In St. Louis, a team of students aboard a well-equipped van visits senior centers, a nursing home, a church, and other sites, learning to conduct comprehensive, hourlong geriatric assessments.
The team — future doctors, social workers, psychologists, and therapists — looks for such common problems as frailty, muscle weakness, and cognitive decline. The patients they evaluate, free of charge, receive printed plans to help guide their care.
Across Oregon, community health workers have enrolled in an eight-hour online training program — with sections on Medicare and Medicaid, hospice and palliative care, and communication with patients and families — to help them work with older adults.
"We need these front-line public health workers to know how to provide age-friendly care," said Laura Byerly, the geriatrician at the Oregon Health & Science University who leads its efforts.
And in Louisville, the same federally funded program provides geriatrics training across Kentucky. Sometimes, though, it takes a less formal approach.
Sam Cotton, the social worker who directs its dementia program, recently heard from a local Methodist church whose parishioners were caring for relatives with dementia. Could someone talk to the congregation about this demanding role? Cotton, an assistant professor at the University of Louisville, said sure, she would be there.
These programs, and 39 more like them across the country, aim to address an alarming fact: The number of geriatricians and other health care providers knowledgeable about aging has failed to keep up with the burgeoning population age 65 and older.
Since 2015, therefore, Congress has authorized funding for the Geriatrics Workforce Enhancement Program, or GWEP, which trains about 70,000 people a year.
Recently, these grants to universities and hospitals, up to $1 million each this year, appeared imperiled. In July, without warning or explanation, the annual disbursements to the recipients, some of which had participated since the program began in 2015, were substantially reduced.
Instead of an expected $41.8 million, the grantees collectively received $27.5 million, a 34% shortfall, according to the Eldercare Workforce Alliance. And more cuts appeared to be coming.
The Trump administration's proposed budget for fiscal 2026 eliminated GWEP, along with many other programs funded through the Health Resources and Services Administration, an agency of the Department of Health and Human Services.
Although the program had always drawn bipartisan support, and had been repeatedly authorized for five years, the president's budget zeroed it out, citing "an effort to streamline the bureaucracy, reset the proper balance between federal and state responsibilities, and save taxpayer funds."
As 10 weeks passed without clarification — was the missing money merely delayed or gone for good? — program directors frantically called their congressional representatives while contemplating painful layoffs and an uncertain future.
"This money was appropriated, signed, and sealed, so where is it?" Cotton said last month. Besides her role in the Louisville program, she serves as board president of the National Association of Geriatric Education Centers.
Grantees' questions to HRSA, the funding agency, brought few answers. Then, on Sept. 10, the programs discovered that, as mysteriously as they had vanished, the rest of the allocated funds had suddenly materialized.
And GWEP has been restored to both the House and Senate bills funding the federal health department, though the bills could still change or be voted down — or a continuing resolution could freeze current funding.
The rescue may reflect, in part, the efforts of a powerful GWEP supporter, Republican Sen. Susan Collins of Maine, who faces reelection next year.
In a Senate floor speech on Sept. 3, Collins called the program a "modest investment that will help ensure that our older Americans have the expert care that they need, that their caregivers are provided with training, that other support employees and health care providers receive the skills that they need."
Still, "it has been a roller coaster, to say the least," said Marla Berg-Weger, GWEP co-director at Saint Louis University, which trains about 9,800 people annually.
The payments withheld for 10 weeks equaled the amount that each grant had earmarked for Alzheimer's and dementia training, program directors found. The programs were required to designate $230,000 of a $1 million grant to dementia training for both professionals and community members, but some had chosen to spend more and therefore had larger shortfalls.
The GWEP at Louisiana State University, for instance, initially received just $152,000 of its expected $976,659 and halted (temporarily, the director hopes) all its geriatric rotations and internships in Louisiana and Mississippi.
What has been going on? HRSA, the federal agency funding the programs, said in an email that "all grant programs have been thoroughly reviewed to ensure alignment with administration priorities," causing "brief delays in executing certain payments."
"It's surprising to me that anyone would question the value of having a workforce knowledgeable about care for older adults," said Carole Johnson, the agency's administrator during the Biden administration.
"Everybody in the field hoped this program would grow, not wither," she added.
Appropriations have increased only slightly in recent years. Yet "the recipients are very resourceful," Johnson added. "It's a ‘big bang for the buck' program and a smart use of federal resources."
The number of practicing geriatricians — 6,580 this year, according to HRSA estimates — is likely to decrease slightly in the coming years, even as the need for such expertise climbs. It's hard to attract medical students and doctors to a relatively low-paying specialty whose patients are mostly insured by Medicare, though surveys have shown high job satisfaction among geriatricians.
Most older patients receive care not from geriatricians but from primary care doctors, other medical specialists, physician assistants, nurse practitioners, social workers, pharmacists, and direct care workers.
Accordingly, GWEPs emphasize extending knowledge about care for elders — whose risks, symptoms, goals, and treatments often differ from those of younger patients — to a wide array of providers, especially in rural and underserved areas. They also educate patients themselves and family caregivers.
The Saint Louis University program, for example, recently introduced an apprenticeship for certified nursing aides, or CNAs, working at a suburban nursing home.
"The turnover of nursing home employees in general, and CNAs in particular, is very high," Berg-Weger explained. These jobs are often poorly paid and stressful, and the 75 hours of training required for certification doesn't delve deeply into the particular needs and characteristics of older patients.
Six women have enrolled in Saint Louis' first apprenticeship class, designed to accommodate 10 at a time. Over a year, they'll receive 144 hours of education on such subjects as medications, fall prevention, and dementia.
The curriculum features both in-person classes with a geriatrician and a geriatric nurse practitioner, and more than 40 short videos the GWEP team has produced. Aides "can watch on their phones during their breaks," Berg-Weger said.
At the end of the year, graduates become certified geriatrics specialists and receive a $1,000 stipend from the program and a 12% raise from their employers. "Our plan is to offer this to other facilities," Berg-Weger said.
And to GWEPs in other states, if they survive.
The New Old Age is produced through a partnership with The New York Times.
TURLOCK, Calif. — California, like much of the nation, is not producing enough nurses working at bedsides to meet the needs of an aging and diverse population, fueling a workforce crunch that risks endangering quality patient care. Nearly 60% of California counties, stretching between the borders with Mexico and Oregon, face a nursing shortage, according to state data.
Democratic Gov. Gavin Newsom and state lawmakers have tried to bolster the state's health care workforce, in part by implementing recommendations from the California Future Health Workforce Commission, a 24-member panel of state, labor, academic, and industry representatives. The state in recent years has expanded the scope of practice for nurse practitioners, allowing them to practice medicine — ordering tests and prescribing medication, for instance — without traditional doctor supervision, and has worked to expand academic nursing slots and training programs.
Still, California's shortage of registered nurses is expected to grow from 3.7% in 2024 to 16.7% by 2033, or more than 61,000 nurses, due to inadequate recruitment, training, and retention, according to Kathryn Phillips, associate director of the Improving Access team at the California Health Care Foundation, a nonprofit philanthropic organization specializing in health care research and education.
Regional shortages, particularly in the Central Valley and rural North, are expected to swell. "There are major deficits and those could get even worse," Phillips said.
Researchers say the gap between nursing supply and demand is exacerbated by inadequate career pathways and high turnover in a labor-intensive industry, but nurses and their unions argue the problem is driven primarily by a management-induced staffing crisis and poor working conditions. Nurses say nursing remains a noble calling, but many report feeling pressured to turn over beds and take on more patients, stress that can dissuade young people from entering the field and drive experienced nurses to leave or retire early.
Industry representatives cast those concerns as union talking points to drive up labor costs, but nurses say they are losing benefits while being overworked, hobbling morale and hampering their ability to provide even basic health care in hospitals, clinics, and nursing homes around the state.
Lorena Burkett, a registered nurse at Emanuel Medical Center in Turlock, an agricultural city in the heart of the Central Valley, recounted being so overloaded last year that she didn't promptly log a medical chart after administering a psychiatric patient's medication, a critical step for ensuring proper drug doses.
"I was being told get him out, and I forgot to scan his opioid medication; I missed it," said Burkett, a 12-year veteran, who later updated the patient's record. "After that I said no more. We have to prioritize patient care, but we are under a lot of pressure to get patients out and turn profits."
Tenet Healthcare, the Dallas-based for-profit hospital system that owns Emanuel, declined to respond to Burkett's claim, as well as questions about staffing levels. In a statement, Tenet spokesperson Rob Dyer said that the hospital provides "quality and compassionate care" and broadly disputed nurses' concerns.
"We are currently in contract negotiations with the union which represents our nurses," he said, "and suspect that this is what is behind these false claims."
Improving Conditions for Nurses
Two years ago, state lawmakers approved $300 million to help financially struggling hospitals maintain operations, which can include retaining nurses. Lawmakers are also trying to improve nurses' work conditions in hospitals and to protect patient care by strengthening minimum nurse staffing at health care facilities. Some also call for investing in a more robust nursing workforce.
