HELENA, Mont. — A last-minute change to a 2019 bill put an end date on Montana’s Medicaid expansion program, setting the stage for what is anticipated to be the most significant health care debate of the 2025 Montana Legislature.

In recent interviews, legislative leaders predicted a vigorous debate over keeping the Medicaid expansion program, which pays the medical bills of more than 75,000 low-income Montanans at an annual cost of about $1 billion to the federal and state governments. They also expect the topic to seep into other health policy decisions, such as the approval of new spending on Montana’s behavioral health system and regulation of hospital tax-exempt status.

“It all kind of links together,” said state Sen. Dennis Lenz, a Billings Republican and chair of the Senate Public Health, Welfare, and Safety Committee.

Legislators from both parties also expect lawmakers from the GOP majority to continue to pursue abortion restrictions, despite a November statewide vote making abortion a right under the Montana Constitution.

The Medicaid expansion debate, however, looms largest among the health care topics.

“This is definitely the elephant in the room, so to speak,” said Senate Minority Leader Pat Flowers, a Belgrade Democrat.

Montana expanded Medicaid, initially for four years, in 2015, through a coalition of minority Democrats, some moderate Republicans, and a Democratic governor. A similar coalition renewed the program in 2019, but at the last moment, Senate Republicans tacked on an end date of June 30, 2025. That put the matter in the lap of this year’s legislature.

Republicans still hold strong majorities in the state House and Senate, whose leaders voiced concerns about the expansion program.

This time around, the governor — Greg Gianforte — is a Republican. Last year, the Gianforte administration completed a postpandemic eligibility reassessment that cut the number of expansion enrollees from a high of 125,000 people in April and May 2023 to approximately 76,600 people as of October, the most recent data available.

Gianforte has included funding for Medicaid expansion in his proposed budget, which must be approved by the legislature to take effect. His office said he wants “strong work requirements for able-bodied adults without dependents” to take part in the program. Spokesperson Kaitlin Price said the governor “has been clear that the safety net of Medicaid should be there for those who truly need it, but that it will collapse if all are allowed to climb on it.”

GOP legislative leaders clearly are skeptical of the program, saying it won’t continue without some “sideboards,” or additional requirements of enrollees and providers.

Whether any expansion bill passes “will depend on the people pushing it,” said Senate President Matt Regier, a Kalispell Republican who opposes expansion. “If there is no give-and-take, it could be an interesting vote.”

Flowers said he knows getting Medicaid expansion through the Senate will be tough. Republicans hold a 32-18 majority, and the GOP caucus leans conservative.

“There are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you’re going to see that in their consistent voting against reauthorizing,” Flowers said.

Medicaid, funded by both the state and federal governments, provides health coverage for certain groups of low-income people. Expansion extended Medicaid coverage to nondisabled adults ages 19 to 64 with incomes up to 138% of the federal poverty level — about $20,800 a year for an individual in 2024.

The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, starting in 2014. But a 2012 U.S. Supreme Court ruling said states could choose whether to adopt the change, and 40 have done so.

Republican state Rep. Ed Buttrey said he would sponsor a bill to reauthorize Medicaid expansion without an expiration date, but many GOP lawmakers remain unconvinced that expansion is needed, viewing it as a costly, unnecessary welfare program.

“I understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with — I guess I can’t get around it — socialized medicine,” said House Speaker Brandon Ler (R-Savage).

In September, representatives from a pair of conservative-funded think tanks made a case for ending Medicaid expansion, saying its enrollment and costs are bloated. The consulting firm Manatt, on the other hand, said more people have access to critical treatment because of Medicaid expansion.

At the least, it appears many Republicans want to require participants to work, pay premiums, or meet other conditions, if the program is to continue.

Premiums and work requirements are in Montana’s law right now. The Biden administration, though, nixed both, so they haven’t been in effect. Montana Republicans expect the incoming Trump administration to be more open to such provisions.

Democrats say Medicaid expansion has succeeded on many fronts: covering thousands of low-income workers, helping keep rural health care providers and hospitals afloat, and bringing hundreds of millions of federal dollars into Montana’s economy. The state pays 10% of the program’s costs, which totaled about $962.4 million in fiscal year 2024. The federal government picked up $870 million of that tab.

“With all that, it’s just stunning to me that there could be opposition,” Flowers said. “There is just no reason for us, collectively as a state, not to support this.”

Democrats will have their own expansion bill, brought by Rep. Mary Caferro of Helena. She said the bill would remove the work requirements and premiums, shine more light on the contracting activities of the state health department, and reopen some public assistance offices that have been closed. It also would make expansion permanent.

“We’re 10 years into this program,” said Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates health policy legislation. “I think that continuing a cycle of uncertainty for patients and providers doesn’t make sense.”

Legislators also see the expansion debate tying into other health care discussions.

Regier and Lenz said Montana’s nonprofit hospitals — strong supporters of expansion — have benefited greatly from the program and may need to give something back in return. One possibility: more government oversight of the “community benefits” that hospitals must provide to receive tax-exempt status.

They also noted that Montanans pay a fee for hospital stays to support the Medicaid program and that a fee on hospital outpatient revenue helps pay the costs of Medicaid expansion. Those fees and the resulting money raised for hospitals may merit review, they said.

Meanwhile, backers said Medicaid expansion underpins one of the governor’s major policy priorities, to improve the state’s behavioral health system. Gianforte has proposed spending up to $100 million over the next two years on 10 recommendations made by an advisory commission that reviewed the system for the past 18 months.

If Medicaid expansion ends, many adults would lose access to the mental health and addiction treatment system that Gianforte wants to improve, advocates said, while treatment providers would lose a significant source of revenue.

Money for the behavioral health changes would come, in part, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals during the budgeting process. Howell said Democrats want to look at whether the changes would use enough of the $300 million fund quickly enough and on the most pressing needs.

Meanwhile, Republicans said they’ll likely introduce bills on abortion — even though Montanans approved Constitutional Initiative 128 by a 58-42 margin in November. CI-128 said the right to an abortion cannot be “denied or burdened” except by a “compelling government interest achieved by the least restrictive means.”

“It’s not going to slow us down in our pro-life positions,” Ler said of CI-128.

At a minimum, GOP leaders said, some of CI-128’s terms should be defined.

“With a very poorly written ballot initiative like that, we need to say, ‘What does that abortion industry look like under CI-128 and what’s our role as a state?’” Regier said.

But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, said the CI-128 vote provided a strong mandate for the right of privacy.

Enacting restrictions would lead to “that slippery slope of what’s next, if we allow legislators to rule on what’s happening in the doctor’s office,” she said. “What kind of can of worms could be opened to other invasions of privacy?”

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

USE OUR CONTENT

This story can be republished for free (details).

HHS Office for Civil Rights settles with Virtual Private Network Solutions for $90,000 to resolve ransomware attack investigation under the HIPAA Security Rule.

Biden-Harris administration announces $700 million to deliver clean drinking water and sanitation infrastructure on tribal lands by investing in America agenda

HHS Office for Civil Rights settles with Elgon Information Systems for $80,000 to resolve ransomware attack investigation under the HIPAA Security Rule.

The Biden-Harris Administration Awards 14 States with CCBHC Medicaid Demonstration Planning Grants

Surgeon General Vivek Murthy urges Americans to recenter their lives around relationships, service, and purpose.

The federal Consumer Financial Protection Bureau on Tuesday issued new regulations barring medical debts from American credit reports, enacting a major new consumer protection just days before President Joe Biden is set to leave office.

The rules ban credit agencies from including medical debts on consumers’ credit reports and prohibit lenders from considering medical information in assessing borrowers.

These rules, which the federal watchdog agency proposed in June, could be reversed after President-elect Donald Trump takes office Jan. 20. But by finalizing the regulations now, the CFPB effectively dared the incoming Trump administration and its Republican allies in Congress to undue rules that are broadly popular and could help millions of people who are burdened by medical debt.

“People who get sick shouldn’t have their financial future upended,” CFPB Director Rohit Chopra said in announcing the new rules. “The CFPB’s final rule will close a special carveout that has allowed debt collectors to abuse the credit reporting system to coerce people into paying medical bills they may not even owe.”

The regulations fulfill a pledge by the Biden administration to address the scourge of health care debt, a problem that touches an estimated 100 million Americans, forcing many to make sacrifices such as limiting food, clothing, and other essentials.

