents to compensate surrogates, including for medical and legal expenses. But as the legislation moved forward early this year, religious and conservative groups, and some Republican lawmakers, continued voicing their opposition.

Michigan’s surrogacy laws were not preventing altruistic surrogacy in the state, argued Genevieve Marnon, the legislative director of Right to Life of Michigan, at a state Senate committee hearing in March.

“However, current law does require a legal adoption of a child who is born of one woman and then given to another person,” Marnon said. “That practice is child-protective, to prevent the buying and selling of children, and to ensure children are going to a safe home.”

Michigan’s ban on surrogacy is “in keeping with much of the rest of the world,” Marnon said in March. Several European countries ban or restrict surrogacy, including Italy, which is cracking down on international surrogacy, an arrangement involving a surrogate mother who lives in a different country than the biological parents.

“India, Thailand, and Cambodia had laws similar to those contemplated in these bills, but due to exploitation of their women caused by surrogacy tourism, they changed their laws to stop that,” Marnon told the senators in March.

In January, Pope Francis called for a universal ban on surrogacy, “which represents a grave violation of the dignity of the woman and the child, based on the exploitation of situations of the mother’s material needs,” he said.

Rebecca Mastee, a policy advocate with the Michigan Catholic Conference, told lawmakers that while she acknowledged the suffering of people with infertility, surrogacy can exploit women and treat babies like commodities.

“At the core of such agreements is a contract for a human being,” she said.

“That made my blood boil, hearing that,” said Eric Portenga. He and his husband, Kevin O’Neill, had traveled from their home in Ann Arbor to the Capitol in Lansing to attend the hearings in March.

If you’ve been through the surrogacy process “you know there’s no commodification at all,” Portenga said. “You want a family because you have love to give. And you want to build the love that you have, with your family.”

When Portenga and O’Neill were trying to become fathers, they reached out to surrogacy agencies in other states but were told the process would cost $200,000. “We would have had to have sold the house,” O’Neill said.

Like the Myers, the couple turned to Facebook and social media, “just putting our story out there that we wanted to become dads,” O’Neill said. A friend of a friend, Maureen Farris, reached out to the couple: She’d been wanting to help a family through surrogacy for years, she said. And Farris lived just a few hours south in Ohio, where surrogacy contracts and compensation are legal.

Farris’ contract with Portenga and O’Neill was fairly standard. Both sides had to undergo psychological background checks and have legal representation. The contract also set compensation for Farris, which covered medical and legal fees. The contract stipulated Farris couldn’t travel to Michigan beyond a certain point in her pregnancy because if she’d gone into labor and given birth in the state, she would be considered the legal parent of the child.

That contract, Portenga and O’Neill said, gave Farris more protection and agency than she would have had in Michigan at the time. “They’re carrying a human life inside of them,” O’Neill said of surrogates. “They’re not able to work. Their bodies will be changed forever. They’re getting compensated for the amazing gift they’re giving people.”

After the embryo transfer was successful, Portenga and O’Neill learned Farris was pregnant — with identical triplet girls.

“They came out and just unraveled this huge string of ultrasound photographs and, and that’s when we knew our life had changed,” Portenga said, sitting at home in the family’s kitchen. The girls were born in Ohio — where the dads could be legally named their parents — and then the family of five returned to Michigan.

Today, Sylvie, Parker, and Robin O’Neill are 2 years old, and very busy. Parker is the “leader of the pack,” while Robin is the “brains of the operation” — she can count to 10 but likes to skip the number five. Sylvie is “the most affectionate, the most sensitive, of the three of them,” O’Neill said. “But their bond is so amazing to watch. And we’re so lucky to be their dads.”

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

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Cinco trabajadores de una granja avícola en el noreste de Colorado han dado positivo para la gripe aviar, informó el Departamento de Salud Pública estatal el 14 de julio. Esto eleva el número conocido de casos en Estados Unidos a nueve.

Es probable que las cinco personas se infectaran por manipular pollos, a los que se les había encargado sacrificar en respuesta a un brote de gripe aviar en esa granja.

Más de 99 millones de pollos y pavos se han infectado con una cepa altamente patógena de la gripe aviar que surgió en las granjas avícolas del país a principios de 2022.

Desde entonces, el gobierno federal ha compensado a los granjeros avícolas con más de $1,000 millones por destruir bandadas y huevos infectados para frenar la propagación de los brotes.

El virus de la gripe aviar H5N1 se ha estado propagando entre las granjas avícolas de todo el mundo durante casi 30 años. Se estima que 900 personas se han infectado por aves y aproximadamente la mitad han muerto por la enfermedad.

Este año, en Estados Unidos, el virus hizo un cambio sin precedentes “saltando” al ganado lechero. Esto representa una amenaza mayor porque significa que el virus se ha adaptado para replicarse dentro de las células de las vacas, que son más parecidas a las humanas.

Las otras cuatro personas diagnosticadas este año en el país trabajaban en tambos que estaban sufriendo brotes.

Los científicos han advertido que el virus podría mutar para propagarse de persona a persona, como la gripe estacional, y desencadenar una pandemia. Aún no hay señales de que esto esté ocurriendo.

Hasta ahora, los nueve casos reportados este año han sido leves: con irritación ocular, secreción nasal y otros síntomas respiratorios. Sin embargo, los números siguen siendo demasiado bajos para decir algo certero sobre la enfermedad porque, en general, los síntomas de la gripe pueden variar entre las personas y solo una minoría necesita hospitalización.

El número de personas que han contraído el virus de las aves de corral o el ganado puede ser mayor que nueve. Los Centros para el Control y Prevención de Enfermedades (CDC) han hecho pruebas solo a unas 60 personas en los últimos cuatro meses, y los laboratorios de diagnóstico más grandes, que típicamente detectan enfermedades, aún no tienen permitido realizar pruebas.

Es muy importante hacerles estas pruebas a los trabajadores de granjas para detectar el virus de la gripe aviar H5N1, estudiarlo y frenarlo antes que se convierta en parte de sus ecosistemas.

Los investigadores han instado a una respuesta más agresiva por parte de los CDC y otras agencias federales para prevenir futuras infecciones. Muchas personas expuestas regularmente al ganado y a las aves de corral en las granjas aún carecen de equipo de protección y no reciben ningún tipo de educación sobre la enfermedad.

Y todavía no tienen permiso para recibir una vacuna contra la gripe aviar.

Casi una docena de expertos en virología y brotes entrevistados recientemente por KFF Health News no están de acuerdo con la decisión de los CDC de no vacunar, lo que, dicen, podría ayudar a prevenir la infección y hospitalización por gripe aviar.

“Deberíamos hacer todo lo posible para eliminar las posibilidades de que los trabajadores en tambos y granjas de aves contraigan este virus”, dijo Angela Rasmussen, viróloga de la Universidad de Saskatchewan, en Canadá. “Si este virus tiene suficientes oportunidades para saltar de las vacas o las aves de corral a las personas, eventualmente se volverá mejor para infectarlas”.

Para comprobar si los casos no se están detectando, investigadores en Michigan han enviado a los CDC muestras de sangre de trabajadores de tambos. Si detectan anticuerpos contra la gripe aviar, es probable que las personas se infecten más fácilmente por el ganado de lo que se creía anteriormente.

“Es posible que las personas hayan tenido síntomas que no se sintieran cómodas informando, o que sus síntomas fueran tan leves que no pensaron que valiera la pena mencionarlos”, dijo Natasha Bagdasarian, directora ejecutiva de salud médica del estado de Michigan.

Con la esperanza de frustrar una posible pandemia, Estados Unidos, el Reino Unido, Países Bajos y una docena de otros países están almacenando millones de dosis de una vacuna contra la gripe aviar fabricada por la compañía de vacunas CSL Seqirus.

La formulación más reciente de Seqirus fue aprobada el año pasado por el equivalente europeo de la Administración de Drogas y Alimentos (FDA), y una versión anterior tiene la aprobación de la FDA. En junio, Finlandia decidió ofrecer vacunas a las personas que trabajan en granjas de pieles como medida de precaución porque sus granjas de visones y zorros sufrieron duros golpes por la gripe aviar el año pasado.

De manera controversial, los CDC han decidido no ofrecer vacunas contra la gripe aviar a los grupos de riesgo.

Aunque hay millones de dosis disponibles, Demetre Daskalakis, director del Centro Nacional para la Inmunización y Enfermedades Respiratorias de los CDC, dijo a KFF Health News que en este momento la agencia no está recomendando una campaña de vacunación por varias razones. Una de ellas es que los casos aún parecen ser limitados y el virus no se está propagando rápidamente entre las personas a medida que estornudan y respiran.

La agencia sigue calificando el riesgo público como bajo. En una declaración publicada en respuesta a los nuevos casos de Colorado, los CDC dijeron que sus recomendaciones sobre la gripe aviar siguen siendo las mismas: “Una evaluación de estos casos ayudará a determinar si esta situación justifica un cambio en la evaluación del riesgo para la salud humana”.

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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HOUSTON — As Tina Kitzmiller sat inside her sweltering apartment, windows and doors open in the hope of catching even the slightest breeze, she was frustrated and worried for her dog and her neighbors.

It had been days since Hurricane Beryl blew ashore from the Gulf of Mexico on July 8, causing widespread destruction and knocking out power to more than 2 million people, including the Houston senior independent living facility where Kitzmiller lives. Outdoor temperatures had reached at least 90 degrees most days, and the heat inside the building was stifling.