"Nurses are working in hospitals and other places that are severely understaffed," said Michelle Mahon, director of nursing practice for National Nurses United, a union that represents 225,000 nurses.
Phillips said the reasons vary. In the San Francisco Bay Area, nurses must contend with a high cost of living, a lack of affordable housing, and expensive child care. In the Central Valley, there's insufficient education, training, and mentoring. And the rural North has a hard time attracting enough nurses to replace those who are retiring and to meet the needs of an aging population.
University of California-San Francisco researchers who have studied the nursing workforce say although people are still seeking jobs in nursing, student enrollments and graduations have declined.
The California Board of Registered Nursing shows nearly 552,000 active licensed registered nurses in California as of Oct. 1. Yet the California Nurses Association says significantly fewer were practicing, pointing to 2024 data indicating only 350,850 were working in the field. The same problem persists nationally, according to National Nurses United, which reported that, as of May 2024, more than 1.1 million licensed nurses were not working in the field.
California Hospital Association spokesperson Jan Emerson-Shea said hospitals around the state are facing "skyrocketing costs" for labor, pharmaceuticals, medical equipment, and compliance with government mandates. Patient care costs have soared 30% in the past five years and continue to rise, she said. Meanwhile, 53% of hospitals in the state "lose money every day caring for patients," she said.
And it could get worse.
Under the GOP tax-and-spending bill that President Donald Trump called the "One Big Beautiful Bill," the state estimates roughly 3.4 million Californians could lose health coverage due in part to major Medicaid cuts and new rules like work requirements that narrow eligibility for low-income and disabled residents. California is at risk of losing $30 billion in annual funding, and hospitals will be hit particularly hard because they rely on federal reimbursements and need enough insured patients to remain solvent.
Emerson-Shea said California hospitals stand to lose up to $128 billion over 10 years due to the law.
"This projection does not include the likely increases in uncompensated care due to Medicaid work requirements, coverage losses due to the elimination of the Affordable Care Act subsidies, more frequent Medi-Cal redeterminations, and coverage losses for those with unsatisfactory immigration status," Emerson-Shea said.
While some California hospitals lose money on patient care, financial data shows the industry is making money, earning about $11.5 billion in net income, or profit, in 2024, said Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, pointing to preliminary state data comparing 365 hospitals. "The industry as a whole has returned to pre-covid profitability levels," Stremikis said.
He acknowledged, though, that Medicaid cuts will reduce revenue for all facilities.
Hospitals will be burdened as uninsured patients, who often arrive with prolonged illness or injuries that can make treatment more expensive, increase in number. That will exacerbate health care challenges in high-poverty communities with large Medi-Cal populations, since the safety net program generally pays hospitals and providers less than private insurance or Medicare.
Already, some hospitals are closing due to financial struggles, before the impacts of the federal health care cuts are felt, and others are limiting access to care, including by shuttering maternity wards and emergency rooms. Officials at Glenn Medical Center, about 85 miles north of Sacramento, reported that it would be shutting down its ER at the end of September due to staffing shortages.
Pandemic-Era Burnout Persists
Front-line nurses said the well-documented burnout of health workers from the covid-19 pandemic, mixed with growing hospital demands, is still being felt today as many part ways with the industry. That is prompting some hospitals to hire more traveling nurses from out of state.
At Hazel Hawkins Memorial Hospital, a financially strained public facility in San Benito County near the Central Coast, the California Nurses Association said the hospital is employing 22 traveling nurses, although the hospital put the number at 16. Local nurses said temporary workers can ease workloads, but they worry hospitals are using traveling nurses to avoid labor contracts that require higher pay and benefits. They say hospitals should invest in well-trained, local staff familiar with the community.
ER nurse Ariahnna Sanchez said workers at Hazel Hawkins, a 25-bed critical access facility, are pressured to discharge patients quickly so more patients can be seen. As union contracts come up for renegotiation, union officials say, hospitals have slashed benefits and haven't offered adequate raises to keep up with the cost of living. Salaries vary by region but the average annual wage for California registered nurses was $148,330 in 2024, according to the U.S. Bureau of Labor Statistics.
"The morale is so bad right now," Sanchez said. "We're trying to fight the good fight but we're constantly holding people in the emergency room who should be admitted due to the hospital being at max capacity."
State data shows San Benito County has an extreme shortage of nurses and needs about 180 more to accommodate the local population. But Hazel Hawkins disputes it has a shortage. The California Nurses Association said 40 nurses have left since last year, whereas the hospital said it has replaced 15 of 21 departing nurses.
Hazel Hawkins spokesperson Marcus Young said nurses are conflating staffing levels with protocols for handling ER patients when there aren't enough beds. "There is no material shortage of nurses and hospital operations are not being impacted today," Young said. "We are in full compliance with state-mandated nurse-to-patient ratios at all times."
California law dictates staffing minimums at hospitals, ranging from one nurse for every three patients to one nurse for every five patients, depending on the level of care the patients require. Research has shown that clinical errors can increase in hospitals and other health care workplaces when nurses are stressed and overwhelmed. Studies indicate that burnout related to work overload, career satisfaction, and patient satisfaction is a major concern and can lead to mistakes.
The state has issued 32 citations to California hospitals since 2020 for violating these minimum nurse staffing levels, financial penalties totaling $840,000, according to the state Department of Public Health. Neither Hazel Hawkins nor the Turlock hospital Emanuel had any citations. Spokesperson Mark Smith said the agency could not provide information on any "potential, pending or ongoing investigations" into health care facilities alleged to be in violation of state nursing ratios.
Burkett, the nurse in Turlock, said though she can see up to five patients at a time, she exceeded her ratio twice in the past year. In its latest quarterly financial filing, Tenet reported $288 million in net income, up from $259 million over the same period last year.
"I've taken that assignment against my will," Burkett said, noting that the union distributes forms protecting nurses from repercussions if mistakes happen on their watch when they take on more patients than the state allows. "It says I'm taking these patients against my better judgment and I'm protected because I am not agreeing to this, but the hospital is making me do it," she added. "It's tough. I mean, you just have to juggle and do what you can and hope you're not going to miss something important. It's not safe."
State Sen. Caroline Menjivar, a Democrat representing part of the Los Angeles region, has legislation on Newsom's desk to strengthen the state's nurse-to-patient ratio law by requiring hospitals to work harder to identify available nurses to meet staffing mandates.
"Hospitals for years have been getting a pass on minimum nurse staffing," said Menjivar, a former emergency medical technician. "If we do not provide more support to our nurses, then we do not get the quality care that is needed."
Menjivar's niece Megan Noguera-DeLeon is excited about becoming a nurse, despite workplace challenges. A nursing student who expects to graduate next year from West Coast University in Southern California, she said relatives who work as nurses have warned her how tough the job can be. She's worried about burning out but remains committed to the mission.
"I think taking care of people is a beautiful thing," Noguera-DeLeon said. "I know this job can be really hard and a lot of nurses are experiencing burnout, but honestly I've seen firsthand how much nurses can help people even on the darkest of days, and I want to help people."
Hours into the federal government shutdown, Julio Fuentes stood steps from the U.S. Capitol to deliver an urgent message about the Hispanic voting bloc that helped the GOP sweep into power last year.
Those votes, he cautioned, are at risk if Congress doesn't pass a law to preserve lower premiums on Affordable Care Act marketplace plans for the roughly 4.7 million people living in his home state of Florida who are enrolled in the coverage.
"Hispanic voters helped return Donald Trump to the White House," said Fuentes, CEO of the Florida State Hispanic Chamber of Commerce, who called on Congress to reopen the government to work out a deal on the tax credits. "Republican leaders would do right by their constituents to keep coverage affordable, and they will remember that heading into the midterms."
With less than a month to go before many Americans pick their health insurance plans for the next year, Democrats in Congress are holding up government funding to pressure Republicans into extending billions of dollars in federal tax credits that have in recent years dramatically lowered premiums and contributed to record-low rates of uninsured Americans.
Democrats see the high-stakes standoff as a chance to talk about affordable health care as millions of Americans — including those enrolled in coverage through a workplace or Medicare — brace for higher costs next year. Party leaders, hoping to win back support from some of the working-class supporters who have drifted away from them, have used the moment to remind voters of the recent cuts Republicans have approved to some health care programs.
Republicans are outwardly exuding confidence that the approach will not find traction, reminding the public that Democrats forced the shutdown. But a new KFF analysis shows that 80% of all premium tax credits benefited enrollees in states Trump won.
The shutdown coincides with open enrollment season, with insurers preparing to send notices revealing next year's premium rates for roughly 24 million people enrolled in ACA coverage. The average enrollee is expected to pay more than double if the tax credits are left to expire. Insurers have also said they'll have to dramatically raise the price of premiums because healthier people will opt out of coverage as it becomes more expensive, leaving a sicker pool of Americans — and less money to cover them.
