More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies and long-term care companies.
This article was published on Thursday, June 26, 2025 in KFF Health News.
In a top-rated nursing home in Alexandria, Virginia, the Rev. Donald Goodness is cared for by nurses and aides from various parts of Africa. One of them, Jackline Conteh, a naturalized citizen and nurse assistant from Sierra Leone, bathes and helps dress him most days and vigilantly intercepts any meal headed his way that contains gluten, as Goodness has celiac disease.
"We are full of people who come from other countries," Goodness, 92, said about Goodwin House Alexandria's staff. Without them, the retired Episcopal priest said, "I would be, and my building would be, desolate."
The long-term health care industry is facing a double whammy from President Donald Trump's crackdown on immigrants and the GOP's proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.
But in January, the Trump administration rescinded former President Joe Biden's 2021 policy that protected health care facilities from Immigration and Customs Enforcement raids. The administration's broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. "People may be here on a green card, and they are afraid ICE is going to show up," said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.
Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid. Care for 6 in 10 residents is paid for by Medicaid, the state-federal health program for poor or disabled Americans.
"We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges," said Eric Roberts, an associate professor of internal medicine at the University of Pennsylvania.
The industry hasn't recovered from covid-19, which killed more than 200,000 long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors' offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death has risen alarmingly from 17% in 2015 to 28% in 2024.
In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that would require most of the nation's nearly 15,000 nursing homes to hire more workers.
The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.
In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency "is committed to supporting a strong, stable long-term care workforce" and "continues to work with states and providers to ensure quality care for older adults and individuals with disabilities." In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers "need to do that by coming here the legal way" but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.
Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the best-staffed nursing homes in the country. Forty percent of the organization's 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.
"As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization," said Rob Liebreich, Goodwin's president and CEO.
Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. "She was sitting outside," Conteh, 56, recalled in an interview.
Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn't afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.
Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.
"Nearly every one of us from Africa, we know how to care for older adults," she said.
Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.
In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents' skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called "small houses" and a wing for memory care, at least 72 were born abroad, Hutter said.
Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.
"I have a bad leg and I can't stand on it very much, or I'd fall over," he said. "She's in there at 7:30 in the morning, and she helps me bathe." Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.
Conteh said Goodness was withdrawn when he first arrived. "He don't want to come out, he want to eat in his room," she said. "He don't want to be with the other people in the dining room, so I start making friends with him."
She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community's resident council and enjoys distributing the mail to other residents on his floor.
"The people that work in my building become so important to us," Goodness said.
While Trump's 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, including refugees who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security revoked the work permits for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.
"I've just spent my morning firing good, honest people because the federal government told us that we had to," Rachel Blumberg, president of the Toby & Leon Cooperman Sinai Residences of Boca Raton, a Florida retirement community, said in a video posted on LinkedIn. "I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals."
At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. "They're scared," she said. "Nobody trusts anybody." Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.
"If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?" Conteh asked. "What will become of our old people that we're taking care
Nearly seven months after the fatal shooting of an insurance CEO in New York drew widespread attention to health insurers' practice of denying or delaying doctor-ordered care, the largest U.S. insurers agreed Monday to streamline their often cumbersome preapproval system.
Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials.
While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement.
"The pledge is not a mandate," Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. "This is an opportunity for the industry to show itself."
Oz said he wants insurers to eliminate preapprovals for knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems. Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care.
The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer.
But health policy analysts say prior authorization — a system that forces some people to delay care or abandon treatment — may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments.
"So much of the prior authorization process is behind the black box," said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.
Often, she said, patients aren't even aware that they're subject to prior authorization requirements until they face a denial.
"I'm not sure how this changes that," Pestaina said.
The pledge from insurers follows the killing of UnitedHealthcare CEO Brian Thompson, who was shot in midtown Manhattan in early December on the way to an investor meeting, forcing the issue of prior authorization to the forefront.
Oz acknowledged "violence in the streets" prompted Monday's announcement. Klomp told KFF Health News that insurers were reacting to the shooting because the problem has "reached a fever pitch." Health insurance CEOs now move with security details wherever they go, Klomp said.