Kitzmiller moved there not long ago with Kai, her 12-year-old dog, shortly after riding out 90-plus-mph winds from a May derecho under a comforter on the floor of the 33-foot RV she called home. She didn’t need medical care, as a nursing home would offer, and thought she and Kai could be safer at an independent senior facility than in the RV. She assumed her new home would have an emergency power system in place at least equivalent to that of the post offices she’d worked in for 35 years.

“I checked out the food. I checked out the activities,” said Kitzmiller, 61, now retired. “I didn’t know I needed to inquire about a generator.”

Even after multiple incidents of extreme weather — including a 2021 Texas winter storm that caused widespread blackouts and prompted a U.S. Senate investigation — not much has changed for those living in long-term care facilities when natural disasters strike in Texas or elsewhere.

“There has been some movement, but I think it’s been way too slow,” said David Grabowski, a professor of health care policy at Harvard Medical School. “We keep getting tested and we keep failing the test. But I do think we are going to have to face this issue.”

A power outage can be difficult for anyone, but older adults are especially vulnerable to temperature extremes, with medications or medical conditions affecting their bodies’ ability to regulate heat and cold. Additionally, some medications need refrigeration while others cannot get too cold.

Federal guidelines require nursing homes to maintain safe indoor temperatures but do not regulate how. For example, facilities face no requirement that generators or other alternative energy sources support heating and air conditioning systems. States are largely responsible for compliance, Grabowski said, and if states are failing in that regard, change doesn’t happen.

Furthermore, while nursing homes face such federal oversight, lower-care-level facilities that provide some medical care — known as assisted living — are regulated at the state level, so the rules for emergency preparedness vary widely.

Some states have toughened those guidelines. Maryland adopted rules for generators in assisted living facilities following Hurricane Isabel, which left more than 1.2 million residents in the state without power in 2003. Florida did so for nursing homes and assisted living facilities in 2018, after Hurricane Irma led to deaths at one facility.

But Texas has not. And no requirements for generators exist in Texas for the roughly 2,000 assisted living facilities or the even less regulated independent living sites, like Kitzmiller’s.

Generally, apartment complexes marketed to senior citizens, known in the industry as independent living facilities, don’t have any special regulations in Texas and many other states.

Nationally, assisted living facilities and independent living facilities have been the fastest-growing sectors in senior living. Residents at such facilities often have medical needs, Grabowski said, but for a variety of reasons have chosen to live in an environment that allows more independence than a nursing home, which would provide medical care. That doesn’t mean the residents in these lower-care-level facilities are any less susceptible to extreme temperatures when the power goes out.

“If you’re overwhelmed by the heat in your apartment, that’s unsafe,” he said.

Republican state Rep. Ed Thompson tried several times since 2020 to pass legislation requiring assisted living facilities in Texas to have backup generators. But the bills failed. He is not seeking reelection this year.

“It’s horrible what the state of Texas is doing,” said Thompson, blaming corporate greed and politicians more interested in stirring up their base and raising their national profile than improving the lives of Texans. “How we treat our elderly says something about us — and they’re not being treated right.”

Nim Kidd, chief of the Texas Division of Emergency Management, said at a July 11 press conference that senior facility operators are accountable if they do not keep residents safe. “That location is responsible for the health, safety, and welfare of the patients and residents that are there,” he told reporters. “It is that facility’s responsibility.”

Under Texas law, power restoration is supposed to be prioritized for nursing, assisted living, and hospice facilities.

The resistance to adding oversight or more governmental protections has not surprised Gregory Shelley, a senior manager at the Harris County Long-Term Care Ombudsman Program at UTHealth Houston’s Cizik School of Nursing. He said that while he believes the safety and health of residents are paramount, he recognizes that installing generators is expensive. He also said some people within the industry continue to believe extreme events are rare.

“But all of us in Houston this year already learned that they’re happening more frequently,” Shelley said. “This is already the third time since May that big portions of Houston have been without power for long periods of time.”

After the 2021 blackouts, Texas’ Health and Human Services Commission conducted a voluntary survey that found 47% of the assisted living and 99% of the nursing care facilities that responded reported having generators.

The U.S. Senate investigation following the 2021 Texas storm recommended a national requirement that assisted living facilities have emergency power supplies to both maintain safe temperatures and keep medical equipment running.

A 2023 annual report from Texas’ long-term care ombudsman, Patty Ducayet, also recommended requiring generators at assisted living centers. The report suggested that all long-term care facilities maintain safe temperatures in a location that can be accessed by every resident. The report recommended requiring assisted living facilities to annually submit emergency response plans to state regulators to be reviewed by state officials. The recommendations have not been adopted.

On July 15 — more than a week after Beryl hit — Kitzmiller said she just wanted the power back on. She praised the staff at her facility but said she worried for residents who were isolated on her building’s second and third floors, which were hotter amid the outage. Some were unable to keep required medicine refrigerated, she said. And without functioning elevators, many couldn’t get to the first floor, where it was cooler.

Mostly, Kitzmiller said, she was frustrated with companies and politicians who hadn’t yet fixed the problem.

“It’s their mothers, their grandmothers, and their family in these homes, these facilities,” she said. “All I can think is ‘Shame on you.’”

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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Readout of HHS Secretary Xavier Becerra’s Meeting with Japan Minister Keizo Takemi of Japan and Canada Minister Mark Holland.

Five people who work at a poultry farm in northeastern Colorado have tested positive for the bird flu, the Colorado public health department reported July 14. This brings the known number of U.S. cases to nine.

The five people were likely infected by chickens, which they had been tasked with killing in response to a bird flu outbreak at the farm.

More than 99 million chickens and turkeys have been infected with a highly pathogenic strain of the bird flu that emerged at U.S. poultry farms in early 2022. Since then, the federal government has compensated poultry farmers more than $1 billion for destroying infected flocks and eggs to keep outbreaks from spreading.

The H5N1 bird flu virus has spread among poultry farms around the world for nearly 30 years. An estimated 900 people have been infected by birds, and roughly half have died from the disease.

The virus made an unprecedented shift this year to dairy cattle in the U.S. This poses a higher threat because it means the virus has adapted to replicate within cows’ cells, which are more like human cells. The four other people diagnosed with bird flu this year in the U.S. worked on dairy farms with outbreaks.

Scientists have warned that the virus could mutate to spread from person to person, like the seasonal flu, and spark a pandemic. There’s no sign of that, yet.

So far, all nine cases reported this year have been mild, consisting of eye irritation, a runny nose, and other respiratory symptoms. However, numbers remain too low to say anything certain about the disease because, in general, flu symptoms can vary among people with only a minority needing hospitalization.

The number of people who have gotten the virus from poultry or cattle may be higher than nine. The Centers for Disease Control and Prevention has tested only about 60 people over the past four months, and powerful diagnostic laboratories that typically detect diseases remain barred from testing. Testing of farmworkers and animals is needed to detect the H5N1 bird flu virus, study it, and stop it before it becomes a fixture on farms.

Researchers have urged a more aggressive response from the CDC and other federal agencies to prevent future infections. Many people exposed regularly to livestock and poultry on farms still lack protective gear and education about the disease. And they don’t yet have permission to get a bird flu vaccine.

Nearly a dozen virology and outbreak experts recently interviewed by KFF Health News disagree with the CDC’s decision against vaccination, which may help prevent bird flu infection and hospitalization.

“We should be doing everything we can to eliminate the chances of dairy and poultry workers contracting this virus,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “If this virus is given enough opportunities to jump from cows or poultry into people, it will eventually get better at infecting them.”

To understand whether cases are going undetected, researchers in Michigan have sent the CDC blood samples from workers on dairy farms. If they detect bird flu antibodies, it’s likely that people are more easily infected by cattle than previously believed.

“It’s possible that folks may have had symptoms that they didn’t feel comfortable reporting, or that their symptoms were so mild that they didn’t think they were worth mentioning,” said Natasha Bagdasarian, chief medical executive for the state of Michigan.

In hopes of thwarting a potential pandemic, the United States, United Kingdom, Netherlands, and about a dozen other countries are stockpiling millions of doses of a bird flu vaccine made by the vaccine company CSL Seqirus.

Seqirus’ most recent formulation was greenlighted last year by the European equivalent of the FDA, and an earlier version has the FDA’s approval. In June, Finland decided to offer vaccines to people who work on fur farms as a precaution because its mink and fox farms were hit by bird flu last year.

The CDC has controversially decided not to offer at-risk groups bird flu vaccines. Demetre Daskalakis, director of the CDC’s National Center for Immunization and Respiratory Diseases, told KFF Health News that the agency is not recommending a vaccine campaign at this point for several reasons, even though millions of doses are available. One is that cases still appear to be limited, and the virus isn’t spreading rapidly between people as they sneeze and breathe.

The agency continues to rate the public’s risk as low. In a statement posted in response to the new Colorado cases, the CDC said its bird flu recommendations remain the same: “An assessment of these cases will help inform whether this situation warrants a change to the human health risk assessment.”

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OSKALOOSA, Iowa — Rural regions like the one surrounding this southern Iowa town used to have a lot more babies, and many more places to give birth to them.

At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000. Those facilities, representing about a third of all Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted. In some Iowa counties, annual numbers of births have fallen by three-quarters since the height of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, state and federal records show.

Similar trends are playing out nationwide, as hospitals struggle to maintain staff and facilities to safely handle dwindling numbers of births. More than half of rural U.S. hospitals now lack the service.

“People just aren’t having as many kids,” said Addie Comegys, who lives in southern Iowa and has regularly traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when big families didn’t seem so rare.