"Over the next few days, what you're going to see is more than 20 million Americans experience dramatically increased health care premiums, copays, and deductibles because of the Republican unwillingness to extend the Affordable Care Act tax credits," House Minority Leader Hakeem Jeffries said Oct. 2 on the steps of the Capitol.
Open enrollment in most states begins on Nov. 1. Some insurers and exchanges have delayed sending notices detailing premium rates for next year, because they are waiting to see what unfolds in Washington. For example, Covered California, the state's insurance marketplace, is planning to mail out notices to more than a million enrollees later than usual this year, on Oct. 15.
From her home in Richmond, Virginia, 31-year-old Natalie Tyer is anxiously awaiting the arrival of her notice. She checks the state's marketplace website daily to see whether new rates for her insurance plan have been posted.
Tyer has been relying on marketplace coverage for over a year now while she works part-time for a small video production company and pursues a master's degree to become a school counselor. The tax credits help cover $255 of her monthly premium, bringing it down to $53. Since she's generally healthy, if the credits expire and her premiums go up significantly, she might drop coverage altogether.
"I very well might have to go without health insurance and may have to rely on hope," Tyer said.
Democrats' push to center the shutdown on health care affordability, though, runs up against many uncomfortable realities of the federal government's closure, which will leave millions of federal workers without paychecks, hamper some functions of public health agencies, and threaten food assistance payments for low-income mothers, among other effects.
The ACA, meanwhile, has been a political flash point since 2010, when Republicans fought against the passage of the landmark health care legislation. A wave of Republican congressional victories soon followed that fight, spurring a government shutdown in 2013, when the GOP tried to gut the program. Party leaders again tried to repeal it in 2017 to follow through on a Trump campaign promise.
The latest clash — over the billions of dollars in tax credits that Democrats issued during the covid-19 pandemic to boost enrollment in the ACA — has been simmering for months. Democrats, who wrote the original legislation introducing and then extending them, set the enhanced tax credits to expire at the end of this year. Even some Republicans began warning this summer that letting those tax credits lapse could be detrimental, with Republican pollsters Tony Fabrizio and Bob Ward issuing a memo cautioning that an extension of the credits could make a difference in next year's midterm election.
Extending the ACA tax credits, which have reduced monthly premiums to as little as $0 for poorer enrollees and capped the amount middle-income Americans pay to just 8.5% of their income, also would be a popular move.
More than three-quarters of Americans want those tax credits to continue, according to a new KFF poll conducted before the shutdown. About 3 in 4 people said they will blame Trump or the GOP if they end. KFF is a health information nonprofit that includes KFF Health News.
Although they've declined to address the tax credits so far this year, Republican Party leaders have signaled they are willing to extend the ACA tax credits, but with new restrictions on who qualifies for them. GOP leadership has also said they want to hash out the policy details over several weeks, not under the gun of a shutdown.
On Oct. 6, House Speaker Mike Johnson accused Democrats of manufacturing a political issue to shut down the government and urged them to pass the continuing resolution just to "keep the lights on."
"They decided that they would pick a fight on health care," Johnson said, adding that he believes the tax credits are "a Dec. 31 issue," referring to when the credits are set to expire.
Since open enrollment begins next month, insurers will need to start posting premium prices for customers to window-shop in the coming days. Democrats have argued that waiting months to work out a deal, which could change those prices, might spur widespread confusion.
While more Americans appear to be faulting Trump and Republicans for the shutdown, only a quarter of people are convinced that the Democrats' proposal to extend the ACA tax credits is worth closing the government over, according to a CBS News poll over the weekend.
Health care is typically a winning message for Democrats, who have struggled to coalesce around issues that appeal to the working class in recent years, said William Pierce, a health policy consultant who served under President George W. Bush.
"It's all about health care. They need to make this all about health care," Pierce said, describing it as a weak spot for Republicans. "They need to just keep talking about it, constantly."
Republicans in the White House and Congress have countered with factually dubious claims that Democrats are seeking to expand free health care for immigrants who do not have legal status in the U.S.
In fact, such immigrants are not eligible for enrollment in the marketplace, and Democrats have not proposed opening ACA coverage to them in their proposal.
Back in Richmond, as Tyer worries about her coverage for next year, she's bothered to see the debate focus on immigrants. Some of her classmates and colleagues are worried, too.
"The reality is, what's happening with these tax credits is that normal people — people who want to work in the public sector, who want to educate kids — we are also going to lose health care," Tyer said.
KFF Health News senior correspondent Bernard J. Wolfson contributed to this report.
About 1,500 federally funded health centers that serve millions of low-income people face significant financial challenges, their leaders say, as the government shutdown compounds other cuts to their revenue.
Some of these community health centers may have to cut medical and administrative staff or reduce services. Some could eventually close. The result, their advocates warn, may be added pressure on already crowded hospital emergency rooms.
"This is the worst time in all the years I have been working in health care," said Jim Mangia, president and CEO of St. John's Community Health, a network of 28 clinics that serves more than 144,000 patients in Los Angeles, Riverside, and San Bernardino counties in California. "We are facing federal cuts and extreme state cuts that will impact services."
St. John's and other federally qualified health centers offer primary care and a wide range of other services free of charge or on a sliding fee scale. Nationwide, they see nearly 34 million patients in the country's most underserved areas.
The federal funds come through two primary routes, both of which face challenges: grants paid in part through the federal Community Health Center Fund and reimbursements for patients' care through programs like Medicaid, which provides health insurance for low-income people and people with disabilities. Medicaid is jointly funded by states and the federal government.
Congress has approved the grant money in dribs and drabs recently. In March, lawmakers extended the funds until Sept. 30. That money expired after the Republican-controlled Congress did not pass a funding law, leading to a government shutdown.
Advocates say the health centers need long-term funding to help them plan with more certainty, ideally through a multiyear fund.
The centers received $4.4 billion in grants in early 2024. The National Association of Community Health Centers is advocating for at least $5.8 billion in grants annually for two years to keep the centers fully functional.
The health center safety net faces "multiple layers of challenges," said Vacheria Keys, vice president of policy and regulatory affairs for the association.
The new spending law that Republicans call the "One Big Beautiful Bill Act" will significantly cut Medicaid, raising the second set of threats for health centers.
Medicaid accounted for 43% of the $46.7 billion in health center revenue in 2023.
Advocates said lower Medicaid payments will exacerbate a gap between funding and operational costs.
Funding for workforce programs also is needed to support the delivery of health care services as centers struggle to hire and retain workers, said Feygele Jacobs, director of the Geiger Gibson Program in Community Health at George Washington University.
The first clinics of this type opened in places such as Massachusetts in the 1960s. Congress typically has funded them with bipartisan support, with minor fluctuations.
The struggle this year began when the Trump administration froze domestic aid through a January memo, which prevented some centers from receiving already approved grant money. As a consequence, some health centers in states such as Virginia closed or merged operations.
The upcoming cuts also are set to arrive at a time when patients will face new demands and challenges. The Medicaid changes in President Donald Trump's tax-and-spending law include requirements for Medicaid enrollees to report their work or other service hours to keep their benefits.
Meanwhile, more generous tax credits the Biden administration and Congress provided consumers to help pay for Affordable Care Act health insurance are set to expire at the end of the year. Some consumers' costs will spike if Congress doesn't renew them.
One reason the government shut down is that Democrats want to extend the tax credits, which protect consumers from higher insurance costs. The Republican funding bill did not include an extension; Republican congressional leaders say the issue should be addressed separately.
Consumers "will need more support than ever," said Jacobs, noting that Medicaid cuts and the expiration of the higher tax credits will both "potentially throw people out of coverage."
"We are also receiving 300 calls per day from patients concerned about their coverage," said Mangia, from St. John's.
Republicans are not directly targeting the centers, although they supported the Medicaid cuts that will affect the clinics' finances. Many Republicans say Medicaid spending has ballooned and that reducing the program's growth will make it more sustainable.
State and Local Support
While advocating for longer-term federal funding, the centers also are looking to their community and local governments for backing.
While some states boosted their support of the centers, others are going in the opposite direction. Anticipating the impact of Medicaid cuts, states such as California made their own cuts to the program.
California Gov. Gavin Newsom's office, the federal Department of Health and Human Services, and the federal Health Resources and Services Administration did not respond to requests for comment.
In Los Angeles, Mangia said, one potential solution is to work with partners at the county level, noting that L.A. County has about 10 million residents.
"We can tax ourselves to increase funding for health care services," he said.
Health center leaders are building a coalition that "hopefully" will include the main stakeholders in the county's health care system — community health centers, clinics, hospitals, doctors, health plans, unions — to begin the process to fill out a ballot petition, Mangia said. The goal: Put the question about taxes for health centers on the ballot and let voters decide.
"We are learning that the federal government and the state government are not reliable when it comes to continuing to fund health care," Mangia said.