"There's no question that health insurers have a reputation problem," said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina.
The pledge shows that insurers are hoping to stave off "more draconian" legislation or regulation in the future, Hartwig said.
But government interventions to improve prior authorization will be used "if we're forced to use them," Oz said during the news conference.
"The administration has made it clear we're not going to tolerate it anymore," he said. "So either you fix it or we're going to fix it."
Here are the key takeaways for consumers:
1. Prior authorization isn't going anywhere.
Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism that patients and providers level against insurance companies. And it isn't clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment.
2. Reform efforts aren't new.
Most states have already passed at least one law imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted "gold card" programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements.
Nationally, rules proposed by the first Trump administration and finalized by the Biden administration are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid.
Beyond that, some insurance companies committed to improvement long before Monday's announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February.
3. Insurance companies are already supposed to be doing some of these things.
For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage.
But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term "non-approved requests" in Monday's announcement.
Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is "a standard already in place." But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds.
4. Health insurers will increasingly rely on artificial intelligence.
Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved.
The use of AI in making prior authorization decisions isn't new — and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions "in real-time" by 2027.
"Artificial intelligence should help this tremendously," Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference.
"But remember, artificial intelligence is only as good as what you put into it," he added.
Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials.
5. Key details remain up in the air.
Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January.
He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn't clear when that platform will be unveiled. The same holds true for "performance targets" that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them.
While the AMA, which represents doctors, applauded the announcement, "patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions," the association's president, Bobby Mukkamala, said in a statement. He noted that health insurers made "past promises" to improve prior authorization in 2018.
Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements.
Patient advocates are in the process of identifying "low-value codes," Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules.
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Republican efforts to restrict taxes on hospitals, health plans, and other providers that states use to help fund their Medicaid programs could strip them of tens of billions of dollars. The move could shrink access to health care for some of the nation's poorest and most vulnerable people, warn analysts, patient advocates, and Democratic political leaders.
No state has more to lose than California, whose Medicaid program, called Medi-Cal, covers nearly 15 million residents with low incomes and disabilities. That's twice as many as New York and three times as many as Texas.
A proposed rule by the Centers for Medicare & Medicaid Services, echoed in the Republican House reconciliation bill as well as a more drastic Senate bill, would significantly curtail the federal dollars many states draw in matching funds from what are known as provider taxes. Although it's unclear how much states could lose, the revenue up for grabs is big. For instance, California has netted an estimated $8.8 billion this fiscal year from its tax on managed care plans and took in about $5.9 billion last year from hospitals.
California Democrats are already facing a $12 billion deficit, and they have drawn political fire for scaling back some key health care policies, including full Medi-Cal coverage for immigrants without permanent legal status. And a loss of provider tax revenue could add billions to the current deficit, forcing state lawmakers to make even more unpopular cuts to Medi-Cal benefits.
"If Republicans move this extreme MAGA proposal forward, millions will lose coverage, hospitals will close, and safety nets could collapse under the weight," Gov. Gavin Newsom, a Democrat, said in a statement, referring to President Donald Trump's "Make America Great Again" movement.
The proposals are also a threat to Proposition 35, a ballot initiative California voters approved last November to make permanent the tax on managed care organizations, or MCOs, and dedicate some of its proceeds to raise the pay of doctors and other providers who treat Medi-Cal patients.
All states except Alaska have at least one provider tax on managed care plans, hospitals, nursing homes, emergency ground transportation, or other types of health care businesses. The federal government spends billions of dollars a year matching these taxes, which generally lead to more money for providers, helping them balance lower Medicaid reimbursement rates while allowing states to protect against economic downturns and budget constraints.
New York, Massachusetts, and Michigan would also be among the states hit hard by Republicans' drive to scale back provider taxes, which allow states to boost their share of Medicaid spending to receive increased federal Medicaid funds.
In a May 12 statement announcing its proposed rule, CMS described a "loophole" as "money laundering," and said California had financed coverage for over 1.6 million "illegal immigrants" with the proceeds from its MCO tax. CMS said its proposal would save more than $30 billion over five years.