Credit reporting, a threat that has been wielded by medical providers and debt collectors to get patients to pay their bills, is the most common collection tactic used by hospitals, a KFF Health News analysis found.

The impact can be devastating, especially for those with large health care debts.

There is growing evidence, for example, that credit scores depressed by medical debt can threaten people’s access to housing and drive homelessness. People with low credit scores can also have trouble getting a loan or can be forced to borrow at higher interest rates.

That has prompted states including Colorado, New York, and California to enact legislation prohibiting medical debt from being included on residents’ credit reports or factored into their credit scores. Still, many patients and consumer advocates have pushed for a national ban.

The CFPB has estimated that the new credit reporting rule will boost the credit scores of people with medical debt on their credit reports by an average of 20 points.

But the agency’s efforts to restrict medical debt collections have drawn fierce pushback from the collections industry. And the new rules will almost certainly be challenged in court.

Congressional Republicans have frequently criticized the watchdog agency. Last year, then-chair of the House Financial Services Committee Patrick McHenry (R-N.C.) labeled the CFPB’s medical debt proposal “regulatory overreach.”

More recently, billionaire Elon Musk, whom Trump has tapped to co-lead his initiative to shrink government, called for the elimination of the watchdog agency. “Delete CFPB,” Musk posted on the social platform X.

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

USE OUR CONTENT

This story can be republished for free (details).

Joey Ballard is an internal medicine resident at the University of Illinois-Chicago. He wrote to “An Arm and a Leg” about a resolution the American Medical Association recently adopted calling on hospitals to do more to make sure patients who qualify for charity care get it. And that legislators and regulators make sure that’s happening.

Ballard helped write that resolution. He told “An Arm and a Leg” host Dan Weissmann that he first heard about charity care after listening to an episode of the podcast.

Ballard spoke with Weissmann about organizing as a medical student, bringing the resolution to the AMA, and the optimism he feels about the fight for charity care at the hospital where he works.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the transcript Transcript: A Listener Fighting the Good Fight

Dan: Hey there– 

A few weeks ago, we put out an update about charity care. That’s the commitment by hospitals to lower or just forgive bills for folks who can’t pay them. And our story was partly about how much less charity care hospitals give out than their own policies say they should. 

And a few days later, I got an email from a listener. 

Joey: I’m Joey Ballard, and I’m an internal medicine resident. 

Dan: Joey sent me a link: The American Medical Association — or AMA, the country’s largest group representing doctors, and for a long time one of the most powerful lobbying groups in the country– had just passed a resolution supporting legislation that would require hospitals to do more. 

Joey said he was the original author of that resolution. He had proposed it as a medical student. 

And he had gotten the idea from listening to… this podcast. We talked. Joey says he’s listened to every episode, since early in med school — and he sees it as a supplement to what that curriculum provides. 

Joey: I feel like you really have to seek out other sources to understand the system and sort of what I’m actually joining and what I’m facilitating as a physician… I mean, the podcast, like, really did that, and sort of helps peel back this other layer and sort of show more what it’s like for patients that I don’t always get to see from my perspective. 

Dan: This is, I am sure you can imagine, music to my ears. 

And now, he’s pushing for more changes, closer to home — at the institution where he’s doing his residency, the University of Illinois at Chicago. I wanted to bring you a little bit of his story to close out this year. 

This is An Arm and a Leg– a show about why health care costs so freaking much and what we can maybe do about. I’m Dan Weissmann. I’m a reporter and I like a challenge so the job we’ve chosen on this show is to take one of the

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.2 

most enraging, terrifying, and depressing parts of American life and bring you something entertaining, empowering, and useful. 

This is not the only time Joey has proposed a resolution to the AMA. And it’s not his only success. 

Joey: I’ve had four that have been adopted by the AMA, which is pretty, yeah, pretty exciting. And then I’ve had over 10 for Indiana, the Indiana State Medical Association. Um, so yeah, that kept me busy for sure. 

Dan: In Joey’s first year of med school at Indiana University, IU, he joined the med-student division of Physicians for a National Health Program — a membership organization that’s been advocating for single-payer health care for almost 40 years. The med-student version is Students for a National Health Program, SNaHP for short. 

Joey: I was pretty lucky. IU is actually the largest med school in the country. In terms of enrollment. And so we had a pretty strong Snap chapter, that had a lot of great events that really piqued my interest early on. 

Dan: Joey says SNaHP encouraged students to get involved with state medical societies, to help noodge the AMA towards supporting single-payer health care. Joey jumped in. 

Joey: And then like through that, I was like, oh, like, it’s not just single payer. I can sort of use this for any kind of thing in medicine I want to highlight or bring up 

Dan: In his first years of med school, Joey had proposed four resolutions that got adopted by the Indiana State Medical Association, including one supporting policies that would prevent some people from getting kicked off Medicaid. . By early 2023, he was ready to set his sights on the AMA itself. 

Joey: and that’s when I started like reaching out to other student contacts and figure out how does this work? How do I actually do this for the AMA in the first place? 

Dan: The answer turned out to be: Posting a suggestion on a dedicated online forum for student AMA members.

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.3 

Joey: I had posted several and the charity care one was the one that by far and away got the most feedback and people reaching out to me saying that they wanted to work on it and thought it was important. 

Dan: That was almost two years ago. Next came months of online collaboration with other students — Google docs and group chats — to draft and refine the resolution itself. 

Here are a few highlights from what they came up with: 

* Requiring nonprofit hospitals to check to see if any given patient qualifies for charity care BEFORE sending them a bill. 

* Close some loopholes in the federal law: Currently, the law only requires hospitals to HAVE a charity care policy, but it doesn’t set even a minimum standard for how generous that policy has to be. And there’s no mechanism to monitor or enforce even that requirement. 

The resolution says enforcement penalties should even include the loss of tax-exempt status — which is often worth many, many millions of dollars to nonprofit hospitals. 

They worked for months, and there were lots of steps still ahead. 

A big one was a vote by AMA’s student section — November 2023. Then — seven months later — the AMA itself asked a panel called the Council on Medical Service to consider the proposal and make a report. 

And the Council made a tweak: Instead of saying the AMA should “advocate for” policies like this, the Council’s version said the AMA should “support” them. 

Joey: …Which is an important distinction in that it’s not taking active measures to actively seek out these changes or reach out to lawmakers to draft these kinds of things. 

Dan: “Support” is more like, if someone else is pushing this, they can add us to the list of supporters. 

Then in November 2024, the AMA’s house of delegates considered the committee’s report.

Guess what? Not only did they back the resolution, they changed “support” back to “advocate for.” I asked the AMA what that meant they’d actually DO next. A spokesman told me he couldn’t disclose their legislative strategy, so fair enough. 

The meeting was in Florida this year, so Joey — in the middle of residency in Chicago — wasn’t able to be there. 

Joey: these meetings that are days long, you know, different places of the country. It’s especially as like residents that like, I don’t have the time to be able to do that. 

Dan: Joey says residency doesn’t leave him as much time as med school did, to work on AMA resolutions at all. But seeing the resolution pass? That was big. 

Joey: that inspired me to be like, okay, what can I do now? It was like, I feel like I need to take a look at what my institution is doing and what we can improve from that perspective. 

Dan: He’s started working on a proposal to get his hospital, the University of Illinois at Chicago, UIC to screen all patients for charity care before sending a bill, and to swear off practices like suing patients over bills they can’t pay, and seeking to garnish their wages. He says he’s been picking up support as he goes, starting with individual colleagues and other doctors… 

Joey: …and then the big one is our union. 

Dan: Residents at UIC are unionized. Joey says he brought up his pitch at a recent union meeting. His idea is a letter to the chief medical officer, with as many signatures as possible. The union said he could add them to the list. 

Joey says he hopes to have that letter ready in a few weeks. Then what? He’s not sure. 

Joey: There’s things we talked about during the union meeting that, you know, because UIC is a public institution, that there’s a lot more ways that it’s accountable and ways that we can find out things. Which I’m sure we’ll explore. But… optimistic for now. 

Dan: And he’ll keep at it.

Joey: I do find like extreme meaning in my day to day, um, as a physician, but I feel like this advocacy work is just something that’s even in some ways like deeper, and like means more to me. 

