The Biden administration faces what looks like a growing problem for the federal Affordable Care Act’s insurance exchange: disreputable insurance brokers enrolling people who don’t need coverage or switching them to new plans without their authorization.

It happened to Michael Debriae, a restaurant server who lives in Charlotte. Unbeknownst to him, an agent in Florida with whom he’d never spoken enrolled him in an ACA plan in March 2023. Debriae had insurance through his job and discovered the Obamacare coverage only when his longtime pharmacy rejected a 90-day refill because the ACA plan didn’t allow it.

He filed a complaint with the federal marketplace and canceled the plan. But because the pharmacy had billed the ACA plan for other prescriptions, federal investigators told him they couldn’t retroactively cancel his coverage. He got stuck with a $700 tax bill — his entire tax refund, he said — for some of the tax credits the IRS paid his Obamacare insurer from March until July.

The ACA saw record enrollment for this year of more than 21 million people, but growing complaints from consumers like Debriae and agents who say they’ve lost clients to unauthorized switches cast a shadow on that achievement, a KFF Health News investigation found.

On Feb. 26, the Centers for Medicare and Medicaid Services sent an “unauthorized plan switch” update to insurance industry representatives acknowledging “a large number” of 2024 cases and outlining technical efforts to resolve problems.

“CMS is committed to protecting consumers in the marketplace,” Jeff Wu, deputy director for policy for the Center for Consumer Information & Insurance Oversight at CMS, said in a March statement.

Wu’s office didn’t disclose the number of complaints that have been filed or how many brokers it has sanctioned. CMS reports enforcement actions to state insurance departments, whose authority includes revoking licenses, Wu’s statement said.

Brokers say the ease with which unscrupulous agents can get into policyholder accounts in the 32 states served by the federal marketplace plays a major role in the problem. With only a person’s name, date of birth and state, a licensed agent can access a policyholder’s coverage through the federal exchange or its direct enrollment platforms. It’s harder to do in ACA marketplaces run by states, which often require additional information.

Federal regulators imposed new rules in June that require brokers to get policyholders’ written or recorded verbal consent before making changes to their coverage. But brokers say they’re rarely asked to provide that documentation to regulators.

CMS is “actively considering further regulatory and technological solutions,” Wu said.

Many state-run exchanges do more than the federal marketplace to secure accounts. In Colorado, for example, customers specify which brokers can have access. California sends a one-time passcode to enrollees to provide to their agents.

Jonathan Kanfer, an insurance broker in West Palm Beach, Fla., says his agency lost 700 clients to unauthorized plan switches. He said he’s had telemarketers offer him lists of potential clients, telling him, “You don’t even have to speak with the people.”

He turns them down, but he said rival agents might be enticed by the opportunity to collect the monthly commissions that insurers pay.

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

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

This story can be republished for free (details).

A TMJ patient in Maine had six surgeries to replace part or all of the joints of her jaw.

Another woman in California, desperate for relief, used a screwdriver to lengthen her jawbone daily, turning screws that protruded from her neck.

A third in New York had bone from her rib and fat from her belly grafted into her jaw joint, and twice a prosthetic eyeball was surgically inserted into the joint as a placeholder in the months it took to make metal hinges to implant into her jaw.

“I feel like Mr. Potato Head,” said Jenny Feldman, 50, of New York City, whose medical records show she’s had at least 24 TMJ-related surgeries since she was a teenager. “They’re moving ribs into my face, and eyeballs, and I feel like a toy … put together [by] somebody just tinkering around.”

These are some of the horrors of temporomandibular joint disorders, known as TMJ or TMD, which afflict up to 33 million Americans, according to the National Institutes of Health. Dentists have attempted to heal TMJ patients for close to a century, and yet the disorders remain misunderstood, under-researched, and ineffectively treated, according to an investigation by KFF Health News and CBS News.

Dental care for TMJ can do patients more harm than good, and a few fall into a spiral of futile surgeries that may culminate in their jaw joints being replaced with metal hinges, according to medical and dental experts, patients, and their advocates speaking in interviews and video testimony submitted to the FDA.

TMJ disorders cause pain and stiffness in the jaw and face that can range from discomfort to disabling, with severe symptoms far more common in women. Dentists have commonly treated the disorder with splints and orthodontics. And yet these treatments are based on “strongly held beliefs” and “inadequate research” — not compelling scientific evidence nor consistent results — according to the National Academies of Sciences, Engineering and Medicine, which reviewed decades of research on the topic. The NIH echoes this message, warning that there is “not a lot of evidence” that splints reduce pain and recommends “staying away” from any treatment that permanently changes the teeth, bite, or jaw.

“I would say that the treatments overall have not been effective, and I can understand why,” said Rena D’Souza, director of the NIH’s National Institute of Dental and Craniofacial Research. “We don’t understand the disease.”

For this investigation, journalists with KFF Health News and CBS News interviewed 10 TMJ patients with severe symptoms who said they felt trapped by an escalating series of treatments that began with splints or dental work and grew into multiple surgeries with diminishing returns and dwindling hope.

In every interview, the patients said the TMJ pain worsened throughout their treatment and they regretted some, if not all, of the care they received.

“The grand irony to me is that I went to the doctor for headaches and neck pain, and I’ve had 13 surgeries on my face and jaw, and I still have even worse neck pain,” said Tricia Kalinowski, 63, of Old Orchard Beach, Maine. “And I live with headaches and jaw pain every day.”

TMJ has become an umbrella term for about 30 disorders that afflict roughly 5% to 10% of Americans. Minor symptoms may not require treatment at all, and many cases resolve by themselves over time. Severe symptoms include chronic pain and may limit the ability to eat, sleep, or talk.

In a comprehensive study of TMJ disorders by the national academies, including input from more than 110 patients, experts found that most health care professionals, including dentists, have received “minimal or no training” on TMJ disorders and patients are “often harmed” by “overly aggressive” care and the lack of proven treatments.

Almost 100 years this has been in dentistry, and look at what we have… A whole ton of people pretending they know everything, and we don’t know anything.

The American Dental Association, which represents about 160,000 dentists nationwide and establishes guidelines for the profession, declined an interview request. In a written statement, ADA President Linda Edgar said that TMJ disorders are “often managed rather than cured” and that it sees “great potential” in new efforts to research more treatment options.

Terrie Cowley, a longtime TMJ patient who leads the TMJ Association, an advocacy group that has spoken with tens of thousands of patients, said she was so disillusioned with dental care for TMJ that she advises many patients to avoid treatment entirely, potentially for years.

“Almost 100 years this has been in dentistry, and look at what we have,” Cowley said. “A whole ton of people pretending they know everything, and we don’t know anything.”

‘Not Taken Seriously’

Scientific studies have found that TMJ disorders arise up to nine times as often in women, particularly those in their 20s and 30s, leading to theories that the cause may be linked to reproductive hormones. But a true understanding of TMJ disorders remains elusive.

Kyriacos Athanasiou, a biomedical engineering professor at the University of California-Irvine, said it was because TMJ disorders are more prevalent among women that they were historically dismissed as neither serious nor complex, slowing research into the cause and treatment.

The resulting dearth of knowledge, which is glaring when compared with other joints, has been “a huge disservice” to patients, Athanasiou said. In a 2021 study he co-authored, researchers found that the knee, despite being a much simpler joint, was the subject of about six times as many research papers and grants in a single year than the jaw joint.

D’Souza agreed that TMJ disorders were “not taken seriously” for decades, along with other conditions that predominantly affect women.

“That has been a bias that is really long-standing,” she said. “And it’s certainly affected the progress of research.”

Patients have felt the effect too. In interviews, female patients said they felt patronized or trivialized by male health care providers at some point in their TMJ treatment, if not throughout. Some said they felt blamed for their own pain because they were viewed as too stressed and clenching their jaw too much.

“We desperately need research to find the reasons why more women get TMJ disease,” wrote Lisa Schmidt, a TMJ Association board member, in a 2021 newsletter from the organization. “And surgeons need to stop blaming this condition on women.”

Every time you have a surgery, your pain gets worse… If I could go back in time and go talk to younger Lisa, I would say ‘Run!’

Schmidt, 52, of Poway, California, said she was diagnosed with TMJ disorder in 2000 due to headaches, and an orthodontist immediately recommended her for a splint, braces, and surgery.

After wearing the splint for only three days, Schmidt said, she was in “excruciating pain” and could no longer open her mouth far enough to eat solid food. Schmidt said she spent the next 17 years stuck on a “surgery carousel” with no escape, and eventually was in so much pain she abandoned her career as an aerospace scientist who worked alongside NASA astronauts.

Schmidt said her low point came in 2016. In an attempt to restore bone that had been cut away in prior surgeries, a surgeon implanted long screws into Schmidt’s jaw that protruded downward out of her neck. Schmidt said she was instructed to tighten those screws with a screwdriver daily for about 20 days, lengthening the corners of her jaw to restore the bone that had been lost. It didn’t work, Schmidt said, and she was left in more pain than ever.

“Every time you have a surgery, your pain gets worse,” Schmidt said. “If I could go back in time and go talk to younger Lisa, I would say ‘Run!’”

Lack of Sufficient Evidence

Many of the shortcomings of TMJ care were laid bare in the 426-page report published by the national academies in March 2020 that received limited public attention amid the coronavirus pandemic. The report’s 18 authors include medical and dental experts from Harvard, Duke, Clemson, Michigan State, and Johns Hopkins universities.

Sean Mackey, a Stanford professor who co-led the team, said it found that patients were often steered toward costly treatments and “pathways of futility” instead of being taught to manage their pain through strategies and therapies with “good evidence.”

“We learned it’s a quagmire,” Mackey said. “There is a perverse incentive in our society that pays more for things we do to people than [for] talking and listening to people. … Some of those procedures, some of those surgeries, clearly are not helping people.”

Among its many findings, the national academies said it has been widely assumed in the field of dentistry that TMJ disorders are caused by a misaligned bite, so treatments have focused on patients’ teeth and bite for more than 50 years. But there is a “notable absence of sufficient evidence” that a misaligned bite is a cause of TMJ disorders, and the belief traces back to “inadequate research” in the 1960s that has been repeated in “poorly-designed studies” ever since, the report states.