"This proposed rule stops the shell game and ensures federal Medicaid dollars go where they're needed most — to pay for health care for vulnerable Americans who rely on this program, not to plug state budget holes or bankroll benefits for noncitizens," Mehmet Oz, the CMS administrator, said in the statement.
Medicaid allows coverage for noncitizens who are legally present and have been in the country for at least five years. And California uses state money to pay for almost all of the Medi-Cal coverage for immigrants who are not in the country legally.
California, New York, Michigan, and Massachusetts together account for more than 95% of the "federal taxpayer losses" from the loophole in provider taxes, CMS said. But nearly every state would feel some impact, especially under the provisions in the reconciliation bill, which are more restrictive than the CMS proposal.
None of it is a done deal. The CMS proposal, published May 15, has not been adopted yet, while the House and Senate bills must be negotiated into one and passed by both chambers of Congress. But the restrictions being contemplated would be far-reaching.
A report by Michigan's Department of Health and Human Services, ordered by Democratic Gov. Gretchen Whitmer, found that a reduction of revenue from the state's hospital tax could "destabilize hospital finances, particularly in rural and safety-net facilities, and increase the risk of service cuts or closures." Losing revenue from the state's MCO tax "would likely require substantial cuts, tax increases, or reductions in coverage and access to care," it said.
CMS declined to respond to questions about its proposed rule.
The Republicans' House-passed reconciliation bill, though not the CMS proposal, also prohibits any new provider taxes or increases to existing ones. The Senate version, released June 16, would gradually reduce the allowable amount of many provider taxes.
The American Hospital Association, which represents nearly 5,000 hospitals and health systems nationwide, said the proposed moratorium on new or increased provider taxes could force states "to make significant cuts to Medicaid to balance their budgets, including reducing eligibility, eliminating or limiting benefits, and reducing already low payment rates for providers."
Because provider taxes draw matching federal dollars, Washington has a say in how they are implemented. And the Republicans who run the federal government are looking to spend far fewer of those dollars.
In California, the insurers that pay the MCO tax are reimbursed for the portion levied on their Medi-Cal enrollment. That helps explain why the tax rate on Medi-Cal enrollment is sharply higher than on commercial enrollment. Over 99% of the tax money the insurers pay comes from their Medi-Cal business, which means most of the state's insurers get back almost all the tax they pay.
That imbalance, which CMS describes as a loophole, is one of the main things Republicans are trying to change. If either the CMS rule or the corresponding provisions in the House reconciliation bill were enacted, states would be required to levy provider taxes equally on Medicaid and commercial business to draw federal dollars.
California would likely be unable to raise the commercial rates to the level of the Medi-Cal ones, because state law constrains the legislature's ability to do so. The only way to comply with the rule would be to lower the tax rate on Medi-Cal enrollment, which would sharply reduce revenue.
CMS has warned California and other states for years, including under the Biden administration, that it was considering significant changes to MCO and other provider taxes. Those warnings were never realized. But the risk may be greater this time, some observers say, because the effort to shrink provider taxes is embedded in both Republican reconciliation bills and intertwined with a broader Republican strategy — and set of proposals — to cut Medicaid spending by $800 billion or more.
"All of these proposals move in the same direction: fewer people enrolled, less generous Medicaid programs over time," said Edwin Park, a research professor at Georgetown University's McCourt School of Public Policy.
California's MCO tax is expected to net California $13.9 billion over the next two fiscal years, according to January estimates. The state's hospital tax is expected to bring in an estimated $9 billion this year, up sharply from last year, according to the Department of Health Care Services, which runs Medi-Cal.
Losing a significant slice of that revenue on top of other Medicaid cuts in the House reconciliation bill "all adds up to be potentially a super serious impact on Medi-Cal and the California state budget overall," said Kayla Kitson, a senior policy fellow at the California Budget & Policy Center.
And it's not only California that will feel the pain.
"All states are going to be hurt by this," Park said.
Millions of Americans who have waited decades for fast internet connections will keep waiting after the Trump administration threw a $42 billion high-speed internet program into disarray.
The Commerce Department, which runs the massive Broadband Equity, Access, and Deployment Program, announced new rules in early June requiring states — some of which were ready to begin construction later this year — to solicit new bids from internet service providers.