Dan: It means so much to me to know that doctors like Joey are making this their work. And it means a lot to me personally that people like Joey are finding the work we do here useful. 

In his initial note, Joey asked me where he might look for certain pieces of data. 

I sent him what I had, and forwarded his note to a couple people. One was Eli Rushbanks, who leads research and policy at Dollar For, the folks who have taught me the most about charity care. 

And the other was Luke Messac, the doctor and historian who wrote the book on some of these issues “Your Money or Your Life: Debt Collection and American Medicine.” You might’ve heard Luke on this show when his book came out in 2023. 

They both wrote back to Joey right away. Luke also wrote to thank me for introducing him to the folks at Dollar For. 

I hope we can keep on making connections for people fighting the good fights. There’s a lot of good fights to be had. 

If you’re catching this the day we release it or the next day– it’s the END of 2024. And our year-end fundraiser is still going. 

Gifts are still being matched. And in fact, we’ve got a new stretch goal. We’ve got backers who will match up to $30,000 in gifts. 

The place to go is arm and a leg show dot com, slash support That’s arm and a leg show, dot com, slash, support. Thank you. We’ll be back in January with more new episodes. 

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. 

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

USE OUR CONTENT

This story can be republished for free (details).

SACRAMENTO, Calif. — Six years after he entered office vowing to be California’s “health care governor,” Democrat Gavin Newsom has steered tens of billions in public funding to safety net services for the state’s neediest residents while engineering rules to make health care more accessible and affordable for all Californians.

More than a million California residents living in the U.S. without authorization now qualify for Medi-Cal, the state’s version of Medicaid, making California among the first states to cover low-income people regardless of their immigration status. The state is experimenting with Medicaid money to pay for social services such as housing and food assistance, especially for those living on the streets or with chronic diseases. And the state is forcing the health care industry to rein in soaring costs while imposing new rules on doctors, hospitals, and insurers to provide better-quality, more accessible care.

However, Newsom has so far failed to fully deliver on his most sweeping health care policies — and many changes are not yet visible to the public: Health care costs continue to rise, homelessness is worsening, and many Californians still struggle to get basic medical care.

Now, some of Newsom’s signature health initiatives, which could shape his profile on the national stage, are in peril as Donald Trump returns to the White House. According to national health policy experts, California stands to lose billions of dollars in health care funding should the Trump administration alter Medicaid programs as Republicans have indicated is likely. Such a move could force the state to dramatically slash benefits or eligibility.

And although allowing immigrants without legal status to enroll in free health care has been funded almost entirely with state money, it makes California a political target.

“That is fuel to feed the Republican MAGA argument that we are taking tax dollars from good Americans and providing health care to immigrants,” said Mark Peterson, a health care expert at UCLA, referring to the “Make America Great Again” movement.

Newsom declined an interview with KFF Health News. In a statement, he acknowledged that many of his initiatives are works in progress. But although he will attempt to work with Trump, the governor vowed to protect his health care agenda in his final two years in office.

“We are approaching the incoming administration with an open hand, not a closed fist,” Newsom said. “It is a top priority of my administration to ensure that quality health care is available and affordable for all Californians.”

Mark Ghaly, a former Health and Human Services secretary under Newsom, said transforming the way health care is paid for and delivered can be bumpy. “We didn’t do it perfectly,” Ghaly said. “Implementation is always messy in a state of 40 million people.”

Ahead of Trump’s Jan. 20 inauguration, Newsom has proposed allocating $25 million to challenge Trump on reproductive health care, disaster relief, and other services. His request is pending in the state’s Democratic-controlled legislature.

Here are the major initiatives that will shape Newsom’s health care legacy:

Medicaid

Potential federal cuts loom large in America’s most populous state. Of the whopping $261 billion California spends annually on health care and social services, nearly $116 billion flows from the federal government. Most of that goes to Medicaid, which covers more than 1 in 3 Californians. GOP leaders in Washington have floated ideas to kneecap Medicaid, which could slash benefits or cut enrollment.

In addition, California’s expansion of Medi-Cal to 1.5 million immigrants without legal status is projected to cost the state roughly $6.4 billion for the fiscal year ending June 30. Newsom suggested in early December that the state would continue to fund the immigrant health care expansion in the upcoming budget year but declined to say whether he would preserve the coverage in future years.

Advocacy groups are readying to defend those benefits should Trump target California over the issue. “We want to continue to protect access to care and not see a rollback,” said Amanda McAllister-Wallner, interim executive director of Health Access California.

Generic Drugs

Citing the high cost of prescription drugs, Newsom in 2022 plowed $100 million into his plan to produce generic insulin for California and launch a state manufacturing plant to produce a range of generic drugs. Three years later, California has done neither. Newsom did, however, announce a deal in April to purchase in bulk the opioid reversal drug naloxone, which the state made available to schools, health clinics, and other institutions at a discount.

“It’s certainly disappointing that there isn’t much more progress on it,” said former state Sen. Richard Pan, who authored the original generic drug legislation.

On generic insulin, Newsom acknowledged “that it’s taken longer than we hoped to get insulin on the market, but we remain committed to delivering $30 insulin available to all who need it as soon as we can.”

Abortion

The governor helped lead the successful 2022 campaign to enshrine access to abortion in the state constitution. He signed laws to ensure abortions and miscarriages are not criminalized and to allow out-of-state doctors to perform abortions in California; built a stockpile of abortion medication when mifepristone faced a national ban; and set aside $20 million to help Californians who can’t afford abortion care to access it.

Newsom, who has made reproductive rights a central tenet of his political agenda, also funded ads and traversed the country attacking Trump and other Republicans in red states who have rolled back abortion access.

After Trump won the election, Newsom called a special legislative session to ready for potential legal battles with the federal government. He told KFF Health News the state is preparing “in every possible way to protect the rights guaranteed in California’s Constitution and ensure bodily autonomy for all those in our state.”

Rising Health Care Costs

In 2022, Newsom created the Office of Health Care Affordability to set limits on health care spending and impose penalties on industry payers and providers that fail to meet targets. By 2029, California will cap annual price increases for health insurers, doctors, and hospitals at 3%.

While Trump has voiced concern about the steady rise of health care costs nationally — and the quality of health care Americans are receiving — his ideas have focused on deregulation and replacing the Affordable Care Act, which experts say could cost millions their health coverage and increase patient health care spending. California could potentially lose federal subsidies that have helped offset insurance premiums for most of the roughly 1.8 million people who buy their health coverage from Covered California, the state’s ACA marketplace, which would increase patient out-of-pocket costs.

The state could use money it raises from its own health insurance penalty on the uninsured, which Newsom adopted after the Obamacare individual mandate was zeroed out by Congress in 2017. Those state revenues are projected to be $298 million this fiscal year, according to the state Department of Finance. That’s a fraction of the federal health insurance subsidies California receives — roughly $1.7 billion annually.

Health and Homelessness

Under Newsom, California has spent unprecedented public money on tackling homelessness, yet the crisis has worsened under his watch.

From 2019, when Newsom took office, to 2023, homelessness jumped 20% to more than 181,000, despite his funneling more than $20 billion into trying to get people off the streets, including converting hotels and motels into homeless housing. He has also plowed roughly $12 billion into CalAIM, an experimental effort to infuse Medi-Cal with social services, including rental and eviction assistance.

A state audit last year found the state isn’t doing a good job of tracking the effectiveness of taxpayer money. CalAIM isn’t serving as many Californians as expected and patients face difficulty receiving new benefits from health insurers.

“The homelessness crisis on our streets is unacceptable,” Newsom acknowledged. “But we are starting to see progress.”

Experts expect the Trump administration to reverse liberal policies that have allowed Medicaid money to be used for health care experiments through waivers encouraged by the Biden administration. Notably, Trump has attacked Newsom for his handling of the homelessness crisis and has vowed to more forcefully move people off the streets. California’s CalAIM waiver ends at the end of 2026.

Instead of expanding housing and food assistance, for instance, the state could instead see federal moves to end CalAIM benefits and make Medicaid more restrictive.

Mental Health and Substance Use

Newsom has launched the most extensive overhaul of California’s behavioral health system in decades, directing billions in state funding toward a new network of treatment facilities and prevention programs.

Two of his most controversial signature initiatives, Proposition 1 and CARE Court, infuse money into treatment and housing for Californians with behavioral health conditions, especially homeless people living in crisis. And CARE Court allows judges to compel treatment for those suffering from debilitating mental illness and substance use.