Therefore, TMJ treatment that makes permanent changes to the bite — like installing braces or crowns or grinding teeth down — has “no supporting evidence,” according to the national academies report. The NIH warns that these TMJ treatments “don’t work and may make the problem worse.”

Dental splints, the most common TMJ treatment, also known as night guards or mouth guards, are removable dental appliances that are molded to fit over the teeth and can cost hundreds or even thousands of dollars out-of-pocket, according to the TMJ Association. Like most medical devices, splints generally go through the FDA’s 510(k) clearance process, which does not require each splint to be proven effective before it can be sold, according to the agency.

The national academies’ report states that splints produce “mixed results” for TMJ patients, and even when splints succeed at reducing jaw pain it is not understood why they work. Hundreds of splint designs exist, the report states, and some dentists reject research that challenges the use of splints unless it focuses on the specific design they prefer.

“Because of the hundreds of variations in [splint] design, it is unlikely that any study could ever be conducted that will be considered sufficient to a particular dentist with a pre-existing belief about the effectiveness of one appliance,” the report states.

Other treatments fare no better. The FDA has not labeled any drugs specifically for TMJ disorders, and pain medicines can be too weak or addictive to be a long-term solution, according to the TMJ Association. Botox injections may ease pain but have raised concerns about bone loss during animal testing. The NIH warns that minor surgeries that flush the jaw with liquid bring only temporary pain relief and that more complex surgeries should be reserved for severe cases because they have yet to be proved safe or effective in the long term.

To improve care, the national academies called for better education about TMJ disorders across medicine and dentistry and more research funding from the NIH, which has a “ripple effect” on research and training across the nation.

Since the 2020 report, the NIH has launched a TMJ research collaborative and increased annual research funding from about $15 million to about $34 million, D’Souza said. TMJ care was added to the standards that dental schools must teach to be accredited in 2022. The national academies launched an ongoing forum on TMJ disorders last year.

But TMJ funding still pales in comparison to other ailments. The NIH spends billions each year to research deadly diseases, like cancer and heart disease, that also afflict large numbers of Americans. It spends millions more on research of non-life-threatening conditions like arthritis, back pain, eczema, and headaches.

Mackey noted that much of the NIH’s spending is allocated by Congress.

“If Congress comes in and says, ‘We want to devote X amount of money to [TMJ],’ all of the sudden you will see an increase in money,” Mackey said. “So that’s my message to people out there: Raise your voices. Write your legislator.”

Total Jaw Replacements

Plagued by TMJ symptoms, and after failed treatments, some patients turn to a last resort: replacing their jaw joint with synthetic implants. Surgeons might replace the cartilage disk at the core of the joint or use “total joint replacement surgery” to fasten a metal hinge to the bones of the skull.

But the implants have a harrowing history: Several disk implants were recalled or discontinued in the ’90s due to dangerous failures. The FDA now classifies TMJ implants among its most closely monitored medical devices because the products on the market today can cause “adverse health consequences” if the devices fail, according to the agency’s website.

Two companies, Zimmer Biomet and Stryker, make the only total jaw replacement implants currently sold in the U.S.

Zimmer Biomet, which has made its implant for more than two decades, described it in email statements as “a safe and efficacious solution” for patients who need their jaw joint replaced, either due to TMJ disorders, failed surgeries, injuries, or other ailments. An FDA-mandated study completed in 2017 found about 14% of patients who get the Zimmer Biomet implant require additional surgery or removal within 10 years, said agency spokesperson Carly Pflaum.

Stryker, which in 2021 bought a company that made a total jaw replacement implant and now makes the implant itself, declined to comment. Although the NIH has advised TMJ patients to avoid surgery since at least 2022, Stryker launched a “patient-facing website” for the implant last year and is recruiting surgeons to be added to a “surgeon locator” feature on the site, according to posts on Facebook and LinkedIn.

A study of the Stryker implant’s success rate was mandated by the FDA and completed in 2020, but the agency has yet to make the results public.

D’Souza, the NIH official, said that based on her professional experience, she estimates that most total jaw replacement surgeries are ultimately ineffective.

“The success rate is low,” D’Souza said. “It is not very encouraging.”

Multiple patients provided KFF Health News and CBS News with medical records showing their total jaw replacement implants had to be removed due to malfunction, infection, or previously unknown metal allergies. Several patients said that since their implants were removed months or years ago, they have lived with no hinge in their jaw at all.

Kalinowski, the TMJ patient in Maine, has had portions of her jaw joint replaced six times, including receiving four implants. Her medical records show that the cartilage disk on her right side was replaced in 1986 with an implant that was later recalled and again in 1987 with another that was later discontinued. Her left and right disks were replaced in 1992 with a muscle flap and rib graft, respectively, and her entire right joint was replaced with yet another implant that was later discontinued in 1998. Both joints were replaced again in 2015, her records show.

Since then, Kalinowski said, her artificial jaw has functioned properly, although she remains in pain and cannot move her jaw from side to side. Her mouth hangs open when her face is at rest, and she drinks protein shakes for lunch because it’s easier than struggling with solid food.

But the “worst part,” Kalinowski said, is that her surgeries caused nerve damage on her lower face, and so she has not felt her husband’s kisses since the ’90s.

“If there was one moment in my life I could take back and do over again, it would be that first surgery. Because it set me on a trajectory,” Kalinowski said. “And it never goes away.”

CBS News producer Nicole Keller contributed to this article.

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

This story can be republished for free (details).

For Cindy Westman, $30 buys a week’s worth of gas to drive to medical appointments and run errands.

It’s also how much she spent on her monthly internet bill before the federal Affordable Connectivity Program stepped in and covered her payments.

“When you have low income and you are living on disability and your daughter’s disabled, every dollar counts,” said Westman, who lives in rural Illinois.

More than 23 million low-income households — urban, suburban, rural, and tribal — are enrolled in the federal discount program Congress created in 2021 to bridge the nation’s digital connectivity gap. The program has provided $30 monthly subsidies for internet bills or $75 discounts in tribal and high-cost areas.

But the program is expected to run out of money in April or May, according to the Federal Communications Commission. In January, FCC Chairwoman Jessica Rosenworcel asked Congress to allocate $6 billion to keep the program running until the end of 2024. She said the subsidy gives Americans the “internet service they need to fully participate in modern life.”

The importance of high-speed internet was seared into the American psyche by scenes of children sitting in parking lots and outside fast-food restaurants to attend school online during the covid-19 pandemic. During that same period, health care providers and patients like Westman say, being connected also became a vital part of today’s health care delivery system.

Westman said her internet connection has become so important to her access to health care she would sell “anything that I own” to stay connected.

Westman, 43, lives in the small town of Eureka, Illinois, and has been diagnosed with genetic and immune system disorders. Her 12-year-old daughter has cerebral palsy and autism.

She steered the $30 saved on her internet toward taking care of her daughter, paying for things such as driving 30 minutes west to Peoria, Illinois, for two physical therapy appointments each week. And with an internet connection, Westman can access online medical records, and whenever possible she uses telehealth appointments to avoid the hour-plus drive to specialty care.

“It’s essential for me to keep the internet going no matter what,” Westman said.

Expanding telehealth is a common reason health care providers around the U.S. — in states such as Massachusetts and Arkansas — joined efforts to sign their patients up for the federal discount program.

“This is an issue that has real impacts on health outcomes,” said Alister Martin, an emergency medicine physician at Massachusetts General Hospital. Martin realized at the height of the pandemic that patients with means were using telehealth to access covid care. But those seeking in-person care during his ER shifts tended to be lower-income, and often people of color.

“They have no other choice,” Martin said. “But they probably don’t need to be in the ER action.” Martin became a White House fellow and later created a nonprofit that he said has helped 1,154 patients at health centers in Boston and Houston enroll in the discount program.

At the University of Arkansas for Medical Sciences, a federal grant was used to conduct dozens of outreach events and help patients enroll, said Joseph Sanford, an anesthesiologist and the director of the system’s Institute for Digital Health & Innovation.

“We believe that telehealth is the great democratization to access to care,” Sanford said. New enrollment in the discount program halted nationwide last month.

Leading up to the enrollment halt, Sen. Peter Welch (D-Vt.) led a bipartisan effort to introduce the Affordable Connectivity Program Extension Act in January. The group requested $7 billion — more than the FCC’s ask — to keep the program funded. “Affordability is everything,” Welch said.

In December, federal regulators surveyed program recipients and found that 22% reported no internet service before, and 72% said they used their ACP-subsidized internet to “schedule or attend healthcare appointments.”

Estimates of how many low-income U.S. households qualify for the program vary, but experts agree that only about half of the roughly 50 million eligible households have signed on.

“A big barrier for this program generally was people don’t know about it,” said Brian Whitacre, a professor and the Neustadt chair in the Department of Agricultural Economics at Oklahoma State University.

Whitacre and others said rural households should be signing up at even higher rates than urban ones because a higher percentage of them are eligible.

Yet, people found signing up for the program laborious. Enrollment was a two-step process. Applicants were required to get approved by the federal government then work with an internet service provider that would apply the discount. The government application was online — hard to get to if you didn’t yet have internet service — though applicants could try to find a way to download a version, print it, and submit the application by mail.

When Frances Goli, the broadband project manager for the Shoshone-Bannock Tribes in Idaho, began enrolling tribal and community members at the Fort Hall Reservation last year, she found that many residents did not know about the program — even though it had been approved more than a year earlier.

Goli and Amber Hastings, an AmeriCorps member with the University of Idaho Extension Digital Economy Program, spent hours helping residents through the arduous process of finding the proper tribal documentation required to receive the larger $75 discount for those living on tribal lands.

“That was one of the biggest hurdles,” Goli said. “They’re getting denied and saying, come back with a better document. And that is just frustrating for our community members.”

Of the more than 200 households Goli and Hastings aided, about 40% had not had internet before.