The delay leaves millions of rural Americans stranded in places where health care is hard to access and telehealth is out of reach.
"This does monumental harm to rural America," said Christopher Ali, a professor of telecommunications at Penn State.
The Biden-era program, known as BEAD, was hailed when created in 2021 as a national plan to bring fast internet to all, including millions in remote rural areas.
A yearlong KFF Health News investigation, with partner Gray Media's InvestigateTV, found nearly 3 million people live in mostly rural counties that lack broadband as well as primary care and behavioral health care providers. In those same places, the analysis found, people live sicker and die earlier on average.
The program adopts a technology-neutral approach to "guarantee that American taxpayers obtain the greatest return on their broadband investment," according to the June policy notice. The program previously prioritized the use of fiber-optic cable lines, but broadband experts like Ali said the new focus will make it easier for satellite-internet providers such as Elon Musk's Starlink and Amazon's Kuiper to win federal funds.
"We are going to connect rural America with technologies that cannot possibly meet the needs of the next generation of digital users," Ali said. "They're going to be missing out."
Republicans have criticized BEAD for taking too long, and Commerce Secretary Howard Lutnick vowed in March to get rid of its "woke mandates." The revamped "Benefit of the Bargain BEAD Program," which was released with a fact sheet titled "Ending Biden's Broadband Burdens," includes eliminating some labor and employment requirements and obligations to perform climate analyses on projects.
The requirement for states to do a new round of bidding with internet service providers makes it unclear whether states will be able to connect high-speed internet to all homes, said Drew Garner, director of policy engagement at the Benton Institute for Broadband & Society.
Garner said the changes have caused "pure chaos" in state broadband offices. More than half the states have been knocked off their original timeline to deliver broadband to homes, he said.
The change also makes the program more competitive for satellite companies and wireless providers such as Verizon and T-Mobile, Garner said.
Garner analyzed in March what the possible increase in low-Earth-orbit satellites would mean for rural America. He found that fiber networks are generally more expensive to build but that satellites are more costly to maintain and "much more expensive" to consumers.
Commerce Secretary Lutnick said in a June release that the new direction of the program would be efficient and deliver high-speed internet "at the right price." The agency overseeing BEAD declined to release a specific amount it hopes to save with the restructuring.
More than 40 states had already begun selecting companies to provide high-speed internet and fill in gaps in underserved areas, according to an agency dashboard created to track state progress.
In late May, the website was altered and columns showing the states that had completed their work with federal regulators disappeared. Three states — Delaware, Louisiana, and Nevada — had reached the finish line and were waiting for the federal government to distribute funding.
The tracker, which KFF Health News saved in March, details the steps each state made in their years-long efforts to create location-based maps and bring high-speed internet to those missing service. West Virginia had completed selection of internet service providers and a leaked draft of its proposed plan shows the state was set to provide fiber connections to all homes and businesses.
Sen. Shelley Moore Capito (R-W.Va.) praised removal of some of the hurdles that delayed implementation and said she thought her state would not have to make very many changes to existing plans during a call with West Virginia reporters.
West Virginia's broadband council has worked aggressively to expand in a state where 25% of counties lack high-speed internet and health providers, according to KFF Health News' analysis.
In Lincoln County, West Virginia, Gary Vance owns 21 acres atop a steep ridge that has no internet connection. Vance, who sat in his yard enjoying the sun on a recent day, said he doesn't want to wait any longer.
Vance said he has various medical conditions: high blood sugar, deteriorating bones, lung problems — "all kinds of crap." He's worried about his family's inability to make a phone call or connect to the internet.
"You can't call nobody to get out if something happens," said Vance, who also lacks running water.
KFF Health News, using data from federal and academic sources, found more than 200 counties — with large swaths in the South, Appalachia, and the remote West — lack high-speed internet, behavioral health providers, and primary care doctors who serve low-income patients on Medicaid. On average, residents in those counties experienced higher rates of diabetes, obesity, chronically high blood pressure, and cardiovascular disease.
The gaps in telephone and internet services didn't cause the higher rates of illness, but Ali said it does not help either.