Both have been hamstrung by funding challenges, rely on counties for implementation, and could take years to produce noticeable results. Whereas Newsom has sought to expand community-based treatment, Trump has promised a return to institutionalization and suggested homeless people and those with severe behavioral health conditions be moved to “large parcels of inexpensive land.”

Newsom said he hopes his “innovative” approaches will transform behavioral health care with “a laser focus on people with the most serious illness and substance use disorders.”

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.

USE OUR CONTENT

This story can be republished for free (details).

SACRAMENTO, California.— Seis años después de asumir el cargo prometiendo ser el “gobernador de la salud” de California, el demócrata Gavin Newsom ha destinado decenas de miles de millones de dólares de fondos públicos a servicios de la red de seguridad para los residentes más necesitados del estado, mientras diseña reglas para hacer que la atención médica sea más accesible y asequible para todos los californianos.

Más de un millón de residentes de California que viven en Estados Unidos sin papeles ahora califican para Medi-Cal, la versión estatal de Medicaid: ha sido uno de los primeros en cubrir a personas de bajos ingresos independientemente de su estatus migratorio.

El estado también está experimentando con fondos de Medicaid para pagar servicios sociales como asistencia para vivienda y alimentos, especialmente para aquellos que viven en las calles o tienen enfermedades crónicas. Además, está obligando a la industria de la salud a controlar los costos desbordantes mientras impone nuevas reglas a médicos, hospitales y aseguradoras para ofrecer una atención de mejor calidad y más accesible.

Sin embargo, hasta ahora, Newsom no ha logrado cumplir por completo con sus políticas de salud más ambiciosas, y muchos cambios aún no son visibles para el público: los costos de la salud siguen aumentando, la escasez de vivienda está empeorando y muchos californianos todavía luchan por obtener atención médica básica.

Ahora, algunas de las iniciativas emblemáticas de Newsom en materia de salud, que podrían definir su perfil en el escenario nacional, están en peligro con el regreso de Donald Trump a la Casa Blanca.

Según expertos en políticas sanitarias, California podría perder miles de millones de dólares en financiamiento para la atención médica si la nueva administración Trump altera los programas de Medicaid, algo que los republicanos han dicho que es probable. Tal movimiento podría obligar al estado a recortar drásticamente beneficios, e incluso la elegibilidad.

Y aunque la inscripción para que inmigrantes indocumentados obtengan atención médica gratuita se ha financiado casi completamente con dinero estatal, esto convierte a California en un blanco político.

“Eso es combustible para alimentar el argumento de la republicana MAGA de que estamos tomando dólares de impuestos de buenos estadounidenses y proporcionando atención médica a los inmigrantes”, dijo Mark Peterson, experto en atención médica de UCLA, en referencia al movimiento “Make America Great Again”.

Newsom rechazó una entrevista con KFF Health News. En un comunicado, reconoció que muchas de sus iniciativas todavía están en proceso de implementarse. Pero, aunque intentará trabajar con Trump, el gobernador prometió proteger su agenda de atención médica en sus dos últimos años en el cargo.

“Nos estamos acercando a la administración entrante con una mano abierta, no con un puño cerrado”, dijo Newsom. “Es una prioridad principal de mi administración asegurar que la atención médica de calidad esté disponible y sea asequible para todos los californianos”.

Mark Ghaly, ex secretario de Salud y Servicios Humanos bajo Newsom, dijo que transformar la forma en que se paga y ofrece la atención médica puede ser complicado. “No lo hicimos perfectamente”, dijo Ghaly. “La implementación siempre es complicada en un estado de 40 millones de personas”.

Antes de la inauguración de Trump el 20 de enero, Newsom ha propuesto asignar $25 millones para desafiar a Trump en atención reproductiva, ayuda por desastres y otros servicios. Su solicitud está pendiente en la Legislatura estatal controlada por demócratas.

Estas son las principales iniciativas que conformarán el legado de Newsom en salud:

Medicaid

Se avecinan posibles recortes federales en el estado más poblado de Estados Unidos. De los asombrosos $261 mil millones que California gasta anualmente en atención médica y servicios sociales, casi $116 mil millones provienen del gobierno federal. La mayor parte de eso va a Medicaid, que cubre a más de 1 de cada tres californianos. Líderes republicanos en Washington han planteado ideas para debilitar el programa, lo que podría reducir beneficios o disminuir la inscripción.

Además, la expansión de Medi-Cal en California para 1.5 millones de inmigrantes sin papeles se proyecta que costará al estado aproximadamente $6.4 mil millones para el año fiscal que termina el 30 de junio.

A principios de dciembre, Newsom sugirió que el estado continuaría financiando la expansión de atención médica para inmigrantes en el próximo año fiscal, pero no quiso decir si mantendría la cobertura en años futuros.

Grupos de defensa están listos para proteger esos beneficios si Trump hace de California su blanco. “Queremos continuar protegiendo el acceso a la atención y no ver un retroceso”, dijo Amanda McAllister-Wallner, directora ejecutiva interina de Health Access California.

Medicamentos genéricos

Citando el alto costo de los medicamentos recetados, en 2022 Newsom destinó $100 millones a su plan para producir insulina genérica para California y lanzar una planta estatal de fabricación para producir una gama de medicamentos genéricos.

Tres años después, California no ha logrado ninguno de los dos. Sin embargo, en abril Newsom anunció un acuerdo para comprar al por mayor naloxone, el medicamento para revertir las sobredosis de opioides, que el estado puso a disposición de escuelas, clínicas de salud y otras instituciones a un precio reducido.

“Es ciertamente decepcionante que no haya mucho más progreso”, dijo el ex senador estatal Richard Pan, quien redactó la legislación original de medicamentos genéricos.

Sobre la insulina genérica, Newsom reconoció “que ha tomado más tiempo del que esperábamos llevar insulina al mercado, pero seguimos comprometidos a ofrecer insulina a $30 disponible para todos los que la necesiten lo antes posible”.

Aborto

El gobernador ayudó a liderar la exitosa campaña de 2022 para incluir el acceso al aborto en la constitución estatal. Firmó leyes para garantizar que los abortos, espontáneos o no, no fueran criminalizados, para permitir que médicos de otros estados realicen abortos en California, almacenar medicamentos abortivos cuando mifepristona enfrentó una prohibición nacional, y destinó $20 millones para ayudar a los californianos que no pueden pagar el cuidado del aborto.

Newsom, quien ha hecho de los derechos reproductivos un pilar central de su agenda política, también financió anuncios y recorrió el país atacando a Trump y a otros republicanos en estados conservadores que han restringido el acceso al aborto.

Después de la victoria electoral de Trump, Newsom convocó una sesión legislativa especial para prepararse para posibles batallas legales con el gobierno federal. Dijo a KFF Health News que el estado se está preparando “de todas las maneras posibles para proteger los derechos garantizados en la constitución de California y asegurar la autonomía para todos los que están en nuestro estado”.

Costos crecientes de la atención médica

En 2022, Newsom creó la Office of Health Care Affordability para establecer límites al gasto en salud e imponer sanciones a las aseguradoras y proveedores de atención médica que no cumplieran con los objetivos. Para 2029, California limitará los aumentos anuales de precios para aseguradoras, médicos y hospitales al 3%.

Si bien Trump ha expresado preocupación por el aumento constante de los costos de la atención médica a nivel nacional y la calidad de la atención, sus ideas se han centrado en la desregulación y en reemplazar la Ley de Cuidado de Salud a Bajo Precio (ACA), lo que, según los expertos, podría costar a millones su cobertura de salud y aumentar los gastos de los pacientes.

California podría perder subsidios federales que han ayudado a reducir las primas de seguros para la mayoría de los aproximadamente 1.8 millones de personas que compran su cobertura de salud a través de Covered California, el mercado estatal de la ACA, lo que aumentaría los gastos de bolsillo de los pacientes.

El estado podría usar el dinero que recauda de sus propias multas por no tener seguro de salud, adoptada por Newsom después que el Congreso eliminara el mandato individual de Obamacare en 2017. Según el Departamento de Finanzas del estado, esos ingresos estatales están proyectados en $298 millones para este año fiscal. Eso es una fracción de los aproximadamente $1.7 mil millones anuales en subsidios federales para seguros de salud que recibe California.