In the tribal lands of Oklahoma, said Sachin Gupta, director of government business and economic development at internet service provider Centranet, years ago the funding may not have mattered.

“But then covid hit,” Gupta said. “The stories I have heard.”

Elders, he said, reportedly “died of entirely preventable causes” such as high blood pressure and diabetes because they feared covid in the clinics.

“It’s really important to establish connectivity,” Gupta said. The end of the discounts will “take a toll.”

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

This story can be republished for free (details).

Companies have increasingly offered generous fertility benefits to attract and keep top-notch workers. Now, the federal government is getting in on the act. Starting this year, federal employees can choose plans that cover several fertility services, including up to $25,000 annually for in vitro fertilization procedures and up to three artificial insemination cycles each year.

With about 2.1 million civilian employees, the federal government is the nation’s largest employer. Now, just as businesses of every stripe prioritize fertility benefits, in vitro fertilization — a procedure in use for more than 40 years — has become a tricky topic for some anti-abortion Republican members of Congress and even presidential candidates.

It was inevitable that disagreements over IVF among abortion opponents would eventually break into the open, said Mary Ziegler, a legal historian and expert on reproductive health.

“The anti-abortion movement from the 1960s onward has been a fetal personhood movement,” said Ziegler, a law professor at the University of California-Davis. Since the U.S. Supreme Court’s Dobbs decision eliminated the constitutional right to abortion, anti-abortion groups and the Republican Party are grappling with what “fetal personhood” means and how that fits into their position on IVF and other technologies that help people have babies.

The Alabama Supreme Court set the stage for the recent brouhaha with a ruling last month that frozen embryos created through IVF are children under state law. A pair of Democratic senators advanced legislation that would override state laws by establishing a statutory right to access IVF and other such technologies. The bill was blocked on the Senate floor by a Republican opponent.

These events highlight the tough spot in which Republicans find themselves. Many support IVF, and they are keenly aware that it’s extremely popular: 86% of adults in a recent CBS News-YouGov poll said IVF should be legal. The outcry over the Alabama ruling and Republicans’ inability to coalesce around a federal response, however, has exposed fault lines in the party.

Some anti-abortion groups have strenuously objected to measures like that Senate bill, arguing that lawmakers must balance IVF with the responsibility to respect life.

Republicans “are trying to finesse it, which is very hard,” Ziegler said.

About 10% of women and men face fertility problems, according to the National Institute of Child Health and Human Development. IVF, a process in which an egg is fertilized in a laboratory and later implanted in the uterus, is among the most expensive fertility treatments, costing about $20,000 for one round. Even with insurance coverage, the procedure is pricey, but for some people it’s the only way to conceive.

In recent years, the number of companies offering fertility benefits to employees has grown steadily. In the early 2000s, fewer than a quarter of employers with at least 500 workers covered IVF, according to benefits consultant Mercer’s annual employer survey. In 2023, that figure had roughly doubled, to 45%. Employers typically cap IVF benefits. In 2023, employers had a median lifetime maximum benefit of $20,000 for IVF, according to the Mercer survey.

The federal government’s IVF benefit — paying up to $25,000 a year — is more generous than that of a typical employer. Coverage is available through the popular Blue Cross and Blue Shield Federal Employee Program’s standard option. Altogether, two dozen 2024 health plans for federal workers offer enhanced IVF coverage, with varying benefits and cost sharing, according to the federal Office of Personnel Management, which manages the federal health plans.

“OPM’s mission is to attract and retain the workforce of the future,” said Viet Tran, OPM’s press secretary, in written answers to questions. He noted that surveys have found that federal health benefits have influenced employees’ decisions to stay with the federal government.

Starting this year, plans offered to federal employees are required to offer fertility benefits, according to OPM.

But it’s unclear how the emerging political debate surrounding IVF and other reproductive health issues could affect national benefit and coverage trends.

Last month, after the Alabama Supreme Court ruled that frozen embryos left over following IVF procedures are considered children under state law, the state legislature quickly passed and Republican Gov. Kay Ivey signed a bill that grants immunity to patients and providers who participate in IVF services. During the ensuing dust-up, a coalition of more than a dozen anti-abortion groups signed a letter drawing a clear line in the sand. “Both science and logic have made it clear that embryos must be accorded the same human rights” as other human beings, it read. The Alabama law didn’t address the underlying issue of the “personhood” of the embryos, leaving open the door for further litigation and potential restrictions on IVF in Alabama and other states, some legal analysts say.

More than a third of states have laws on the books that classify fetuses as people at some stage of pregnancy, according to an analysis by Politico.

It’s unclear whether the turmoil surrounding the Alabama case will have long-term repercussions for employee benefits there or in other states.

“If this were something that were to happen in multiple states, employers would have to figure out how to navigate around that,” said Jim Winkler, chief strategy officer of the Business Group on Health, a nonprofit that represents the interests of large employers. At this point, employers will want to keep a watchful eye on the issue but probably not plan any changes, Winkler said.

A Mercer blog post advised businesses with Alabama employees to review health plan policies related to medical travel and leave benefits. Further, “employers should monitor other states that broadly define fetal personhood and restrict reproductive healthcare,” the blog post advised.

The situation is reminiscent of what happened with abortion coverage following the Supreme Court’s Dobbs decision in 2022. As states imposed restrictions on access to abortions, many companies began providing travel expenses for their workers to seek them.

But what happened with abortion may not be a good predictor of what will happen with IVF, said Dorianne Mason, director of health equity at the National Women’s Law Center.

Following the Alabama judge’s ruling, “the legislature in Alabama moved so quickly to respond to the outcry,” Mason said. “When we look at the legislative response to IVF, it’s moving in a markedly different direction on access to care” than has occurred with other types of reproductive care.

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

This story can be republished for free (details).

Work requirements in Medicaid expansion programs are back on the agenda in many statehouses — despite their lackluster track record.

In Mississippi, the idea has momentum from GOP lawmakers advancing legislation to expand Medicaid. In Kansas, the Democratic governor proposed work requirements to try to soften Republican opposition to expansion. (She’s had little luck, so far.)

The controversial policy even has fresh traction in states that expanded Medicaid years ago, including Idaho and Louisiana.

Just two states have implemented a special program to require low-income adults to prove they’re working in exchange for health coverage under Medicaid. In 2019, a court ended Arkansas’s initiative, but not before 18,000 people lost coverage.

Since then, only the signature Medicaid experiment of Georgia Gov. Brian Kemp (R), called Pathways to Coverage, has survived legal challenges and gotten off the ground.

Yet it’s off to a rocky start, with low enrollment and mounting administrative costs already exceeding $20 million. “It doesn’t work, and it’s perfectly clear in Georgia,” said Joan Alker, executive director and co-founder of the Georgetown Center for Children and Families.

Only about 3,500 people have enrolled so far. That’s a small fraction of the Georgians who would be eligible if the state adopted the Affordable Care Act’s Medicaid expansion without work requirements.

Some Georgia Republicans blocked a bill in March that would have authorized a full Medicaid expansion, arguing that Pathways needs more time. The program is just one part of an overall plan to move people into private insurance, Kemp spokesperson Garrison Douglas told us.

Work requirements can come with big administrative price tags, according to a 2019 report from the Government Accountability Office, which recommended that the Centers for Medicare & Medicaid Services consider administrative costs in waiver applications.

States have to set up technology to check compliance, plus hire staff to keep all the paperwork straight. Under Georgia’s plan, people earning up to the federal poverty level — $15,060 for an individual adult — must document that they’re working, in school, doing community service or performing other qualifying activities. Taking care of a child or parent doesn’t count.

Documents obtained by KFF Health News show that administrative costs along with consulting fees have absorbed more than 90 percent of the Georgia program’s spending. As of Dec. 31, about $2 million went to Medicaid managed-care companies; $24 million was spent on administration and consultants. The administrative costs are expected to balloon to $122 million over four years.

Critics argue that the red tape keeps people from getting health care. And while work requirements don’t significantly boost employment, simply providing health coverage can, according to a 2023 KFF brief.

But don’t expect the idea to disappear — especially if former president Donald Trump returns to the White House. The first Trump administration approved Medicaid work-requirement programs in 13 states.

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

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

This story can be republished for free (details).

Patients hurl verbal abuse at Michelle Ravera every day in the emergency room. Physical violence is less common, she said, but has become a growing threat.

Ravera, an ER nurse at Sutter Medical Center in Sacramento, recalled an incident in which an agitated patient wanted to leave. “Without any warning he just reached up, grabbed my glasses, and punched me in the face,” said Ravera, 54. “And then he was getting ready to attack another patient in the room.” Ravera and hospital security guards subdued the patient so he couldn’t hurt anyone else.

Violence against health care workers is on the rise, including in the ER, where tensions can run high as staff juggle multiple urgent tasks. Covid-19 only made things worse: With routine care harder to come by, many patients ended up in the ER with serious diseases — and brimming with frustrations.

In California, simple assault against workers inside an ER is considered the same as simple assault against almost anyone else, and carries a maximum punishment of a $1,000 fine and six months in jail. In contrast, simple assault against emergency medical workers in the field, such as an EMT responding to a 911 call, carries maximum penalties of a $2,000 fine and a year in jail. Simple assault does not involve the use of a deadly weapon or the intention to inflict serious bodily injury.

State Assembly member Freddie Rodriguez, who worked as an EMT, has authored a bill to make the punishments consistent: a $2,000 fine and one year in jail for simple assault on any on-the-job emergency health care worker, whether in the field or an ER. The measure would also eliminate the discrepancy for simple battery.

Patients and family members are assaulting staff and “doing things they shouldn’t be doing to the people that are there to take care of your loved ones,” said Rodriguez, a Democrat from Pomona. The bill passed the state Assembly unanimously in January and awaits consideration in the Senate.

Rodriguez has introduced similar measures twice before. Then-Gov. Jerry Brown vetoed one in 2015, saying he doubted a longer jail sentence would deter violence. “We need to find more creative ways to protect the safety of these critical workers,” he wrote in his veto message. The 2019 bill died in the state Senate.