Ali, who traveled rural America for his book "Farm Fresh Broadband: The Politics of Rural Connectivity," said telehealth, education, banking, and the use of artificial intelligence all require fast download and upload speeds that cannot always be guaranteed with satellite or wireless technology.
It's "the politics of good enough," Ali said. "And that is always how we've treated rural America."
Fiber-optic cables, installed underground or on poles, consistently provide broadband speeds that meet the Federal Communications Commission's requirements for broadband download speed of 100 megabits per second and 20 Mbps upload speed. By contrast, a national speed analysis, performed by Ookla, a private research and analytics company, found that only 17.4% of Starlink satellite internet users nationwide consistently get those minimum speeds. The report also noted Starlink's speeds were rising nationwide in the first three months of 2025.
In March, West Virginia's Republican governor, Patrick Morrisey, announced plans to collaborate with the Trump administration on the new requirements.
Republican state Del. Dan Linville, who has been working with Morrisey's office, said his goal is to eventually get fiber everywhere but said other opportunities could be available to get internet faster.
In May, the West Virginia Broadband Enhancement Council signaled it preferred fiber-optic cables to satellite for its residents and signed a unanimous resolution that noted "fiber connections offer the benefits of faster internet speeds, enhanced data security, and the increased reliability that is necessary to promote economic development and support emerging technologies."
Nurse practitioners are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines.
This article was published on Wednesday, June 18, 2025 in KFF Health News.
On Fridays, Stephanie Johnson has a busy schedule, driving her navy-blue Jeep from one patient's home to the next, seeing eight in all. Pregnant with her second child, she schleps a backpack instead of a traditional black bag to carry a laptop and essential medical supplies — stethoscope, blood pressure cuff, and pulse oximeter.
Forget a lunch break; she often eats a sandwich or some nuts as she heads to her next patient visit.
On a gloomy Friday in January, Johnson, a nurse practitioner who treats older adults, had a hospice consult with Ellen, a patient in her 90s in declining health. To protect Ellen's identity, KFF Health News is not using her last name.
"Hello. How are you feeling?" Johnson asked as she entered Ellen's bedroom and inquired about her pain. The blinds were drawn. Ellen was in a wheelchair, wearing a white sweater, gray sweatpants, and fuzzy socks. A headband was tied around her white hair. As usual, the TV was playing loudly in the background.
"It's fine, except this cough I've had since junior high," Ellen said.
Ellen had been diagnosed with vascular dementia, peripheral vascular disease, and Type 2 diabetes. Last fall, doctors made the difficult decision to operate on her foot. Before the surgery, Ellen was always colorful, wearing purple, yellow, blue, pink, and chunky necklaces. She enjoyed talking with the half dozen other residents at her adult family home in Washington state. She had a hearty appetite that brought her to the breakfast table early. But lately, her enthusiasm for meals and socializing had waned.
Johnson got down to eye level with Ellen to examine her, assessing her joints and range of motion, checking her blood pressure, and listening to her heart and lungs.
Carefully, Johnson removed the bandage to examine Ellen's toes. Her lower legs were red but cold to the touch, which indicated her condition wasn't improving. Ellen's two younger sisters had power of attorney for her and made it clear that, above all, they wanted her to be comfortable. Now, Johnson thought it was time to have that difficult conversation with them about Ellen's prognosis, recommending her for hospice.
"Our patient isn't just the older adult," Johnson said. "It's also often the family member or the person helping to manage them."
Nurse practitioners are having those conversations more and more as their patient base trends older. They are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines. The Health Resources and Services Administration projects a 50% increase in demand for geriatricians from 2018 to 2030, when the entire baby boom generation will be older than 65. By then, hundreds of geriatricians are expected to retire or leave the specialty, reducing their number to fewer than 7,600, with relatively few young doctors joining the field.
That means many older adults will be relying on other primary care physicians, who already can't keep up with demand, and nurse practitioners, whose ranks are booming. The number of nurse practitioners specializing in geriatrics has more than tripled since 2010, increasing the availability of care to the current population of seniors, a recent study in JAMA Network Open found.
According to a 2024 survey, of the roughly 431,000 licensed nurse practitioners, 15% are, like Johnson, certified to treat older adults.