“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.

These days, many Americans choose to have small families or no children at all. Modern birth control methods help make such decisions stick. The trend is amplified in small towns when young adults move away, taking any childbearing potential with them.

Hospital leaders who close obstetrics units often cite declining birth numbers, along with staffing challenges and financial losses. The closures can be a particular challenge for pregnant women who lack the reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.

The baby boom peaked in 1957, when about 4.3 million children were born in the United States. The annual number of births dropped below 3.7 million by 2022, even though the overall U.S. population nearly doubled over that same period.

West Virginia has seen the steepest decline in births, a 62% drop in those 65 years, according to federal data. Iowa’s births dropped 43% over that period. Of the state’s 99 counties, just four — all urban or suburban — recorded more births.

Births have increased in only 13 states since 1957. Most of them, such as Arizona, California, Florida, and Nevada, are places that have attracted waves of newcomers from other states and countries. But even those states have had obstetrics units close in rural areas.

In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by pulling in patients from 14 other counties. Last year, the hospital even managed the rare feat of recruiting two obstetrician-gynecologists to expand its services.

The publicly owned hospital, called Mahaska Health, expects to deliver 250 babies this year, up from about 160 in previous years, CEO Kevin DeRonde said.

“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.

Many of the U.S. hospitals that are now dropping obstetrics units were built or expanded in the mid-1900s, when America went on a rural-hospital building spree, thanks to federal funding from the Hill-Burton Act.

“It was an amazing program,” said Brock Slabach, chief operations officer for the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”

Slabach said that in addition to declining birth numbers, obstetrics units are experiencing a drop in occupancy because most patients go home after a night or two. In the past, patients typically spent several days in the hospital after giving birth.

Dwindling caseloads can raise safety concerns for obstetrics units.

A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year. The authors said they didn’t support closing low-volume units, because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers.

Stephanie Radke, a University of Iowa obstetrics and gynecology professor who studies access to birthing services, said it is almost inevitable that when rural birth numbers plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.

Radke said maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It’s difficult to maintain quality of care when the staff doesn’t consistently practice deliveries, she said, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”

In some cases, she said, hospitals near each other have consolidated obstetrics units, pooling their resources into one program that has enough staffers and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.

The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.

Johnson said rural areas that have seen the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after they move to the U.S., he said.

Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle. Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower.

In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and to give birth, Kozhimannil said. That leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services, she said.

Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. But Oskaloosa’s hospital hit the jackpot last year, when it recruited Taylar Swartz and Garth Summers, a married couple who both recently finished their obstetrics training. Swartz grew up in the area, and she wanted to return to serve women there.

She hopes the number of obstetrics units will level off after the wave of closures. “It’s not even just for delivery, but we need access just to women’s health care in general,” she said. “I would love to see women’s health care be at the forefront of our government’s mind.”

Swartz noted that the state has only one obstetrics training program, which is at the University of Iowa. She said she and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.

Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home, but she wasn’t confident in its quality. Other hospitals in her region had shuttered their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and to give birth there. She knows many other women are not so lucky, and she worries other obstetrics units are at risk.

“It’s sad, but I could see more closing,” she said.

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SACRAMENTO — When then-Gov. Arnold Schwarzenegger called for nearly all Californians to buy health insurance or face a penalty, Anthony Wright slammed the 2007 proposal as “unwarranted, unworkable, and unwise” — one that would punish those who could least afford coverage. The head of Health Access California, one of the state’s most influential consumer groups, changed course only after he and his allies extracted a deal to increase subsidies for people in need.

The plan was ultimately blocked by Democrats who wanted the state to adopt a single-payer health care system instead. Yet the moment encapsulates classic Anthony Wright: independent-minded and willing to compromise if it could help Californians live healthier lives without going broke.

This summer, Wright will assume the helm of the health consumer group Families USA, taking his campaign for more affordable and accessible health care to the national level and a deeply divided Congress. In his 23 years in Sacramento, Wright has successfully lobbied to outlaw surprise medical billing, require companies to report drug price increases, and cap hospital bills for uninsured patients — policies that have spread nationwide.

“He pushed the envelope and gave people aspirational leadership,” said Jennifer Kent, who served as Schwarzenegger’s head of the Department of Health Care Services, which administers the state Medicaid program. The two were often on opposing sides on health policy issues. “There was always, like, one more thing, one more goal, one more thing to achieve.”

Recently, Wright co-led a coalition of labor and immigrant rights activists to provide comprehensive Medicaid benefits to all eligible California residents regardless of immigration status. The state funds this coverage because the federal government doesn’t allow it.

His wins have come mostly under Democratic governors and legislatures and when Republican support hasn’t been needed. That will not be the case in Washington, D.C., where Republicans currently control the House and the Senate Democratic Caucus has a razor-thin majority, which has made it extremely difficult to pass substantive legislation. November’s elections are not expected to ease the partisan impasse.

Though both Health Access and Families USA are technically nonpartisan, they tend to align with Democrats and lobby for Democratic policies, including abortion rights. But “Anthony doesn’t just talk to his own people,” said David Panush, a veteran Sacramento health policy consultant. “He has an ability to connect with people who don’t agree with you on everything.”

Wright, who interned for Vice President Al Gore and worked as a consumer advocate at the Federal Communications Commission in his 20s, acknowledges his job will be tougher in the nation’s capital, and said he is “wide-eyed about the dysfunction” there. He said he also plans to work directly with state lawmakers, including encouraging those in the 10, mostly Republican states that have not yet expanded Medicaid under the Affordable Care Act to do so.

In an interview with California Healthline senior correspondent Samantha Young, Wright, 53, discussed his accomplishments in Sacramento and the challenges he will face leading a national consumer advocacy group. His remarks have been edited for length and clarity.

Q: Is there something California has done that you’d like to see other states or the federal government adopt?

Just saying “We did this in California” is not going to get me very far in 49 other states. But stuff that has already gone national, like the additional assistance to buy health care coverage with state subsidies, that became something that was a model for what the federal government did in the American Rescue Plan [Act] and the Inflation Reduction Act. Those additional tax credits have had a huge impact. About 5 million Americans have coverage because of them. Yet, those additional tax credits expire in 2025. If those tax credits expire, the average premium will spike $400 a month.

Q: You said you will find yourself playing defense if former President Donald Trump is elected in November. What do you mean?

Our health is on the ballot. I worry about the Affordable Care Act and the protections for preexisting conditions, the help for people to afford coverage, and all the other consumer patient protections. I think reproductive health is obviously front and center, but that’s not the only thing that could be taken away. It could also be something like Medicare’s authority to negotiate prices on prescription drugs.

Q: But Trump has said he doesn’t want to repeal the ACA this time, rather “make it better.”

We just need to look at the record of what was proposed during his first term, which would have left millions more people uninsured, which would have spiked premiums, which would have gotten rid of key patient protections.

Q: What’s on your agenda if President Joe Biden wins reelection?

It partially depends on the makeup of Congress and other elected officials. Do you extend this guarantee that nobody has to spend more than 8.5% of their income on coverage? Are there benefits that we can actually improve in Medicare and Medicaid with regard to vision and dental? What are the cost drivers in our health system?

There is a lot we can do at both the state and the federal level to get people both access to health care and also financial security, so that their health emergency doesn’t become a financial emergency as well.

Q: Will it be harder to get things done in a polarized Washington?

The dysfunction of D.C. is a real thing. I don’t have delusions that I have any special powers, but we will try to do our best to make progress. There are still very stark differences, whether it’s about the Affordable Care Act or, more broadly, about the social safety net. But there’s always opportunities for advancing an agenda.

There could be a lot of common ground on areas like health care costs and having greater oversight and accountability for quality in cost and quality in value, for fixing market failures in our health system.

Q: What would happen in California if the ACA were repealed?

When there was the big threat to the ACA, a lot of people thought, “Can’t California just do its own thing?” Without the tens of billions of dollars that the Affordable Care Act provides, it would have been very hard to sustain. If you get rid of those subsidies, and 5 million Californians lose their coverage, it becomes a smaller and sicker risk pool. Then premiums spike up for everybody, and, basically, the market becomes a death spiral that will cover nobody, healthy or sick.

Q: California expanded Medicaid to qualified immigrants living in the state without authorization. Do you think that could happen at the federal level?

Not at the moment. I would probably be more focused on the states that are not providing Medicaid to American citizens [who] just happen to be low-income. They are turning away precious dollars that are available for them.

Q: What do you take away from your time at Health Access that will help you in Washington?

It’s very rare that anything of consequence is done in a year. In many cases, we’ve had to run a bill or pursue a policy for multiple years or sessions. So, the power of persistence is that if you never give up, you’re never defeated, only delayed. Prescription drug price transparency took three years, surprise medical bills took three years, the hospital fair-pricing act took five years.

Having a coalition of consumer voices is important. Patients and the public are not just another stakeholder. Patients and the public are the point of the health care system.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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KFF Health News contributor Andy Miller discussed the Federal Trade Commission criticizing pharmacy benefit managers on KCBS on July 9. He also discussed diversity, equity, and inclusion programs in medicine and bird flu on WUGA’s “The Georgia Health Report” on July 5 and June 28, respectively.