Stacey Knoll thought the court summons she received was a scam. She didn't remember getting any medical bills from Montrose Regional Health, a nonprofit hospital, after a 2020 emergency room visit.
So she was shocked when, three years after the trip to the hospital, her employer received court orders requiring it to start funneling a chunk of her paychecks to a debt collector for an unpaid $881 medical bill — which had grown to $1,155.26 from interest and court fees.
The timing was terrible. After leaving a bad marriage and staying in a shelter, she had just gotten full custody of her three children, steady housing in Montrose, Colorado, and a job at a gas station.
"And that's when I got that garnishment from the court," she said. "It was really scary. I'd never been on my own or raised kids on my own."
KFF Health News reviewed 1,200 Colorado cases in which judges, over a two-year period from Feb. 1, 2022, through Feb. 1, 2024, gave permission to garnish wages over unpaid bills. At least 30% of the cases stemmed from medical care — even when patients' bills should have been covered by Medicaid, the public insurance program for those with low incomes or disabilities. That 30% is likely an underestimate since medical debt is often hidden behind other types of debt, such as from credit cards or payday loans. But even that minimum would translate to roughly 14,000 cases a year in Colorado in which courts approved taking people's wages because of unpaid medical bills.
Among the other findings:
Patients were pursued for medical bills ranging from under $30 to over $30,000, with most of the bills amounting to less than $2,400. As the cases rolled through the legal system, accumulating interest and court fees, the amount that patients owed often grew by 25%. In one case, it snowballed by more than 400%.
Cases trailed people for up to 14 years after they received medical care, with debt collectors reviving their cases even as they moved from job to job.
Medical providers of all stripes are behind these bills — big health care chains, small rural hospitals, physician groups, public ambulance services, and more. In several cases, hospitals won permission to take the pay of their own employees who had unpaid bills from treatment at the facilities.
Colorado has company. It is one of 45 states that allow wage garnishment for unpaid medical bills. Only Delaware, New York, North Carolina, Pennsylvania, and Texas have banned wage garnishment for medical debt.
As KFF Health News has reported, medical debt is devastating for millions of people across the country. And now the problem is likely to grow more pressing nationwide. Millions of Americans are expected to lose health insurance in the coming years due to Medicaid changes in President Donald Trump's tax and spending law and if Congress allows some Affordable Care Act subsidies to expire. That means health crises for the newly uninsured could lead them, too, into a spiral of medical debt.
"If you can't maintain your health, how are you going to work to pay back a debt?" said Adam Fox, deputy director of the Colorado Consumer Health Initiative, a nonprofit aimed at lowering health costs. "And if you fundamentally can't pay the bill, wage garnishment isn't going to help you do that. It's going to put you in more financial distress."
Flying Blind on Medical Debt
When someone fails to pay a bill, the creditor that provided the service — whether for a garage door repair, a car loan, or medical care — can take the debtor to court. Creditors can also pass the debt to a debt collector or debt buyer, who can do the same.
"At any given point, about 1% of working adults are being garnished for some reason," said Anthony DeFusco, an economist at the University of Wisconsin-Madison, who studied paycheck data from ADP, a payroll processor that distributes paychecks to about a fifth of private sector U.S. workers. "That's a big chunk of the population."
But specific research into the practice of garnishing wages over medical debt is scant. Studies in North Carolina, Virginia, and New York have found that nonprofit hospitals commonly garnish wages from indebted patients, with some studies finding those patients tend to work in low-wage occupations.
Marty Makary, who led research on medical debt wage garnishment in Virginia at Johns Hopkins University before joining Trump's cabinet as Food and Drug Administration commissioner, has called the practice "aggressive." He co-authored a study that found 36% of Virginia hospitals, mostly nonprofit and mostly in urban areas, were using garnishment to collect unpaid debts in 2017, affecting thousands of patients.
The Colorado findings from KFF Health News show that hospitals are far from the only medical providers going after patients' paychecks, though.
Researchers and advocates say that, in addition to a dearth of court case data, another phenomenon tends to obscure how often this happens. "People find debt shameful," said Lester Bird, a senior manager at the Pew Charitable Trusts who specializes in courts. "A lot of this exists in the shadows."
Without data on how often this tactic is employed, lawmakers are flying blind — even as a 2024 Associated Press-NORC poll showed about 4 in 5 U.S. adults believe it's important for the federal government to provide medical debt relief.
'Blood From a Turnip'
Colorado was among the first of 15 states to scratch medical debt from credit reports. Debt buyers in the state aren't allowed to foreclose on a patient's home. If qualified patients opt to pay in monthly installments, those payments shouldn't exceed 6% of their household income — and the remaining debt gets wiped after about three years of paying.
But if they don't agree to a payment plan, Coloradans can have up to 20% of their disposable earnings garnished. The National Consumer Law Center gave the state a "D" grade for state protections of family finances.
Consumer advocates said they aren't sure how well even those Colorado requirements are being followed. And people wrote letters to the courts saying wage garnishment would exacerbate their already dire financial situations.
"I have begun to fall behind on my electricity, my gas, my water my credit cards," wrote a man in western Colorado in a letter to a judge that KFF Health News obtained in the court filings. Court records show he was working in construction and at a rent-to-own store, with about $8,000 in medical debt. He wrote to the judge that he was paying close to $1,000 a month. "The way things are going now I will lose everything."
The people being sued in KFF Health News' Colorado review worked in a wide array of jobs. They worked in school districts, ranching, mining, construction, local government, even health care. Several worked at stores such as Walmart and Family Dollar, or at gas stations, restaurants, or grocery stores.
"You're really kicking people when they're down," said Lois Lupica, a former attorney working with the Denver-based Community Economic Defense Project and the Debt Collection Lab at Princeton. "They're basically suing the you-can't-get-blood-from-a-turnip population."
In 2022, court records show, Valley View health system based in Glenwood Springs was allowed to garnish the wages of one of its patients over a $400 medical bill. The patient was working at a local organization that the health system supported as part of the community benefits it provides to keep its tax-exempt status. Nonprofit hospitals like Valley View are required to provide community benefits, which can also include charity care that covers patients' bills.
Stacey Gavrell, the health system's chief community relations officer, said it offers options such as interest-free payment plans and care at reduced or no cost to families with incomes up to 500% of the federal poverty level.
"As our rural region's largest healthcare provider, it is imperative to the health and well-being of our community that Valley View remains a financially viable organization," she said. "Most of our patients work with us to develop a payment plan or pursue financial assistance."
The collection agency that took the employee to court, A-1 Collection Agency, advertises itself on its website as empathetic: "We understand times are tough and money is tight."
Pilar Mank, who oversees operations at A-1's parent company, Healthcare Management, said it accepts payment plans as small as $50 a month and that most of the hospitals it works with allow it to offer a discount if patients pay all at once.
"Suing a patient is the absolute last resort," she said. "We try everything we can to work with the patient."
Hospitals sometimes also garnish wages from their own employees for care they provided them. In one case, a hospital employee worked her way up from housekeeper to registrar to quality analyst. She even participated in public events representing her employer and appeared on the hospital's website as a featured employee — while the court issued writs of garnishment until her $10,000 in medical bills from the hospital was paid off.
"Hospital care costs money to deliver," said Colorado Hospital Association spokesperson Julie Lonborg about hospitals' garnishing their own employees' wages. "In some ways, I think it's funny to be asked the question. I would understand if someone said, 'Why aren't you garnishing their wages?'"
Studies show that hospital debt collection efforts through wage garnishment bring in only about 0.2% of hospital revenues, said April Kuehnhoff, a senior attorney with the National Consumer Law Center, which advocates for people with low incomes.
"We also know that there are states that don't allow this at all," she said. "Hospitals are continuing to provide medical care to consumers."
Smooth Sailing for Collectors — But Not for Patients
Health care providers appeared as the plaintiffs in only 2% of the medical debt cases. Instead, cases were filed almost entirely by third-party debt collectors and buyers, with BC Services and Professional Finance Company behind more than half of the cases, followed by A-1 Collection Agency and Wakefield & Associates.
Debt buyers make money by buying debt from providers who've given up on getting paid then collecting what they can of the money owed, plus interest. Debt collectors get paid a percentage of what they recover. Some companies do a bit of both.
BC Services declined to comment, and Wakefield & Associates did not respond to questions.
Charlie Shoop, president of Professional Finance Company, said his company initiates wage garnishment on less than 1% of all accounts placed with it for collection.
In many states, the path for filing a case against a debtor and garnishing their wages is relatively smooth — especially if the debtor doesn't appear in court.
"It's unbelievably easy," said Dan Vedra, a lawyer in Colorado who often represents consumers in debt cases. "If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes."
Within KFF Health News' sample, nearly all the medical debt cases were default judgments, meaning the patient did not defend themselves in court or in writing. Missing a court date can happen for a variety of reasons, such as not receiving the notice in the mail, assuming it was a scam, knowingly ignoring it, or not having the time to take off from work.