Salud y falta de vivienda

Bajo el liderazgo de Newsom, California ha gastado cantidades sin precedentes de dinero público para abordar la crisis de personas sin hogar, pero la situación ha empeorado bajo su mandato.

Desde 2019, cuando Newsom asumió el cargo, hasta 2023, la falta de vivienda aumentó un 20%: más de 181,000 personas no tienen techo, a pesar que el estado destinó más de $20 mil millones para tratar de sacar a las personas de las calles, incluido un programa para convertir hoteles y moteles en viviendas para los sin hogar.

Además, se han invertido aproximadamente $12 mil millones en CalAIM, un esfuerzo experimental para integrar servicios sociales en Medi-Cal, como asistencia para alquilar y para prevenir desalojos.

El año pasado, una auditoría estatal encontró que el estado no estaba haciendo un buen trabajo en el seguimiento de la efectividad del dinero de los contribuyentes. CalAIM no está sirviendo a tantos californianos como se esperaba, y los pacientes enfrentan dificultades para recibir los nuevos beneficios de los aseguradores de salud.

“La crisis de personas sin hogar en nuestras calles es inaceptable”, reconoció Newsom. “Pero estamos comenzando a ver avances”.

Se espera que la administración Trump revierta las políticas liberales que han permitido el uso de dinero de Medicaid para experimentos de atención médica a través de exenciones alentadas por la administración Biden.

Notablemente, Trump ha criticado a Newsom por su manejo de la crisis de personas sin hogar y ha prometido sacar a las personas de las calles con más fuerza. La exención de CalAIM en California termina a finales de 2026.

Por ejemplo,en lugar de expandir la asistencia de vivienda y alimentos, el estado podría enfrentarse a movimientos federales para terminar los beneficios de CalAIM y hacer que Medicaid sea más restrictivo.

Salud mental y adicciones

Newsom ha lanzado la reforma más extensa del sistema de salud conductual de California en décadas, destinando miles de millones en fondos estatales a una nueva red de instalaciones de tratamiento y programas de prevención.

Dos de sus iniciativas emblemáticas más controvertidas, la Proposición 1 y CARE Court, inyectan dinero en el tratamiento y la vivienda para californianos con afecciones de salud conductual, especialmente personas sin hogar que viven en crisis. CARE Court permite a los jueces ordenar tratamiento para quienes sufren enfermedades mentales debilitantes y trastornos por adicciones.

Ambas iniciativas han enfrentado desafíos de financiamiento, dependen de los condados para su implementación y podrían tardar años en producir resultados visibles.

Mientras que Newsom ha buscado expandir el tratamiento comunitario, Trump ha sugerido un regreso a la institucionalización y propuso trasladar a personas sin hogar y a aquellos con graves afecciones de salud conductual a “grandes extensiones de tierra económica”.

Newsom dijo que espera que sus enfoques “innovadores” transformen la atención de salud conductual con “un enfoque en las personas con enfermedades más graves y adicciones”.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la 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.

USE OUR CONTENT

This story can be republished for free (details).

KFF Health News Midwest correspondent Cara Anthony and Emily Kwong, host of NPR’s podcast “Shortwave,” talk about Black families living in the aftermath of lynchings and police killings in their communities. Anthony shares her southeastern Missouri-based reporting from “Silence in Sikeston,” a documentary film, podcast, and print reporting project. She discusses the latest research on the health effects of racism and violence, including the emerging, controversial field of epigenetics.

Hear the full podcast episodes Anthony and Kwong reference from “Silence in Sikeston” here. They discuss material from Episode 1, “Racism Can Make You Sick”; Episode 2, “Hush, Fix Your Face”; and Episode 3, “Trauma Lives in the Body.”

In 1942, Mable Cook was a teenager. She was standing on her front porch when she witnessed the lynching of Cleo Wright.

In the aftermath, Cook received advice from her father that was intended to keep her safe.

“He didn’t want us talking about it,” Cook said. “He told us to forget it.”

More than 80 years later, residents of Sikeston, Missouri, still find it difficult to talk about the lynching.

Conversations with Cook, who was one of the few remaining witnesses of the lynching, launch a discussion of the health consequences of racism and violence in the United States. Racial equity scholar Keisha Bentley-Edwards explains the physical, mental, and emotional burdens on Sikeston residents and Black Americans in general.

“Oftentimes, people who experience racial trauma are forced to not acknowledge it,” Bentley-Edwards said. “They’re forced to question whether or not it happened in the first place.”

When Anthony uncovered details of a police killing in her own family while reporting this project, she unpacked her family’s story with Aiesha Lee, a licensed professional counselor and an assistant professor at Penn State.

“This pain has compounded over generations,” Lee said. “We’re going to have to deconstruct it or heal it over generations.”

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

USE OUR CONTENT

This story can be republished for free (details).

When Michael Adams was researching health insurance options in 2023, he had one very specific requirement: coverage for prosthetic limbs.

Adams, 51, lost his right leg to cancer 40 years ago, and he has worn out more legs than he can count. He picked a gold plan on the Colorado health insurance marketplace that covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. That function adds stability and helps prevent falls.

But when his leg needed replacing last January after about five years of everyday use, his new marketplace health plan wouldn’t authorize it. The roughly $50,000 leg with the electronically controlled knee wasn’t medically necessary, the insurer said, even though Colorado law leaves that determination up to the patient’s doctor, and his has prescribed a version of that leg for many years, starting when he had employer-sponsored coverage.

“The electronic prosthetic knee is life-changing,” said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, “it would be like going back to having a wooden leg like I did when I was a kid.” The microprocessor in the knee responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling.

People who need surgery to replace a joint typically don’t encounter similar coverage roadblocks. In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, though health plans often negotiate lower rates.

To people in the amputee community, the coverage disparity amounts to discrimination.

“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.

AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition. Even though coverage for basic prostheses may be included in a plan, “often insurance companies will put caps on the devices and restrictions on the types of devices approved,” White said.

An estimated 2.3 million people are living with limb loss in the U.S., according to an analysis by Avalere, a health care consulting company. That number is expected to as much as double in coming years as people age and a growing number lose limbs to diabetes, trauma, and other medical problems.

Fewer than half of people with limb loss have been prescribed a prosthesis, according to a report by the AHRQ. Plans may deny coverage for prosthetic limbs by claiming they aren’t medically necessary or are experimental devices, even though microprocessor-controlled knees like Adams’ have been in use for decades.

Cain was instrumental in getting passed a 2000 Colorado law that requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20% coinsurance payment. Since that measure was enacted, about half of states have passed “insurance fairness” laws that require prosthetic coverage on par with other covered medical services in a plan or laws that require coverage of prostheses that enable people to do sports. But these laws apply only to plans regulated by the state. Over half of people with private coverage are in plans not governed by state law.

The Medicare program’s 80% coverage of prosthetic limbs mirrors its coverage for other services. Still, an October report by the Government Accountability Office found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.

Cost is a factor for many people.

“No matter your coverage, most people have to pay something on that device,” White said. As a result, “many people will be on a payment plan for their device,” she said. Some may take out loans.

The federal Consumer Financial Protection Bureau has proposed a rule that would prohibit lenders from repossessing medical devices such as wheelchairs and prosthetic limbs if people can’t repay their loans.

“It is a replacement limb,” said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prostheses. Repossession is “literally a punishment to the individual.”

Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his portion of the insurer’s negotiated rate for the knee and foot portion of the leg but did not include the costly part that fits around his stump, which didn’t need replacing. The insurer approved the prosthetic leg on appeal, claiming it had made an administrative error, Adams said.

“We’re fortunate that we’re able to afford that 20%,” said Adams, who is a self-employed leadership consultant.

Leah Kaplan doesn’t have that financial flexibility. Born without a left hand, she did not have a prosthetic limb until a few years ago.

Growing up, “I didn’t want more reasons to be stared at,” said Kaplan, 32, of her decision not to use a prosthesis. A few years ago, the cycling enthusiast got a prosthetic hand specially designed for use with her bike. That device was covered under the health plan she has through her county government job in Spokane, Washington, helping developmentally disabled people transition from school to work.

But when she tried to get approval for a prosthetic hand to use for everyday activities, her health plan turned her down. The myoelectric hand she requested would respond to electrical impulses in her arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she said she can’t afford.