• Click here to hear Miller on KCBS
• Click here to hear Miller on “The Georgia Health Report” on July 5
• Click here to hear Miller on “The Georgia Health Report” on June 28
• Read Lauren Sausser’s “Mississippi Lacks Black Doctors, Even as Lawmakers Increasingly Target Diversity Programs”
• Read Amy Maxmen’s “‘We’re Flying Blind’: CDC Has 1M Bird Flu Tests Ready, but Experts See Repeat of Covid Missteps”

KFF Health News senior correspondent Aneri Pattani discussed the Supreme Court decision to throw out a bankruptcy deal involving the makers of OxyContin, which would have shielded the owners of Purdue Pharma from civil lawsuits, on NPR’s “Weekend Edition Sunday” on June 30. Pattani discussed the same issue in a Facebook Live conversation with Community Education Group on July 3.

• Click here to hear Pattani on “Weekend Edition Sunday”
• Click here to watch Pattani’s discussion with “Community Education Group”
• Read Pattani’s “Supreme Court Upends Purdue Pharma Opioid Settlement”

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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HHS Secretary Becerra today declared a Public Health Emergency for the state of Texas.

Colorado se encuentra entre los 10 estados que han desafiliado a la mayor proporción de beneficiarios de Medicaid desde que el gobierno de Estados Unidos levantara una restricción de la pandemia sobre la eliminación de afiliados al programa médico.

Es el único estado demócrata entre un grupo de estados republicanos con altas tasas de desafiliación, que incluye a Idaho, Montana, Texas y Utah, en un proceso de Medicaid que comenzó en la primavera de 2023.

Colorado también es el único estado que tenía todos los ingredientes políticos para amortiguar las consecuencias de este proceso, según analistas de políticas de Medicaid en KFF.

Pero al parecer esta amortiguación no se puso en marcha.

“Realmente hay una división en Colorado entre nuestras políticas progresistas y nuestra administración subfinanciada y fragmentada”, dijo Bethany Pray, directora legal y de políticas del Colorado Center on Law and Policy, un grupo de asistencia legal con sede en Denver.

Según los datos de KFF, durante las desafiliaciones, Colorado ha visto una caída neta en la inscripción a Medicaid y al Programa de Seguro Médico Infantil (CHIP), mayor que cualquier estado excepto Utah.

Defensores del acceso a la atención médica, investigadores y administradores de condados —quienes manejan la mayor parte de las redeterminaciones de Medicaid en Colorado— dicen que los problemas principales involucran una tecnología obsoleta y bajas tasas de renovaciones automáticas. Ambos crean obstáculos para la inscripción que socavan a las políticas progresistas del estado.

Los funcionarios estatales tienen una visión más optimista. Dicen que la caída en la inscripción es una señal de que hicieron un buen trabajo inscribiendo a las personas en el apogeo de la pandemia de covid-19. En segundo lugar, dicen que la economía de Colorado está funcionando bien, por lo que más personas pueden obtener seguro a través de sus trabajos.

“Cuando tenemos una tasa de desempleo realmente estelar, no tantas personas necesitan programas de la red de seguridad, y estamos orgullosos de eso. Nuestra gente está prosperando”, dijo Kim Bimestefer, quien lidera el Departamento de Política y Financiamiento de Atención Médica y es la principal funcionaria de Medicaid del estado. Su departamento también ha dicho que algunas personas optan por no llenar sus documentos de elegibilidad porque saben que sus ingresos son demasiado altos para calificar.

Los datos de la Oficina de Estadísticas Laborales muestran que, si bien es cierto que la tasa de desempleo de Colorado es más baja que la del país en su conjunto, es más alta de lo que era antes de la pandemia.

Funcionarios del estado dicen que creen que las inscripciones en Medicaid disminuyeron porque muchas de esas personas encontraron trabajo, como lo reflejan las tasas de desempleo más bajas. Pero ese escenario ocurrió en menos de la mitad de los condados del estado, según un análisis de KFF Health News.

Notablemente, en 11 condados donde el desempleo se estancó o aumentó de enero de 2020 a abril de 2024, la proporción de la población cubierta por Medicaid se redujo. Una baja tasa de desempleo no significa necesariamente que haya menos necesidad de cobertura de Medicaid, porque muchas personas empleadas ganan salarios lo suficientemente bajos como para seguir calificando para el programa.

Colorado aumentó la inscripción en Medicaid y CHIP en un 35% durante la emergencia de salud pública de covid, en comparación con aproximadamente el 30% a nivel nacional, y entre los estados que expandieron Medicaid.

“Crecimos más, lo que significa, lógicamente, que vamos a dar de baja a más personas”, dijo Bimestefer. “Subimos alto, vamos a bajar más bajo, porque nuestra economía es estelar”.

El sitio web de su departamento inicialmente afirmó que la inscripción en Medicaid de Colorado había crecido más que cualquier otro estado con Medicaid expandido, excepto Hawaii. Pero los datos de los Centros de Servicios de Medicare y Medicaid (CMS) muestran que el aumento de la inscripción durante la pandemia en otros estados, incluidos Indiana, Dakota del Norte, Virginia y Nevada, también superaron a la de Colorado.

Incluso si hubiera crecido más, el argumento de que lo que sube debe bajar no se sostiene, dijeron analistas de políticas de Medicaid.

“Un argumento contrario a eso es que sabemos que nunca hubo una participación total en Medicaid antes de la pandemia”, dijo Jennifer Tolbert, subdirectora del Program on Medicaid and the Uninsured de KFF.

Tolbert dijo que estaba sorprendida por la magnitud de las pérdidas de inscripción en Medicaid de Colorado, dado que era el único estado en la nación que cumplía con todos los criterios que KFF esperaba que amortiguaran los efectos de las desafiliaciones. Esas políticas incluyen haber expandido Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) y el procesamiento automático de renovaciones.

Tolbert fue una de varios investigadores que dijeron que incluso si el desempleo volviera a los niveles previos a la pandemia, esperarían una proporción más alta, no más baja, de habitantes de Colorado inscritos en la cobertura de la red de seguridad.

Ally Sullivan, portavoz del gobernador demócrata Jared Polis, dijo que un factor que complica ls cosas en el sistema de Colorado es que es uno de los pocos estados donde la mayor parte del trabajo de verificación de elegibilidad recae en los condados, “lo que agregó complejidad al proceso de desafiliaciones”.

“Colorado está comprometido a garantizar que sus habitantes que ya no califican para la cobertura de Medicaid se conecten a otras fuentes asequibles de cobertura lo antes posible, y el estado está haciendo grandes esfuerzos para hacerlo”, decía el comunicado.

Minnesota es otro estado donde la verificación de elegibilidad recae en gran medida en los condados. Sin embargo, dio de baja solo al 26% de su población bajo Medicaid, en comparación con el 48% de Colorado.

Al igual que Colorado, Minnesota tiene un gobernador demócrata. También se parece a Colorado en su población, aumento de inscripción durante la pandemia, el porcentaje de sus residentes que viven en áreas prósperas y su tasa de desempleo, por debajo de la nacional.

Pero Bimestefer descartó cualquier comparación. “No me importa Minnesota”, dijo Bimestefer. “Esto es Colorado. No me importa lo que hizo Minnesota”.

Defensores del acceso a la atención médica e investigadores dijeron que un conjunto de problemas tecnológicos y administrativos han contribuido a que la tasa de desafiliaciones fuera alta.

Primero, la base de datos de elegibilidad de Colorado, el Sistema de Gestión de Beneficios de Colorado, está obsoleta, según personas que la usan o están familiarizadas con sistemas en otros estados.

“Es como seguir usando un viejo celular”, dijo Sarah Grusin, abogada del Programa Nacional de Ley de Salud. “Tenemos cosas mejores”.

Las organizaciones de Grusin y Pray presentaron una queja de derechos civiles ante varias agencias federales diciendo que los problemas del sistema que terminaron con la cobertura de los habitantes de Colorado discapacitados equivalían a discriminación.

“Tomó muchos meses arreglar algo que no parece tan complicado”, dijo Pray.

Bimestefer dijo que su departamento está trabajando en un plan para mejorar el sistema, que es administrado por Deloitte bajo un contrato de $354.4 millones hasta 2027. Una reciente investigación de KFF Health News sobre sistemas de elegibilidad administrados por Deloitte encontró problemas generalizados. En Colorado, una auditoría ordenada por el estado en 2020 halló que a muchos beneficiarios de Medicaid se les habían enviado avisos y plazos incorrectos.

Kenneth Smith, ejecutivo de Deloitte que lidera su división nacional de servicios humanos, dijo que Deloitte es uno de los muchos actores que administran los beneficios de Medicaid, y que los estados son los dueños de la tecnología y toman las decisiones sobre su implementación.

Los problemas tecnológicos de Colorado también han debilitado su capacidad para usar una herramienta poderosa en la inscripción: la renovación automática.

Bimestefer dijo que, el otoño pasado, su agencia tuvo que elegir entre arreglar el sistema para que dejara de dar de baja a niños que no debían perder la cobertura, o comenzar a renovar automáticamente a personas sin ingresos o con ingresos por debajo del nivel federal de pobreza. No podía hacer ambas cosas, dijo.

Expertos como Tricia Brooks, profesora investigadora del Centro de Niños y Familias de la Universidad de Georgetown, dijeron que es especialmente importante aumentar las renovaciones automáticas en estados como Colorado, donde la mayor parte del trabajo de renovación recae en personal de los gobiernos de los condados.

“¿Qué pasa cuando no se obtiene una alta tasa de renovaciones automáticas? Estás enviando esos formularios de renovación”, dijo Brooks, lo que significa más bajas. “No recibieron el correo. El aviso fue confuso. Intentaron obtener ayuda a través del centro de llamadas. La lista de por qué las personas no renuevan es larga”.