Johnson and her husband, Dustin, operate an NP-led private practice in greater Seattle, Washington, a state where she can practice independently. She and her team, which includes five additional nurse practitioners, each try to see about 10 patients a day, visiting each one every five to six weeks. Visits typically last 30 minutes to an hour, depending on the case.
"There are so many housebound older adults, and we're barely reaching them," Johnson said. "For those still in their private homes, there's such a huge need."
Laura Wagner, a professor of nursing and community health systems at the University of California-San Francisco, stressed that nurse practitioners are not trying to replace doctors; they're trying to meet patients' needs, wherever they may be.
"One of the things I'm most proud of is the role of nurse practitioners," she said. "We step into places where other providers may not, and geriatrics is a prime example of that."
Practice Limits
Nurse practitioners are registered nurses with advanced training that enables them to diagnose diseases, analyze diagnostic tests, and prescribe medicine. Their growth has bolstered primary care, and, like doctors, they can specialize in particular branches of medicine. Johnson, for example, has advanced training in gerontology.
"If we have a geriatrician shortage, then hiring more nurse practitioners trained in geriatrics is an ideal solution," Wagner said, "but there are a lot of barriers in place."
In 27 states and Washington, D.C., nurse practitioners can practice independently. But in the rest of the country, they need to have a collaborative agreement with or be under the supervision of another health care provider to provide care to older adults. Medicare generally reimburses for nurse practitioner services at 85% of the amount it pays physicians.
Last year, in more than 40 states, the American Medical Association and its partners lobbied against what they see as "scope creep" in the expanded roles of nurse practitioners and other health workers. The AMA points out that doctors must have more schooling and significantly more clinical experience than nurse practitioners. While the AMA says physician-led teams keep costs lower, a study published in 2020 in Health Services Research found similar patient outcomes and lower costs for nurse practitioner patients. Other studies, including one published in 2023 in the journal Medical Care Research and Review, have found health care models including nurse practitioners had better outcomes for patients with multiple chronic conditions than teams without an NP.
"I would fully disagree that we're invading their scope of practice and shouldn't have full scope of our own," Johnson said.
She has worked under the supervision of physicians in Pennsylvania and Washington state but started seeing patients at her own practice in 2021. Like many nurse practitioners, she sees her patients in their homes. The first thing she does when she gets a new patient is manage their prescriptions, getting rid of unnecessary medications, especially those with harsh side effects.
She works with the patient and a family member who often has power of attorney. She keeps them informed of subtle changes, such as whether a person was verbal and eating and whether their medical conditions have changed.
While there is some overlap in expertise between geriatricians and nurse practitioners, there are areas where nurses typically excel, said Elizabeth White, an assistant professor of health services, policy, and practice at Brown University.
"We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs. That's very much in the nursing domain," she said.
That care coordination will become even more critical as the U.S. ages. Today, about 18% of the U.S. population is 65 or over. In the next 30 years, the share of seniors is expected to reach 23%, as medical and technological advances enable people to live longer.
Patient and Family
In an office next to Ellen's bedroom, Johnson called Ellen's younger sister Margaret Watt to recommend that Ellen enter hospice care. Johnson told her that Ellen had developed pneumonia and her body wasn't coping.
Watt appreciated that Johnson had kept the family apprised of Ellen's condition for several years, saying she was a good communicator.
"She was accurate," Watt said. "What she said would happen, happened."
A month after the consult, Ellen died peacefully in her sleep.
"I do feel sadness," Johnson said, "but there's also a sense of relief that I've been with her through her suffering to try to alleviate it, and I've helped her meet her and her family's priorities in that time."
Jariel Arvin is a reporter with the Investigative Reporting Program at the University of California-Berkeley Graduate School of Journalism. He reported this article through a grant from The SCAN Foundation.
Without enhanced subsidies, ACA insurance premiums would rise by more than 75% on average.
This article was published on Tuesday, June 17, 2025 in KFF Health News.
MIAMI — Josefina Muralles works a part-time overnight shift as a receptionist at a Miami Beach condominium so that during the day she can care for her three kids, her aging mother, and her brother, who is paralyzed.