Vedra and other debt law experts said a high rate of default judgments indicates a system that favors the pursuers over the pursued — and increases the chances someone will be harmed by an erroneous bill.
But in New Hampshire, creditors now have to keep going to court for each paycheck they want to garnish, because the state allows creditors to garnish only wages that have already been earned, said Maanasa Kona, an associate research professor at the Center on Health Insurance Reforms at Georgetown University.
Wrongly Pursued for Bills
The nation's medical billing setup is already prone to errors due to its complexity, according to Barak Richman, a law professor at George Washington University and a senior scholar at Stanford Medicine who has studied medical debt collection practices in several states. "Bills are not only noncomprehensible, but often wrong," Richman said.
Indeed, Colorado's Health Care Policy & Financing Department, which runs Medicaid in the state, said it sent out nearly 11,000 letters in the past fiscal year to health providers and collectors that erroneously went after patients on Medicaid. Bills for Medicaid recipients are supposed to be sent to Medicaid, not the patients, who typically pay a nominal amount, if anything, for their care.
Shoop said his industry has pushed Colorado, without success, for access to a database that would allow them to confirm if patients had Medicaid coverage.
Colorado's Medicaid program declined to comment.
Patricia DeHerrera in Rifle, Colorado, had to prove that she and her children had Medicaid when they received care at Grand River Health — but only after A-1 contacted her employer at the time, the gas station chain Kum & Go, with court-approved paperwork to take a portion of her paychecks.
She contacted the state, which sent letters to the hospital and the collector notifying them they were engaging in "illegal billing action" and telling the collector to stop. The companies did.
Theresa Wagenman, controller for Grand River Health, said if a patient can present a letter from a Medicaid caseworker saying they're eligible, then their bills get removed from the collections pipeline. Wagenman also said patients get at least eight letters in the mail and several phone calls before Grand River gives the go-ahead for the collector to send them to court.
DeHerrera's main advice to others in this situation: "Know your rights. Otherwise, they're going to take advantage of you."
Nicole Silva, who lives in the 900-person town of Sanford in south-central Colorado, said she and her family were all on Medicaid when her daughter was in a car crash. Still, court records show, her wages were garnished for a $2,181.60 ambulance ride, which grew to more than $3,000 from court fees and interest.
She tried to prove the bill was wrong, contacting her county's social services office, but Silva said it wasn't helpful and she wasn't able to reach the right person at a state office. The state Medicaid program confirmed to KFF Health News that her daughter was covered at the time of the wreck.
Fighting the bill felt like too much for Silva and her husband to handle while parenting a growing number of kids, one of them severely disabled, and working — she as a preschool teacher and he as a rancher.
Not receiving the roughly $500 a month that she said came out of her pay was enough to affect their ability to pay other bills. "It was deciding to buy groceries or pay the electric bill," Silva said.
When their electricity got shut off, she said, they had to scramble to borrow money from colleagues and friends to get it turned back on — with an extra fee.
She said the saga makes her hesitant to call an ambulance in the future.
Fox, of the Colorado Consumer Health Initiative, said consumers often think they cannot do anything to stop their wages from being garnished, but they can contest it in court, for example by pointing out they should have qualified for discounted — or charity — care if the hospital that provided the treatment is a nonprofit.
DeFusco, the economist, believes filing for Chapter 7 bankruptcy is an underused option for debtors. It halts garnishment in its tracks, though not always permanently, and it comes with other consequences. But he understands it's a Catch-22: It's a complex process and typically necessitates hiring a lawyer.
"To get rid of your debt, you need money," he said. "And the whole reason you're in this situation is because you don't have money."
Methodology
We wanted to know how often Coloradans get their wages garnished due to medical debt. Courts don't compile this information, and researchers and advocates haven't tracked it systematically.
So we created our own database. We requested a list of all civil cases across the state in which judges gave permission for a person's earnings to be garnished — known as writs of garnishment in court lingo — from Feb. 1, 2022, through Feb. 1, 2024. The Colorado Supreme Court Library provided a list from all courts except for Denver County Court, which provided its own records. The combined list comprised nearly 90,000 unique court cases. We split up the cases by county population — small (fewer than 10,000 people), medium (10,000 to 100,000 people), and large (more than 100,000 people) — then generated a random sample of 400 cases from each group to ensure we evaluated medical debt across counties of all sizes.
To identify medical debt cases, we looked at the original creditors named in court records, primarily the complaints or affidavits of indebtedness. Often, this information was available through a state website. When it wasn't available online, we asked county courthouses to send us supporting documents. We counted dentists as medical providers. We excluded 14 cases in which the debt wasn't exclusively medical.
We looked only at cases in which courts approved money to be garnished from someone's paycheck, as opposed to from other sources such as their bank accounts. We did not review garnishment cases involving child support, taxes, or federal student loans.
KFF Health News intern Henry Larweh, data editor Holly K. Hacker, Mountain States editor Matt Volz, and web editor Lydia Zuraw contributed to this report.
Ramifications from a shutdown on public health systems and health programs will be felt far beyond Washington, D.C., halting almost all of the federal government's nonessential functions.
This article was published on Wednesday, October 1, 2025 in KFF Health News.
Threats of a federal government shutdown have gone from being an October surprise to a recurring theme. This time around, though, the stakes are higher.
Federal funding ran out at midnight on Oct. 1, after Congress failed to pass even a stopgap budget while negotiations continued.
Now the question is how long the deadlock will last, with Democrats pitted against Republicans and a presidential administration that has broken with constitutional norms and regularly used political intimidation and primary threats to achieve its ends. Because Republicans hold only a slim majority in the Senate, any deal will need to attract at least a few Democratic votes.
Ramifications from a shutdown on public health systems and health programs will be felt far beyond Washington, D.C., halting almost all of the federal government's nonessential functions, including many operations related to public health.
Even on Sept. 30, as the clock ticked toward midnight, President Donald Trump renewed threats about mass firings of federal workers if Democrats didn't acquiesce to GOP demands. Some people worry that such workforce reductions would further enable the administration to undermine federal government operations and reduce the budget impasse to what's been described as three-dimensional chess or a game of chicken.
Such threats to fire, rather than temporarily suspend, federal workers are "unprecedented," said G. William Hoagland of the Bipartisan Policy Center. The lack of negotiations between Capitol Hill Republicans and Democrats in advance of the shutdown is also unprecedented in his experience, said Hoagland, a longtime GOP Senate Budget Committee aide.
The stalemate centers largely on health coverage, with Democrats and Republicans clashing over the Affordable Care Act and Medicaid cuts. For Americans with ACA marketplace plans, government subsidies cap the percentage of household income they must pay toward premiums. Lawmakers expanded the subsidies in 2021 and extended that additional help through the end of 2025, and the looming expiration of those expanded subsidies would increase costs and reduce eligibility for assistance for millions of enrollees.
Democrats want a further extension of the subsidies, but many GOP lawmakers are resistant to extending them as is and say that debate must wait until after a budget deal to keep the federal government afloat. Antagonism has grown, with the parties in a pitched battle to convince voters the other party is to blame for the government's closure.
Said Senate Minority Leader Chuck Schumer on the Senate floor Sept. 30: "Republicans have chosen the losing side of the health care debate, because they're trying to take away people's health care; they're going to let people's premiums rise."
But Senate Majority Leader John Thune accused Democrats of attempting to "take government funding hostage."
The longer a shutdown lasts, the more impacts could be felt. For example, some community health centers would be at risk of closure as their federal funding dries up.
Long-term projects by the Federal Emergency Management Agency to reduce damage from future natural disasters will stop, for example. Rescue services at national parks that stay open will be limited. And at the National Institutes of Health, many new patients awaiting access to experimental treatments may not be admitted to its clinical center.
Entitlement programs such as Medicaid and Medicare will continue, as will operations at the Indian Health Service. But disease surveillance, support from the Centers for Disease Control and Prevention to local and state health departments, and funding for health programs will all be hampered, based on federal health agencies' contingency plans.
The Department of Health and Human Services is expected to furlough about 40% of its workforce, which has already been downsized by about 20,000 positions under the Trump administration. Across the federal government, roughly 750,000 employees will be furloughed, according to an estimate released Sept. 30 by the Congressional Budget Office, a nonpartisan agency that calculates the cost of legislation. While furloughed employees won't be working, eventually they will get back pay, totaling about $400 million daily, the CBO estimated.
At HHS, research is expected to pause on the links between drug prices and the Inflation Reduction Act, the major law enacted under former President Joe Biden to boost the economy. Despite reports that Food and Drug Administration Commissioner Marty Makary said the FDA would basically be untouched, the agency won't accept new drug applications and food safety efforts will be reduced. Federal oversight of a program that helps hospitals save lives and evacuate individuals in environmental crises is expected to stop.
Fewer federal staff will be available to provide help to Medicaid and Medicare enrollees. CDC responses to inquiries about public health matters will be suspended. And the work of a federal vaccine injury program is also anticipated to stop.