De hecho, dos tercios de los habitantes de Colorado dados de baja perdieron la cobertura por razones de procedimiento. Eso concuerda con el promedio nacional, según KFF. Pero junto con el hecho de que Colorado ha dado de baja a tanta gente en general, eso significa que más de 500,000 habitantes del estado, o aproximadamente el 9% de la población, fueron dados de baja por razones de procedimiento. Más que la población de su segunda ciudad más grande, Colorado Springs.

Se determinó que al menos un tercio de los dados de baja eran elegibles para Medicaid.

Funcionarios de centros comunitarios de salud de Colorado y centros de salud mental dicen que están viendo un aumento de pacientes que llegan a sus puertas sin seguro, una señal, dicen, de que los habitantes de Colorado dados de baja de Medicaid no necesariamente están mejor en términos de seguro de salud.

El 58% de los que fueron dados de baja han regresado a Medicaid o ahora tienen otro seguro. Pero el estado aún no sabe qué pasó con el 42% restante de las personas que fueron dadas de baja, y dijo que realizaría una encuesta para averiguarlo.

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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A lawsuit winding its way through the courts could undermine the power of federal agencies to mandate the services health insurance providers must cover. And that could threaten access to free birth control for millions of Americans.

The case is called Braidwood Management Inc. v. Becerra, and it was brought by plaintiffs looking to strike down Obamacare’s requirements that private insurers cover certain kinds of preventive care without cost sharing. (Think everything from no-cost cancer screenings to free IUDs.)

Studies have shown the requirements to cover preventive care have increased consumers’ use of short- and long-term birth control methods.

Without those nationwide standards, the United States would return to a “wild West” dynamic “in which insurers and employers pick and choose which services they want to cover or which services they want to charge for,” said Zachary Baron, a health policy researcher at Georgetown Law.

The plaintiffs, a group of individuals and Christian-owned businesses, argue the three groups that set coverage standards — including an independent advisory panel to the Health Resources and Services Administration — haven’t been properly appointed by Congress.

In June, the U.S. Court of Appeals for the 5th Circuit issued a self-described “mixed bag” of an opinion. It agreed that one body hadn’t been properly appointed, making its recommendations since the Affordable Care Act became law unconstitutional. But the court said only the plaintiffs get to ignore its standards.

The appeals court sent questions about the other two groups — including the advisory panel to HRSA that makes recommendations on contraception — back to a lower court to consider.

The case is likely headed back to U.S. District Judge Reed O’Connor. O’Connor’s previous ruling that one body hadn’t been properly appointed was supported by the appeals court. His remedy — blocking its mandates nationwide — wasn’t.

O’Connor is notoriously hostile to the ACA — he struck down the law in 2018. The Supreme Court later overturned that ruling.

And that makes reproductive rights advocates nervous.

O’Connor “is someone who is willing to impose remedies where he takes access to care away from everybody in the country,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center.

A lack of federal requirements for birth control coverage would leave it up to the states to mandate what insurers have to provide. Fourteen states and D.C. currently protect the right to contraception.

But states can go only so far with those rules, because of a federal law that prevents them from regulating employer-funded health plans, which cover about 65 percent of workers.

“If the plaintiffs win here, it would leave significant gaps in coverage that states would be unable to fill,” Baron said.

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Few people want to go into a nursing home, but doing so can be the right choice if you or a loved one is physically or cognitively disabled or recovering from surgery. Unfortunately, homes vary greatly in quality, and many don’t have enough nurses and aides to give residents the care they need.

Q: How do I find nursing homes worth considering?

Start with Medicare’s online comparison tool, which you can search by city, state, ZIP code, or home name. Ask for advice from people designated by your state to help people who are older or have disabilities search for a nursing home. Every state has a “no wrong door” contact for such inquiries.

You can also reach out to your local area agency on aging, a public or nonprofit resource, and your local long-term care ombudsman, who helps residents resolve problems with their nursing home.

Find your area agency on aging and ombudsman through the federal government’s Eldercare Locator website or by calling 1-800-677-1116. Identify your ombudsman through the National Consumer Voice for Quality Long-Term Care, an advocacy group. Some people use private placement agencies, but they may refer you only to homes that pay them a referral fee.

Q: What should I find out before visiting a home?

Search online for news coverage and for reviews posted by residents or their families.

Call the home to make sure beds are available. Well-regarded homes can have long waiting lists.

Figure out how you will pay for your stay. Most nursing home residents rely primarily on private long-term care insurance, Medicare (for rehabilitation stays) or Medicaid (for long-term stays if you have few assets). In some cases, the resident pays entirely out-of-pocket. If you’re likely to run out of money or insurance coverage during your stay, make sure the home accepts Medicaid. Some won’t admit Medicaid enrollees unless they start out paying for the care themselves.

If the person needing care has dementia, make sure the home has a locked memory-care unit to ensure residents don’t wander off.

Q: How can I tell if a home has adequate staffing?

Medicare’s comparison tool gives each home a rating of one to five stars based on staffing, health inspection results, and measurements of resident care such as how many residents had pressure sores that worsened during their stay. Five is the highest rating. Below that overall rating is one specifically for staffing.

Be sure to study the annual staff turnover rate, at the bottom of the staffing page. Anything higher than the national rate — an appalling 52% — should give you pause.

You should also pay attention to the inspection star rating. The “quality” star rating is less reliable because homes self-report many of the results and have incentives to put a glossy spin on their performance.

Q: Does a home with three, four, or five stars provide good care?

Not necessarily. Medicare’s ratings compare the staffing of a home against that of other homes, not against an independent standard. The industry isn’t as well staffed as many experts think it needs to be: About 80% of homes, even some with four and five stars, are staffed below the standards the Biden administration will be requiring homes to meet in the next five years.

Q: How many workers are enough?

There’s no straightforward answer; it depends on how frail and sick a nursing home’s residents are. Medicare requires homes to prominently post their staffing each day. The notices should show the number of residents, registered nurses, licensed vocational nurses, and nurse aides. RNs are the most skilled and manage the care. LVNs provide care for wounds and catheters and handle basic medical tasks. Nurse aides help residents eat, dress, and get to the bathroom.

Expert opinions vary on the ideal ratios of staffing. Sherry Perry, a Tennessee nursing assistant who is the chair of her profession’s national association, said that preferably a nursing assistant should care for eight or fewer residents.

Charlene Harrington, an emerita professor of nursing at the University of California-San Francisco, recommends that on the day shift there be one nurse aide for every seven residents who need help with physical functioning or have behavioral issues; one RN for every 28 residents; and one LVN for every 38 residents. Patients with complex medical needs will need higher staffing levels.

Staffing can be lower at night because most residents are sleeping, Harrington said.

Nursing home industry officials say that there’s no one-size-fits-all ratio and that a study the federal government published last year found quality improved with higher staffing but didn’t recommend a particular level.

Q: What should I look for when I visit a home?

Watch to see if residents are engaged in activities or if they are alone in their rooms or slumped over in wheelchairs in hallways. Are they still in sleeping gowns during the day? Do nurses and aides know the residents by name? Is food available only at mealtimes, or can residents get snacks when hungry? Watch a meal to see whether people are getting the help they need. You might visit at night or on weekends or holidays, when staffing is thinnest.

Q: What should I ask residents and families in the home?

Are residents cared for by the same people or by a rotating cast of strangers? How long do they have to wait for help bathing or getting out of bed? Do they get their medications, physical therapy, and meals on time? Do aides come quickly if they turn on their call light? Delays are strong signs of understaffing.

Medicare requires homes to allow residents and families to form councils to address common issues. If there’s a council, ask to speak to its president or an officer.

Ask what proportion of nurses and aides is on staff or from temporary staffing agencies; temp workers won’t know the residents’ needs and likes as well. A home that relies heavily on temporary staff most likely has trouble recruiting and keeping employees.

Q: What do I need to know about a home’s leadership?

Turnover at the top is a sign of trouble. Ask how long the home’s administrator has been on the job; ideally it should be at least a year. (You can look up administrator turnover on the Medicare comparison tool: It’s on the staffing page beneath staff turnover. But be aware the information may not be up to date.) You should also ask about the tenure of the director of nursing, the top clinical supervisor in a home.

During your tour, observe how admissions staff members treat the person who would be living there. “If you walk in to visit with your mom and they greeted you and didn’t greet your mom or focused all their attention on you, go somewhere else,” advised Carol Silver Elliott, president of the Jewish Home Family, a nonprofit in Rockleigh, New Jersey.

Q: Does it matter who owns the home?

It often does. Generally, nonprofit nursing homes provide better care because they can reinvest revenue back into the home rather than paying some of it to owners and investors.

But there are some very good for-profit homes and some lousy nonprofits. Since most homes in this country are for-profit, you may not have a choice in your area. As a rule of thumb, the more local and present the owner, the more likely the home will be well run. Many owners live out of state and hide behind corporate shell companies to insulate themselves from accountability. If nursing home representatives can’t give you a clear answer when you ask who owns it, think twice.

Finally, ask if the home’s ownership has changed in the past year or so or if a sale is pending. Stable, well-run nursing homes aren’t usually the ones owners are trying to get rid of.

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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For hours, John Pernorio repeatedly mashed the call button at his bedside in the Heritage Hills nursing home in Rhode Island. A retired truck driver, he had injured his spine in a fall on the job decades earlier and could no longer walk. The antibiotics he was taking made him need to go to the bathroom frequently. But he could get there only if someone helped him into his wheelchair.

By the time an aide finally responded, he’d been lying in soiled briefs for hours, he said. It happened time and again.