She helps her mother feed, bathe, and give medicine to her adult brother, Rodrigo Muralles, who has epilepsy and became disabled after contracting covid-19 in 2020.
"He lives because we feed him and take care of his personal needs," said Josefina Muralles, 41. "He doesn't say, 'I need this or that.' He has forgotten everything."
Though her husband works full time, the arrangement means their household income is just above the federal poverty line — too high to qualify for Florida's Medicaid program but low enough to make Muralles and her husband eligible for subsidized health insurance through the Affordable Care Act marketplace, also known as Obamacare.
Next year, Muralles said, she and her husband may not be able to afford that health insurance coverage, which has paid for her prescription blood thinners, cholesterol medication, and two surgeries, including one to treat a genetic disorder.
Extra subsidies put in place during the pandemic — which reduced the premiums Muralles and her husband paid by more than half, to $30 a month — are in place only through Dec. 31. Without enhanced subsidies, Affordable Care Act insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to estimates from KFF, a health information nonprofit that includes KFF Health News.
Florida and Texas would be hit especially hard, as they have more people enrolled in the marketplace than other states. Some of their congressional districts alone, especially in South Florida, have more people signed up for Obamacare than entire states.
Like many of the more than 24 million Americans enrolled in the insurance marketplace this year, Muralles was unaware that the enhanced subsidies are slated to expire. She said she cannot afford a premium hike because inflation has already eaten into her household's budget.
"The rent is going up," she said. "The water bill is going up."
Low-income enrollees like the Muralles couple would see the biggest percentage increases in premiums if enhanced subsidies expire.
Middle-income enrollees who earn more than four times the federal poverty line would no longer be eligible for subsidies at all. Those middle-income enrollees (who earn at least $62,600 for a single person in 2025) are disproportionately older, self-employed, and living in rural areas.
The Congressional Budget Office estimated that letting the enhanced subsidies expire would, by 2034, increase the number of people without health insurance by 4.2 million. In tandem with changes to Medicaid in the House of Representatives' reconciliation bill and the Trump administration's proposed rules for the marketplace, including toughening income verification and shortening enrollment periods, it would increase the number of uninsured people by 16 million over that time period.
A study by the Urban Institute, a nonprofit think tank, found that Hispanic and Black people would see greater coverage losses than other groups if the extra subsidies lapse.
Fuentes noted that about 5 million Hispanics are enrolled in the ACA marketplace, and that Donald Trump won the Hispanic vote in Florida in 2024. He hopes the president and congressional Republicans see extending the enhanced subsidies as a way to hold on to those voters.
"This is probably a good way, or a good start, to possibly grow that base even more," he said.
Enrollment in the marketplace has grown faster since 2020 in the states won by Trump in 2024. A recent KFF survey found that 45% of Americans who buy their own health insurance identify as or lean Republican, including 3 in 10 who identify as Make America Great Again supporters. Smaller shares identify as Democrats or Democratic-leaning independents (35%) or do not lean toward either party (20%).
Kush Desai, a White House spokesperson, said the rules proposed by the Trump administration, combined with the provisions in the House-passed budget bill, would "strengthen the ACA marketplace." He noted that the CBO projects the legislation would reduce premiums for some plans about 12% on average by 2034 — but out-of-pocket costs would rise or remain the same for most subsidized ACA consumers.
"Democrats know Americans broadly support ending waste, fraud, and abuse, as The One, Big, Beautiful Bill does, which is why they are desperately trying to change the conversation," Desai said.
But Lauren Aronson, executive director of Keep Americans Covered, a group in Washington, D.C., representing health insurers, hospitals, physicians, and patient advocates, said it is critical to raise awareness about the likely impact of losing the enhanced subsidies, which are also known as advanced premium tax credits. She is encouraged that Democrats have proposed legislation to extend the enhanced tax credits, and that some Republican senators have voiced support.
What worries Aronson most is that the Republican-controlled Congress is more focused on extending tax cuts than enhanced subsidies, she said. The current bill extending the 2017 tax cuts would increase the federal deficit by about $2.4 trillion over the next decade, according to the CBO, while making the enhanced subsidies permanent would increase the deficit by $358 billion over roughly the same period.
