The last time I stepped on a plane for vacation, for fun, was more than three years ago. I haven’t been able to visit California, whose coast I adore. Nor Rome, where my husband and I lived for some time.

And yet, I’m told, I’ve been on a journey. Two journeys, actually: First, a “traumatic brain injury journey,” experienced at Johns Hopkins Hospital after I banged my head and developed trouble with my balance and gait. More recently, I’ve been a traveling companion on my husband’s “cancer journey” at Memorial Sloan Kettering, in New York City.

These are two of the highest-ranked hospitals in the country. The care was excellent in both places. But neither of these journeys resembled our bike ride in Ireland or the wine-tasting trip in Sonoma a few years before.

So much of being seriously ill has been rebranded in American health care as a kind of adventure. Experts speak of stroke journeys. Hospital systems invite people on kidney transplant journeys. The language has trickled down into advertising: Take a hair loss journey or a weight loss journey (newly popular because of Wegovy and similar drugs). The heart failure journey even comes with a map.

A map? But on these journeys, you don’t get to go anywhere — except maybe the hospital or doctor’s office, which is likely, too, to have bought into the travel concept. In the past two decades, American hospitals have gotten into the business of hotel-like hospitality (illness can be fun!) rather than confine themselves to the business of disease (what a downer). And although the care might stay solid, the focus on luxurious amenities and the fancy new buildings that house them is one of the factors that have helped send costs for patients soaring that much higher, to prices well above those in other developed countries.

In this version of health care, I’m no longer a patient. I’m a client, a customer, or (worse) a guest, no matter that I didn’t choose this journey cum illness. I appreciate a little luxury and privacy as much as the next person. But, at a time when Americans’ life spans are getting shorter and 4 in 10 adults say they’ve delayed or gone without necessary care because of cost, is it worth it?

In recent years, tight budgets, staffing shortages, and burnout have hit American hospitals. At the same time, many health centers in the U.S. — including the most prestigious ones, and even some community hospitals — have morphed into seven-star hotels. New hospital buildings, such as recent projects at the University of Michigan hospital system and Valley Hospital in Paramus, New Jersey, offer all-private rooms, in many cases with couches and flat-screen TVs. A hospital might now boast about its views, high-thread-count sheets, or food provided by a Michelin-starred chef.

Those commissioning and designing these pavilions cite research showing that private rooms are better for healing, because they offer a better chance at sleep and a lower chance of infection. (Actually, the evidence is pretty murky.)

But we’re suckers for this type of thing, and the industry knows that even small comforts can make us feel better, regardless of whether we’re actually getting better. In 2008, researchers at the National Bureau of Economic Research estimated that a hospital investing in amenities would increase demand by 38%, whereas a similar investment in clinical quality would lead to only a 13% increase. More recently, hospital executives told The Boston Globe that the main reason hospitals have moved in this direction is that “people’s expectations have changed,” and it creates a “competitive advantage” that can be marketed to potential customers.

And so the Mayo Clinic now offers complimentary concierge services, which can help with recommending nearby restaurants and finding pet care. I think that’s the hospitality version of what used to be called the hospital “help desk,” whose function was merely to explain to visitors how to get to patient rooms. Cleveland Clinic, which employs a team of curators, owns one of the largest contemporary art collections in the region, and its leaders see that collection as one tool for “positively affecting patient outcomes.” Patients at Cedars-Sinai can experience its “therapeutic art collection” of Chagalls, Picassos, and Oldenburgs.

Hospital food has gotten so good that in some areas people go to their local hospital for haute cuisine rather than medical needs. And when you look at the numbers on your hospital bill, remember that all of this adds up. For the amount that American patients (or their insurers) pay for some luxury hospital journeys, they could sign up for a Virgin Galactic suborbital joy ride.

This transformation from hospital to hospitality has filled up hospital C-suites with chief experience officers, whose function is to “manage patients’ experiences throughout their healthcare journey,” as described by the publication HealthTech. The Cleveland Clinic was the first major academic medical center to add one, back in 2007; now some health systems hire for this and similar positions directly from the hospitality industry, picking people who’d previously been managers at a Ritz-Carlton or a Trump hotel.

The American Hospital Association acknowledges and defends the transformation. “These are not just ‘nice to haves,’” Nancy Foster, AHA’s vice president of quality and patient-safety policy, wrote to me in an email. “Actions hospitals can take to reduce stress and provide other psychological support can have a meaningful impact on one’s physical and behavioral health, including the ability to recover more rapidly.” But pretending that illness is an Abercrombie & Kent safari is harmful. These amenities have a cost, and they are not worth nearly what we’re paying for them as we’re billed for $100,000 joint replacements and $9,000 CT scans. Room charges in many hospitals can exceed $1,000 a night. And “facility fees” for outpatient procedures and even office visits can reach hundreds of dollars, and simply don’t exist elsewhere. A hospital’s function is to diagnose and to heal, at a price that sick people can afford. I dream of a no-frills Target- or Ikea-like hospital for care.

That doesn’t mean hospitals need to resemble prisons. Hospitals certainly have room to improve on breakfasts featuring Lilliputian plastic cups of orange juice and rubbery eggs. But to understand one of the many reasons Americans pay so much for health care, consider this: The best hospitals in Europe are utilitarian structures that most resemble urban high schools. When I got stitches for a deep cut in my forehead in Gemelli Hospital — where the pope gets health care — I sat on a gurney in a big, dark room with other patients.

Instead of providing free coffee and a piano in a soaring, art-filled marble lobby, how about focusing on the very basic things that health systems in the U.S. should do, but — in my experience — in many cases do not, like making it easier for patients to schedule appointments? Shortening the now lengthy wait times to see physicians who take insurance plans? Paying for adequate staffing on nights and weekends, so patients don’t linger in bed pointlessly for two days until social workers return on Monday? Or ending those two-day stays in emergency rooms when all inpatient beds are full? (Hotels aspire to run at full occupancy to maximize revenue; hospitals, I’d argue, should not.)

This winter, I’m planning a journey for which I look forward to some good food and art. We haven’t yet determined the exact destination, but it will not be a U.S. hospital.

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

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Four out of five people eligible for coverage at $10 or less per month

The day her Medicaid coverage ended, Beverly Likens was in the hospital after a scary trip to the emergency room.

The Kentucky resident was diagnosed with severe anemia and given a blood transfusion after her hemoglobin levels had plummeted. Likens, 48 at the time, was days from having surgery to treat chronic uterine bleeding that she said left her bleeding “constantly.”

But soon a problem appeared: The hospital said she didn’t have Medicaid coverage, jeopardizing her procedure. Likens, who is disabled, was rocked by the news. She believed she’d done what was needed to maintain her eligibility. “I was just ready to fall to pieces,” Likens said, fearing she was “going to spend the rest of my life getting blood transfusions.”

Millions of people nationwide have lost Medicaid benefits after a pandemic-era mandate for coverage expired in March — most of them for administrative reasons unrelated to their actual eligibility. Even the Biden administration and state officials had braced for complications in the historic unwinding of the continuous enrollment requirement, and had assured the public they would guard against such lapses.

Likens and an attorney who had tried to help retain her coverage said technological errors in Kentucky’s eligibility system and state missteps caused Likens’ coverage gap, throwing her surgery into limbo. As her situation demonstrates, a lapse of even a few days can have life-altering consequences.

The state never should have let Likens become uninsured, said attorney Cara Stewart, director of policy advocacy at Kentucky Voices for Health. Stewart tried to submit a new Medicaid application for Likens before her coverage stopped in June. She got stuck in a loop in Kentucky’s online system that “didn’t go away” and prevented the form from getting through. “I was just furious,” Stewart said.

Likens should never have had to reapply for coverage, Stewart said, arguing that the state violated federal regulations that say, before concluding someone is ineligible and terminating benefits, states must consider all scenarios in which someone might qualify. Likens, who doesn’t have children and isn’t working, should have qualified for Medicaid based on her income, which falls below federal limits.

Medicaid, a safety-net health program jointly run by the federal government and states, covers millions of people with disabilities, pregnant women, children, adults without children, and seniors. Often a person who qualifies for Medicaid initially for one reason could remain eligible even when life circumstances change, as long as their income remains below certain thresholds.

Before she lost her coverage, Likens qualified for Medicaid because she had Supplemental Security Income, a program for people with little to no income or assets who are blind, disabled, or at least 65 years old. Likens has multiple chronic conditions, including diabetes, hypertension, and heart disease, and said she initially got on the program after her grandfather, who supported her financially, passed away. Likens was his caretaker and didn’t go to college; following his death, she grappled with depression and anxiety that she still treats with medication and therapy.

Apart from limits on earnings, the SSI program limits beneficiaries’ assets to $2,000 for individuals and $3,000 for couples. After the Social Security Administration told her in March she was no longer eligible for SSI because she had assets whose cash value exceeded federal limits, a Kentucky agency that oversees Medicaid sent Likens a notice in April stating her health benefits would automatically stop at the end of June.

The state didn’t assess whether she qualified another way, even though regulations from the Centers for Medicare & Medicaid Services require states to consider all factors. Instead, Kentucky said she “may be eligible for Medicaid another way” and directed her to apply again.

Kentucky health officials maintained they didn’t do anything wrong. In a September letter to the Kentucky Equal Justice Center, a nonprofit that supplies legal aid, state officials said the requirement to consider whether someone qualifies for Medicaid under a different category does not apply to people with SSI benefits.

Because her Medicaid eligibility solely hinged on her receipt of SSI, “the Department for Medicaid Services does not have sufficient information on record to determine if the individual qualifies for another Medicaid type of assistance,” wrote Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services, and Lisa Lee, commissioner of the Department for Medicaid Services. “Individuals receive clear guidance in the notice they receive to file an application to determine whether they are eligible in other types of assistance.”