Rodriguez said ERs have become more dangerous for health care workers since then and that “there has to be accountability” for violent behavior. Opponents fear stiffer penalties would be levied disproportionately on patients of color or those with developmental disabilities. They also point out that violent patients can already face penalties under existing assault and battery laws.

Data from the California Division of Occupational Safety and Health shows that reported attacks on ER workers by patients, visitors, and strangers jumped about 25% from 2018 to 2023, from 2,587 to 3,238. The rate of attacks per 100,000 ER visits also increased.

Punching, kicking, pushing, and similar aggression accounted for most of the attacks. Only a small number included weapons.

These numbers are likely an undercount, said Al’ai Alvarez, an ER doctor and clinical associate professor at Stanford University’s Department of Emergency Medicine. Many hospital staffers don’t fill out workplace violence reports because they don’t have time or feel nothing will come of it, he said.

Ravera remembers when her community rallied around health care workers at the start of the pandemic, acting respectfully and bringing food and extra N95 masks to workers.

“Then something just switched,” she said. “The patients became angrier and more aggressive.”

Violence can contribute to burnout and drive workers to quit — or worse, said Alvarez, who has lost colleagues to suicide, and thinks burnout was a key factor. “The cost of burnout is more than just loss of productivity,” he said. “It's loss of human beings that also had the potential to take care of many more people.”

The National Center for Health Workforce Analysis projects California will experience an 18% shortage of all types of nurses in 2035, the third worst in the country.

Federal legislation called the Safety From Violence for Healthcare Employees Act would set sentences of up to 10 years for assault against a health care worker, not limited to emergency workers, and up to 20 years in cases involving dangerous weapons or bodily injury. Though it was introduced in 2023, it has not yet had a committee hearing.

Opponents of the California bill, which include ACLU California Action, the California Public Defenders Association, and advocates for people with autism, argue it wouldn’t deter attacks — and would unfairly target certain patients.

“There's no evidence to suggest that increased penalties are going to meaningfully address this conduct,” said Eric Henderson, a legislative advocate for ACLU California Action. “Most importantly, there are already laws on the books to address assaultive conduct.”

Beth Burt, executive director of the Autism Society Inland Empire, said the measure doesn’t take into account the special needs of people with autism and other developmental disorders.

The smells, lights, textures, and crowds in the ER can overstimulate a person with autism, she said. When that happens, they can struggle to articulate their feelings, which can result in a violent outburst, “whether it’s a 9-year-old or a 29-year-old,” Burt said.

She worries that hospital staff may misunderstand these reactions, and involve law enforcement when it’s not necessary. As “a parent, it is still my worst fear” that she’ll get a phone call to inform her that her adult son with autism has been arrested, she said.

Burt would rather the state prioritize de-escalation programs over penalties, such as the training programs for first responders she helped create through the Autism Society Inland Empire. After implementing the training, hospital administrators asked Burt to share some strategies with them, she said. Hospital security staffers who do not want to use physical restraints on autistic patients have also sought her advice, she said.

Supporters of the bill, including health care and law enforcement groups, counter that people with mental health conditions or autism who are charged with assault in an ER may be eligible for existing programs that provide mental health treatment in lieu of a criminal sentence.

Stephanie Jensen, an ER nurse and head of governmental affairs for the Emergency Nurses Association, California State Council, said her organization is simply arguing for equity. “If you punch me in the hospital, it’s the same as if you punch me on the street,” she said.

If lawmakers don’t act, she warned, there won’t be enough workers for the patients who need them.

“It’s hard to keep those human resources accessible when it just seems like you’re showing up to get beat up every day,” Jensen said. “The emergency department is taking it on the chin, literally and figuratively.”

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.

This story can be republished for free (details).

SACRAMENTO, Calif. — California Gov. Gavin Newsom’s administration has abandoned proposed protections for millions of California workers toiling in sweltering warehouses, steamy kitchens, and other dangerously hot workplaces — upending a regulatory process that had been years in the making.

The administration’s eleventh-hour move, which it attributed to the cost of the new regulations, angered workplace safety advocates and state regulators, setting off a mad scramble to implement emergency rules before summer.

But it’s unclear how, when, or if the emergency rules will come down, and whether they’ll be in place in time to protect workers from the intensifying heat.

“It’s the administration’s moral obligation to fix this,” said Lorena Gonzalez Fletcher, a former state lawmaker and the chief officer of the California Labor Federation, which represents more than 1,300 unions. “There needs to be emergency regulations or legislation quickly, because we can’t stop summer.”

California has had heat standards on the books for outdoor workers since 2005, and indoor workplaces were supposed to be next. The proposed standards would have required work sites to be cooled below 87 degrees Fahrenheit when employees are present and below 82 degrees in places where workers wear protective clothing or are exposed to radiant heat, such as furnaces. Buildings could be cooled with air conditioning, fans, misters, and other methods.

The rules would have allowed workarounds for businesses that couldn’t cool their workplaces sufficiently, such as laundries or restaurant kitchens.

Despite concerns from the administration, the California Occupational Safety and Health Standards Board approved the rules at its March 21 meeting, prompting a tense political standoff between workplace safety advocates and Newsom, the second-term Democratic governor who has sought to elevate his national profile and claim progressive leadership on climate change and worker rights — key platforms for the Democratic Party.

State Department of Finance spokesperson H.D. Palmer said the issue isn’t the state’s ballooning budget deficit — estimated between $38 billion and $73 billion — but a legal requirement to nail down the cost of the rules to the state government.

“It wasn’t, ‘We’re trying to sink these regulations,’” Palmer said.

Palmer said the administration received a murky cost estimate from the California Department of Corrections and Rehabilitation indicating that implementing the standards in its prisons and other facilities could cost billions. The board’s economic analysis, on the other hand, pegged the cost at less than $1 million a year.

“Without our concurrence of the fiscal estimates, those regulations in their latest iteration will not go into effect,” he said.

According to Corrections spokesperson Albert Lundeen, the rules would entail major spending that could require the legislature to fund “extensive capital improvements.” He added that the agency is committed to discussing “how these regulations could be implemented cost-effectively at our institutions to further bolster worker safety.”

Board members argue the state has had years to analyze the cost of the proposed standards, and that it must quickly impose emergency regulations. But it’s not clear how that might happen, whether in days by the administration or months via the state budget process — or another way.

“This is a public health emergency,” said Laura Stock, a board member who is also an expert on workplace safety and health at the University of California-Berkeley.

Newsom spokesperson Erin Mellon defended the move to halt permanent regulations, saying approving them would be “imprudent” without a detailed cost estimate.

“The administration is committed to implementing the indoor heat regulations and ensuring workplace protections,” she said in a statement. “We are exploring all options to put these worker protections in place, including working with the legislature.”

Only Minnesota and Oregon have adopted heat rules for indoor workers. Legislation has stalled in Congress, and even though the Biden administration has initiated the long process of establishing national heat standards for outdoor and indoor work, they may take years to finalize.

Seven workers died in California from indoor heat between 2010 and 2017. Heat stress can lead to heat exhaustion, heatstroke, cardiac arrest, and kidney failure. In 2021, the Centers for Disease Control and Prevention reported, 1,600 heat-related deaths occurred nationally, which is likely an undercount because health care providers are not required to report them. It’s not clear how many of these deaths are related to work, either indoors or outdoors.

The process to adopt California’s indoor head standards started in 2016 and involved years of negotiations with businesses and labor advocates.

Several board members acknowledged that they were frustrated by the administration’s lack of support when they adopted the regulations in March — after their meeting was temporarily halted by angry, chanting warehouse workers — knowing they would not go into effect. Instead, they said, they wanted to amplify pressure on Newsom.

“Every summer is hotter than the last, and workers who aren’t protected are going to suffer heat illness or death,” said Dave Harrison, a board member and powerful union leader with Operating Engineers Local 3. “Our hope was that the vote would be symbolic in sending a message to the state government that, listen, this is important, so we decided to vote on it anyway and put it back into the state’s court.”

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.

This story can be republished for free (details).

DENVER, Colorado. — En febrero, la hija adolescente de Norma Brambila le escribió una carta que ahora lleva en su cartera. Es un dibujo de una rosa y una nota alentadora que anima a su mamá a “seguir luchando” contra su enfermedad, y que le recuerda que algún día se reunirá con su familia en el cielo.

Brambila, una organizadora comunitaria que emigró de México hace un cuarto de siglo, solo tenía sinusitis, pero sus hijos nunca la habían visto tan enferma. “Estuve en cama durante cuatro días”, dijo.

Sin seguro de salud, Brambila había estado evitando buscar atención médica, esperando que el ajo y la canela surtieran efecto. Pero cuando sintió que ya no podía respirar, fue a la sala de emergencias. La factura de $365 —suficiente para cubrir una semana de alimentos para su familia— era más de lo que podía pagar, y terminó endeudada.

La deuda también afectó otra decisión que había estado considerando: si ir a México para tener una cirugía para que le extrajeran un crecimiento en su abdomen que, dijo, es tan grande como una papaya.

Brambila vive en un vecindario del suroeste de Denver llamado Westwood, una comunidad mayoritariamente hispana y de bajos ingresos donde muchos residentes son inmigrantes. Westwood también está en un código postal, 80219, con algunos de los niveles más altos de deuda médica en Colorado.

Allí, más de uno de cada 5 adultos han tenido históricamente facturas médicas impagas en sus informes de crédito, una tasa más parecida a la de West Virginia que a la del resto de Colorado, según datos de crédito de 2022 analizados por el Urban Institute, una organización sin fines de lucro.

Las luchas del área reflejan una paradoja sobre Colorado. En general, la carga de deuda médica del estado es más baja que la de la mayoría. Pero las disparidades raciales y étnicas son más amplias.

La brecha entre la carga de deuda en los códigos postales donde los residentes son principalmente hispanos y/o no blancos y los códigos postales que son principalmente blancos no hispanos es el doble de lo que es a nivel nacional. (Los hispanos pueden ser de cualquier raza o combinación de razas).