Working with her doctor, she has appealed the decision to her insurer and been denied three times. Kaplan said she’s still not sure exactly what the rationale is, except that the insurer has questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent review organization certified by the state insurance commissioner’s office.

A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic has ordered the hand and made the customized socket that will fit around the end of her arm. But until insurance coverage is sorted out, she can’t use it.

At this point she feels defeated. “I’ve been waiting for this for so long,” Kaplan said.

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

USE OUR CONTENT

This story can be republished for free (details).

Today, HHS announced it would award $306 million dollars to continue its H5N1 Avian Flu response.

Publication of press release regarding Surgeon General’s Advisory on Alcohol and Cancer Risk

In Pawtucket, Rhode Island, near a storefront advertising “free” cellphones, J.R. sat in an empty back stairwell and showed a reporter how he tries to avoid overdosing when he smokes crack cocaine. KFF Health News is identifying him by his initials because he fears being arrested for using illegal drugs.

It had been several hours since his last hit, and the chatty, middle-aged man’s hands moved quickly. In one hand, he held a glass pipe. In the other, a lentil-size crumb of cocaine.

Or at least J.R. hoped it was cocaine, pure cocaine — uncontaminated by fentanyl, a potent opioid that was linked to about 75% of all overdose deaths in Rhode Island in 2022. He flicked his lighter to “test” his supply. He believed that if it had a “cigar-like sweet smell,” he said, it would mean that the cocaine was laced with fentanyl. He put the pipe to his lips and took a tentative puff. “No sweet,” he said, reassured.

But this method offers only false and dangerous reassurance. A mistake can be fatal.

It is impossible to tell whether a drug contains fentanyl by the taste or smell. “Somebody can believe that they can smell it or taste it, or see it … but that’s not a scientific test,” said Josiah “Jody” Rich, an addiction specialist and researcher who teaches at Brown University. “People are going to die today because they buy some cocaine that they don’t know has fentanyl in it.”

The first wave of the long-running and devastating opioid epidemic began in the United States with the abuse of prescription painkillers in the early 2000s. The second wave involved an increase in heroin use, starting around 2010. The third wave began when powerful synthetic opioids such as fentanyl started appearing in the supply around 2015. Now experts are observing a fourth phase of the deadly epidemic.

The mix of stimulants such as cocaine and methamphetamines with fentanyl — a synthetic opioid 50 times as powerful as heroin — is driving what experts call the opioid epidemic’s “fourth wave.” The mixture of stimulants and fentanyl presents powerful challenges to efforts to reduce overdoses because many users of stimulants don’t know they are at risk of ingesting opioids, so they don’t take overdose precautions.

The only way to know whether cocaine or other stimulants contain fentanyl is to use drug-checking tools such as fentanyl test strips — a best practice for what’s known as “harm reduction,” now embraced by federal health officials in combating drug overdose deaths. Fentanyl test strips cost as little as $2 for a two-pack online, but many front-line organizations also give them out free.

Nationwide, illicit stimulants mixed with fentanyl were the most common drugs found in fentanyl-related overdoses, according to a study published in 2023 in the scientific journal Addiction. The stimulant in the fatal mixture tends to be cocaine in the Northeast, and methamphetamine in the West and much of the Midwest and South.

“The No. 1 thing that people in the U.S. are dying from in terms of drug overdoses is the combination of fentanyl and a stimulant,’’ said Joseph Friedman, a researcher at UCLA and the study’s lead author. “Black and African Americans are disproportionately affected by this crisis to a large magnitude, especially in the Northeast.”

Friedman was also the lead author of another new study, published in the American Journal of Psychiatry, that shows the fourth wave of the opioid epidemic is driving up the mortality rate among older Black Americans (ages 55-64) and, more recently, Hispanic people. Friedman said part of the reason street fentanyl is so deadly is that there’s no way to tell how potent it is. Hospitals have safely used medical-grade fentanyl for surgical pain because the potency is strictly regulated, but “the potency fluctuates wildly in the illicit market” Friedman said.

Studies of street drugs, he said, show that in illicit drugs the potency can vary from 1% to 70% fentanyl.

“Imagine ordering a mixed drink in a bar and it contains one to 70 shots,” Friedman said, “and the only way you know is to start drinking it. … There would be a huge number of alcohol overdose deaths.”

Drug-checking technology can provide a rough estimate of fentanyl concentration, he said, but to get a precise measure requires sending drugs to a laboratory.

It’s not clear how much of the latest trend in polydrug use — in which users mix substances, such as cocaine and fentanyl, for example — is accidental versus intentional. It can vary for individual users: a recent study from Millennium Health found that most people who use fentanyl do so at times intentionally and other times unintentionally.

People often use stimulants to power through the rapid withdrawal from fentanyl, Friedman said. And the high-risk practice of using cocaine or meth with heroin, known as “speedballing,” has been around for decades. Other factors include manufacturers’ adding the cheap synthetic opioid to a stimulant to stretch their supply, or dealers mixing up bags.

Researchers say many people still think they are using unadulterated cocaine or crack — a misconception that can be deadly. “Folks who are using stimulants, and not intentionally using opioids, are unprepared to respond to an opioid overdose,” said Brown University epidemiologist Jaclyn White Hughto, “because they don’t perceive themselves to be at risk.” Hughto is a principal investigator in a new, unpublished study called “Preventing Overdoses Involving Stimulants.”

Hughto and the team surveyed more than 260 people in Rhode Island and Massachusetts who use drugs, including some who manufacture and distribute stimulants such as cocaine. More than 60% of the people they interviewed in Rhode Island had bought or used stimulants that they later found out had fentanyl in them. And many of the people interviewed in the study also use drugs alone. That means that if they do overdose, they may not be found until it’s too late.

In 2022, Rhode Island had the fourth-highest rate of overdose deaths involving cocaine in 2022, after Washington, D.C., Delaware, and Vermont, according to the Centers for Disease Control and Prevention.

The fourth wave is also hitting stimulant users who choose pills over what they perceive as more dangerous drugs such as cocaine in an effort to avoid fentanyl. That’s what happened to Jennifer Dubois’ son Cliffton.

Dubois was a single mother raising two Black sons. The older son, Cliffton, had been struggling with addiction since he was 14, she said. Cliffton also had been diagnosed with attention-deficit/hyperactivity disorder and a mood disorder.

In March 2020, Cliffton had checked into a rehab program as the pandemic ramped up, Dubois said. Because of the lockdown at rehab, Cliffton was upset about not being able to visit with his mother. “He said, ‘If I can’t see my mom, I can’t do treatment,’” Dubois recalled. “And I begged him” to stay in treatment.

But soon after, Cliffton left the rehab program. He showed up at her door. “And I just cried,” she said.

Dubois’ younger son was living at home. She didn’t want Cliffton doing drugs around his younger brother. So she gave Cliffton an ultimatum: “If you want to stay home, you have to stay drug-free.”

Cliffton went to stay with family friends, first in Atlanta and later in Woonsocket, an old mill city that has Rhode Island’s highest rate of drug overdose deaths.

In August 2020, Cliffton overdosed but was revived. Cliffton later confided that he’d been snorting cocaine in a car with a friend, Dubois said. Hospital records show he tested positive for fentanyl.

“He was really scared,” Dubois said. After the overdose, he tried to “leave the cocaine and the hard drugs alone,” she said. “But he was taking pills.” Eight months later, on April 17, 2021, Cliffton was found unresponsive in the bedroom of a family member’s home.

The night before, Cliffton had bought counterfeit Adderall, according to the police report. What he didn’t know was that the Adderall pill was laced with fentanyl. “He thought by staying away from the street drugs and just taking pills, he was doing better,” Dubois said.

A fentanyl test strip could have saved his life.

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

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

USE OUR CONTENT

This story can be republished for free (details).

CHARLESTON, W.Va. — More than three years have passed since federal health officials arrived in central Appalachia to assess an alarming outbreak of HIV spread mostly between people who inject opioids or methamphetamine.

Infectious disease experts from the Centers for Disease Control and Prevention made a list of recommendations following their visit, including one to launch syringe service programs to stop the spread at its source. But those who’ve spent years striving to protect people who use drugs from overdose and illness say the situation likely hasn’t improved, in part because of politicians who contend that such programs encourage illegal drug use.