That explanation is “absolutely wrong,” said Elizabeth Priaulx, a senior disability legal specialist with the National Disability Rights Network. “They failed on many levels.” Priaulx pointed to policy guidance CMS issued in May, which says if a person with SSI experiences a change in circumstances, states must reassess whether they’re eligible for Medicaid in another way before terminating coverage.

As of 2021, there were 7.7 million SSI recipients, according to the Social Security Administration.

Spokespeople for Kentucky’s Cabinet for Health and Family Services didn’t respond to multiple requests for comment.

CMS regulations require states to first try renewing people automatically — a policy designed to help keep eligible people enrolled during what’s known as the Medicaid “unwinding.” States can do so by checking data sources, such as if a Medicaid recipient is enrolled in other public assistance programs for food and housing, or by checking federal and state income tax information. If that doesn’t work, states must send an enrollee a renewal form asking for additional information. Likens said she never got one.

All states are conducting automatic renewals for at least some enrollees. However, states generally are behind on such renewals for some beneficiaries, including seniors and people with disabilities, increasing the risk someone could lose coverage when they shouldn’t, said Joan Alker, executive director of the Georgetown University Center for Children and Families.

“Given the high level of procedural terminations, there undoubtedly are people who are eligible in another category, but they’re falling through the cracks,” Alker said.

After Likens was told to apply again for Medicaid, technological errors in Kentucky’s online system kept the application in limbo until her benefits lapsed in June, Stewart said. The state contracts with Deloitte to operate its eligibility system; a company spokesperson declined to comment.

In early July, after spending hours on the phone, Medicaid officials told her Likens’ coverage was reapproved. But it wouldn’t show up in the computer systems for Likens’ providers for days. On July 10, she received an electronic portal message from a nurse at Pikeville Medical Center saying her insurance was registering as inactive, and her surgery might be delayed as a result.

Likens replied that the state told her she was “for sure approved for coverage,” and that her updated eligibility status “should go back to active soon.” After constant calls, Stewart said, her reinstated Medicaid came through in mid-July and she had surgery July 17.

Likens was reinstated because her income was low enough. Kentucky expanded Medicaid under the Affordable Care Act, which in 2023 means a single adult without children must earn less than $20,120 annually to qualify. But she worries about others who “don’t get as lucky as I did.”

“It is not fair for any Kentuckian to have to go without health care,” she said.

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

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Reesha Ahmed was on cloud nine.

It was January and Ahmed was at an OB-GYN’s office near her home in Venus, Texas, for her first prenatal checkup. After an ultrasound, getting anti-nausea medication, and discussing her pregnancy care plan, she said, a nurse made a convenient suggestion: Head to the lab just down the hall for a standard panel of tests.

The lab was inside Texas Health Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Worth suburb. Ahmed, just eight weeks pregnant, said the doctor told her everything about the visit was routine. “Nothing really stood out,” Ahmed said. “And, of course, there’s just a lot of excitement, and so I really didn’t think twice about anything.”

Her blood tests checked for multiple sexually transmitted infections, her blood type, and various hormones. Within days, Ahmed began bleeding and her excitement turned to fear. A repeat ultrasound in early February showed no fetus.

“My heart kind of fell apart at that moment because I knew exactly what that meant,” she said. She would have a miscarriage.

Then the bills came.

The Patient: Reesha Ahmed, 32, has an Anthem Blue Cross and Blue Shield policy through her employer.

Medical Services: An analysis of Pap smear results and several blood tests in tandem with Ahmed’s initial prenatal visit, including complete blood count, blood type, and testing for STIs such as hepatitis B, syphilis, and HIV.

Service Provider: Ahmed got her tests at Texas Health Mansfield, a tax-exempt hospital jointly operated by Texas Health Resources, a faith-based nonprofit health system, and AdventHealth, another religious nonprofit.

Total Bill: The hospital charged $9,520.02 for the blood tests and pathology services. The insurer negotiated that down to $6,700.50 and then paid $4,310.38, leaving Ahmed with a lab bill of $2,390.12.

What Gives: Ahmed’s situation reveals how hospital-based labs often charge high prices for tests. Even when providers are in network, a patient can be on the hook for thousands of dollars for common blood tests that are far cheaper in other settings. Research shows hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

The situation was particularly difficult for Ahmed because she had lost the pregnancy.

“To come to terms with it mentally, emotionally, physically — dealing with the ramifications of the miscarriage — and then having to muster up the fighting strength to then start calling your insurance, and the billing department, the provider’s office, trying to fight back a bill that you don’t feel like you were correctly sent? It’s just, it’s a lot,” she said.

In Texas, the same lab tests were at least six times as expensive in a hospital as in a doctor’s office, according to research from the Health Care Cost Institute, a nonprofit that examines health spending.

The markup can be even higher depending on the test. HCCI data, based on 2019 prices, shows the median price for a complete blood count in Texas was $6.34 at an independent lab and $58.22 at a hospital. Texas Health charged Ahmed $206.69 for that test alone.

“It is convenient to get your lab done right in the same building,” said Jessica Chang, a senior researcher at HCCI, but “many patients are not thinking about how highly marked up these lab tests are.” Chang said she suspects many hospitals tack on their overhead costs when they bill insurance.

Anthem also charged Ahmed for at least four tests that most insurance plans would consider preventive care and therefore covered at no cost to patients under the Affordable Care Act’s requirements for covering preventive care, which includes aspects of prenatal care. Her EOBs, or “explanation of benefits” notices, show she paid out-of-pocket for a test identifying her Rh factor — which detects a protein on the surface of red blood cells — as well as for tests for hepatitis B, hepatitis C, and syphilis.

Asked to review Ahmed’s tests, Anthem spokesperson Emily Snooks wrote in an email to KFF Health News that the claims “were submitted as diagnostic — not preventive — and were paid according to the benefits in the member’s health plan.”

There “definitely shouldn’t be” out-of-pocket costs for those screenings, said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

The Centers for Disease Control and Prevention recommends screening pregnant patients for several infectious diseases that pose major risks during pregnancy. Ina Park, a professor of family community medicine at the University of California-San Francisco and an expert on STIs, said the tests Ahmed received didn’t raise red flags from a clinical perspective. “It’s really more what the actual lab charged based on what the tests actually cost,” Park said. “This is a really exorbitant price.”

For example, Ahmed paid $71.86 in coinsurance for a hepatitis B test for which the hospital charged $418.55. The hospital charged $295.52 to screen for syphilis; her out-of-pocket cost was $50.74.

“You just wonder, is the insurance company really negotiating with this provider as aggressively as they should to keep the reimbursement to a reasonable amount?” Corlette said.

The Resolution: Ahmed refused to pay the bills and Texas Health sent the debt to collections. When she tried to get answers about the costs, she said she was bounced between the doctor’s office and the hospital billing department. Ahmed submitted a complaint to the Texas attorney general’s office, which passed it to the Texas Health and Human Services Commission. She never heard back.

According to Ahmed, a hospital representative suggested her bloodwork might have been coded incorrectly and agreed the charges “were really unusually high,” Ahmed said, but she was told there was nothing the hospital could do to change it. The hospital did not comment on the reason behind the high charge. And in a March 7 email, an AdventHealth employee told Ahmed the doctor’s office had “no control” over the hospital’s billing.

Ahmed filed an appeal with Anthem, but it was denied. The insurance company stated the claims were processed correctly under her benefits, which cover 80% of what the insurer agrees to pay for in-network lab services after she meets her deductible. Ahmed has a $1,400 deductible and a $4,600 out-of-pocket maximum for in-network providers.

“We depend on health care providers to submit accurate billing information regarding what medical care was needed and delivered,” Snooks said. Asked about reimbursements to the Texas Health lab, she added, “The claim was reimbursed based on the laboratory’s contract with the health plan.”

After a KFF Health News reporter contacted Texas Health on Oct. 9, the hospital called Ahmed on Oct. 10 and said it would zero out her bills and remove the charges from collections. Ahmed was relieved, “like a giant burden’s just been lifted off my shoulders.”

“It’s just been fighting this for 10 months now, and it’s finally gone,” she said.

Texas Health Resources and AdventHealth declined to respond to detailed questions about Ahmed’s charges and the tests she was directed to obtain.

“We are sorry Ms. Ahmed did not get clarity on her care with us. Our top priority is to provide our patients with safe, effective and medically appropriate care,” Laura Shea, a spokesperson for the hospital, said in an emailed statement.

The Takeaway: Ahmed’s problem demonstrates the pitfalls of using a hospital lab for routine testing.

For standard bloodwork “it’s really hard to argue that there’s a quality difference” between independent labs and hospitals that would warrant higher prices, Chang said. That holds true for other services, too, like imaging. “There’s nothing special about the machines that hospitals use for a CT or MRI scan. It’s the same machine.”

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Broadly, state and federal lawmakers are paying attention to this issue. Congress is considering legislation that would equalize payments for certain services regardless of whether they are provided in a hospital outpatient department or a doctor’s office, although not lab services. Hospitals have tried to fend off such a policy, known as “site-neutral payments.”

For example, the Lower Costs, More Transparency Act would require the same prices under Medicare for physician-administered drugs regardless of whether they’re given in a doctor’s office or an off-campus hospital outpatient department. That bill also would require labs to make public the prices they charge Medicare for tests. Another bill, the Bipartisan Primary Care and Health Workforce Act, would ban hospitals from charging commercial health plans some facility fees — which they use to cover operating or administrative expenses.

According to the National Conference of State Legislatures, Colorado, Connecticut, Ohio, New York, and Texas have limited providers’ ability to charge privately insured patients facility fees for certain services. Colorado, Connecticut, Maryland, and New York require health facilities to disclose facility fees to patients before providing care; Florida instituted similar requirements for free-standing emergency departments.