La deuda médica en Colorado también se concentra en códigos postales con porcentajes relativamente altos de inmigrantes, muchos de ellos de México.

El Urban Institute encontró que el 19% de los adultos en estos lugares tenían deuda médica en sus informes de crédito, en comparación con el 11% en comunidades con menos inmigrantes.

A nivel nacional, aproximadamente 100 millones de personas tienen alguna forma de deuda de atención médica, según una investigación de KFF Health News y NPR. Esto incluye no solo facturas impagas que terminan en agencias de cobros, sino también aquellas que se están pagando a través de planes de pago, tarjetas de crédito u otros tipos de préstamos.

Los datos revelan que las brechas raciales y étnicas en la deuda médica existen casi en todas partes. Pero la división de Colorado —en línea con la de Carolina del Sur, según los datos del Urban Institute— existe aunque el estado tiene algunas de las protecciones más amplias del país contra estas deudas.

Esta brecha amenaza con profundizar desigualdades de larga data, dicen defensores de pacientes y consumidores. Y resalta la necesidad de más acción para abordar la deuda médica.

"Exacerba las brechas raciales de riqueza", dijo Berneta Haynes, abogada principal del National Consumer Law Center, una organización sin fines de lucro que fue co-autora de un informe sobre deuda médica y disparidades raciales.

Haynes dijo que demasiados residentes de Colorado, especialmente residentes de minorías, siguen atrapados en un círculo vicioso en el que evitan la atención médica para evitar las facturas, lo que resulta en más deuda y peor salud.

Brambila dijo que ha visto este ciclo con demasiada frecuencia en Westwood, en su trabajo como organizadora comunitaria. "Realmente me encantaría ayudar a la gente a pagar sus facturas médicas", agregó.

¿Salud o deuda?

Roxana Burciaga, que creció en Westwood y trabaja en Mi Casa Resource Center, en el vecindario, dijo que al menos una vez a la semana escucha preguntas sobre cómo pagar la atención médica.

La deuda médica es un "gran, gran, gran tema en nuestra comunidad", dijo.

La gente no entiende lo que cubre realmente su seguro o no puede conseguir citas para atención preventiva que se ajusten a sus horarios de trabajo, explicó.

Muchos, como Brambila, ignoran la atención preventiva para evitar las facturas y terminan en salas de emergencias.

Los médicos y enfermeras también dicen que observan estas tensiones.

Amber Koch-Laking, médica de familia en el Denver Health’s Westwood Family Health Center, parte del sistema de salud público de la ciudad, dijo que las finanzas a menudo surgen en conversaciones con pacientes. Muchos intentan obtener citas de telesalud para evitar el costo de ir en persona.

Sumándose a la presión están las “desafiliaciones” de Medicaid, el proceso por el cual los estados vuelven a examinar la elegibilidad (proceso que se había suspendido durante la pandemia) para la cobertura de salud para personas de bajos ingresos, dijo Koch-Laking.

"Dicen, 'Oh, estoy perdiendo mi Medicaid en tres semanas, ¿puedes ocuparte de estas siete cosas sin una visita?' o '¿Podemos hacerlo por el portal?, porque no puedo pagar una cita".

Buscando la solución correcta

Colorado ha tomado medidas para proteger a los pacientes de la deuda médica, incluida la expansión de la cobertura de Medicaid a través de la Ley de Cuidado de Salud a Bajo Precio (ACA) promulgada en 2010.

Más recientemente, líderes estatales exigieron a los hospitales ampliar la asistencia financiera para pacientes de bajos ingresos y prohibieron que todo tipo de deudas médicas se reflejaran en los informes de crédito de los consumidores.

Pero las complejidades de muchos programas de asistencia siguen siendo una barrera importante para los inmigrantes y otras personas con conocimiento limitado de inglés, dijo Julissa Soto, consultora de equidad en salud con sede en Denver enfocada en los latinos de Colorado.

Por ejemplo, muchos pacientes no saben que pueden recibir ayuda para sus facturas médicas del estado o de organizaciones comunitarias.

"El sistema de atención médica es un rompecabezas. Mejor aprende a jugar con el rompecabezas", dijo Soto, contando que ella misma vivió la experiencia de tener cuentas médicas enviadas a agencias de cobros cuando emigró por primera vez a Estados Unidos desde México.

"Muchos hospitales también tienen financiamiento para ayudarte con tu deuda. Solo tienes que llegar a la persona adecuada, porque parece que nadie quiere informarnos que esos programas existen", dijo. Y agregó que simplificar las facturas ayudaría mucho a muchos pacientes. Varios estados, incluidos Oregon, Illinois y Maryland, han intentado facilitar que las personas accedan a la ayuda financiera del hospital al requerir que los hospitales analicen proactivamente a los pacientes.

Defensores de pacientes y consumidores dicen que Colorado también podría restringir aún más el agresivo cobro de deudas, como las demandas, que siguen siendo comunes en el estado.

Nueva York, por ejemplo, prohibió el embargo de salarios después de descubrir que la práctica afectaba desproporcionadamente a las comunidades de bajos ingresos. En ese estado, la investigación también mostró que la carga de la deuda médica estaba afectando dos veces más a las comunidades minoritarias en comparación con las comunidades blancas no hispanas.

Elisabeth Benjamin, abogada de la Community Service Society de Nueva York, dijo que los hospitales estaban embargando los salarios de personas que trabajaban en Walmart y Taco Bell.

Maryland promulgó límites a las demandas por cobros de deudas después que defensores descubrieran que los pacientes que vivían en vecindarios predominantemente minoritarios estaban siendo víctimas de estas prácticas de manera desproporcionada.

Incluso en condados ricos, "los bolsillos que se están persiguiendo están en vecindarios mayoritariamente latinos", dijo Marceline White, directora ejecutiva del grupo de defensa Economic Action Maryland. El grupo de White ayudó a aprobar una ley que exige a los hospitales reembolsar a los pacientes de bajos ingresos y evitar el escenario que estaba viendo, en el cual los hospitales estaban "demandando a pacientes que deberían haber recibido atención gratuita".

Cobrando un alto precio

En Colorado, los legisladores están considerando una medida para mejorar el acceso de los pacientes a la ayuda financiera: una modificación al programa estatal Hospital Discounted Care, que haría que los hospitales fueran sitios de elegibilidad presunta para Medicaid.

Mientras tanto, algunos defensores de los consumidores dicen que las protecciones existentes no están funcionando lo suficientemente bien.

Los datos estatales muestran que los pacientes que recibían asistencia financiera eran principalmente blancos no hispanos. Y, aunque no está claro por qué, el 42% de los pacientes que podrían haber sido elegibles no fueron evaluados por los hospitales para recibir esa asistencia.

"Lo que está claro es que muchas personas no lo están logrando", dijo Bethany Pray, directora adjunta del Colorado Center on Law and Policy, un grupo de ayuda legal con sede en Denver que impulsó la legislación de atención con descuento.

Entre las comunidades de inmigrantes del estado, la deuda médica —y el miedo a la deuda— continúan cobrándose un alto precio.

"Lo que hemos escuchado de nuestros constituyentes es que la deuda médica a veces es la diferencia entre que tengan vivienda y que estén sin hogar", dijo Shontel Lewis, miembro del Concejo Municipal de Denver. Su distrito incluye el código postal 80216, otro lugar al norte del centro de la ciudad que está agobiado por una deuda médica generalizada.

Paola Becerra es una inmigrante que vive en Estados Unidos sin papeles y estaba embarazada cuando la trasladaron en autobús desde un refugio de Texas a Denver hace unos meses.

Dijo que se ha saltado las visitas de atención prenatal porque no podía pagar los copagos de $50. Tiene cobertura de salud de emergencia a través de Medicaid, que no cubre visitas preventivas, y ya acumuló alrededor de $1,600 en facturas.

"No sabía que iba a llegar embarazada", dijo Becerra, quien pensó que ya no podía concebir cuando salió de Colombia. "Tienes que renunciar a tu salud. O pago el alquiler o pago el hospital".

Para Rocío Leal, organizadora comunitaria en Boulder, la deuda médica se ha convertido en una característica definitoria de su vida.

A pesar del seguro de salud que tenía a través de su trabajo, Leal terminó con préstamos al día de alto interés para pagar por nacimientos saludables, embargo de salarios, citas prenatales que se perdió para ahorrar dinero y un puntaje de crédito "arruinado", que limitó sus opciones de vivienda.

Leal recordó momentos en los que pensó que serían desalojados y otros momentos en los que les cortaron la electricidad. "No es que lo estemos evitando y no queramos pagar. Es solo que a veces no tenemos la opción de pagar", dijo.

Agregó que, ahora, los peores momentos han quedado atrás. Está en una casa que ama, donde los vecinos traen pasteles para agradecer a su hijo por quitar la nieve de sus pórticos. Sus hijos están bien. Una hija obtuvo un promedio de calificaciones perfecto por segundo semestre consecutivo. Otra está tocando el violín en la orquesta escolar. Su tercera hija asiste a un club de arte. Y su hijo fue aceptado recientemente en la universidad para estudiar ingeniería biomédica.

Están cubiertos por Medicaid, lo que ha eliminado la incertidumbre en torno a las grandes facturas médicas. Pero la deuda médica sigue persiguiendo a Leal, que tiene diabetes tipo 2.

Cuando la remitieron al Boulder Medical Center para que le revisaran los ojos después del diagnóstico de diabetes, dijo que le dijeron que había una alerta roja junto a su nombre. La última vez que había interactuado con el centro médico había sido unos 12 años atrás, cuando no pudo pagar las facturas del pediatra.

"Estaba en proceso de mudanza y luego embargaron mis salarios", recordó. "Solo pensé, '¿Qué más debo?'".

Con el corazón latiendo con fuerza, colgó el teléfono.

El corresponsal senior de KFF Health News, Noam N. Levey, contribuyó para este informe.

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

This story can be republished for free (details).