Joe Solomon is a Charleston City Council member and co-director of SOAR WV, a group that works to address the health needs of people who use drugs. He’s proud of how his close-knit community has risen to this challenge but frustrated with the restraints on its efforts.

“You see a city and a county willing to get to work at a scale that’s bigger than ever before,” Solomon said, “but we still have one hand tied behind our back.”

The hand he references is easier access to clean syringes.

In April 2021, the CDC came to Charleston — the seat of Kanawha County and the state capital, tucked into the confluence of the Kanawha and Elk rivers — to investigate dozens of newly detected HIV infections. The CDC’s HIV intervention chief called it “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

Now, despite attention and resources directed toward the outbreak, researchers and health workers say HIV continues to spread. In large part, they say, the outbreak lingers because of restrictions state and local policymakers have placed on syringe exchange efforts.

Research indicates that syringe service programs are associated with an estimated 50% reduction in HIV and hepatitis C, and the CDC issued recommendations to steer a response to the outbreak that emphasized the need for improved access to those services.

That advice has thus far gone unheeded by local officials.

In late 2015, the Kanawha-Charleston Health Department launched a syringe service program but shuttered it in 2018 under pressure, with then-Mayor Danny Jones calling it a “mini-mall for junkies and drug dealers.”

SOAR stepped in, hosting health fairs at which it distributed naloxone, an opioid overdose reversal drug; offered treatment and referrals; provided HIV testing; and exchanged clean syringes for used ones.

But in April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID. The Charleston City Council subsequently added guidelines of its own, including requiring individual labeling of syringes.

As a result of these restrictions, SOAR ceased exchanging syringes. West Virginia Health Right now operates an exchange program in the city under the restrictions.

Robin Pollini is a West Virginia University epidemiologist who conducts community-based research on injection drug use. “Anyone I’ve talked to who’s used that program only used it once,” she said. “And the numbers they report to the state bear that out.”

A syringe exchange run by the health department in nearby Cabell County — home to Huntington, the state’s largest city after Charleston — isn’t so constrained. As Solomon notes, that program exchanges more than 200 syringes for every one exchanged in Kanawha.

A common complaint about syringe programs is that they result in discarded syringes in public spaces. Jan Rader, director of Huntington’s Mayor’s Office of Public Health and Drug Control Policy, is regularly out on the streets and said she seldom encounters discarded syringes, pointing out that it’s necessary to exchange a used syringe for a new one.

In August 2023, the Charleston City Council voted down a proposal from the Women’s Health Center of West Virginia to operate a syringe exchange in the city’s West Side community, with opponents expressing fears of an increase in drug use and crime.

Pollini said it’s difficult to estimate the number of people in West Virginia with HIV because there’s no coordinated strategy for testing; all efforts are localized.

“You would think that in a state that had the worst HIV outbreak in the country,” she said, “by this time we would have a statewide testing strategy.”

In addition to the testing SOAR conducted in 2021 at its health fairs, there was extensive testing during the CDC’s investigation. Since then, the reported number of HIV cases in Kanawha County has dropped, Pollini said, but it’s difficult to know if that’s the result of getting the problem under control or the result of limited testing in high-risk groups.

“My inclination is the latter,” she said, “because never in history has there been an outbreak of injection-related HIV among people who use drugs that was solved without expanding syringe services programs.”

“If you go out and look for infections,” Pollini said, “you will find them.”

Solomon and Pollini praised the ongoing outreach efforts — through riverside encampments, in abandoned houses, down county roads — of the Ryan White HIV/AIDS Program to test those at highest risk: people known to be injecting drugs.

“It’s miracle-level work,” Solomon said.

But Christine Teague, Ryan White Program director at the Charleston Area Medical Center, acknowledged it hasn’t been enough. In addition to HIV, her concerns include the high incidence of hepatitis C and endocarditis, a life-threatening inflammation of the lining of the heart’s chambers and valves, and the cost of hospital resources needed to address them.

“We’ve presented that data to the legislature,” she said, “that it’s not just HIV, it’s all these other lengthy hospital admissions that, essentially, Medicaid is paying for. And nothing seems to penetrate.”

Frank Annie is a researcher at CAMC specializing in cardiovascular diseases, a member of the Charleston City Council, and a proponent of syringe service programs. Research he co-authored found 462 cases of endocarditis in southern West Virginia associated with injection drug use, at a cost to federal, state, and private insurers of more than $17 million, of which less than $4 million was recovered.

Teague is further concerned for West Virginia’s rural counties, most of which don’t have a syringe service program.

Tasha Withrow, a harm reduction advocate in bordering rural Putnam County, said her sense is that HIV numbers aren’t alarmingly high there but said that, with little testing and heightened stigma in a rural community, it’s difficult to know.

In a January 2022 follow-up report, the CDC recommended increasing access to harm reduction services such as syringe service programs through expansion of mobile services, street outreach, and telehealth, using “patient-trusted” individuals, to improve the delivery of essential services to people who use drugs.

Teague would like every rural county to have a mobile unit, like the one operated by her organization, offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more. That’s an expensive undertaking. She suggested opioid settlement money through the West Virginia First Foundation could pay for it.

Pollini said she hopes state and local officials allow the experts to do their jobs.

“I would like to see them allow us to follow the science and operate these programs the way they’re supposed to be run, and in a broader geography,” she said. “Which means that it shouldn’t be a political decision; it should be a public health decision.”

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

USE OUR CONTENT

This story can be republished for free (details).

BAKER CITY, Ore. — In what has become a routine event in rural America, a hospital maternity ward closed in 2023 in this small Oregon town about an hour from the Idaho border.

For Shyanne McCoy, 23, that meant the closest hospital with an obstetrician on staff when she was pregnant was a 45-mile drive away over a mountain pass.

When McCoy developed symptoms of preeclampsia last January, she felt she had the best chance of getting the care she needed at a larger hospital in Boise, Idaho, two hours away. She spent the final week of her pregnancy there, too far from home to risk leaving, before giving birth to her daughter.

Six months later, she said it seems clear to her that the health care needs of rural young women like her are largely ignored.

For McCoy and others, figuring out how to obtain adequate care to safely have a baby in Baker City has quickly eclipsed concerns about another medical service lacking in the area: abortion. But in Oregon and elsewhere in the country, progressive lawmakers’ attempts to expand abortion access sometimes clash with rural constituencies.

Oregon is considered one of the most protective states in the country when it comes to abortion. There are no legal limits on when someone can receive an abortion in the state, and the service is covered by its Medicaid system. Still, efforts to expand access in the rural, largely conservative areas that cover most of the state have encountered resistance and incredulity.

It’s a divide that has played out in elections in such states as Nevada, where voters passed a ballot measure in November that seeks to codify abortion protections in the state constitution. Residents in several rural counties opposed the measure.

In Oregon, during the months just before the Baker City closure was announced, Democratic state lawmakers were focused on a proposed pilot program that would launch two mobile reproductive health care clinics in rural areas. The bill specified that the van-based clinics would include abortion services.

State Rep. Christine Goodwin, a Republican from a southwestern Oregon district, called the proposal the “latest example” of urban legislators telling rural leaders what their communities need.

The mobile health clinic pilot was eventually removed from the bill that was under discussion. That means no new abortion options in Oregon’s Baker County — and no new state-funded maternity care either.

“I think if you expanded rural access in this community to abortions before you extended access to maternal health care, you would have an uprising on your hands,” said Paige Witham, 27, a member of the Baker County health care steering committee and the mother of two children, including an infant born in October.

A study published in JAMA in early December that examined nearly 5,000 acute care hospitals found that by 2022, 52% of rural hospitals lacked obstetrics care after more than a decade of unit closures. The health implications of those closures for young women, the population most likely to need pregnancy care, and their babies can be significant. Research has shown that added distance between a patient and obstetric care increases the likelihood the baby will be admitted to a neonatal intensive care unit, or NICU.

Witham said that while she does not support abortion, she believes the government should not “legislate it away completely.” She said that unless the government provides far more support for young families, like free child care and better mental health care, abortion should remain legal.

Conversations with a liberal school board member, a moderate owner of a timber company, members of Baker City’s Republican Party chapter, a local doula, several pregnant women, and the director of the Baker County Health Department — many of whom were not rigidly opposed to abortion — all turned up the same answer: No mobile clinics offering abortions here, please.