Patients should keep copies of itemized bills and insurance statements. While not the only evidence, those documents can help patients avoid out-of-pocket costs for recommended preventive screenings.

For now, patients can proactively avoid such extreme bills: When your doctor says you need blood tests, ask that the requisition be sent to a commercial lab like Labcorp or Quest Diagnostics that is in your network and have the tests done there. If they can’t do it electronically, ask for a paper requisition.

“Don’t always just go to the lab that your doctor recommends to you,” Corlette said.

Stephanie O’Neill reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? 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.

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HHS’ Office for Civil Rights Settles HIPAA Investigation of St. Joseph’s Medical Center for Disclosure of Patients’ Protected Health Information to a News Reporter

The Department of Defense relies on hundreds, if not thousands, of weapons and products such as uniforms, batteries, and microelectronics that contain PFAS, a family of chemicals linked to serious health conditions.

Now, as regulators propose restrictions on their use or manufacturing, Pentagon officials have told Congress that eliminating the chemicals would undermine military readiness.

PFAS, known as “forever chemicals” because they don’t break down in the environment and can build up in the human body, have been associated with such health problems as cancer. In July, a new federal study showed a direct link between testicular cancer and PFOS, a PFAS chemical that has been found in the blood of thousands of military personnel.

Congress has pressured the Defense Department to clean up U.S. military sites and take health concerns more seriously. Under the fiscal 2023 James M. Inhofe National Defense Authorization Act, the Pentagon was required to assess the ubiquity of per- and polyfluoroalkyl substances, or PFAS, in products and equipment used by the military.

In a report delivered to Congress in August, Defense Department officials pushed back against health concerns raised by environmental groups and regulators. “DoD is reliant on the critically important chemical and physical properties of PFAS to provide required performance for the technologies and consumable items and articles which enable military readiness and sustainment,” the authors said.

Further, they wrote: “Losing access to PFAS due to overly broad regulations or severe market contractions would greatly impact national security and DoD’s ability to fulfill its mission.”

According to the report, most major weapons systems, their components, microelectronic chips, lithium-ion batteries, and other products contain PFAS chemicals. These include helicopters, airplanes, submarines, missiles, torpedoes, tanks, and assault vehicles; munitions; semiconductors and microelectronics; and metalworking, cooling, and fire suppression systems — the latter especially aboard Navy ships.

PFAS are also present in textiles such as uniforms, footwear, tents, and duffel bags, for which the chemicals help repel water and oil and increase durability, as well as nuclear, chemical, and biological warfare protective gear, the report says.

The Pentagon’s report to Congress was released last month by the American Chemistry Council.

Defending a Tradition of Defense

Military officials’ defense of PFAS use comes as concerns mount over the health risks associated with the chemicals. Beyond cancer, some types of PFAS have been linked to low birth weight, developmental delays in children, thyroid dysfunction, and reduced response to immunizations. Health concerns grew with the release of the study definitively linking testicular cancer in military firefighters to a foam retardant containing PFAS.

But that wasn’t the first time U.S. military officials were warned about the potential health threat. In the 1970s, Air Force researchers found that firefighting foam containing PFAS was poisonous to fish and, by the 1980s, to mice.

In 1991, the U.S. Army Corps of Engineers told Fort Carson, Colorado, to stop using firefighting retardants containing PFAS because they were “considered hazardous material in a number of states.”

The Environmental Protection Agency has struggled to determine whether there are acceptable levels of PFAS in drinking water supplies, given the existence of hundreds of varieties of these chemicals. But in March, the EPA did propose federal limits on the levels of PFAS in drinking water supplies.

The regulation would dramatically reduce limits on six types of the chemicals, with caps on the most common compounds, known as PFOA and PFOS, at 4 parts per trillion. Currently, the Defense Department’s threshold for drinking water is 70 parts per trillion based on a 2016 EPA advisory. As part of a widespread testing program, if levels are found on installations or in communities above that amount, the military furnishes alternative drinking water supplies.

The Defense Department has used PFAS-laced firefighting foam along with other products containing the chemicals for more than a half-century, leading to the contamination of at least 359 military sites or nearby communities, with an additional 248 under investigation, according to the department.

In its report, however, the Department of Defense did not address the health concerns and noted that there is “no consensus definition of PFAS as a chemical class.” Further, it said that the broad term, which addresses thousands of man-made chemical chains, “does not inform whether a compound is harmful or not.”

Researchers with the Environmental Working Group, an advocacy group that focuses on PFAS contamination nationwide, said the report lacked acknowledgment of the health risks or concerns posed by PFAS and ignored the availability of PFAS-free replacements for material, tents, and duffel bags.

The military report also did not address possible solutions or research on non-PFAS alternatives or address replacement costs, noted EWG’s Jared Hayes, a senior policy analyst, and David Andrews, a senior scientist.

“It’s kind of like that report you turn in at school,” Andrews said, “when you get a comment back that you did the minimum amount possible.”

Andrews added that the report fell short in effort and scope.

The Defense Department announced this year it would stop buying firefighting foam containing PFAS by year’s end and phase it out altogether in 2024. It stopped using the foam for training in 2020, by order of Congress.

The report noted, however, that while new Navy ships are being designed with alternative fire suppression systems such as water mists, “limited use of [PFAS-containing systems] remains for those spaces where the alternatives are not appropriate,” such as existing ships where there is no alternative foam that could be swapped into current systems.

According to the report, “the safety and survivability of naval ships and crew” from fires on ships depends on current PFAS-based firefighting foams and their use will continue until a capable alternative is found.

Pervasive Yet Elusive

Commercially, PFAS chemicals are used in food packaging, nonstick cookware, stain repellents, cosmetics, and other consumer products.

The fiscal 2023 National Defense Authorization Act also required the Defense Department to identify consumer products containing PFAS and stop purchasing them, including nonstick cookware and utensils in dining facilities and ship galleys as well as stain-repellent upholstered furniture, carpeting, and rugs.

But in a briefing to Congress in August accompanying the report on essential uses, Pentagon officials said they couldn’t comply with the law’s deadline of April 1, 2023, because manufacturers don’t usually disclose the levels of PFAS in their products and no federal laws require them to do so.

Come Jan. 1, however, makers of these chemicals and products containing them will be required to identify these chemicals and notify “downstream” manufacturers of other products of the levels of PFAS contained in such products and ingredients, even in low concentrations, according to a federal rule published Oct. 31 by the EPA.

This would include household items like shampoo, dental floss, and food containers.

Officials reiterated that the Defense Department is committed to phasing out nonessential and noncritical products containing PFAS, including those named above as well as food packaging and personal protective firefighting equipment.

And it is “developing an approach” to remove items containing PFAS from military stores, known as exchanges, also required by the fiscal 2023 NDAA.

Risk-Benefit Assessments

In terms of “mission critical PFAS uses,” however, the Pentagon said the chemicals provide “significant benefits to the framework of U.S. critical infrastructure and national and economic security.”

Andrews of EWG noted that the industry is stepping up production of the chemicals due to market demand and added that the federal government has not proposed banning PFAS chemicals, as the Defense Department alluded to when it emphasized the critical role these substances play in national security and warned against “overly broad regulations.”

“The statements are completely unsubstantiated, and it’s almost a fear-mongering statement,” Andrews said. “I think the statement is really going beyond anything that’s even being considered in the regulatory space.”

“There haven’t been realistic proposals policy-wise of a complete ban on PFAS,” his colleague Hayes added. “What people have been pushing for and talking about are certain categories of products where there are viable alternatives, where there is a PFAS-free option. But to ban it outright? I haven’t really seen that as a realistic policy proposal.”

Kevin Fay, executive director of the Sustainable PFAS Action Network, a coalition of corporations, industry advocates, and researchers who support the use and management of PFAS compounds, said the Defense Department has a point and it is up to federal regulators to “responsibly manage” these chemicals and their use to strike a balance among environmental, health, and industrial needs.

“The U.S. Department of Defense’s report on critical PFAS uses is crystal clear: regulating PFAS through a one-size fits all approach will gravely harm national security and economic competitiveness,” Fay wrote in an email to KFF Health News.

Adding that not all PFAS compounds are the same and arguing that not all are harmful to human health, Fay said risk-based categorization and control is vital to the continued use of the chemicals.

But, he added, in locations where the chemicals pose a risk to human health, the government should act.

“The federal government should implement plans to identify and remediate contaminated sites, properly identify risk profiles of the many types of PFAS compounds, and encourage innovation by clearing the regulatory path for viable alternatives to specific dangerous compounds,” Fay wrote.

Assessments are completed or underway at 714 active and former military installations, National Guard facilities, and other former defense sites to determine the extent of contamination in groundwater, soil, and the water supply to these locations and nearby communities.

Last year, the Pentagon issued a temporary moratorium on burning materials containing PFAS. Studies have shown that the practice can release toxic gases. But on July 11, the Defense Department lifted the moratorium on incineration, along with interim guidance on PFAS disposal.

Military personnel who were exposed to PFAS — including through firefighting foam — say they live in fear that they or their family members will develop cancer as a result of their service.

“I’ve got more of some of those materials in my system than 90-plus percent of those on the planet. This is bad. It doesn’t go away,” said Christian Jacobs, who served in the Army for four years and worked as a civilian Defense Department firefighter for nearly three decades. “It keeps me up at night.”

KFF Health News visual reporter Hannah Norman contributed to this report.

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

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Assisted living centers have become an appealing retirement option for hundreds of thousands of boomers who can no longer live independently, promising a cheerful alternative to the institutional feel of a nursing home.