DENVER — In February, Norma Brambila’s teenage daughter wrote her a letter she now carries in her purse. It is a drawing of a rose, and a note encouraging Brambila to “keep fighting” her sickness and reminding her she’d someday join her family in heaven.

“Diagnosis: Debt Colorado” is a reporting partnership among Colorado newsrooms led by KFF Health News and the Colorado News Collaborative that explores the scale, impact, and causes of medical debt in Colorado. The ongoing series builds on KFF Health News’ award-winning reporting on medical debt in the United States.

Brambila, a community organizer who emigrated from Mexico a quarter-century ago, had only a sinus infection, but her children had never seen her so ill. “I was in bed for four days,” she said.

Lacking insurance, Brambila had avoided seeking care, hoping garlic and cinnamon would do the trick. But when she felt she could no longer breathe, she went to an emergency room. The $365 bill — enough to cover a week of groceries for her family — was more than she could afford, pushing her into debt. It also affected another decision she’d been weighing: whether to go to Mexico for surgery to remove the growth in her abdomen that she said is as big as a papaya.

Brambila lives in a southwestern Denver neighborhood called Westwood, a largely Hispanic, low-income community where many residents are immigrants. Westwood is also in a ZIP code, 80219, with some of the highest levels of medical debt in Colorado.

More than 1 in 5 adults there have historically had unpaid medical bills on their credit reports, more in line with West Virginia than the rest of Colorado, according to 2022 credit data analyzed by the nonprofit Urban Institute.

The area’s struggles reflect a paradox about Colorado. The state’s overall medical debt burden is lower than most. But racial and ethnic disparities are wider.

The gap between the debt burden in ZIP codes where residents are primarily Hispanic and/or non-white and ZIP codes that are primarily non-Hispanic white is twice what it is nationally. (Hispanics can be of any race or combination of races.)

Medical debt in Colorado is also concentrated in ZIP codes with relatively high shares of immigrants, many of whom are from Mexico. The Urban Institute found that 19% of adults in these places had medical debt on their credit reports, compared with 11% in communities with fewer immigrants.

Nationwide, about 100 million people have some form of health care debt, according to a KFF Health News-NPR investigation. This includes not only unpaid bills that end up in collections, but also those being paid off through installment plans, credit cards, or other loans.

Racial and ethnic gaps in medical debt exist nearly everywhere, data shows. But Colorado’s divide — on par with South Carolina’s, according to the Urban Institute data — exists even though the state has some of the most extensive medical debt protections in the country.

The gap threatens to deepen long-standing inequalities, say patient and consumer advocates. And it underscores the need for more action to address medical debt.

“It exacerbates racial wealth gaps,” said Berneta Haynes, a senior attorney with the nonprofit National Consumer Law Center who co-authored a report on medical debt and racial disparities. Haynes said too many Colorado residents, especially residents of color, are still caught in a vicious cycle in which they forgo medical care to avoid bills, leading to worse health and more debt.

Brambila said she has seen this cycle all too often around Westwood in her work as a community organizer. “I really would love to help people to pay their medical bills,” she said.

Health or Debt?

Roxana Burciaga, who grew up in Westwood and works at Mi Casa Resource Center there, said she hears questions at least once a week about how to pay for medical care.

Medical debt is a “big, big, big topic in our community,” she said. People don’t understand what their insurance actually covers or can’t get appointments for preventive care that suit their work schedules, she said.

Many, like Brambila, skip preventive care to avoid the bills and end up in the emergency room.

Doctors and nurses say they see the strains, as well.

Amber Koch-Laking, a family physician at Denver Health’s Westwood Family Health Center, part of the city’s public health system, said finances often come up in conversations with patients. Many patients try to get telehealth appointments to avoid the cost of going in person.

Adding to the crunch is Medicaid "unwinding", the process of states reexamining post-pandemic eligibility for health coverage for low-income people, Koch-Laking said. “They say, ‘Oh, I'm losing my Medicaid in three weeks, can you take care of these seven things without a visit?’ Or like, ‘Can we just do it over the portal, because I can't afford it?’”

Looking for the Right Fix

Colorado has taken steps to protect patients from medical debt, including expanding Medicaid coverage through the 2010 Affordable Care Act. More recently, state leaders required hospitals to expand financial assistance for low-income patients and barred all medical debts from consumers’ credit reports.

But the complexities of many assistance programs remain a major barrier for immigrants and others with limited English, said Julissa Soto, a Denver-based health equity consultant focused on Latino Coloradans.

Many patients, for example, may not know they can seek help with medical bills from the state or community nonprofits.

“The health care system is a puzzle. You better learn how to play with puzzles,” said Soto, who said she was sent to collections for medical bills when she first immigrated to the U.S. from Mexico. “Many hospitals also have funding to help out with your debt. You just have to get to the right person, because it seems that nobody wants to let us know that those programs exist.”

She said simplifying bills would go a long way to helping many patients.

Several states, including Oregon, Maryland, and Illinois, have tried to make it easier for people to access hospital financial aid by requiring hospitals to proactively screen patients.

Patient and consumer advocates say Colorado could also further restrict aggressive debt collection, such as lawsuits, which remain common in the state.

New York, for example, banned wage garnishment after finding that the practice disproportionately affected low-income communities. Research there also showed that medical debt burden was falling about twice as hard on communities of color as it was on non-Hispanic white communities.

Elisabeth Benjamin, a lawyer with the Community Service Society of New York, said hospitals were garnishing the wages of people working at Walmart and Taco Bell.

Maryland enacted limits on debt collection lawsuits after advocates found that patients living in predominantly minority neighborhoods were being disproportionately targeted. Even in wealthy counties, “the pockets that are being pursued are majority Latino neighborhoods,” said Marceline White, executive director of the advocacy group Economic Action Maryland.

White's group helped pass a law requiring hospitals to pay back low-income patients and avoid the scenario she was seeing, in which hospitals were “suing patients who should have gotten free care.”

Exacting a Heavy Toll

In Colorado, lawmakers are considering a measure to improve patients’ access to financial aid: a modification to the state’s Hospital Discounted Care program that would make hospitals presumptive eligibility sites for Medicaid.

Meanwhile, some consumer advocates say existing protections aren’t working well enough.

State data shows patients who received financial assistance were primarily white. And, though it’s unclear why, 42% of patients who may have been eligible were not fully screened by hospitals for financial assistance.

“What is clear is that a lot of people are not making it through,” said Bethany Pray, deputy director of the Colorado Center on Law and Policy, a Denver-based legal aid group that pushed for the discounted care legislation.

Within the state’s immigrant communities, medical debt — and the fear of debt — continues to take a heavy toll.

“What we’ve heard from our constituents is that medical debt sometimes is the difference between them being housed and them being unhoused,” said Denver City Council member Shontel Lewis. Her district includes the 80216 ZIP code, another place north of the city center that is saddled with widespread medical debt.

Paola Becerra is an immigrant living in the U.S. without legal permission who was pregnant when she was bused to Denver from a Texas shelter a few months ago.

She said she has skipped prenatal care visits because she couldn’t afford the $50 copays. She has emergency health coverage through Medicaid, but it doesn’t cover preventive visits, and she has already racked up about $1,600 in bills.

“I didn't know that I was going to arrive pregnant,” said Becerra, who thought she could no longer conceive when she left Colombia. “You have to give up your health. Either I pay the rent, or I pay the hospital.”

For Rocio Leal, a community organizer in Boulder, medical debt has become a defining feature of her life.

Despite the health insurance she had through her job, Leal ended up with high-interest payday loans to pay for healthy births, wage garnishment, prenatal appointments she missed to save money, and a “ruined” credit score, which limited her housing options.

Leal recalled times she thought they’d be evicted and other times the electricity was cut off. “It's not like we're avoiding and don't want to pay. It's just sometimes we don't have an option to pay,” she said.

Leal said the worst times are behind her now. She’s in a home she loves, where neighbors bring cakes over to thank her son for shoveling the snow off their driveway.

Her children are doing well. One daughter got a perfect GPA for the second semester in a row. Another is playing violin in the school orchestra. Her third daughter attends art club. And her son was recently accepted to college for biomedical engineering. They are covered by Medicaid, which has removed the uncertainty around big medical bills.

But medical debt still haunts Leal, who has Type 2 diabetes.

When she was referred to Boulder Medical Center to get her eyes checked after the diabetes diagnosis, she said she was told there was a red flag by her name. The last time she’d interacted with the medical center was about a dozen years earlier, when she’d been unable to pay pediatrician bills.

“I was in the process of moving and then my wages were garnished,” she recalled. “I just was like, ‘What else do I owe?’”

Heart pounding, she hung up the phone.

KFF Health News senior correspondent Noam N. Levey contributed to this report.

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

This story can be republished for free (details).

First, her favorite doctor in Providence, Rhode Island, retired. Then her other doctor at a health center a few miles away left the practice. Now, Piedad Fred has developed a new chronic condition: distrust in the American medical system.

“I don’t know,” she said, her eyes filling with tears. “To go to a doctor that doesn’t know who you are? That doesn’t know what allergies you have, the medicines that make you feel bad? It’s difficult.”

At 71, Fred has never been vaccinated against covid-19. She no longer gets an annual flu shot. And she hasn’t considered whether to be vaccinated against respiratory syncytial virus, or RSV, even though her age and an asthma condition put her at higher risk of severe infection.

“It’s not that I don’t believe in vaccines,” Fred, a Colombian immigrant, said in Spanish at her home last fall. “It’s just that I don’t have faith in doctors.”

The loss of a trusted doctor is never easy, and it’s an experience that is increasingly common.

The stress of the pandemic drove a lot of health care workers to retire or quit. Now, a nationwide shortage of doctors and others who provide primary care is making it hard to find replacements. And as patients are shuffled from one provider to the next, it’s eroding their trust in the health system.

The American Medical Association’s president, Jesse Ehrenfeld, recently called the physician shortage a “public health crisis.”

“It’s an urgent crisis, hitting every corner of this country, urban and rural, with the most direct impact hitting families with high needs and limited means,” Ehrenfeld told reporters in October.