“It was degrading,” said Pernorio, 79. “I spent 21 hours a day in bed.”

Payroll records show that during his stay at Heritage Hills, daily aide staffing levels were 25% below the minimums under state law. The nursing home said it provided high-quality care to all residents. Regardless, it wasn’t in trouble with the state, because Rhode Island does not enforce its staffing rule.

An acute shortage of nurses and aides in the nation’s nearly 15,000 nursing homes is at the root of many of the most disturbing shortfalls in care for the 1.2 million Americans who live in them, including many of the nation’s frailest old people.

They get festering bedsores because they aren’t turned. They lie in feces because no one comes to attend to them. They have devastating falls because no one helps them get around. They are subjected to chemical and physical restraints to sedate and pacify them.

California, Florida, Massachusetts, New York, and Rhode Island have sought to improve nursing home quality by mandating the highest minimum hours of care per resident among states. But an examination of records in those states revealed that putting a law on the books was no guarantee of better staffing. Instead, many nursing homes operated with fewer workers than required, often with the permission of regulators or with no consequences at all.

“Just setting a number doesn’t mean anything if you’re not going to enforce it,” said Mark Miller, former president of the national organization of long-term care ombudsmen, advocates in each state who help residents resolve problems in their nursing homes. “What’s the point?”

Now the Biden administration is trying to guarantee adequate staffing the same way states have, unsuccessfully, for years: with tougher standards. Federal rules issued in April are expected to require 4 out of 5 homes to boost staffing.

The administration’s plan also has some of the same weaknesses that have hampered states. It relies on underfunded health inspectors for enforcement, lacks explicit penalties for violations, and offers broad exemptions for nursing homes in areas with labor shortages. And the administration isn’t providing more money for homes that can’t afford additional employees.

Serious health violations have become more widespread since covid-19 swept through nursing homes, killing more than 170,000 residents and driving employees out the door.

Pay remains so low — nursing assistants earn $19 an hour on average — that homes frequently lose workers to retail stores and fast-food restaurants that pay as well or better and offer jobs that are far less grueling. Average turnover in nursing homes is extraordinarily high: Federal records show half of employees leave their jobs each year.

Even the most passionate nurses and aides are burning out in short-staffed homes because they are stretched too thin to provide the quality care they believe residents deserve. “It was impossible,” said Shirley Lomba, a medication aide from Providence, Rhode Island. She left her job at a nursing home that paid $18.50 an hour for one at an assisted living facility that paid $4 more per hour and involved residents with fewer needs.

The mostly for-profit nursing home industry argues that staffing problems stem from low rates of reimbursement by Medicaid, the program funded by states and the federal government that covers most people in nursing homes. Yet a growing body of research and court evidence shows that owners and investors often extract hefty profits that could be used for care.

Nursing home trade groups have complained about the tougher state standards and have sued to block the new federal standards, which they say are unworkable given how much trouble nursing homes already have filling jobs. “It’s a really tough business right now,” said Mark Parkinson, president and chief executive of one trade group, the American Health Care Association.

And federal enforcement of those rules is still years off. Nursing homes have as long as five years to comply with the new regulations; for some, that means enforcement would fully kick in only at the tail end of a second Biden administration, if the president wins reelection. Former President Donald Trump’s campaign declined to comment on what Trump would do if elected.

Persistent Shortages

Nursing home payroll records submitted to the federal government for the most recent quarter available, October to December 2023, and state regulatory records show that homes in states with tougher standards frequently did not meet them.

In more than two-thirds of nursing homes in New York and more than half of those in Massachusetts, staffing was below the state’s required minimums. Even California, which passed the nation’s first minimum staffing law two decades ago, has not achieved universal compliance with its requirements: at least 3½ hours of care for the average resident each day, including two hours and 24 minutes of care from nursing assistants, who help residents eat and get to the bathroom.

During inspections since 2021, state regulators cited a third of California homes — more than 400 of them — for inadequate staffing. Regulators also granted waivers to 236 homes that said workforce shortages prevented them from recruiting enough nurse aides to meet the state minimum, exempting them from fines as high as $50,000.

In New York, Gov. Kathy Hochul declared an acute labor shortage, which allows homes to petition for reduced or waived fines. The state health department said it had cited more than 400 of the state’s 600-odd homes for understaffing but declined to say how many of them had appealed for leniency.

In Florida, Gov. Ron DeSantis signed legislation in 2022 to loosen the staffing rules for all homes. The law allows homes to count almost any employee who engages with residents, instead of just nurses and aides, toward their overall staffing. Florida also reduced the daily minimum of nurse aide time for each resident by 30 minutes, to two hours.

Now only 1 in 20 Florida nursing homes are staffed below the minimum — but if the former, more rigorous rules were still in place, 4 in 5 homes would not meet them, an analysis of payroll records shows.

“Staffing is the most important part of providing high-quality nursing home care,” said David Stevenson, chair of the health policy department at Vanderbilt University School of Medicine. “It comes down to political will to enforce staffing.”

The Human Toll

There is a yawning gap between law and practice in Rhode Island. In the last three months of 2023, only 12 of 74 homes met the state’s minimum of three hours and 49 minutes of care per resident, including at least two hours and 36 minutes of care from certified nursing assistants, payroll records show. One of the homes below the minimum was Heritage Hills Rehabilitation & Healthcare Center in Smithfield, where Pernorio, president of the Rhode Island Alliance for Retired Americans, went last October after a stint in a hospital.

“From the minute the ambulance took me in there, it was downhill,” he said in an interview.

Sometimes, after waiting an hour, he would telephone the home’s main office for help. A nurse would come, turn off his call light, and walk right back out, and he would push the button again, Pernorio reported in his weekly e-newsletter.

While he praised some workers’ dedication, he said others frequently did not show up for their shifts. He said staff members told him they could earn more flipping hamburgers at McDonald’s than they could cleaning soiled patients in a nursing home.

In a written statement, Heritage Hills did not dispute that its staffing, while higher than that of many homes, was below the minimum under state law.

Heritage Hills said that after Pernorio complained, state inspectors visited the home and did not cite it for violations. “We take every resident concern seriously,” it said in the statement. Pernorio said inspectors never interviewed him after he called in his complaint.

In interviews, residents of other nursing homes in the state and their relatives reported neglect by overwhelmed nurses and aides.

Jason Travers said his 87-year-old father, George, fell on the way to the bathroom because no one answered his call button.

“I think the lunch crew finally came in and saw him on the floor and put him in the bed,” Travers said. His father died in April 2023, four months after he entered the home.

Relatives of Mary DiBiasio, 92, who had a hip fracture, said they once found her sitting on the toilet unattended, hanging on to the grab bar with both hands. “I don’t need to be a medical professional to know you don’t leave somebody hanging off the toilet with a hip fracture,” said her granddaughter Keri Rossi-D’entremont.

When DiBiasio died in January 2022, Rhode Island was preparing to enact a law with nurse and aide staffing requirements higher than anywhere else in the country except Washington, D.C. But Gov. Daniel McKee suspended enforcement, saying the industry was in poor financial shape and nursing homes couldn’t even fill existing jobs. The governor’s executive order noted that several homes had closed because of problems finding workers.

Yet Rhode Island inspectors continue to find serious problems with care. Since January 2023, regulators have found deficiencies of the highest severity, known as immediate jeopardy, at 23 of the state’s 74 nursing homes.

Homes have been cited for failing to get a dialysis patient to treatment and for giving one resident a roommate’s methadone, causing an overdose. They have also been cited for violent behavior by unsupervised residents, including one who shoved pillow stuffing into a resident’s mouth and another who turned a roommate’s oxygen off because it was too noisy. Both the resident who was attacked and the one who lost oxygen died.

Bottom Lines

Even some of the nonprofit nursing homes, which don’t have to pay investors, are having trouble meeting the state minimums — or simply staying open.

Rick Gamache, chief executive of the nonprofit Aldersbridge Communities, which owns Linn Health & Rehabilitation in East Providence, said Rhode Island’s Medicaid program paid too little for the home to keep operating — about $292 per bed, when the daily cost was $411. Aldersbridge closed Linn this summer and converted it into an assisted living facility.

“We’re seeing the collapse of post-acute care in America,” Gamache said.

Many nursing homes are owned by for-profit chains, and some researchers, lawyers, and state authorities argue that they could reinvest more of the money they make into their facilities.

Bannister Center, a Providence nursing home that payroll records show is staffed 10% below the state minimum, is part of Centers Health Care, a New York-based private chain that owns or operates 31 skilled nursing homes, according to Medicare records. Bannister lost $430,524 in 2021, according to a financial statement it filed with Rhode Island regulators.

Last year, the New York attorney general sued the chain’s owners and investors and their relatives, accusing them of improperly siphoning $83 million in Medicaid funds out of their New York nursing homes by paying salaries for “no-show” jobs, profits above what state law allowed, and inflated rents and fees to other companies they owned. For instance, one of those companies, which purported to provide staff to the homes, paid $5 million to the wife of Kenny Rozenberg, the chain’s chief executive, from 2019 to 2021, the lawsuit said.

The defendants argued in court papers that the payments to investors and owners were legal and that the state could not prove they were Medicaid funds. They have asked for much of the lawsuit to be dismissed.

Jeff Jacomowitz, a Centers Health Care spokesperson, declined to answer questions about Bannister, Centers’ operations, or the chain’s owners.

Miller, the District of Columbia’s long-term care ombudsman, said many nursing home owners could pay better wages if they didn’t demand such high profits. In D.C., 7 in 10 nursing homes meet minimum standards, payroll records show.