But their cost is so crushingly high that most Americans can’t afford them.

These highly profitable facilities often charge $5,000 a month or more and then layer on fees at every step. Residents’ bills and price lists from a dozen facilities offer a glimpse of the charges: $12 for a blood pressure check; $50 per injection (more for insulin); $93 a month to order medications from a pharmacy not used by the facility; $315 a month for daily help with an inhaler.

The facilities charge extra to help residents get to the shower, bathroom, or dining room; to deliver meals to their rooms; to have staff check-ins for daily “reassurance” or simply to remind residents when it’s time to eat or take their medication. Some even charge for routine billing of a resident’s insurance for care.

“They say, ‘Your mother forgot one time to take her medications, and so now you’ve got to add this on, and we’re billing you for it,’” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit.

About 850,000 older Americans reside in assisted living facilities, which have become one of the most lucrative branches of the long-term care industry that caters to people 65 and older. Investors, regional companies, and international real estate trusts have jumped in: Half of operators in the business of assisted living earn returns of 20% or more than it costs to run the sites, an industry survey shows. That is far higher than the money made in most other health sectors.

Rents are often rivaled or exceeded by charges for services, which are either packaged in a bundle or levied à la carte. Overall prices have been rising faster than inflation, and rent increases since the start of last year have been higher than at any previous time since at least 2007, according to the National Investment Center for Seniors Housing & Care, which provides data and other information to companies.

There are now 31,000 assisted living facilities nationwide — twice the number of skilled nursing homes. Four of every five facilities are run as for-profits. Members of racial or ethnic minority groups account for only a tenth of residents, even though they make up a quarter of the population of people 65 or older in the United States.

A public opinion survey conducted by KFF found that 83% of adults said it would be impossible or very difficult to pay $60,000 a year for an assisted living facility. Almost half of those surveyed who either lived in a long-term care residence or had a loved one who did encountered unexpected add-on fees for things they assumed were included in the price.

Assisted living is part of a broader affordability crisis in long-term care for the swelling population of older Americans. Over the past decade, the market for long-term care insurance has virtually collapsed, covering just a tiny portion of older people. Home health workers who can help people stay safely in their homes are generally poorly paid and hard to find.

And even older people who can afford an assisted living facility often find their life savings rapidly drained.

Unlike most residents of nursing homes, where care is generally paid for by Medicaid, the federal-state program for the poor and disabled, assisted living residents or their families usually must shoulder the full costs. Most centers require those who can no longer pay to move out.

The industry says its pricing structures pay for increased staffing that helps the more infirm residents and avoids saddling others with costs of services they don’t need.

Prices escalate greatly when a resident develops dementia or other serious illnesses. At one facility in California, the monthly cost of care packages for people with dementia or other cognitive issues increased from $1,325 for those needing the least amount of help to $4,625 as residents’ needs grew.

“It’s profiteering at its worst,” said Mark Bonitz, who explored multiple places in Minnesota for his mother, Elizabeth. “They have a fixed amount of rooms,” he said. “The way you make the most money is you get so many add-ons.” Last year, he moved his mother to a nonprofit center, where she lived until her death in July at age 96.

LaShuan Bethea, executive director of the National Center for Assisted Living, a trade association of owners and operators, said the industry would require financial support from the government and private lenders to bring prices down.

“Assisted living providers are ready and willing to provide more affordable options, especially for a growing elderly population,” Bethea said. “But we need the support of policymakers and other industries.” She said offering affordable assisted living “requires an entirely different business model.”

Others defend the extras as a way to appeal to the waves of boomers who are retiring. “People want choice,” said Beth Burnham Mace, a special adviser for the National Investment Center for Seniors Housing & Care. “If you price it more à la carte, you’re paying for what you actually desire and need.”

Yet residents don’t always get the heightened attention they paid for. Class-action lawsuits have accused several assisted living chains of failing to raise staffing levels to accommodate residents’ needs or of failing to fulfill billed services.

“We still receive many complaints about staffing shortages and services not being provided as promised,” said Aisha Elmquist, until recently the deputy ombudsman for long-term care in Minnesota, a state-funded advocate. “Some residents have reported to us they called 911 for things like getting in and out of bed.”

‘Can You Find Me a Money Tree?’

Florence Reiners, 94, adores living at the Waters of Excelsior, an upscale assisted living facility in the Minneapolis suburb of Excelsior. The 115-unit building has a theater, a library, a hair salon, and a spacious dining room.

“The windows, the brightness, and the people overall are very cheerful and very friendly,” Reiners, a retired nursing assistant, said. Most important, she was just a floor away from her husband, Donald, 95, a retired water department worker who served in the military after World War II and has severe dementia.

She resisted her children’s pleas to move him to a less expensive facility available to veterans.

Reiners is healthy enough to be on a floor for people who can live independently, so her rent is $3,330 plus $275 for a pendant alarm. When she needs help, she’s billed an exact amount, like a $26.67 charge for the 31 minutes an aide spent helping her to the bathroom one night.

Her husband’s specialty care at the facility cost much more: $6,150 a month on top of $3,825 in rent.

Month by month, their savings, mainly from the sale of their home, and monthly retirement income of $6,600 from Social Security and his municipal pension, dwindled. In three years, their assets and savings dropped to about $300,000 from around $550,000.

Her children warned her that she would run out of money if her health worsened. “She about cried because she doesn’t want to leave her community,” Anne Palm, one of her daughters, said.

In June, they moved Donald Reiners to the VA home across the city. His care there costs $3,900 a month, 60% less than at the Waters. But his wife is not allowed to live at the veterans’ facility.

After nearly 60 years together, she was devastated. When an admissions worker asked her if she had any questions, she answered, “Can you find me a money tree so I don’t have to move him?”

Heidi Elliott, vice president for operations at the Waters, said employees carefully review potential residents’ financial assets with them, and explain how costs can increase over time.

“Oftentimes, our senior living consultants will ask, ‘After you’ve reviewed this, Mr. Smith, how many years do you think Mom is going to be able to, to afford this?’” she said. “And sometimes we lose prospects because they’ve realized, ‘You know what? Nope, we don’t have it.’”

Potential Buyers From the Bahamas

For residents, the median annual price of assisted living has increased 31% faster than inflation, nearly doubling from 2004 to 2021, to $54,000, according to surveys by the insurance firm Genworth. Monthly fees at memory care centers, which specialize in people with dementia and other cognitive issues, can exceed $10,000 in areas where real estate is expensive or the residents’ needs are high.

Diane Lepsig, president of CarePatrol of Bellevue-Eastside, in the Seattle suburbs, which helps place people, said that she has warned those seeking advice that they should expect to pay at least $7,000 a month. “A million dollars in assets really doesn’t last that long,” she said.

Prices rose even faster during the pandemic as wages and supply costs grew. Brookdale Senior Living, one of the nation’s largest assisted living owners and operators, reported to stockholders rate increases that were higher than usual for this year. In its assisted living and memory care division, Brookdale’s revenue per occupied unit rose 9.4% in 2023 from 2022, primarily because of rent increases, financial disclosures show.

In a statement, Brookdale said it worked with prospective residents and their families to explain the pricing and care options available: “These discussions begin in the initial stages of moving in but also continue throughout the span that one lives at a community, especially as their needs change.”

Many assisted living facilities are owned by real estate investment trusts. Their shareholders expect the high returns that are typically gained from housing investments rather than the more marginal profits of the heavily regulated health care sector. Even during the pandemic, earnings remained robust, financial filings show.

Ventas, a publicly traded real estate investment trust, reported earning revenues in the third quarter of this year that were 24% above operating costs from its investments in 576 senior housing properties, which include those run by Atria Senior Living and Sunrise Senior Living.

Ventas said the prices for its services were affordable. “In markets where we operate, on average it costs residents a comparable amount to live in our communities as it does to stay in their own homes and replicate services,” said Molly McEvily, a spokesperson.

In the same period, Welltower, another large real estate investment trust, reported a 24% operating margin from its 883 senior housing properties, which include ones operated by Sunrise‌, Atria, Oakmont Management Group, and Belmont Village.‌ Welltower did not respond‌‌ to requests for comment.

The median operating margin for assisted living facilities in 2021 was 23% if they offered memory care and 20% if they didn’t, according to David Schless, chief executive of the American Seniors Housing Association, a trade group that surveys the industry each year.

Bethea said those returns could be invested back into facilities’ services, technology, and building updates. “This is partly why assisted living also enjoys high customer satisfaction rates,” she said.

Brandon Barnes, an administrator at a family business that owns three small residences in Esko, Minnesota, said he and other small operators had been approached by brokers for companies, including one based in the Bahamas. “I don’t even know how you’d run them from that far away,” he said.

Rating the Cost of a Shower, on a Point Scale

To consistently get such impressive returns, some assisted living facilities have devised sophisticated pricing methods. Each service is assigned points based on an estimate of how much it costs in extra labor, to the minute. When residents arrive, they are evaluated to see what services they need, and the facility adds up the points. The number of points determines which tier of services you require; facilities often have four or five levels of care, each with its own price.

Charles Barker, an 81-year-old retired psychiatrist with Alzheimer’s, moved into Oakmont of Pacific Beach, a memory care facility in San Diego, in November 2020. In the initial estimate, he was assigned 135 points: 5 for mealtime reminders; 12 for shaving and grooming reminders; 18 for help with clothes selection twice a day; 36 to manage medications; and 30 for the attention, prompting, and redirection he would need because of his dementia, according to a copy of his assessment provided by his daughter, Celenie Singley.

Barker’s points fell into the second-lowest of five service levels, with a charge of $2,340 on top of his $7,895 monthly rent.