In Fred’s home state of Rhode Island, the percentage of people without a regular source of routine health care increased from 2021 to 2022, though the state’s residents still do better than most Americans.

Hispanic residents and those with less than a high school education are less likely to have a source of routine health care, according to the nonprofit organization Rhode Island Foundation.

The community health centers known as federally qualified health centers, or FQHCs, are the safety net of last resort, serving the uninsured, the underinsured, and other vulnerable people. There are more than 1,400 community health centers nationwide, and about two-thirds of them lost between 5% and a quarter of their workforce during a six-month period in 2022, according to a report by the National Association of Community Health Centers.

Another 15% of FQHCs reported losing between a quarter and half of their staff. And it’s not just doctors: The most severe shortage, the survey found, was among nurses.

In a domino effect, the shortage of clinicians has placed additional burdens on support staff members such as medical assistants and other unlicensed workers.

Their extra tasks include “sterilizing equipment, keeping more logs, keeping more paperwork, working with larger patient loads,” said Jesse Martin, executive vice president of District 1199 NE of the Service Employees International Union, which represents 29,000 health care workers in Connecticut and Rhode Island.

“When you add that work to the same eight hours’ worth of a day’s work you can’t get everything done,” Martin said.

Last October, scores of SEIU members who work at Providence Community Health Centers, Rhode Island’s largest FQHC, held an informational picket outside the clinics, demanding improvements in staffing, work schedules, and wages.

The marketing and communications director for PCHC, Brett Davey, declined to comment.

Staff discontent has rippled through community health care centers across the country. In Chicago, workers at three health clinics held a two-day strike in November, demanding higher pay, better benefits, and a smaller workload.

Then just before Thanksgiving at Unity Health Care, the largest federally qualified health center in Washington, D.C., doctors and other medical providers voted to unionize. They said they were being pressed to prioritize patient volume over quality of care, leading to job burnout and more staff turnover.

The staffing shortages come as community health centers are caring for more patients. The number of people served by the centers between 2015 and 2022 increased by 24% nationally, and by 32.6% in Rhode Island, according to the Rhode Island Health Center Association, or RIHCA.

“As private practices close or get smaller, we are seeing patient demand go up at the health centers,” said Elena Nicolella, RIHCA’s president and CEO. “Now with the workforce challenges, it’s very difficult to meet that patient demand.”

In Rhode Island, community health centers in 2022 served about 1 in 5 residents, which is more than twice the national average of 1 in 11 people, according to RIHCA.

Job vacancy rates at Rhode Island’s community health centers are 21% for physicians, 18% for physician assistants and nurse practitioners, and 10% for registered nurses, according to six of the state’s eight health centers that responded to a survey conducted by RIHCA for The Public’s Radio, NPR, and KFF Health News.

Pediatricians are also in short supply. Last year, 15 pediatricians left staff positions at the Rhode Island health centers, and seven of them have yet to be replaced.

Research shows that some of the biggest drivers of burnout are workload and job demands.

Community health centers tend to attract clinicians who are mission-driven, said Nelly Burdette, who spent years working in health centers before becoming a senior leader of the nonprofit Care Transformation Collaborative of Rhode Island.

These clinicians often want to give back to the community, she said, and are motivated to practice “a kind of medicine that is maybe less corporate,” and through which they can they develop close relationships with patients and within multigenerational families.

So when workplace pressures make it harder for these clinicians to meet their patients’ needs, they are more likely to burn out, Burdette said.

When a doctor quits or retires, Carla Martin, a pediatrician and an internist, often gets asked to help. The week before Thanksgiving, she was filling in at two urgent care clinics in Providence.

“We’re seeing a lot of people coming in for things that are really primary care issues, not urgent care issues, just because it’s really hard to get appointments,” Martin said.

One patient recently visited urgent care asking for a refill of her asthma medication. “She said, ‘I ran out of my asthma medicine, I can’t get a hold of my PCP for refill, I keep calling, I can’t get through,’” Martin said.

Stories like that worry Christopher Koller, president of the Milbank Memorial Fund, a nonprofit philanthropy focused on health policy. “When people say, ‘I can’t get an appointment with my doctor,’ that means they don’t have a usual source of care anymore,” Koller said.

Koller points to research showing that having a consistent relationship with a doctor or other primary care clinician is associated with improvements in overall health and fewer emergency room visits.

When that relationship is broken, patients can lose trust in their health care providers.

That’s how it felt to Piedad Fred, the Colombian immigrant who stopped getting vaccinated. Fred used to go to a community health center in Rhode Island, but then accessing care there began to frustrate her.

She described making repeated phone calls for a same-day appointment, only to be told that none were available and that she should try again tomorrow. After one visit, she said, one of her prescriptions never made it to the pharmacy.

And there was another time when she waited 40 minutes in the exam room to consult with a physician assistant — who then said she couldn’t give her a cortisone shot for her knee, as her doctor used to do.

Fred said that she won’t be going back.

So what will she do the next time she gets sick or injured and needs medical care?

“Well, I’ll be going to a hospital,” she said in Spanish.

But experts warn that more people crowding into hospital emergency rooms will only further strain the health system, and the people who work there.

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

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

This story can be republished for free (details).

When Deanna Gomez found out she was pregnant in September 2023, she felt the timing couldn’t have been worse.

The college senior at California State University-San Bernardino worked 60 hours a week at two jobs. She used birth control. Motherhood was not in the plan. Not yet. “I grew up poor. And I don’t want that for my children, like, ever,” she said.

She wanted a medication abortion. It’s a two-step process: one drug taken at a doctor’s office, and another a day later to induce cramping and bleeding and empty the uterus. Gomez didn’t bother going to the university health clinic, thinking it was only for basic health needs.

She ended up driving more than 300 miles and paying hundreds of dollars in medical and travel expenses to obtain a medication abortion. She missed a month of classes, which put her graduation date in jeopardy. She had no idea she was entitled to a free medication abortion right on campus.

An LAist investigation has found that one year after California became the first state to require its public universities to provide abortion pills to students, basic information on where or how students can obtain the medication is lacking and, often, nonexistent.

“I was really upset when I found out,” Gomez told LAist. “I had to really push myself to make that money happen.”

LAist initially found that 11 of 23 CSU campus clinics did not have any information about medication abortion on their clinic websites, nor did they list it as a service offered. Of the University of California’s 10 campuses, eight mentioned medication abortion on their clinic websites. (Five CSU campuses and one UC campus added information after LAist published a version of this article.)

Through conversations with students and faculty at multiple campuses, LAist found there was little information for students to obtain the pills.

“If I had known that, I would have taken advantage of it,” Gomez said. “I spent a lot of time driving around after work, switching schedules, putting my homework on the back burner.”

California legislators in 2019 passed the law that requires all the state’s 33 public university campuses to provide abortion pills. It took effect in January 2023.

“We wanted to make sure that students, female students, had access to this right,” said Connie Leyva, the former Pomona-area state senator who authored the bill.

The legislature created a $10.3 million fund of privately raised money to help universities implement the new law. Each campus received $200,000 in one-time funding to pay for the medication and cover costs such as facility upgrades, equipment, training, telehealth services, and security upgrades.

The funding did not include any requirement that campus clinics inform students the medication was available to them.

Leyva said she doesn’t recall any conversations about “including something on advertising that you could get a medicated abortion on campus.” She said she’s disappointed in the law’s implementation, but not surprised.

“Everything starts at the top. And if the president or chancellor of the university knows they have to offer it, but if they don’t agree that women should have access to abortion services, then they might just think, ‘We’ll leave it off, we don’t have to worry about it,’” Leyva said.

Spokesperson Ryan King said UC President Michael Drake was not available to comment.

“The student communities at each UC campus are unique,” Heather Harper, a spokesperson for UC Health in Drake’s office, wrote in an email. “As a result, communication to students at each location takes different forms and may include website content, flyers, emails, person-to-person conversations or other methods.”

The office of CSU Chancellor Mildred García did not reply to a request for comment.

At Gomez’s San Bernardino campus, abortion as an option was mentioned only in one place: in small letters on a poster inside exam rooms at the health center.

A student wouldn’t see that until they were already waiting for a doctor or nurse.

“We need to work harder if there is a student who needed the service and wasn’t aware that they could access it through us and not have to pay for it,” said Beth Jaworski, executive director of health, counseling, and wellness at CSU-San Bernardino. “But it’s one student. We haven’t been providing the service very long. It’s been just about a year now.”

Medication abortion has since been added to the list of services on the clinic’s website.

Ray Murillo, California State University’s interim assistant vice chancellor of student affairs, said he and other administrative staffers are developing guidance so campuses share the same information “to help in our training efforts for the frontline staff and providers when they’re being asked questions about the service and what we provide.”

Gomez wants more done, including flyers, emails, and social media posts directed at both faculty and students.

“You want to market the football games, you want to market the volleyball games. Why is that important, and abortions are not?” she said.

Gomez did graduate in December 2023, becoming the first person in her family to earn a bachelor’s degree. But she’s angry at her alma mater for keeping the abortion pills a secret.

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

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

This story can be republished for free (details).

State and local governments are receiving billions of dollars in settlements from companies that made, sold, or distributed prescription painkillers and were accused of fueling the opioid crisis. More than a dozen companies will pay the money over nearly two decades. As of late February 2024, more than $4.3 billion had landed in government coffers.

KFF Health News has been tracking how that money is used — or misused — nationwide.

But determining how much of that windfall arrived in a specific county or city — and how much will follow in the future — can be challenging. Most localities are not required to make the information public.

BrownGreer, the court-appointed firm administering the settlements, tracks much of this data but kept it private until KFF Health News negotiated to obtain it last year. KFF Health News made that information public for the first time last June.

Five months later, BrownGreer began quietly posting updated versions of the information on a public website.

Roma Petkauskas, a partner at BrownGreer, told KFF Health News that the change was made to assist state and local governments in accessing the information easily and “to promote transparency into the administration” of the settlements. She said the data is updated “regularly when new payments are issued,” which can be as frequent as twice a month.