“There’s no staffing shortage — there’s a shortage of good-paying jobs,” he said. “I’ve been doing this since 1984 and they’ve been going broke all the time. If it really is that bad of an investment, there wouldn’t be any nursing homes left.”

The new federal rules call for a minimum of three hours and 29 minutes of care each day per resident, including two hours and 27 minutes from nurse aides and 33 minutes from registered nurses, and an RN on-site at all times.

Homes in areas with worker shortages can apply to be exempted from the rules. Dora Hughes, acting chief medical officer for the U.S. Centers for Medicare & Medicaid Services, said in a statement that those waivers would be “time-limited” and that having a clear national staffing minimum “will facilitate strengthened oversight and enforcement.”

David Grabowski, a health policy professor at Harvard Medical School, said federal health authorities have a “terrible” track record of policing nursing homes. “If they don’t enforce this,” he said, “I don’t imagine it’s going to really move the needle a lot.”

Methodology for Analysis of Nursing Home Staffing

The KFF Health News data analysis focused on five states with the most rigorous staffing requirements: California, Florida, Massachusetts, New York, and Rhode Island.

To determine staffing levels, the analysis used the daily payroll journals that each nursing home is required to submit to the federal government. These publicly available records include the number of hours each category of nursing home employee, including registered nurses and certified nursing assistants, worked each day and the number of residents in each home. We used the most recent data, which included a combined 1.3 million records covering the final three months of 2023.

We calculated staffing levels by following each state’s rules, which specify which occupations are counted and what minimums homes must meet. The analysis differed for each state. Massachusetts, for instance, has a separate requirement for the minimum number of hours of care registered nurses must provide each day.

In California, we used state enforcement action records to identify homes that had been fined for not meeting its law. We also tallied how many California homes had been granted waivers from the law because they couldn’t find enough workers to hire.

For each state and Washington, D.C., we calculated what proportion of homes complied with state or district law. We shared our conclusions with each state’s nursing home regulatory agency and gave them an opportunity to respond.

This analysis was performed by senior correspondent Jordan Rau and data editor Holly K. Hacker.

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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SACRAMENTO — Sonja Verdugo lost her husband to an opioid overdose last year. She regularly delivers medical supplies to people using drugs who are living — and dying — on the streets of Los Angeles. And she advocates at Los Angeles City Hall for policies to address addiction and homelessness.

Yet Verdugo didn’t know that hundreds of millions of dollars annually are flowing to California communities to combat the opioid crisis, a payout that began in 2022 and continues through 2038.

The money comes from pharmaceutical companies that made, distributed, or sold prescription opioid painkillers and that agreed to pay about $50 billion nationwide to settle lawsuits over their role in the overdose epidemic. Even though a recent Supreme Court decision upended a settlement with OxyContin maker Purdue Pharma, many other companies have already begun paying out and will continue doing so for years.

California, the most populous state, is in line for more than $4 billion.

“You can walk down the street and you see someone addicted on every corner — I mean it’s just everywhere,” Verdugo said. “And I’ve never even heard of the funds. And to me, that’s crazy.”

Across the nation, much of this windfall has been shrouded in secrecy, with many jurisdictions offering little transparency on how they’re spending the money, despite repeated queries from people in recovery and families who lost loved ones to addiction.

Meanwhile, there’s plenty of jockeying over how the money should be used. Companies are lobbying for spending on products that range from medication bottles that lock to full-body scanners to screen people entering jails. Local officials are often advocating for the fields they represent, whether it’s treatment, prevention, or harm reduction. And some governments are using it to plug budget gaps.

In California, local governments must report how they spend settlement funds to the state’s Department of Health Care Services, but there’s no requirement that the reports be made public.

KFF Health News obtained copies of the documents via a public records request and is now making available for the first time 265 spending reports from local governments for fiscal year 2022-23, the most recent reports filed.

The reports provide a snapshot of the early spending priorities, and tensions.

Naloxone an Early Winner

As of June 2023, the bulk of opioid settlement funds controlled by California cities and counties — more than $200 million — had yet to be spent, the reports show. It’s a theme echoed nationwide as officials take time to deliberate.

The city and county of Los Angeles accounted for nearly one-fifth of that unspent total, nearly $39 million, though officials say that since the report was filed they’ve begun allocating the money to recovery housing and programs to connect people who are homeless with residential addiction treatment.

Among local governments that did use the cash in the first fiscal year, the most popular object of spending was naloxone, a medication that reverses opioid overdoses and is often known by the brand name Narcan. The medication accounted for more than $2 million in spending across 19 projects.

One of those projects was in Union City, in the San Francisco Bay Area. The community of about 72,000 residents had five suspected fentanyl overdoses, two of them fatal, within 24 hours in September.

The opioid settlement money “was invaluable,” Corina Hahn, the city’s director of community and recreation services, said in her report. “Having these resources available helped educate, train and distribute the Narcan kits to parents, youth and school staff.”

Union City bought 500 kits, each containing two doses of naloxone. The kits cost about $13,500, with an additional $56,000 set aside for similar projects, including backpacks containing Narcan kits and training materials for high school students.

Union City also plans to expand its outreach to homeless people to fund drug education and recovery services, including addiction counseling.

Those are the sorts of lifesaving services that Verdugo, the Los Angeles advocate, said are desperately needed as deaths of people living on the streets pile up.

She lost her 46-year-old husband, Jesse Baumgartner, in June of last year to an addiction that started after he was prescribed pain medications for a high school wrestling injury. He tried kicking his habit for six years using methadone, but each time prescribers lowered his dosage the cravings drove him back to illicit drugs.

“It was just this horrible roller coaster of him not being able to get off of it,” Verdugo said.

By then the couple had survived 4½ years of being homeless and had been in stable housing for about two years.

Fentanyl use, particularly among homeless people, “is just rampant,” she said. People sometimes are initially exposed to the cheap, highly addictive substance unknowingly when it is mixed with something else.

“Once they start using it, it's like they just can't backtrack,” said Verdugo, who works as a community organizer for Ground Game LA.

So she leaves boxes of naloxone at homeless encampments in the hope of saving lives.

“They definitely use it, because it's needed right then — they can't wait for an ambulance to come out,” she said.

Cities Backtrack on Spending for Law Enforcement

By contrast, the cities of Irvine and Riverside, both in Greater Los Angeles, listed plans to prioritize law enforcement by buying portable drug analyzers, though neither city did so in the first fiscal year, 2022-23. Their inclination mirrored patterns elsewhere in the country, with millions in settlement funds flowing to police departments and jails.

But such uses of the money have stirred controversy, and both cities backed away from the drug analyzer purchase after the Department of Health Care Services issued rules that opioid settlement funds may not be used for certain law enforcement efforts. The rules specifically excluded “equipment for the purpose of evidence gathering for prosecution, such as the TruNarc Handheld Narcotics Analyzer.”

In Hawthorne, also near Los Angeles, the police department had already spent about $25,000 of settlement funds on an initial installment to buy 80 BolaWraps, devices that shoot Kevlar tethers to wrap around a person’s limbs or torso.

After the state said BolaWraps were not an allowable expense, the city said it would find other funding sources to pay the remaining installments.

Santa Rosa, in California’s wine country, spent nearly $30,000 on police officer wellness and support.

The funds allowed the police department to boost its contracted wellness coordinator from a part-time to a full-time position, and to buy a mobile machine to measure electrical activity in the brain, said Sgt. Patricia Seffens, a spokesperson.

The goal is to use the technology on police officers to help “assess the traumatic impact of responding to the increasing overdose calls,” Seffens said in an email.

In Dublin, east of San Francisco, officials are using part of their $62,000 in settlement cash for a D.A.R.E. program.

D.A.R.E., which stands for Drug Abuse Resistance Education, is a series of classes taught by police officers in schools to encourage students to resist peer pressure and avoid drugs. It was initially developed during the “Just Say No” campaign in the 1980s.

Studies have found inconsistent results from the program and no long-term effects on drug use, leading many researchers to dismiss it as “ineffective.”

But on its website, D.A.R.E. cites studies since the program was updated in 2009, which found “a positive effect” on fifth graders and “statistically significant reductions” in drinking and smoking about four months after completing the program.

“The D.A.R.E. program when it first came out looks a lot, lot different than what it looks like right now,” said Nate Schmidt, the Dublin police chief.

Schmidt said additional settlement money will be used to distribute naloxone to residents and stock it at schools and city facilities.

Other local governments in California spent modest sums on a wide range of addiction-related measures. Ukiah, in Mendocino County, north of San Francisco, spent $11,000 for a new heating and air conditioning system for a local drug treatment center. Orange and San Mateo counties spent settlement funds in part on medication-assisted treatment for people incarcerated in their jails. The city of Oceanside spent $16,000 to showcase drug prevention art and videos made by middle school students in local movie theaters, in public spaces, and on buses and taxis.

The Department of Health Care Services said it plans to release a statewide report on how the funds were spent, as well as the individual city and county reports, by year’s end.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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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Medical debt is a growing burden for millions of people around the country, from parents in Illinois to immigrants in Colorado to residents of the “Diabetes Belt” across the South, and it’s now being recognized as a health-care problem. People often forgo care or prescriptions if they have debt, according to a KFF Health News investigation, and the psychological toll can be steep, too.

The Biden administration proposed barring medical debt from credit reports. This morning, Senate Health Committee Chair Bernie Sanders (I-Vt.) will convene a hearing in D.C. on medical debt.