Singley became distraught over safety issues that she said did not seem as important to Oakmont as its point system. She complained in a May 2021 letter to Courtney Siegel, the company’s chief executive, that she repeatedly found the doors to the facility, located on a busy street, unlocked — a lapse at memory care centers, where secured exits keep people with dementia from wandering away. “Even when it’s expensive, you really don’t know what you’re getting,” she said in an interview.

Singley, 50, moved her father to another memory care unit. Oakmont did not respond to requests for comment.

Other residents and their families brought a class-action lawsuit against Oakmont in 2017 that said the company, an assisted living and memory care provider based in Irvine, California, had not provided enough staffing to meet the needs of residents it identified through its own assessments.

Jane Burton-Whitaker, a plaintiff who moved into Oakmont of Mariner Point in Alameda, California, in 2016, paid $5,795 monthly rent and $270 a month for assistance with her urinary catheter, but sometimes the staff would empty the bag just once a day when it required multiple changes, the lawsuit said.

She paid an additional $153 a month for checks of her “fragile” skin “up to three times a day, but most days staff did not provide any skin checks,” according to the lawsuit. (Skin breakdown is a hazard for older people that can lead to bedsores and infections.) Sometimes it took the staff 45 minutes to respond to her call button, so she left the facility in 2017 out of concern she would not get attention should she have a medical emergency, the lawsuit said.

Oakmont paid $9 million in 2020 to settle the class-action suit and agreed to provide enough staffing, without admitting fault.

Similar cases have been brought against other assisted living companies. In 2021, Aegis Living, a company based in Bellevue, Washington, agreed to a $16 million settlement in a case claiming that its point system — which charged 64 cents per point per day — was “based solely on budget considerations and desired profit margins.” Aegis did not admit fault in the settlement or respond to requests for comment.

When the Money Is Gone

Jon Guckenberg’s rent for a single room in an assisted living cottage in rural Minnesota was $4,140 a month before adding in a raft of other charges.

The facility, New Perspective Cloquet, charged him $500 to reserve a spot and a $2,000 “entrance fee” before he set foot inside two years ago. Each month, he also paid $1,080 for a care plan that helped him cope with bipolar disorder and kidney problems, $750 for meals, and another $750 to make sure he took his daily medications. Cable service in his room was an extra $50 a month.

A year after moving in, Guckenberg, 83, a retired pizza parlor owner, had run through his life’s savings and was put on a state health plan for the poor.

Doug Anderson, a senior vice president at New Perspective, said in a statement that “the cost and complexity of providing care and housing to seniors has increased exponentially due to the pandemic and record-high inflation.”

In one way, Guckenberg has been luckier than most people who run out of money to pay for their care. His residential center accepts Medicaid to cover the health services he receives.

Most states have similar programs, though a resident must be frail enough to qualify for a nursing home before Medicaid will cover the health care costs in an assisted living facility. But enrollment is restricted. In 37 states, people are on waiting lists for months or years.

“We recognize the current system of having residents spend down their assets and then qualify for Medicaid in order to stay in their assisted living home is broken,” said Bethea, with the trade association. “Residents shouldn’t have to impoverish themselves in order to continue receiving assisted living care.”

Only 18% of residential care facilities agree to take Medicaid payments, which tend to be lower than what they charge self-paying clients, according to a federal survey of facilities. And even places that accept Medicaid often limit coverage to a minority of their beds.

For those with some retirement income, Medicaid isn’t free. Nancy Pilger, Guckenberg’s guardian, said that he was able to keep only about $200 of his $2,831 monthly retirement income, with the rest going to paying rent and a portion of his costs covered by the government.

In September, Guckenberg moved to a nearby assisted living building run by a nonprofit. Pilger said the price was the same. But for other residents who have not yet exhausted their assets, Guckenberg’s new home charges $12 a tray for meal delivery to the room; $50 a month to bill a person’s long-term care insurance plan; and $55 for a set of bed rails.

Even after Guckenberg had left New Perspective, however, the company had one more charge for him: a $200 late payment fee for money it said he still owed.

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 senior correspondent Aneri Pattani discussed how law enforcement agencies are eyeing the opioid settlement funds for their own use on NPR’s “All Things Considered” on Oct. 20.

• Click here to hear Pattani on “All Things Considered”
• Read Pattani’s “Using Opioid Settlement Cash for Police Gear Like Squad Cars and Scanners Sparks Debate”

KFF Health News former senior editor Andy Miller discussed school nursing shortages on WUGA’s “The Georgia Health Report” on Oct. 20.

• Click here to hear Miller on “The Georgia Health Report”
• Read Colleen DeGuzman’s “A Third of Schools Don’t Have a Nurse. Here’s Why That’s a Problem.”

KFF Health News chief Washington correspondent Julie Rovner explained the language of health insurance open enrollment season on iHeart’s “Grown-Up Stuff: How to Adult” on Oct. 17.

• Click here to hear Rovner on “Grown-Up Stuff: How to Adult”

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 new financial report released by the Social Security Administration this week shows that the scope of the agency’s overpayment problem has continued to grow.

As of Oct. 1, the SSA had an uncollected balance of $23 billion in overpayments — money the agency had determined it mistakenly paid to beneficiaries across the country but had not been able to claw back, despite repeated attempts to do so.

In September, a series of investigative reports by KFF Health News and Cox Media Group television stations first revealed the magnitude of the problem and shared the experiences of dozens of people who’ve received letters from the federal agency demanding repayment, sometimes in the tens of thousands of dollars. At the beginning of fiscal year 2023, the agency’s uncollected balance of overpayments was $21.6 billion.

Its latest “Agency Financial Report” also revealed that the SSA made approximately $11.1 billion in new overpayments to beneficiaries during federal fiscal year 2022, the most recent year of data available. That figure represents more than a 65% increase from overpayments made the previous year. For the past several years, the agency routinely distributed between $6 billion and $7 billion in new overpayments each year.

The report shows the majority of the 2022 overpayments occurred within the Old-Age, Survivors, and Disability Insurance (OASDI) programs, an estimated $6.5 billion. Those programs provide retirement and survivors’ benefits to qualified workers and their families, or support workers who become disabled and their families.

In prior years, most of the overpayments occurred within the Supplemental Security Income program, which provides financial support to aged, blind, and disabled adults and children who have limited income and resources. In 2022, overpayments within the SSI program topped $4.6 billion, which is similar to previous years.

The SSA had not yet responded to a request for an explanation of the significant increase in overpayments within OASDI.

(WHIO-TV)

The report said $1.6 billion of the OASDI overpayments and $287 million of the SSI overpayments were within the agency’s control, meaning they weren’t the beneficiaries’ fault.

In recent weeks, beneficiaries have told KFF Health News-Cox Media Group TV reporters they had no idea they were receiving too much money in their monthly checks until they received a letter from Social Security demanding repayment, often within 30 days.

“I almost threw up when I opened that letter,” said Lori, a Florida woman who didn’t want to publicly disclose her last name. She received a notice saying she owed $121,000, a debt she said was later erased following a multiyear fight with the SSA.

The notices often arrive years after the alleged overpayments occur and, by that time, the money owed can balloon to dollar amounts impossible for beneficiaries to repay.

“It’s just scary to my husband and me. Where are we supposed to come up with this money?” Ohio resident Tammy Eichler told WHIO-TV.

When beneficiaries can’t repay the money, the agency may lower their monthly benefit checks, even when the overpayments were the government’s fault. 

“Taking that benefit away from me will make me homeless,” Florida resident Jesse Greatorex told WFTV-TV.

SSA spokesperson Nicole Tiggemann said the SSA is required by law to attempt to recover overpayments once they are detected.

“We will be doing a top-to-bottom review to see how we can further reduce the error rate,” said SSA acting Commissioner Kilolo Kijakazi, who directed an agency-wide review of overpayment policies and procedures following the reporting by KFF Health News and Cox Media Group TV stations in September.

Members of the Social Security Subcommittee of the House Ways and Means Committee held a hearing in October, citing the joint reporting and demanding answers from Kijakazi regarding the number of people affected by overpayments and what the agency plans to do to address the problem.

A group of senators also wrote to Kijakazi asking about overpayments caused by government-issued stimulus checks during the covid-19 pandemic. KFF Health News and Cox Media Group TV stations profiled beneficiaries who believe the agency erroneously counted those payments against their asset limit, in violation of SSA policy.

Sen. Sherrod Brown (D-Ohio) and other members of Congress are considering several legislative changes that could make it easier for people to avoid overpayments: for example, raising the cap on how much money they’re allowed to save.

“I want [the legislation] to fix the people that it’s already happened to. I want it to stop it from happening in the future,” Brown told WHIO-TV.

Ohio resident Addie Arnold, who cares for her disabled niece and received a letter saying they owed the government more than $60,000, wrote to the SSA saying, “I truly do hope and pray that she is allowed to stay on SSI … because she has to continue to live and without it, she will be in a very bad place.”

“Social Security should be to help people, not to destroy them,” Arnold said.

Do you have an experience with Social Security overpayments you’d like to share? Click here to contact our reporting team.

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Xavier Becerra issued statement after President Biden’s announcement to appoint Dr. W. Kimryn Rathmell to be Director of NCI.

Ashley Denney was about seven months pregnant in 2022 when police handcuffed her during an arrest in Carroll County, Georgia. Officers shackled her even though the state bans the use of restraints on pregnant women in custody beginning at the second trimester.

In early July, she said, it happened again.

“I asked the officer, ‘Please, pull over. I’m not supposed to be handcuffed. I’m pregnant,’” said Denney. At the time, she was near the end of her first trimester, though she believed her pregnancy was more advanced. Arresting officers did not know she was pregnant, said an official with the Carrollton Police Department who reviewed video footage of that arrest.