Congressional Democrats insist the ACA subsidies must be renewed now because enrollment for the Obama-era health program opens on Nov. 1. Without the extended subsidies, health insurers are warning of double-digit premium hikes for millions of enrollees.
House Democratic Leader Hakeem Jeffries has argued that a "Republican-caused health care crisis" is hanging over Americans as a result of Trump's new tax-and-spending bill, which adds restrictions to Medicaid that are expected to kick millions off the program. Republicans have also advanced mass layoffs and funding cuts at the nation's health department and caused widespread confusion over access to some vaccines.
"We're not going to simply go along to get along with a Republican bill that continues to gut the health care of everyday Americans," Jeffries told reporters Sept. 29. "These people have been trying to repeal and displace people off the Affordable Care Act since 2010."
Republicans, meanwhile, have blasted Democrats for holding up funding over the subsidies and say any deal will require concessions.
"If there were some extension of the existing policy, I think it would have to come with some reforms," Thune, the Senate Republican leader, said Sept. 26.
Such a deal may involve changes to a policy that caps what consumers have to pay for ACA marketplace plans at 8.5% of their income, no matter how much they earn. It could also alter their ability to obtain plans with no premiums, an option that became more widely available because of the beefed-up subsidies.
Adding restrictions to the ACA subsidies is likely to decrease enrollment in the program, which saw declines during the first Trump administration and did not reach 20 million for the first time until last year, a milestone reached in large part due to the subsidies.
Several Republicans have expressed interest in extending the subsidies, including a group of GOP representatives who proposed legislation to do so last month.
Democrats may be betting that the timing of the shutdown will put pressure on their Republican colleagues to come to the negotiation table on the ACA subsidies.
Within days of the government's closure, ACA enrollees are expected to get notices from their health insurers advising them of steeper premiums. Insurers have said the expiring subsidies have forced those large premium hikes because the healthiest and youngest people are more likely to opt out of coverage when prices go up.
The White House, meanwhile, ramped up its pressure campaign on Democrats. White House press secretary Karoline Leavitt insisted Sept. 29 that Trump wants to keep the government open.
"Our most vulnerable in our society and our country will be impacted by a government shutdown," she said.
At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.
This article was published on Wednesday, October 1, 2025 in KFF Health News.
LOUISVILLE, Tenn. — When a big storm hits, Peninsula Hospital could be underwater.
At this decades-old psychiatric hospital on the edge of the Tennessee River, an intense storm could submerge the building in 11 feet of water, cutting off all roads around the facility, according to a sophisticated computer simulation of flood risk.
Aurora, a young woman who was committed to Peninsula as a teenager, said the hospital sits so close to the river that it felt like a moat keeping her and dozens of other patients inside. KFF Health News agreed not to publish her full name because she shared private medical history.
"My first feeling is doom," Aurora said as she watched the simulation of the river rising around the hospital. "These are probably some of the most vulnerable people."
Covenant Health, which runs Peninsula Hospital, said in a statement it has a "proactive and thorough approach to emergency planning" but declined to provide details or answer questions.
Peninsula is one of about 170 American hospitals, totaling nearly 30,000 patient beds from coast to coast, that face the greatest risk of significant or dangerous flooding, according to a months-long KFF Health News investigation based on data provided by Fathom, a company considered a leader in flood simulation. At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.
Much of this risk to hospitals is not captured by flood maps issued by the Federal Emergency Management Agency, which have served as the nation's de facto tool for flood estimation for half a century, despite being incomplete and sometimes decades out of date. As FEMA's maps have become divorced from the reality of a changing climate, private companies like Fathom have filled the gap with simulations of future floods. But many of their predictions are behind a paywall, leaving the public mostly reliant on free, significantly limited government maps.
"This is highly concerning," said Caleb Dresser, who studies climate change and is both an emergency room doctor and a Harvard University assistant professor. "If you don't have the information to know you're at risk, then how can you triage that problem?"
The deadliest hospital flooding in modern American history occurred 20 years ago during Hurricane Katrina, when the bodies of 45 people were recovered from New Orleans' Memorial Medical Center, including some patients whom investigators suspected were euthanized. More flooding deaths were narrowly avoided one year ago when helicopters rescued dozens of people as Hurricane Helene engulfed Unicoi County Hospital in Erwin, Tennessee.
Rebecca Harrison, a paramedic, called her children from the Unicoi roof to say goodbye.
"I was scared to death, thinking, 'This is it,'" Harrison told CBS News, which interviewed Unicoi survivors as part of KFF Health News' investigation. "Alarms were going off. People were screaming. It was chaos."
The investigation — among the first to analyze nationwide hospital flood risk in an era of warming climate and worsening storms — comes as the administration of President Donald Trump has slashed federal agencies that forecast and respond to extreme weather and also dismantled FEMA programs designed to protect hospitals and other important buildings from floods.
When asked to comment, FEMA said flooding is a common, costly, and "under appreciated" disaster but made no statement specific to hospitals. Spokesperson Daniel Llargués defended the administration's changes to FEMA by reissuing an August statement that dismissed criticism as coming from "bureaucrats who presided over decades of inefficiency."
Alice Hill, an Obama administration climate risk expert, said the Trump administration's dismissal of climate change and worsening floods would waste billions of dollars and endanger lives.
In 2015, Hill led the creation of the Federal Flood Risk Management Standard, which required that hospitals and other essential structures be elevated or incorporate extra flood protections to qualify for federal funding.
"People will die as a result of some of the choices being made today," Hill said. "We will be less prepared than we are now. And we already were, in my estimation, poorly prepared."
'Flood Risk Is Everywhere'
The KFF Health News investigation identified more than 170 hospitals facing a flood risk by comparing the locations of more than 7,000 facilities to peer-reviewed flood hazard mapping provided by Fathom, a United Kingdom company that simulates flooding in spaces as small as 10 meters using laser-precision elevation measurements from the U.S. Geological Survey.
Hospitals were determined to have a significant risk if Fathom's 100-year flood data predicted that a foot or more of water could reach a considerable portion of their buildings, excluding parking garages, or cut off road access to the hospital. A 100-year flood is an intense weather event that has roughly a 1% chance of occurring in any given year but can happen more often.
The investigation found heightened flood risks at large trauma centers, small rural hospitals, children's hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.
Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom's data.
These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.
"The reality is that flood risk is everywhere. It is the most pervasive of perils," said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. "Just because you've never experienced an extreme doesn't mean you never will."
Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.
"A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units," Dresser said. "In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential."
Urban hospitals can face dangerous flooding, too. Fathom's data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.
By Fathom's estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a "ponding and drainage easement."
At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to military documents obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.
Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.
This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by KFF Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.
Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom's data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.
Ochsner Health did not answer questions about flooding preparations at Choctaw General.
FEMA flood maps were launched in the '60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a "snapshot in time" and are not intended to predict where flooding will or won't happen.
FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to "better project flood risk" and give Americans "the information they need to protect their lives and property."
The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.
Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.
"There has been not a single bit of loosening of what I'm calling the FEMA cone of silence," Berginnis said. "I've never seen anything like it."
Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.
The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe have estimated that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.
"Warmer air can hold more moisture, so this leads us to experience heavier downpours," said Kelly Van Baalen, a sea level rise expert at the nonprofit Climate Central. "A 100-year flood today could be a 10-year flood tomorrow."
Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.
Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.
Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, First Street, which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.
"It's a hospital right on the banks of a major American river," said Wing, the Fathom scientist. "It just isn't conceivable that such a location is risk-free."
Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom's predictions, Goodwin began to research flood insurance.
"Water can rise quickly and suddenly, and the destruction is tremendous," he said. "Just because we've never seen it here doesn't mean we won't see it."
'All the Elements of a Real Disaster'
One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.
Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.
Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its reopening is uncertain.
"Why allow something — especially a hospital — to be built in an area like that?" Mitchell told CBS News. "People have to rely on these areas to get medical help, and they're dangerous."
Beyond Unicoi, KFF Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.
For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.
Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.
Neither Buchanan nor LECOM responded to questions about flooding or preparations.
And in West Virginia's capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city's six hospitals at once, along with schools, churches, fire departments, and other facilities.
"I hate to say it," said Behrang Bidadian, a flood plain manager at the West Virginia GIS Technical Center, "but it has all the elements of a real disaster."
At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children's Hospital, cutting off all exits.
And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.
WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.
CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.
Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.
Tugboats and coal barges sail past his neighborhood as if they were cars on his street.
"It's not to say it's not a possibility," he said. "I'm sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn't see it coming either."
'The Water Is Coming'
Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has taken the position that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change "the greatest con job ever perpetrated on the world."
The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to publish a letter in August warning that the agency is being dismantled from within.
Daniel Swain, a University of California climate scientist, said the administration's rejection of climate change has left the nation less prepared for extreme weather, now and in the future.
"It's akin to enforcing malpractice scientifically," Swain said. "Imagine making a medical decision where you are not allowed to look at 20% of the patient's vital signs or test results."
Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:
FEMA disbanded the Technical Mapping Advisory Council, which had repeatedly pushed the agency to modernize its flood maps to estimate future risk and account for the impacts of climate change.
FEMA canceled its Building Resilient Infrastructure and Communities program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
And after stopping enforcement early this year, FEMA intends to rescind the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.
Berginnis, of the Association of State Floodplain Managers, said the administration's unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.
"The president is saying we are closed for business when it comes to hazard mitigation," Berginnis said. "It bugs me to no end that we have to have reminders — like people dying — to show us why it's important to make these investments."
FEMA did not answer specific questions about these decisions. In the statement to KFF Health News, spokesperson Llargués touted the administration's response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.
Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.
Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.
Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.
It is now likely one of the most flood-proofed hospitals in the nation.
But, so far, no storm has tested the facility.
Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is "not an if but a when."
"I hope it doesn't happen in my lifetime," she said, "but frankly, I'd be surprised. The water is coming."
Methodology
After Hurricane Helene made landfall a year ago, a raging river flooded a rural hospital in eastern Tennessee. Patients and employees were rescued from the rooftop. Floods have hit hospitals from New York to Nebraska to Texas in recent years. We wanted to determine how many other U.S. hospitals face similar peril. Ultimately, we found more than 170 hospitals at risk.
For this analysis, we used data from Fathom, a United Kingdom-based company that specializes in flood-risk modeling across the globe. To assess the United States' vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom's modeling has been peer-reviewed and used by insurance companies, the World Bank, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has validated Fathom's U.S. data.
Through a data use agreement, Fathom shared its U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom's data estimates the effects of three main types of flooding: coastal, fluvial (from overflowing rivers, lakes, or streams), and pluvial (rainfall that the ground can't absorb). The data also accounts for dams, reservoirs, and other structures that defend against floods.
To identify at-risk hospitals, we used a publicly available Department of Homeland Security database containing the GPS coordinates of more than 7,000 short-term acute, critical access, rehab, and psychiatric hospitals — basically any hospital with inpatient services. (DHS under the Trump administration has discontinued public access to the database, so data for hospitals and other infrastructure is no longer widely available.)
Using GPS coordinates as the centerpoint, we created a circle with a 150-yard radius around each hospital, which in most cases captured the building plus nearby grounds and access roads. We then mapped Fathom's flood-risk data to see where it overlapped with these circles. We started by looking for hospitals where at least 20% of the circle's area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 320 hospitals across the U.S.
From there, we visually inspected those hospitals using mapping software and Google Maps, both satellite and street view. We trimmed our list to only the hospitals where a considerable portion of the building or all access roads were predicted to have at least a foot of flooding.
If two hospitals were mapped to the same building — for instance, a small rehab facility within a large hospital — we counted only one hospital. We also excluded hospitals recently converted to nursing homes or for other uses.
We ended up with a list of 171 hospitals across the U.S. That is most likely an undercount. Some hospitals could still face significant impact from flooding that is not deep enough or widespread enough to fit our methodology. Our analysis also does not account for how flooding farther from a hospital could affect employees or patients. And it does not assess what steps hospitals may have already taken to prepare for severe weather events.
We also ran a spatial analysis comparing Fathom's data with flood hazard maps from the Federal Emergency Management Agency, which in many cases are incomplete or haven't been updated in years. We found that about a third of hospitals identified as flood risks by Fathom's data did not overlap at all with FEMA's 100- or 500-year hazard areas.
Fathom provided guidance and feedback as we developed our analysis.
CBS News correspondent David Schechter and photojournalist Chance Horner contributed to this report.
The healthcare sector is a bright spot in the economy this year, driving nearly half of the nation's employment gains, but economists and experts say immigration crackdowns and looming Medicaid cuts pose a threat to future job growth.
Employers added 487,000 jobs from January to August, according to the latest nonfarm payroll data from the Bureau of Labor Statistics. The healthcare sector accounted for 48% of that lackluster growth, expanding by about 232,000 jobs, even though the sector employs only about 11% of workers.
"On the labor side, healthcare growth is driving the economy," said Stanford economics professor Neale Mahoney.
Economists say President Donald Trump's immigration crackdown and cuts to public insurance programs threaten to dampen that growth. They could add unease about the economy and cause headwinds for the GOP in next year's midterm elections. The healthcare sector is unusually dependent on foreign-born workers, while a new law trimming federal spending on the $900-billion-a-year Medicaid program is projected, based on a preliminary version of the bill, to trigger the loss of 1.2 million jobs nationwide, according to the Commonwealth Fund.
In recent years, healthcare job growth has been most pronounced in the home health sector, rising by nearly 300,000 jobs to 1.82 million workers from August 2019 to August 2025, as millions of older residents hire workers to visit and take care of them, Mahoney said. Job growth has also been strong at hospitals and doctors' offices. Nursing homes and residential care homes posted weaker numbers from 2019 to 2025 amid an increase in the number of people using caregiving at home.
Some research indicates that healthcare job growth is not always good for the economy. For instance, a growing number of administrators in healthcare may raise healthcare costs without providing much benefit to patients. Yet, healthcare jobs are considered stable and often recession-proof, and the healthcare industry is now the top employer in most states. Even with job growth in the sector, many places remain desperate for healthcare workers to meet rising demand.
But several economists said recent federal policy changes on immigration and Medicaid might drag down job growth.
If immigration crackdowns by the Trump administration continue, it could get tough for healthcare organizations to find enough people to hire. "healthcare as an industry is pretty reliant on immigrant labor," said Allison Shrivastava, an economist with the Indeed Hiring Lab. "It has a large share of non-native labor force, so it's going to be impacted more."
About 18% of Americans employed in healthcare were born abroad, according to 2023 Census Bureau data. And about 5% of healthcare workers were not citizens, including about 60,000 doctors and surgeons, 117,000 registered nurses, and 155,000 home health or personal care aides, census data shows.
Many of those workers are here legally; the Census Bureau does not track how many noncitizens are living in the U.S. with authorization. But even those with legal status, including permanent residents, may be vulnerable to deportation. The federal government deported about 200,000 people from February through August, a significant increase from prior months, according to data obtained by The Guardian.
At the same time, some healthcare workers may choose not to study in or move to America if they perceive it as hostile to immigrants. The number of immigrant visas issued by the United States from March to May fell by about 23,000, or 14%, from the same period last year, State Department data shows. In addition, reported unauthorized border crossing attempts have plummeted.
Shrivastava said Indeed's job posting data shows continued strong demand for doctors among employers willing to help with the visa sponsorship process. But it's not clear if people will take them up on the offers.
Meanwhile, Congress this summer passed what Republicans called the "One Big Beautiful Bill Act," which was quickly signed by Trump. That bill makes about $910 billion in cuts to federal Medicaid spending over 10 years, according to a KFF analysis of data from the Congressional Budget Office.
Medicaid reductions are projected to cause millions to be without health insurance in the coming years. Hospitals, nursing homes, and community health centers will have to absorb more of the cost of treating uninsured people by reducing services and employees, or else close altogether.
The cuts could have a significant impact on the job market. California alone could see up to 217,000 fewer jobs, of which two-thirds would be in the healthcare sector, according to an analysis by the University of California-Berkeley Labor Center conducted before the bill was finalized and signed.
"It doesn't mean necessarily that 200,000 people are going to lose their job," said Miranda Dietz, interim director of the healthcare Program at the Labor Center. "Some people will lose their job, and in some cases, the job growth won't be as fast as anticipated."
Complicating the picture is Trump's recent firing of the official who headed the Labor Department's statistical branch, leading to concerns that jobs data will not be free from political influence.
It's not clear when — or if — immigration actions and Medicaid cuts will affect hiring in the healthcare sector, but there are signs of potential softening. Federal data showed a significant decline in job openings in the healthcare and social assistance sector in July. Indeed's job posting data also shows a decline in some healthcare fields, but Laura Ullrich, director of economic research in North America at the Indeed Hiring Lab, noted that, overall, postings remain above prepandemic levels.
For now, job growth is expected to remain high, particularly among nurse practitioners, physician assistants, and home health aides, according to BLS projections.
Many healthcare jobs require years of higher education but result in high pay, with family physicians typically making more than $240,000 a year and registered nurses typically taking in about $94,000 a year.
Joshua Lejano, president of the Sacramento State chapter of the California Nursing Students' Association, said he is "cautiously optimistic" that he will quickly land a job as a registered nurse when he graduates in December. He said he is completing nursing clinical rotations that give him real-world experience that will condition him for long shifts.
Lejano said hospitals in his area are expanding capacity while some veteran nurses are leaving the profession due to burnout from the covid pandemic, creating openings. "Right now, I think the big thing is just staying on top of all the application cycles," he said.
healthcare jobs that don't require as much training tend to pay much less. Median annual earnings for the U.S.' roughly 4.4 million home health and personal care aides were about $35,000 last year, roughly equivalent to pay for waiters and waitresses, federal data shows.