KFF Health News downloaded the data on March 4 and transformed it from state-by-state spreadsheets with separate entries for each settling company to a searchable database. Users can determine the total dollar amount their city, county, or state has received or expects to receive each year.

Determining how much money has arrived is the first step in assessing whether the settlements will make a dent in the nation’s addiction crisis.

Although this is the most comprehensive data available at a national scale, it provides just a snapshot of all opioid settlement payouts.

The information currently reflects only the largest settlement to date: $26 billion to be paid by pharmaceutical distributors AmerisourceBergen (now called Cencora), Cardinal Health, and McKesson, as well as opioid manufacturer Janssen (now known as Johnson & Johnson Innovative Medicine).

Most states have also settled with drug manufacturers Teva and Allergan, as well as Walmart, Walgreens, and CVS. Petkauskas said BrownGreer began distributing payments from these five companies in 2024 and plans to update its data to reflect such payments in July.

Other settlements, including with OxyContin manufacturer Purdue, are still pending.

This data does not reflect additional settlements that some state and local governments have entered into beyond the national deals, such as the agreement between Illinois, Indiana, Kentucky, Michigan, and Ohio and regional supermarket chain Meijer.

As such, this database undercounts the amount of opioid settlement money most places have received and will receive.

Payment details for some states are not available because those states were not part of national settlement agreements, had unique settlement terms, or opted not to have their payments distributed via BrownGreer. A few examples include:

• Alabama and West Virginia declined to join several national settlements and instead reached individual settlements with many of these companies.
• Texas and Nevada were paid in full by Janssen outside of the national settlement, so their payout data reflects payments only from AmerisourceBergen, Cardinal Health, and McKesson.
• Florida, Louisiana, and Pennsylvania, among others, opted to receive a lump-sum payment via BrownGreer then distribute the money to localities themselves.

KFF Health News’ Colleen DeGuzman contributed to this report. Jai Aslam also contributed.

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

This story can be republished for free (details).

Some consumers covered by Affordable Care Act insurance plans are being switched from one plan to another without their express permission, potentially leaving them unable to see their doctors or fill prescriptions. Some face large IRS bills for back taxes.

Do you have experience with ACA plan-switching or a related enrollment issue you’d like to share? Click here to tell your story.

Unauthorized enrollment or plan-switching is emerging as a serious challenge for the ACA, also known as Obamacare. Brokers say the ease with which rogue agents can get into policyholder accounts in the 32 states served by the federal marketplace plays a major role in the problem, according to an investigation by KFF Health News.

Indeed, armed with only a person’s name, date of birth, and state, a licensed agent can access a policyholder’s coverage through the federal exchange or its direct enrollment platforms. It’s harder to do through state ACA markets, because they often require additional information.

“It’s rampant. It’s horrible,” said Ronnell Nolan, president of Health Agents for America, a nonprofit trade association representing independent insurance brokers.

The growing outcry from agents who have had their clients switched by rivals — which can steer monthly commissions to the new agent — casts a shadow on what otherwise has been a record year for ACA enrollment. More than 21 million people signed up for 2024 coverage.

Federal regulators are aware of the increase in unauthorized switching and say they have taken steps to combat it. It’s unclear, though, if these efforts will be enough.

On Feb. 26, the Centers for Medicare & Medicaid Services sent a “plan switch update” to industry representatives acknowledging “a large number” of 2024 cases and outlining some of its technical efforts to resolve problems when complaints are lodged.

“CMS is committed to protecting consumers in the marketplace,” said Jeff Wu, deputy director for policy for CMS’ Center for Consumer Information & Insurance Oversight, in a written statement to KFF Health News.

His office refused to provide details on how many complaints it has seen or the number of agents it has sanctioned but his statement said when action is taken, CMS reports it to state insurance departments, whose authority includes revoking licenses.

Wu did not answer specific questions about whether two-factor authentication or other safeguards would be added to the federal website, though he wrote that CMS is “actively considering further regulatory and technological solutions to some of these problems.”

In June, new rules kicked in that require brokers to get policyholders’ written or recorded verbal consent before making changes, although brokers said they are rarely asked for those documents.

Finding Out the Hard Way

Some unwitting enrollees, like Michael Debriae, a restaurant server who lives in Charlotte, North Carolina, not only end up in plans they didn’t choose but also bear a tax burden.

That happens when enrollees are signed up for coverage that includes premium tax credits paid by the government to insurers, even though the enrollee is ineligible, either because their income was misstated by the broker making the switch, or they had job-based insurance, like Debriae.

Unbeknownst to him, an agent in Florida with whom he had never spoken enrolled him in an ACA plan in March 2023. It was two months after he canceled his Obamacare coverage because he was able to get health insurance through his job. In June, he discovered he had a new ACA policy when his longtime pharmacy said it could not fill a 90-day prescription, which it had done with no problem in the past.

“That’s when I realized something horribly wrong had happened,” said Debriae.

Debriae got contact information for the Florida broker, but when he called, the office said the agent no longer worked there. He filed a complaint with the federal marketplace and canceled the plan. But he still owed the IRS part of the $2,445 in premium tax credits paid to the insurer from March until July on his behalf.

To be sure, some switches could be legitimate, when enrollees choose a different broker or plan. And agents do have a vested interest in raising the issue. They lose out on commissions when their clients are switched by other agents. But brokers whose clients have been switched through unauthorized transactions say the real losers are consumers.

“People literally losing their plans is fraud, absolute fraud, not a squabble between agents,” said Leslie Shields, an insurance broker in Fort Worth, Texas.

Patients’ new plans might not include their doctors or might come with higher deductibles than their former coverage. Because the agent on the policy is generally switched, too, enrollees don’t know whom to call for help.

“You have surgeries that can’t happen, providers that can’t be seen, or have been changed,” said Shields. “It’s happened in the past, but now it’s literally the worst I’ve seen.”

Ease of access to policyholders’ accounts on the federal marketplace is a double-edged sword, agents say: It aids enrollment, but also makes it easier to switch plans without consent.

“Those bad eggs now have access to all this private information about an individual,” including household income, Social Security numbers, and dependents, said Joshua Brooker, a broker who follows the issue closely as chair of a marketplace committee for the National Association of Benefits and Insurance Professionals, a trade group.

Complaints gained momentum during the most recent open enrollment period, agents say. One worker in a government office that helps oversee operations of the federal exchange told KFF Health News of personally handling more than 1,200 complaints about unauthorized switches or enrollments in the past three months, averaging about 20 a day. About 30 co-workers are working on similar complaints. It can take multiple days to resolve the most urgent cases, and two to four weeks for those deemed less urgent, the worker said.

Florida, Georgia, and Texas appear to be plan-switching hotbeds, agents say. Florida and Texas officials referred questions to federal regulators. Bryce Rawson, press secretary for the Georgia Department of Insurance, says the state saw no switching complaints last year and has about 30 so far in 2024, a small number but one it is taking seriously: “It’s still an active and ongoing investigation.”

By contrast, states that run their own marketplaces — there are 18 and the District of Columbia that do — have been more successful in thwarting such efforts because they require more information before a policy can be accessed, Brooker said.

In Colorado, for example, customers create accounts on the state’s online market and can choose which brokers have access. Pennsylvania has a similar setup. California sends a one-time password to the consumer, who then gives it to the agent before any changes can be made.

Adding such safeguards to healthcare.gov could slow the enrollment process. Federal regulators are “trying to thread a needle between making sure people can get access to coverage and also providing enough of a barrier to capture anyone who is coming in and acting nefariously,” said Brooker.

How Does It Happen?

Many people have no idea how they were targeted, agents say.

Jonathan Kanfer, a West Palm Beach, Florida, agent, suspects names and lists of potential clients are being circulated to agents willing to bend the rules. He said his agency has lost 700 clients to switching.

The agents doing the switching “don’t care about the people,” Kanfer said, only the money, which can amount to a monthly commission of roughly $20 to $25 per enrollee.

“Two weeks ago, someone telemarketed me, gave me a number to call to get leads for Obamacare,” said Kanfer, who turned down the offer. The person told him: “You don’t even have to speak with the people.”

Brokers can get a monthly commission of roughly $20 to $25 per enrollee.

“Two weeks ago, someone telemarketed me, gave me a number to call to get leads for Obamacare,” Kanfer said. The person told him: “You don’t even have to speak with the people.”

Online or social media advertising is a way some outfits troll for prospects, who then end up on lists sold to brokers or are contacted directly by agents. Such lists are not illegal. The problem is the ads are often vague, and consumers responding may not realize the ads are about health insurance or might result in their policies being changed. Such ads promise free “subsidies” worth up to $6,400, often implying the money can help with groceries, rent, or gas. Some do mention “zero-dollar” health insurance.

Yet agents say the ads are misleading because the “subsidies” are actually the premium tax credits many people who enroll in ACA plans are eligible for, based on their income.

“They’re portraying it like it’s money going into your pocket,” said Lauren Jenkins, who runs an insurance brokerage in Coweta, Oklahoma, and has seen about 50 switching cases in recent months. But the money goes to insurers to offset the price of the new plan — which the consumer may not have wanted.

Ambetter Health — a division of Centene that offers ACA plans in more than two dozen states — sent email alerts to brokers in September and November. One noted a jump in complaints “stemming from misleading advertisements.” Another warned of “termination actions” against bad actors and directed agents not to collect consumer information or consent via “online forms or social media ads.”

In response to the switching, Ambetter also instituted a “lock” on policies starting at midnight on Dec. 31, meaning the agent on the policy by that deadline would remain on it for all of 2024, according to an email the insurer sent to brokers.

Results are mixed.

Adam Bercowicz, a licensed independent broker in Fort Lauderdale, Florida, said he and his staff worked New Year’s Eve, monitoring their client lists and watching as some were switched before their eyes.

“If I saw one of my clients was stolen from me at, let’s say, 11:57 p.m., I put myself back on,” said Bercowicz, who estimates he’s had 300 to 400 policies overtaken by other agents not connected to his staff in recent months. “And by 11:58 — a minute later — they were already switched back.”

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

This story can be republished for free (details).