Medical groups, such as the American College of Obstetricians and Gynecologists, widely condemn shackling pregnant people, which they argue is unethical and unsafe because it increases the risk of falls, hinders medical care, and endangers the fetus.

About 40 states, including Georgia, have passed laws limiting the use of restraints such as handcuffs, leg restraints, and belly chains on pregnant people in law enforcement custody, according to a Johns Hopkins University research group. Laws that seek to improve treatment of pregnant women in jails and prisons have drawn bipartisan support, including the First Step Act, which was passed in 2018 and limits the use of restraints on pregnant people in federal custody. Yet advocates say they continue logging reports of law enforcement agencies and hospital staffers ignoring such prohibitions and allowing pregnant people to be chained, handcuffed, or otherwise restrained.

Confusion over the laws, lack of sanctions for violations, and wide loopholes are contributing to the continued shackling of pregnant women in custody. But it’s nearly impossible to get an accurate picture of the prevalence because of limited data collection and little independent oversight.

“People see laws like these, and they say ‘check.’ They don’t know how they are being implemented and if they are creating the outcomes intended,” said Ashley Lovell, co-director of the Alabama Prison Birth Project, a group that works with pregnant prisoners. Without oversight, these laws “are words on paper,” she said. “They don’t mean anything.”

U.S. jails admit 55,000 pregnant people each year, according to estimates based on 2017 data from research led by Carolyn Sufrin, a gynecology and obstetrics associate professor at Johns Hopkins University who researches pregnancy care in jails and prisons. “The fact that we don’t know what is happening is part of the story itself,” she said.

Yet reports of shackling continue to surface, often making local headlines.

In January, a Georgia woman, 32 weeks pregnant, was shackled for hours while waiting for a medical appointment and during transport, according to Pamela Winn, founder of RestoreHER US.America, a group that works with people entangled in the criminal justice system. The woman did not want to be identified because she is in state custody and fears retaliation. She said her handcuffs were removed only after a request from medical staffers.

Her experience was echoed by women nationwide in law enforcement custody.

Minnesota passed an anti-shackling bill in 2014, but six years later a suburban Minneapolis woman sued Hennepin County after a wrongful arrest during which she was shackled while in active labor — an incident first reported by local media.

And despite Texas’ shackling ban, in August 2022 an officer in Harris County, which includes Houston, chained Amy Growcock’s ankle to a bench in a courthouse holding area for hours.

“It was pretty painful,” said Growcock, who was eight months pregnant and worried about circulation being cut off in her swollen leg.

Prohibitions on shackling have run into the realities of the country’s complicated web of penal institutions. Millions of people are held in a system that includes thousands of county jails, state and federal prisons, and private facilities with varying policies. Facilities often operate with little or no independent oversight, said Corene Kendrick, deputy director of the ACLU National Prison Project.

Some ACLU chapters have been logging complaints about violations of state bans on shackling pregnant people in jails and prisons. It appears, from complaints and oversight reports, that officials are usually left to interpret the law and police their own behavior, said Kendrick.

The Georgia law bans restraining pregnant women in their second and third trimesters and allows restraints in certain circumstances immediately postpartum. The state Department of Corrections maintains an anti-shackling policy for pregnant people in state custody and requires violations to be reported. But agency officials, in response to records requests from KFF Health News, said there were no incident reports regarding shackling in 2022 and through late October.

The Georgia Sheriffs’ Association asks county jails to voluntarily submit data on shackling, but only 74 of the 142 jails sent reports in 2022. Those jails reported holding 1,016 pregnant women but only two inmates who were restrained in the immediate postpartum period.

Association officials contend that shackling is rare. “Our jail people have a lot of common sense and compassion and do not do something to intentionally hurt somebody,” said Bill Hallsworth, director of jail and court services for the association. Many rural jails don’t have medical staffers to immediately verify a pregnancy, he added.

The Carrollton Police Department, whose officers handcuffed Denney, maintain that the law didn’t apply during her arrest, before her booking into a facility, according to public information officer Sgt. Meredith Hoyle Browning.

“It sounds like, to me, that there has been wide interpretation of this bill by the people we are asking to enforce it,” said Georgia state Rep. Sharon Cooper, a Republican who authored the state’s bill. Cooper said she hadn’t been notified of any incidents but added that if pregnant incarcerated women are still being shackled, legislators may need to revise the law.

In addition, some incidents in which jailors shackle pregnant people fall into legal loopholes. In Texas, as in many other states, officers can make exceptions when they feel threatened or perceive a flight risk. Last year 111 pregnant women reported being restrained in jail, according to a Texas Commission on Jail Standards report in April. In more than half the cases, women were shackled during transport even though that’s when they are most likely to fall.

The Texas commission has sent memos to jails that violate the shackling policy, but documents reviewed by KFF Health News show the agency stopped short of issuing sanctions.

Most states don’t allocate funding to educate correctional officers and hospital staff members on the laws. More than 80% of perinatal nurses reported that the pregnant prisoners they care for were sometimes or always shackled, and the vast majority were unaware of laws around the use of restraints, as well as of a nurses association’s position against their use, according to a 2019 study.

Even when medical professionals object to restraints, they generally defer to law enforcement officials.

Southern Regional Medical Center, just south of Atlanta, handles pregnant incarcerated patients from the Georgia Department of Corrections, the Clayton County Jail, and other facilities, said Kimberly Golden-Benner, the hospital’s director of business development, marketing, and communications. She said clinicians request that officers remove restraints when pregnant incarcerated patients arrive at the center for labor and delivery. But it’s still at the officers’ discretion, she said.

The Clayton County Sheriff’s Office didn’t return a request for comment. The state Department of Corrections maintains a policy of limiting the use of restraints on pregnant incarcerated people to only extreme cases, such as when there is an imminent escape risk, said Joan Heath, public affairs director. All staff members at facilities for women are required to complete an annual training course that outlines the policy, she said.

Strengthening the laws will require funding for implementation, such as creating model policies for hospitals and law enforcement staffs; continuous training; tighter reporting requirements; and sanctions for violations, advocates say.

“The laws are a necessary step and draw attention to the issue,” said Sufrin, the Johns Hopkins professor. They are “by no means enough to ensure the practice doesn’t happen.”

Winn wants states to allow pregnant women to bond out of jail immediately and defer sentences until after they give birth. In Colorado a law took effect in August that encourages courts to consider alternative sentences for pregnant defendants. Florida lawmakers considered but did not pass a similar measure this year.

The use of restraints is a window into mistreatment that pregnant women face in jails and prisons.

Denney said that in August she was mistakenly given medication for depression and anxiety instead of nausea; her morning sickness worsened, and she missed a meal.

The medical staff doesn’t have a record of Denney being given the wrong medication, said Brad Robinson, chief deputy of the Carroll County Sheriff’s Office.

“They don’t take you seriously,” Denney said of the pregnancy care she has received while incarcerated. “They should at least make sure the babies are all right.”

Growcock said her initial shackling in Houston was the first sign that officers weren’t equipped to handle pregnant people. She gave birth in a jail cell and nearly lost her son less than two weeks after her arrest. The Texas Commission on Jail Standards acknowledged that Growcock, who photographed her ankle in restraints, had been shackled. But the jail overseer admitted no other wrongdoing in her case, according to a memo the commission sent to the Harris County Jail.

“I felt like if I wasn’t getting treated right already, then the whole experience was going to be bad,” she said. “And it was.”

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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LOS ANGELES — June Voros sprang from her couch as a high-pitched beep warned her that she needed a quick dose of sugar.

Her blood sugar was plummeting, and the beep came from a continuous glucose monitor attached to her abdomen. The small but powerful device alerts Voros when her blood sugar is dangerously high or low.

“My blood sugar is at 64. It’s too low and still dropping,” Voros, 32, said on a bright October afternoon. She checks the monitor up to 80 times a day to help prevent complications from Type 1 diabetes.

But the monitor means little without the supplies that make it work, including a receiver, a sensor, and a transmitter — some of which must be replaced every 10 to 30 days. Voros also has an insulin pump, which delivers a steady supply of that hormone to her body, and it requires supplies too.

Until recently, Voros — who is covered by Medi-Cal, California’s Medicaid program for people with low incomes or disabilities — spent countless hours on the phone with her endocrinologists, her Medi-Cal insurer Health Net, and a medical supply company to obtain separate approvals for each item. At times, her authorizations expired too quickly, leaving her short on supplies and forcing her to ration and seek donations on social media from other diabetes patients.

Last year, she received only enough supplies to last six months.

“I’ve had to put in hundreds of hours over the phone in the past few years, and I’ve changed my insurance group twice because of this,” Voros said before slugging apple juice in her studio apartment in the Mission Hills neighborhood, a suburban neighborhood in the San Fernando Valley. “It’s exhausting. It makes you want to give up. But I can’t. I’ll literally die.”

Starting in October, Medi-Cal began relaxing prior authorization requirements that have caused life-threatening delays for Voros and others with diabetes.

Previously, authorizations for medications and supplies lasted six months, though for some patients, like Voros, they expired sooner. Under the new rules, authorizations are supposed to last one year from the date of approval and can include all needed supplies — ending the scramble to secure separate authorizations for each piece of equipment. Patients can receive 90 days’ worth of supplies and medications at once.

The state is also formalizing a policy that allows patients to obtain approvals from their health care providers by phone or video.

“Before, California’s requirements were four pages long, and now it’s just a little more than a page,” said Lisa Murdock, chief advocacy officer for the American Diabetes Association, who helped push for the changes. “This is a really important step forward. It means not having to constantly guess how blood sugars are doing.”