The growth in healthcare jobs has been especially beneficial for women, Ullrich said. Nearly 80% of healthcare and social assistance workers are female, according to a recent Indeed study. The research found that female workers accounted for more than a million new healthcare jobs in the last two years.
The sector is resilient, Shrivastava said, because Americans generally do not view healthcare as a luxury good: They pay for it in good times and bad. Health insurance costs are on track for their biggest jump in at least five years. Also, healthcare spending often centers on old and very old people, a group growing dramatically as baby boomers age. The number of Americans 65 or older rose from 34 million in 1995 to 61 million in 2024.
"So many of these healthcare jobs are to support the growing population of older Americans," Ullrich said. "So that's not surprising that we're seeing growth there. But I think what is surprising is how lopsided it is."
Quinn Cochran-Zipp went to the emergency room three times with severe abdominal pain before doctors figured out she had early-stage cancer in the germ cells of her right ovary. After emergency surgery four years ago, the Greeley, Colorado, lab technician is cancer-free.
The two hospitals that treated Cochran-Zipp at the time determined that she qualified for 100% financial assistance, since her income as a college student was extremely low. Not having to worry about the roughly $100,000 in bills she racked up for her care was an enormous relief, she said.
Then she started receiving unexpected bills from doctors who worked at the hospitals but, because they weren't on staff there, didn't have to abide by the facilities' financial assistance policies.
Those bills, which came from specialists in emergency medicine, anesthesiology, and radiology who treated her, totaled more than $5,000. Although it was a fraction of the total cost of her care, to Cochran-Zipp it was an enormous amount. She went on payment plans and used scholarship and covid stimulus money to help cover the bills.
Cochran-Zipp, now 25 and working at a community health center, is applying to medical schools and hopes to enroll next fall. Her experience as a patient has shaped how she thinks about becoming a doctor.
"I don't think that I could be a provider that, in good conscience, charges patients money in addition to the hospital fees," she said.
Hospital financial assistance programs are commonplace, and many patients rely on them. Most offer varying amounts of financial help to uninsured and lower-income people. Eligibility is typically based on a sliding income scale. Some hospitals apply other tests, such as residency.
But even if people qualify for assistance, they may not get discounts. That's because many physicians working at but not for a hospital aren't bound by its financial assistance policies. Hospitals themselves might limit the types of services eligible for discounted or "charity care," as it's sometimes called.
"It's a hole in the system," said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps patients with serious illnesses cover their medical bills. Case managers who work with patients report that they've seen these problems repeatedly, Donovan said.
In the coming years, more patients will encounter difficulties as demand for financial assistance grows. More than 14 million people are projected to lose health insurance over the next decade, primarily because of changes to the federal Medicaid program and state insurance marketplaces in recently passed tax and spending legislation championed by the Trump administration. Some of these people will likely qualify for discounted care.
Nonprofit hospitals do not pay taxes on the money they make, but to maintain that tax-exempt status, they are required to have policies to help patients pay for emergency and other medically necessary care. For-profit hospitals are not required to offer financial assistance to needy patients, but many do.
However, physicians and other providers who work in a hospital as independent contractors rather than as employees are often not subject to a hospital's financial assistance policy. According to an analysis by the Lown Institute, a health care think tank, physician services in the emergency, radiology, anesthesia, and pathology specialties are commonly excluded from hospital charity care.
For example, at Hartford HealthCare, a large nonprofit health system serving Connecticut, Massachusetts, and Rhode Island, services performed by physicians, nurse practitioners, and physician assistants employed by HHC, including emergency department physicians at four of its hospitals, are covered by its financial assistance policy. But treatment by emergency physicians at three HHC hospitals is not covered by the financial assistance policy, since they are not employees. Care by doctors working in radiology, pathology, and anesthesia isn't covered by the financial assistance policy at any HHC facility.
Hartford HealthCare declined to comment on the record for this article.
Health system researchers have identified another potential barrier to patients' receiving help from hospital financial assistance policies. IRS rules require that nonprofit hospitals include emergency and medically necessary care in their charity care policies, but they give hospitals substantial leeway to define what "medically necessary" care means.
Historically, excluded care has been limited to services that insurance doesn't typically cover, like cosmetic surgery or experimental treatment. But in recent years, hospitals appear to be defining medically necessary care more narrowly, eliminating financial assistance for care that is needed but not urgently required. Care that might fall into this category could be a kidney stone removal, a cancer biopsy, or a cardiac valve replacement, according to a study published this year in The New England Journal of Medicine.
Although the study of 209 nonprofit hospitals with more than 200 beds found only isolated examples of hospitals — about 6% of them — that substantially excluded medically necessary care, researchers are concerned that it could be the leading edge of a larger trend, said Mark Hall, a professor of law and public health at Wake Forest University, who co-authored the study.
"There's not really much in the way of regulatory guidance in what should be in or out" of a financial assistance policy, said Christopher Goodman, a clinical assistant professor at the University of South Carolina School of Medicine, who has published several studies examining hospital financial assistance policies.
The American Hospital Association declined to comment for this article. American Medical Association spokesperson Robert Mills said that the AMA doesn't have a position on whether all contracted physicians should be required to participate in hospital financial assistance policies.
For-profit hospitals have more latitude to fashion their financial assistance policies as they wish.
At HCA Healthcare, one of the country's largest for-profit health care systems, with nearly 200 hospitals in 20 states and the United Kingdom, discounted or free care is available only for "emergent or non-elective services."
"Facility charity policies and uninsured discounts are typically specific to emergency services" at HCA Healthcare, said Harlow Sumerford, an HCA Healthcare spokesperson. "Any third-party providers are independent and would have their own financial policies."
In recent years, several states have passed medical debt protection laws. A few apply to some doctors and other health care providers who practice at health care facilities and bill patients separately for their care.
Colorado's is the most expansive. Under its Hospital Discounted Care law that took effect in September 2022, covered hospitals have to screen all uninsured people and others who request it for eligibility for Medicaid and other health programs, and provide discounted care to people whose income is up to 250% of the federal poverty level (about $80,000 for a family of four). There are limits on how much qualifying patients can be billed each month and, after three years, their debt is retired.
Under the Colorado law, licensed health care professionals who work at a covered hospital can charge qualified patients no more than the rates set by the state.
"This rule has been a game changer for folks in Colorado," said Melissa Duncan, consumer assistance program manager at the Colorado Consumer Health Initiative, which helps patients access health care and cover their bills.
Unfortunately, the law didn't pass in time to help Cochran-Zipp.
As hospitals grapple with the changes expected under the federal health care legislation passed this summer, discounted care programs may make a tempting target, say some health care financing experts. Facing higher rates of uncompensated care and trouble collecting payments from patients, facilities may reduce the financial assistance that they offer.
Hospitals may say "we are going to do all we can to protect our spending," said Ge Bai, a professor of accounting and health policy and management at Johns Hopkins University. "In that environment, charity care will be a burden."
With the Trump administration scaling back federal efforts to protect Americans from medical bills they can't pay, advocates for patients and consumers have shifted their work to contain the nation's medical debt problem to state Capitols.
Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.
Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump's tax and spending law.
"This is an issue that had been top of mind even before the change of administrations in Washington," said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. "The pullback at the federal level made it that much more important that we do something."
This year, Maine joined a growing list of states that have barred medical debt from residents' credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The measure passed unanimously with bipartisan support.
The federal government was poised to bar medical debt from credit reports under regulations issued in the waning days of former President Joe Biden's administration. That would have helped an estimated 15 million people nationwide.
But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.
Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.
Still more states have passed other medical debt protections in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.
In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state's conservative Republican governor this year signed a measure restricting wage garnishment and capping interest rates.
And several GOP lawmakers in California joined Democrats in support of a measure to make it easier for patients to access financial assistance from hospitals for big bills.
"This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats," said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients' debts and has pushed for expanded patient protections.
But in several statehouses, the drive for more safeguards hit walls.
Bills to ban medical debts from appearing on credit reports failed in Wyoming and South Dakota, despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in Indiana, Montana, and Nevada.
In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.
In Maine, the Consumer Data Industry Association, which represents credit bureaus, told lawmakers that regulating medical debt should be left to the federal government. "Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports," warned Zachary Taylor, the group's government relations director.
In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. "Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was," Greenfield said on the House floor.
Under the Biden administration, CFPB researchers found that medical debt, unlike other debt, was not a good predictor of creditworthiness.
But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.
In Montana, legislation to shield a portion of debtors' assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are disproportionately burdened by medical debt.
But when the bill reached the House floor, opponents "showed up en masse," talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. "They lassoed just enough votes to narrowly defeat the bill," he said.
Advocates for patients and legislators who backed some of these measures said they're optimistic they'll be able to overcome industry opposition in the future.
And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A proposal in Texas to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.
"These things can sometimes take time," said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients' group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.
More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation's medical debt problem more dire.