Kelle Osborn, a nurse supervisor for the Baker County Health Department, loved the idea of a mobile clinic that would provide education and birth control services to people in outlying areas. She was less thrilled about including abortion services in a clinic on wheels.

“It’s not something that should just be handed out from a mobile van,” she said of abortion services. She said people in her conservative rural county would probably avoid using the clinics for anything if they were understood to provide abortion services.

Both Osborn and Meghan Chancey, the health department’s director, said they would rank many health care priorities higher, including the need for a general surgeon, an ICU, and a dialysis clinic.

Nationally, reproductive health care services of all types tend to be limited for people in rural areas, even within states that protect abortion access. More than two-thirds of people in “maternity care deserts” — all of which are in rural counties — must drive more than a half-hour to get obstetric care, according to a 2024 March of Dimes report. For people in the Southern states where lawmakers installed abortion bans, abortion care can be up to 700 miles away, according to a data analysis by Axios.

Nathan Defrees grew up in Baker City and has practiced medicine here since 2017. He works for a family medicine clinic. If a patient asks about abortion, he provides information about where and how one can be obtained, but he doesn’t offer abortions himself.

“There’s not a lot of anonymity in small towns for physicians who provide that care,” he said. “Many of us aren’t willing to sacrifice the rest of our career for that.”

He also pointed to the small number of patients requesting the service locally. Just six people living in Baker County had an abortion in 2023, according to data from the Oregon Department of Public Health. Meanwhile, 125 residents had a baby that year.

A doctor with obstetric training living in another rural part of the state has chosen to quietly provide early-stage abortions when asked. The doctor, concerned for their family’s safety in the small, conservative town where they live, asked not to be identified.

The idea that better access to abortion is not needed in rural areas seems naive, the doctor said. People most in need of abortion often don’t have access to any medical service not already available in town, the doctor pointed out. The first patient the doctor provided an abortion for at the clinic was a meth user with no resources to travel or to manage an at-home medication abortion.

“It seemed entirely inappropriate for me to turn her away for care I had the training and the tools to do,” the doctor said.

Defrees said it has been easier for Baker County residents to get an abortion since the U.S. Supreme Court overturned Roe v. Wade.

A new Planned Parenthood clinic in Ontario, Oregon, 70 miles away in neighboring Malheur County, was built primarily to provide services to people from the Boise metro area, but it also created an option for many living in rural eastern Oregon.

Idaho is one of the 16 states with near-total bans on abortion. Like many states with bans, Idaho has struggled to maintain its already small fleet of fetal medicine doctors. The loss of regional expertise touches Baker City, too, Defrees said.

For example, he said, the treatment plan for women who have a desired pregnancy but need a termination for medical reasons is now far less clear. “It used to be those folks could go to Boise,” he said. “Now they can’t. That does put us in a bind.”

Portland is the next closest option for that type of care, and that means a 300-mile drive along a set of highways that can be treacherous in winter.

“It’s a lot scarier to be pregnant now in Baker City than it ever has been,” Defrees said.

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

USE OUR CONTENT

This story can be republished for free (details).

HHS' SAMHSA recently awarded $10 million for the Community-Based Maternal Behavioral Health Services Program, a new grant program supporting the behavioral health of pregnant and postpartum women.

Statement from HHS Secretary Xavier Becerra as New $2,000 Out-of-Pocket Cap Takes Effect, Saving Millions on Prescription Drugs

In 2024, our nationwide team of gumshoes set out to answer your most pressing questions about medical bills, such as: Can free preventive care really come with add-on bills for items like surgical trays? Or, why does it cost so much to treat a rattlesnake bite? Or, if it’s called an urgent care emergency center, which is it?

Affording medical care continues to be among the top health concerns facing Americans today. In the seventh year of KFF Health News’ “Bill of the Month” series, readers shared their most perplexing, vexing, and downright expensive medical bills and asked us to help figure out what happened. Our reporters analyzed $800,000 in charges, including more than $370,000 owed by 12 patients and their families.

This year, we met several patients who fought back.

Caitlyn Mai of Oklahoma City was preapproved for a hearing implant, yet for months she was still hounded by notices saying she owed $139,000.

To resolve the problem, Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department. “I said, ‘I’ve done your job for you — now can you please take it from here?’”

Jamie Holmes of Lynden, Washington, refused to buckle when a surgery center tried to make her pay for two operations after she underwent only one — even after a collection agency sued her.

She showed up at two court hearings and explained her side. “I just got stonewalled so badly. They treated me like an idiot,” she told “Bill of the Month.” “If they’re going to be petty to me, I’m willing to be petty right back.”

As always, we reached out to medical billing experts for their takeaways and learned that these patients had the right idea.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

From our curious, tireless “Bill of the Month” team, happy holidays — and, when in doubt, don’t pay the bill.

The Colonoscopies Were Free. But the ‘Surgical Trays’ Came With $600 Price Tags.

By Samantha Liss, 

January 25, 2024

Health providers may bill however they choose — including in ways that could leave patients with unexpected bills for “free” care. Routine preventive care saddled an Illinois couple with his-and-her bills for “surgical trays.”

Without Medicare Part B’s Shield, Patient’s Family Owes $81,000 for a Single Air-Ambulance Flight

By Tony Leys, 

February 27, 2024

Sky-high bills from air-ambulance providers have sparked complaints and federal action in recent years. But a rural Tennessee resident fell through the cracks of billing protections — and a single helicopter ride could cost much of her estate's value.

A Mom’s $97,000 Question: How Was Her Baby’s Air-Ambulance Ride Not Medically Necessary?

By Molly Castle Work, 

March 25, 2024

There are legal safeguards to protect patients from big bills like out-of-network air-ambulance rides. But insurers may not pay if they decide the ride wasn’t medically necessary.

Sign Here? Financial Agreements May Leave Doctors in the Driver’s Seat

By Katheryn Houghton, 

April 30, 2024

Agreeing to an out-of-network doctor’s own financial policy — which generally protects their ability to get paid and may be littered with confusing insurance and legal jargon — can create a binding contract that leaves a patient owing.

He Fell Ill on a Cruise. Before He Boarded the Rescue Boat, They Handed Him the Bill.

By Bram Sable-Smith, 

May 22, 2024

A man from Michigan was evacuated from a cruise ship after having seizures. First, he drained his bank account to pay his medical bills.

It’s Called an Urgent Care Emergency Center — But Which Is It?

By Renuka Rayasam, 

June 24, 2024

Suffering stomach pain, a Dallas man visited his local urgent care clinic — or so he thought, until he got a bill 10 times what he’d expected.

Her Hearing Implant Was Preapproved. Nonetheless, She Got $139,000 Bills for Months.

By Elisabeth Rosenthal, 

July 17, 2024

Even when patients double-check that their care is covered by insurance, health providers often send them bills as they haggle with insurers over reimbursement, which can last for months. It’s stressful and annoying — but legal.

Patient Underwent One Surgery but Was Billed for Two. Even After Being Sued, She Refused To Pay.

By Tony Leys, 

August 21, 2024

A collection agency sought court authority to garnish a patient’s wages to pay a disputed surgery bill. But after the patient showed up in court to argue the bill was bogus, the judge declined to let the bill collector seize her money.

In Chronic Pain, This Teenager ‘Could Barely Do Anything.’ Insurer Wouldn’t Cover Surgery.

By Lauren Sausser, 

September 25, 2024

An Alabama teen was told he needed surgery for debilitating hip pain. But his family’s insurer denied coverage for the procedure, which lacked a medical billing code. Expected to pay more than $7,000, his father charged it to credit cards.

Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars

By Jackie Fortiér, 

October 30, 2024

For snakebite victims, antivenom is critical — and costly. It took more than $200,000 worth of antivenom to save one toddler’s life after he was bitten by a rattlesnake.

A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445.

By Bram Sable-Smith, 

November 27, 2024

A mom in Peoria, Illinois, took her 3-year-old to the ER one evening last December. While they were waiting to be seen, the toddler seemed better, so they left without seeing a doctor. Then the bill came.

He Went in for a Colonoscopy. The Hospital Charged $19,000 for Two.

By Harris Meyer, 

December 19, 2024

A man in Chicago with a troubling symptom underwent a common procedure. Then he wanted to know why the hospital charged nearly three times its own cost estimate.

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

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

USE OUR CONTENT

This story can be republished for free (details).