Over the past two years, the state also started making continuous glucose monitors and related supplies available to many more people, including all patients with Type 1 diabetes, a chronic autoimmune disease that attacks insulin-producing cells in the pancreas, and those with Type 2 diabetes, gestational diabetes, and hypoglycemia, or chronic low blood sugar. Before last year, the monitors were available to only some patients on a case-by-case basis, according to the state Department of Health Care Services, which administers Medi-Cal.

The enhanced coverage extends to newer, more advanced devices, such as the popular Dexcom G7 and its components, which retail for about $700 on Amazon for a 30-day supply without insurance. Medi-Cal pays roughly $400 for the same equipment.

Diabetes and prediabetes are on the rise in California. About 3.2 million Californians have been diagnosed with diabetes. The Department of Health Care Services says about 1.2 million Medi-Cal enrollees have the disease, according to the latest data available.

Before these changes, Medi-Cal recipients had a harder time securing medication and supplies than people with private insurance, Murdock said.

“Diabetes is a really heartbreaking and costly disease, and to take care of themselves, people with diabetes need easy access to insulin, but also the supplies to manage the disease,” she said.

Patient advocates and state health officials say the changes will save money and lives by giving those with diabetes more control over their blood sugar, and by preventing complications such as organ failure and foot and toe amputations.

This expansion in coverage “improves access and member outcomes, reduces hospitalizations and comorbidities, and improves members’ quality of life with better disease management and less finger sticks,” said Ann Carroll, a Medi-Cal spokesperson. The state, she said, wants to ensure all diabetes patients get “the care they need to lead healthy, fulfilling lives.”

Before Voros got her monitor about three years ago, she had to visit an emergency room repeatedly for seizures and was hospitalized with other diabetic complications. She also lost nerve function in her stomach — which prevents digestion of high-fiber foods like vegetables — as her disease advanced.

“I haven’t had to go to the intensive care unit in almost two years. It has literally saved my life,” she said.

But the bureaucratic hurdles that kept Voros from getting supplies for her monitor were a constant source of stress. That’s changing since she switched to a new medical supply company and Medi-Cal has debuted its new preauthorization process, amid a broader revamp of its pharmacy system.

Getting her supplies on time means peace of mind, Voros said.

“I used to be so afraid to go to sleep at night because of the seizures I’d get from low blood sugar,” she said. “I’ve been really close to death, but now I feel better than I ever have.”

This article is part of “Faces of Medi-Cal,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

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

Congress narrowly avoided a federal government shutdown for the second time in as many months, as House Democrats provided the needed votes for new House Republican Speaker Mike Johnson to avoid his first legislative catastrophe of his brief tenure. But funding the federal government won’t get any easier when the latest temporary patches expire in early 2024. It seems House Republicans have not yet accepted that they cannot accomplish the steep spending cuts they want as long as the Senate and the White House are controlled by Democrats.

Meanwhile, a pair of investigations unveiled this week underscored the difficulty of obtaining needed long-term care for seniors. One, from KFF Health News and The New York Times, chronicles the financial toll on families for people who need help for activities of daily living. The other, from Stat, details how some insurance companies are using artificial intelligence algorithms to deny needed rehabilitation care for Medicare patients.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists Rachel Cohrs Stat News @rachelcohrs Read Rachel's stories Joanne Kenen Johns Hopkins Bloomberg School of Public Health and Politico @JoanneKenen Read Joanne's stories Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories

Among the takeaways from this week’s episode:

• Congress passed a two-part continuing resolution this week that will prevent the federal government from shutting down when the current CR expires Nov. 18 at 12:01 a.m. The new measure extends some current spending levels, including funding for the FDA, through Jan. 19. The rest of federal agencies, including most of the Department of Health and Human Services, are extended to Feb. 2.
• House Speaker Mike Johnson (R-La.) has said he wants to use the next two months to finish work on individual appropriations bills, none of which have passed both the House and Senate so far. The problem: They would deeply cut many popular federal programs. They also are full of changes to abortion restrictions and transgender policies, highlighting the split between the GOP caucus’ far-right wing and its more moderate members.
• In the wake of abortion rights successes in passing abortion rights ballot initiatives, new efforts are taking shape in Ohio and Michigan among state lawmakers who are arguing that when Dobbs turned this decision back to states, it meant to the state legislatures — not to the courts or voters. Most experts agree the approach is unlikely to prevail. Still, it highlights continuing efforts to change the rules surrounding this polarized issue.
• Sen. Tim Scott (R-S.C.) — who was the only remaining Republican presidential candidate pushing for a national, 15-week abortion ban — suspended his campaign last week. He, along with former Vice President Mike Pence, who bowed out of the race at the end of October, were the field’s strongest anti-abortion candidates. This seems to suggest that the 15-week ban is not drawing voter support, even among Republicans. Meanwhile, former President Donald Trump, the GOP’s front-runner by miles, continues to be willing to play both sides of the abortion debate.
• Amid increasing concern about the use of artificial intelligence in health care, a California class-action lawsuit charges that UnitedHealth Group is using algorithms to deny rehabilitation care to enrollees in its Medicare Advantage program. The suit comes in the wake of an investigation by Stat into insurer requirements that case managers hew to the AI estimates of how long the company would pay for rehabilitation care, regardless of the patient’s actual medical situation.
• More than 10 million people have lost Medicaid coverage since states began reviewing eligibility earlier in the year. Advocates for Medicaid patients worry that the Biden administration has not done enough to ensure that people who are still eligible for the program — particularly children — are not mistakenly terminated.

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

Julie Rovner: KFF Health News’ “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts,” by Amy Maxmen.

Alice Miranda Ollstein: The New York Times’ “They Wanted to Get Sober. They Got a Nightmare Instead,” by Jack Healy.

Rachel Cohrs: Stat’s “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” by Casey Ross and Bob Herman.

Joanne Kenen: ProPublica’s “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards,” by Isabelle Taft, Mississippi Today.

Also mentioned in this week’s episode:

KFF Health News’ “Facing Financial Ruin as Costs Soar for Elder Care,” by Reed Abelson, The New York Times, and Jordan Rau.

JAMA Internal Medicine’s “Excess Death Rates for Republican and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic,” by Jacob Wallace, et al.

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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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Press Release for $74.4 million mental health dollars.

CMS releasing several resources to help coordinate health care, public health, and social services.

U.S. Department of Health and Human Services (HHS), celebrates National Rural Health Day

Committee will help advise on research and innovation in the whole-of-government response to the longer-term impacts of COVID-19, Inviting nominations.

HELENA, Mont. — Connie MacDonald works for the State Department at the U.S. consulate in Jeddah, Saudi Arabia. It’s a dream job, and she loved living abroad with her two sons.

But earlier this year, MacDonald said, her 8-year-old son started to become aggressive. At first the family thought it was ADHD. Her son was indeed eventually diagnosed with attention-deficit/hyperactivity disorder — as well as disruptive mood dysregulation disorder, which makes it difficult for her son to control his emotions, particularly anger.

“He was hurting me. He was threatening to kill his brother. One of the last straws was they had four people at school holding him down for almost an hour trying to calm him down,” she said.

The American International School of Jeddah told her that her son couldn’t come back. His behavior was so severe that MacDonald started to look for residential treatment back in the U.S.

She found Intermountain Residential in Montana. Children in the Intermountain program learn to build healthy relationships through intense behavioral therapy over the course of up to 18 months.

Intermountain Residential is one of the only facilities in the U.S. that serves young children with emotional dysregulation, like her son.

MacDonald remembers crying hysterically when she dropped him off in June, but tears gave way to hope as his violent outbursts decreased over the weeks and months afterward.

“Now when we have our weekly calls, it’s very normal. It’s like talking to your child again. It’s wonderful,” she said.

Intermountain is one of about a dozen programs in the nation that provide long-term behavioral health treatment for kids under 10, according to the National Association of Therapeutic Schools and Programs. It’s one of the only options for kids as young as 4.

Intermountain is tucked away in a quiet neighborhood in Helena and has been treating children for over 100 years. The children Intermountain treats have emotional disorders, behavioral issues stemming from mental illness or trauma, and other issues. They struggle with self-harm, severe depression, or violent outbursts that can lead to attacking other people or animals. Most families that come to Intermountain have tried medication, outpatient therapy, or even short-term residential treatment, all without success.

Long-term treatment programs like the one Intermountain offers are often a last resort for families.

It can take months before kids with severe mental and behavioral health issues feel safe enough to open up to Intermountain staff, said Meegan Bryce, who manages the residential program. Some kids have been traumatized or abused while adults were supposed to be caring for them, she said. Living through that can leave them deeply scared of or resistant to adult interaction, even once they’re living in a safe environment. Bryce said that Intermountain staff have to gain a patient’s trust before working to figure out the root cause of the child’s behavior. It takes time before they can make an effective long-term treatment plan based on intensive behavioral therapy and building healthy relationships.

Intermountain parents and staff were shocked when the facility announced suddenly this summer that it would close its doors this fall, blaming staffing shortages.

Some parents threatened to sue. A law firm representing them argued in a September letter to Intermountain’s board that it has a contractual responsibility to finish treating children who remain at its residential facility.

Intermountain then reversed course, saying it would downsize in an attempt to keep the program open. But spokesperson Erin Benedict said it’s no guarantee Intermountain can keep its doors open long-term. Intermountain plans to decrease its capacity from 32 beds to eight.

Megan Stokes, until recently executive director of NATSAP, thinks staffing shortages are not the full story of Intermountain’s troubles.

“We are seeing a lot of long-term facilities moving to what they call the short-term, intensive outpatient. You’re able to get insurance money easier,” she explained. Stokes said she knows of 11 long-term programs for kids 14 and younger that have shifted to offering only shorter stays, of 30 to 90 days.