Now local governments are looking at how they can assist residents by buying up medical debt on the cheap and retiring it.

Under a measure the Los Angeles County Board of Supervisors approved unanimously last month, the county will enter into a pilot program with Undue Medical Debt (previously known as RIP Medical Debt), a national organization that turns the debt collection process on its head. Instead of buying outstanding debt from hospitals and pursuing patients for payment, as commercial debt collectors do, Undue Medical Debt looks to buy debt, usually for pennies on the dollar, then retire it.

Los Angeles County’s $5 million investment is expected to allow Undue Medical Debt to help 150,000 low-income residents and eliminate $500 million in debt. It’s one component of the county’s larger medical debt plan, which includes tracking hospitals’ role in feeding the $2.9 billion problem, boosting bill retirement for low-income patients and monitoring debt collection practices.

Four in 10 adults in the United States struggle with health-care debt, and Los Angeles County has labeled it a public health issue on par with diabetes and asthma.

The logic behind the effort is simple. “Getting health care should never make anyone sicker,” said Naman Shah, medical and dental affairs director at the county public health department.

Undue Medical Debt has contracted with more than a dozen city, county and state governments across the country to provide local debt relief, including Cook County, Ill. (home to Chicago); Toledo; Arizona and New Jersey.

Since its inception, Undue Medical Debt has relieved almost $12 billion in medical debt across the country.

Beginning in 2022, Cook County has leveraged American Rescue Plan dollars — federal emergency funds made available during the coronavirus pandemic — to wipe out over $382 million in medical debt for more than 213,000 residents. About 15 other state or local governments have also used American Rescue Plan funds to retire medical debt, according to Undue Medical Debt, and other jurisdictions are developing similar plans.

Mona Shah of Community Catalyst, a national health equity and policy organization, applauds the local government moves but cautions that one-time debt relief goes only so far. She endorsed Los Angeles County’s approach: pairing debt relief with a longer-term effort to understand and address the root causes of medical debt, in part by getting a better handle on debt collection practices and helping hospitals improve their financial assistance programs.

“We don’t want to ever deny that relief, but we really need to focus on preventing medical debt from happening in the first place,” Shah said.

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

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

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Over three decades of relentless pain, Jonna Tallant has tried about every TMJ treatment: mouthguards, six sets of braces, dental crowns and appliances, drugs, physical therapy, Botox, massage, acupuncture, chiropractic care, and surgery.

Nothing has helped. Tallant, 51, of Knoxville, Tennessee, said she lives in agony and cannot eat any food that must be chewed. Despite spending a small fortune on treatment, she can barely open her mouth enough to squeeze in a toothbrush.

Tallant estimates she has paid at least $200,000 for TMJ care. She provided medical records showing more than $60,000 in out-of-pocket spending in just the past decade. She has exhausted her savings and borrowed money, she said, and her family sold a plot of land to help pay the bills.

Tallant will need another jaw surgery later this year, which could cost as much as $75,000. Her insurance is unlikely to pay for any of it, she said.

“It’s a bottomless pit,” Tallant said, choking up, as she leafed through a pile of medical records splayed on her dining table. “It has consumed so much of my life that there is not much left.”

Temporomandibular joint disorders, known as TMJ or TMD, cause pain and stiffness in the face and jaw and are believed to afflict as many as 33 million Americans. Scientific studies have found that women experience TMJ disorders two to nine times as often as men, and while minor symptoms may not require treatment, severe symptoms can include disabling pain that makes it challenging to eat, work, talk, or sleep.

Despite the commonness of TMJ disorders, treatments are often not covered by medical or dental insurance, leaving patients with out-of-pocket bills that can range from a few hundred dollars to tens of thousands of dollars. Many medical insurers consider TMJ treatment too dental-focused for medical insurance, while dental insurers consider it too medical for dental insurance, leaving patients stuck in a “medical-dental divide” that hinders care and increases cost, according to the National Academies of Science, Engineering, and Medicine.

Worse still, researchers warn that the meager insurance coverage available for TMJ often excludes the safest forms of care while steering patients toward surgery — a riskier and irreversible option that the National Institutes of Health recommends “staying away” from.

Terrie Cowley, a longtime TMJ patient who leads the TMJ Association, an advocacy group, has spoken with patients who refinanced their homes and cashed out retirement accounts to afford the out-of-pocket costs for their care.

“It bankrupts them,” Cowley said. “But it isn’t nearly as horrible as when the treatments go wrong.”

Insurance woes are just one facet of the problems with TMJ care in the United States. In April, a joint investigation by KFF Health News and CBS News found that TMJ disorders have been widely misunderstood by many dentists for decades, so some patients fall into a spiral of ineffective care and futile surgeries that do more harm than good. Dentistry has tried to correct course in recent years with the promising new specialty of orofacial pain, which treats TMJ disorders with a more conservative approach, but these specialists are few and rarely covered by insurance, so their services remain beyond the reach of many patients.

Tony Schwartz, president of the American Board of Orofacial Pain, said the specialty is still fighting for widespread acceptance from insurance companies and some dentists, who cling to “old, debunked theories” that TMJ disorders are caused by misaligned teeth or a bad bite.

“This is the basis for why insurance companies have been so reluctant to, over the years, pay for any treatment,” Schwartz said. “Because there has been so much controversy about what works and what doesn’t work.”

For this article, KFF Health News and CBS News interviewed 10 patients with severe TMJ disorders who have been in treatment for years, if not decades. Almost all the patients described spending thousands of dollars out-of-pocket at every stage of their care, usually because treatment fell outside their medical and dental insurance coverage. Some patients said their medical bills mounted just as debilitating pain forced them to leave jobs or abandon careers. Some underwent expensive TMJ surgeries offered by only a small group of surgeons who generally do not accept insurance.

Kyra Wiedenkeller, 45, of New York state, said she worked as a manager in the music industry, including on “American Idol,” before her “unrelenting pain” became too great.

Wiedenkeller, who is now on disability, said she’s spent at least $100,000 out-of-pocket on TMJ treatment and provided medical documents showing she had been billed for at least that much.

“Every doctor I’ve seen has made me progressively worse,” Wiedenkeller said. “I paid an exorbitant amount of money. I wiped out my 401(k) for these treatments in hopes of getting better time and time again. And just get worse and worse. I feel like there is no end.”

Wiedenkeller’s story echoes findings of the national academies, which conducted a comprehensive study of TMJ in 2020 that included input from more than 110 patients. The study found that TMJ patients are “often harmed” during “overly aggressive” treatment, which frequently falls into a chasm between medical and dental insurance, leaving most bills paid out-of-pocket at costs of up to tens of thousands of dollars.

As an example, the study describes how dental splints — a common TMJ treatment — have been considered to be medical care by some dental insurers and considered dental care by some medical insurance programs, and are “therefore not covered” by either.

And when TMJ is covered by insurance, it tends to exclude “low-risk, effective treatments,” like those used by orofacial pain specialists, but covers “higher-risk” options, like jaw surgery, according to the national academies study. This leads to patients receiving “the care that is best reimbursed, rather than the care that is best,” the study said.

Other researchers have come to the same conclusion.

James Fricton, an orofacial pain specialist who studies the lack of insurance coverage for TMJ care, said that even though surgery is appropriate for few patients, it is the only treatment covered by most insurance plans in most states.

“Patients will assume that insurance companies know what they’re doing,” Fricton said. “If that’s all that’s covered, what do you think they are going to get? Surgery.”

In contrast, insurance coverage appears to be weakest at the other end of the treatment spectrum.

“Orofacial pain,” officially recognized by the American Dental Association in 2020, is now taught in residency programs at a dozen U.S. colleges at least, including the universities of Michigan, Minnesota, and North Carolina. The specialty avoids making irreversible changes to the bite or jaw and instead treats TMJ disorders with tools like counseling, dietary changes, medication, physical therapy, and removable dental splints. Many TMJ patients can be treated by orofacial pain specialists for a few thousand dollars.

The national academies study describes this approach as one of the few promising options for TMJ patients, citing studies that showed improvement among patients who are taught how to manage their pain. But the national academies also said it is a “particular challenge” that this treatment is “often not considered reimbursable by insurance.”

In separate interviews, six orofacial pain specialists with clinics around the country said insurance coverage for this specialty care is patchy, poor, or nonexistent. Several said their specialty is often absent from dropdown menus on standard insurance forms. Most said the insurance industry had fallen behind on the evolving science of TMJ, missing a chance to help patients and cut costs.

“It’s a no-brainer,” said Jeffrey Okeson, dean of the University of Kentucky’s College of Dentistry. “If I was an insurance person, I’d want to supply $1,000 to a patient to do conservative treatment … instead of $15,000 or $30,000 for surgery. Think of the money that can be saved there.”

Okeson and the other orofacial pain specialists said unreliable insurance coverage has hamstrung the specialty by making it less attractive to the next generation of dentists.

Currently there are fewer than 300 certified orofacial pain specialists in the United States, according to a database maintained by the American Board of Orofacial Pain. At least 20 states have no certified specialists, and eight other states have only one or two.

Deepika Jaiswal, the only certified specialist in Iowa, said some patients with TMJ disorders drive across the state to see her.

However, most of her patients — and many of her fellow dentists — remain unaware of the orofacial pain specialty, Jaiswal said, so insurance companies likely feel little pressure to include it in their coverage.

“People don’t even know around the area that we exist,” Jaiswal said. “When there are more providers providing this service, I think at that point there will be more insurance.”

CBS News producer Nicole Keller contributed to this article.

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