Short-term programs are cheaper and insurance companies will pay for them more quickly, Stokes said. Over the course of a year, short-term programs can treat more patients than long-term residential facilities. That can make them more lucrative to run.

But those programs aren’t likely to help kids who might have to leave Intermountain. In fact, short-term programs could cause them harm.

“The problem is if that kid bombs out of that shorter-term stay, or they do well and maybe six months down the road they don’t have the tools in their toolkit to continue that, and now you’re labeled as treatment-resistant, when that kid wasn’t treatment-resistant,” Stokes said.

Kids labeled treatment-resistant can then be rejected from other short-term programs.

For now, parents of kids at Intermountain are looking for other treatment options because of the uncertainty over whether Intermountain will remain open. Parents told NPR and KFF Health News they’ve had to sign up for waitlists that can take a year or longer to clear for the few programs that take kids 10 and younger. That’s if they can find facilities that would accept their kids at all.

Stacy Ballard hasn’t been able to find a facility willing to treat her 10-year-old adoptive son with reactive attachment disorder who is currently at Intermountain. The condition can make it hard for kids to form an attachment with their family. Ballard said her son can be extremely violent.

“He was walking around our house at night thinking about killing all of us, and he said it was almost nightly that he was doing that,” Ballard explained.

Facilities that treat children his age generally won’t treat kids with a reactive attachment disorder diagnosis, which often is associated with severe emotional and behavioral problems.

MacDonald also can’t find another facility that could be a backup option for her son. He was supposed to complete 14 more months of treatment at Intermountain.

She said she can’t gamble on keeping her son at Intermountain because of the uncertainty over whether it will remain open.

So, she’s getting ready to leave Jeddah and fly back to the U.S., taking a leave of absence from her job.

“I’ll take him to my family’s place in South Carolina until I can find another place for him,” she said.

This article is from a partnership that includes MTPR, 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.

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This story can be republished for free (details).

Money talks.

The United States faces a serious shortage of primary care physicians for many reasons, but one, in particular, is inescapable: compensation.

Substantial disparities between what primary care physicians earn relative to specialists like orthopedists and cardiologists can weigh into medical students’ decisions about which field to choose. Plus, the system that Medicare and other health plans use to pay doctors generally places more value on doing procedures like replacing a knee or inserting a stent than on delivering the whole-person, long-term health care management that primary care physicians provide.

As a result of those pay disparities, and the punishing workload typically faced by primary care physicians, more new doctors are becoming specialists, often leaving patients with fewer choices for primary care.

“There is a public out there that is dissatisfied with the lack of access to a routine source of care,” said Christopher Koller, president of the Milbank Memorial Fund, a foundation that focuses on improving population health and health equity. “That’s not going to be addressed until we pay for it.”

Primary care is the foundation of our health care system, the only area in which providing more services — such as childhood vaccines and regular blood pressure screenings — is linked to better population health and more equitable outcomes, according to the National Academies of Sciences, Engineering, and Medicine, in a recently published report on how to rebuild primary care. Without it, the national academies wrote, “minor health problems can spiral into chronic disease,” with poor disease management, emergency room overuse, and unsustainable costs. Yet for decades, the United States has underinvested in primary care. It accounted for less than 5% of health care spending in 2020 — significantly less than the average spending by countries that are members of the Organization for Economic Cooperation and Development, according to the report.

A $26 billion piece of bipartisan legislation proposed last month by Sen. Bernie Sanders (I-Vt.), chair of the Senate Health, Education, Labor, and Pensions Committee, and Sen. Roger Marshall (R-Kan.) would bolster primary care by increasing training opportunities for doctors and nurses and expanding access to community health centers. Policy experts say the bill would provide important support, but it’s not enough. It doesn’t touch compensation.

“We need primary care to be paid differently and to be paid more, and that starts with Medicare,” Koller said.

How Medicare Drives Payment

Medicare, which covers 65 million people who are 65 and older or who have certain long-term disabilities, finances more than a fifth of all health care spending — giving it significant muscle in the health care market. Private health plans typically base their payment amounts on the Medicare system, so what Medicare pays is crucial.

Under the Medicare payment system, the amount the program pays for a medical service is determined by three geographically weighted components: a physician’s work, including time and intensity; the practice’s expense, such as overhead and equipment; and professional insurance. It tends to reward specialties that emphasize procedures, such as repairing a hernia or removing a tumor, more than primary care, where the focus is on talking with patients, answering questions, and educating them about managing their chronic conditions.

Medical students may not be familiar with the particulars of how the payment system works, but their clinical training exposes them to a punishing workload and burnout that is contributing to the shortage of primary care physicians, projected to reach up to 48,000 by 2034, according to estimates from the Association of American Medical Colleges.

The earnings differential between primary care and other specialists is also not lost on them. Average annual compensation for doctors who focus on primary care — family medicine, internists, and pediatricians — ranges from an average of about $250,000 to $275,000, according to Medscape’s annual physician compensation report. Many specialists make more than twice as much: Plastic surgeons top the compensation list at $619,000 annually, followed by orthopedists ($573,000) and cardiologists ($507,000).

“I think the major issues in terms of the primary care physician pipeline are the compensation and the work of primary care,” said Russ Phillips, an internist and the director of the Harvard Medical School Center for Primary Care. “You have to really want to be a primary care physician when that student will make one-third of what students going into dermatology will make,” he said.

According to statistics from the National Resident Matching Program, which tracks the number of residency slots available for graduating medical students and the number of slots filled, 89% of 5,088 family medicine residency slots were filled in 2023, compared with a 93% residency fill rate overall. Internists had a higher fill rate, 96%, but a significant proportion of internal medicine residents eventually practice in a specialty area rather than in primary care.

No one would claim that doctors are poorly paid, but with the average medical student graduating with just over $200,000 in medical school debt, making a good salary matters.

Not in It for the Money

Still, it’s a misperception that student debt always drives the decision whether to go into primary care, said Len Marquez, senior director of government relations and legislative advocacy at the Association of American Medical Colleges.

For Anitza Quintero, 24, a second-year medical student at the Geisinger Commonwealth School of Medicine in rural Pennsylvania, primary care is a logical extension of her interest in helping children and immigrants. Quintero’s family came to the United States on a raft from Cuba before she was born. She plans to focus on internal medicine and pediatrics.

“I want to keep going to help my family and other families,” she said. “There’s obviously something attractive about having a specialty and a high pay grade,” Quintero said. Still, she wants to work “where the whole body is involved,” she said, adding that long-term doctor-patient relationships are “also attractive.”

Quintero is part of the Abigail Geisinger Scholars Program, which aims to recruit primary care physicians and psychiatrists to the rural health system in part with a promise of medical school loan forgiveness. Health care shortages tend to be more acute in rural areas.

These students’ education costs are covered, and they receive a $2,000 monthly stipend. They can do their residency elsewhere, but upon completing it they return to Geisinger for a primary care job with the health care system. Every year of work there erases one year of the debt covered by their award. If they don’t take a job with the health care system, they must repay the amount they received.

Payment Imbalances a Source of Tension

In recent years, the Centers for Medicare & Medicaid Services, which administers the Medicare program, has made changes to address some of the payment imbalances between primary care and specialist services. The agency has expanded the office visit services for which providers can bill to manage their patients, including adding non-procedural billing codes for providing transitional care, chronic care management, and advance care planning.

In next year’s final physician fee schedule, the agency plans to allow another new code to take effect, G2211. It would let physicians bill for complex patient evaluation and management services. Any physician could use the code, but it is expected that primary care physicians would use it more frequently than specialists. Congress has delayed implementation of the code since 2021.

The new code is a tiny piece of overall payment reform, “but it is critically important, and it is our top priority on the Hill right now,” said Shari Erickson, chief advocacy officer for the American College of Physicians.

It also triggered a tussle that highlights ongoing tension in Medicare physician payment rules.

The American College of Surgeons and 18 other specialty groups published a statement describing the new code as “unnecessary.” They oppose its implementation because it would primarily benefit primary care providers who, they say, already have the flexibility to bill more for more complex visits.

But the real issue is that, under federal law, changes to Medicare physician payments must preserve budget neutrality, a zero-sum arrangement in which payment increases for primary care providers mean payment decreases elsewhere.

“If they want to keep it, they need to pay for it,” said Christian Shalgian, director of the division of advocacy and health policy for the American College of Surgeons, noting that his organization will continue to oppose implementation otherwise.

Still, there’s general agreement that strengthening the primary care system through payment reform won’t be accomplished by tinkering with billing codes.

The current fee-for-service system doesn’t fully accommodate the time and effort primary care physicians put into “small-ticket” activities like emails and phone calls, reviews of lab results, and consultation reports. A better arrangement, they say, would be to pay primary care physicians a set monthly amount per patient to provide all their care, a system called capitation.

“We’re much better off paying on a per capita basis, get that monthly payment paid in advance plus some extra amount for other things,” said Paul Ginsburg, a senior fellow at the University of Southern California Schaeffer Center for Health Policy and Economics and former commissioner of the Medicare Payment Advisory Commission.

But if adding a single five-character code to Medicare’s payment rules has proved challenging, imagine the heavy lift involved in overhauling the program’s entire physician payment system. MedPAC and the national academies, both of which provide advice to Congress, have weighed in on the broad outlines of what such a transformation might look like. And there are targeted efforts in Congress: for instance, a bill that would add an annual inflation update to Medicare physician payments and a proposal to address budget neutrality. But it’s unclear whether lawmakers have strong interest in taking action.

“The fact that Medicare has been squeezing physician payment rates for two decades is making reforming their structure more difficult,” said Ginsburg. “The losers are more sensitive to reductions in the rates for the procedures they do.”

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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Secretary Becerra reiterated HHS commitment to continued partnership with public health leaders and advocates.