"Congress is moving forward on a tax reconciliation package that purports to benefit working families," Aronson said. "But if you don't take care of the tax credits, working families will be left holding the bag."
Brian Blase, president of Paragon Health Institute, a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid-19 pandemic to help people at risk of losing coverage.
Instead, he said, the enhanced subsidies facilitated fraud because enrollees did not need to verify their income eligibility to receive zero-premium plans if they reported incomes at or near the federal poverty level.
The enhanced subsidies also worsen health inflation, discourage employers from offering health insurance benefits, and crowd out alternative models, such as short-term insurance and Farm Bureau plans, Blase said.
"Permitting these subsidies to expire would just be going back to Obamacare as it was written," Blase said. "That is a more efficient program than the program that we have now."
New rules for the marketplace proposed by the Trump administration in March are already designed to address fraud, said Anna Howard, a policy expert with the American Cancer Society Cancer Action Network, which advocates for increased health insurance coverage. Howard said extending the enhanced tax credits would help ensure that people who are legitimately eligible for coverage can get it.
"We don't want to see over 5 million people be kicked off their health insurance coverage out of fears of fraud when the policies being proposed don't necessarily address fraud," she said.
Without affordable premiums, many consumers will turn to short-term health plans, health care cost-sharing ministries, and other forms of coverage that do not have the benefits or protections of the health law, she said.
"These are plans that don't provide coverage for prescription drugs, or they have lifetime and annual limits," she said. "For a cancer patient, those plans don't work."
Though the enhanced subsidies do not expire until the end of the year, the Blue Cross Blue Shield Association would prefer Congress to act by fall to avoid confusion during open enrollment, said David Merritt, a senior vice president. Insurers are preparing rates to meet state deadlines. By October, consumers will receive 60-day plan renewal notices with their 2026 premiums.
Without enhanced subsidies, Merritt said, competition in the marketplace will wither, leading to fewer coverage options and higher prices, especially in states that have not expanded Medicaid eligibility and where Obamacare enrollment spiked during the past four years, like Florida and Texas. "Voters and patients are really going to see the impact," he said.
Republican and Democratic representatives for some of the Florida congressional districts with the highest numbers of people in the marketplace did not respond to repeated interview requests.
Muralles, of North Miami, Florida, said she wants her representatives to work in the interest of constituents like herself, who need health insurance coverage to care for their families.
"Now is the time to prove to us that they are with us," Muralles said. "When everybody's healthy, everybody goes to work, everybody can pay taxes, everybody can have a better life."
Nearly two-thirds of adults oppose President Donald Trump's "One Big Beautiful Bill" approved in May by the House of Representatives, according to a KFF poll released Tuesday.
And even Trump's most ardent supporters like the legislation a lot less when they learn how it would cut federal spending on health programs, the poll shows.
The KFF poll found that about 61% of Republicans and Republican-leaning independents — and 72% of the subset who identify with Trump's "Make American Great Again" movement — support the bill, which would extend many of Trump's 2017 tax cuts while reducing spending on domestic programs, including cutting billions from Medicaid.
But when pollsters told survey respondents about the bill's consequences for health care, opposition grew, including among MAGA supporters.
For example, after being told that the bill would decrease funding for local hospitals and increase the number of people without health insurance, support among those who back MAGA dropped more than 20 percentage points — resulting in fewer than half the group still backing the bill.
Ashley Kirzinger, KFF's director of survey methodology and associate director of its Public Opinion and Survey Research program, said it's no surprise polling shows that party affiliation affects how most of the public views the bill.
"But the poll shows that support, even among MAGA supporters, drops drastically once the public hears more about how the bill could impact local hospitals and reduce Medicaid coverage," she said.
"This shows how the partisan lens wears slightly when the public learns more about how the legislation could affect them and their families."
KFF is a health policy research, polling, and news organization that includes KFF Health News.
House Speaker Mike Johnson, a Louisiana Republican who won passage of the legislation in the chamber he controls by a single vote on May 22, has insisted the bill would not "cut Medicaid." The nonpartisan Congressional Budget Office, which calculates the effects of legislation on the nation's deficits and debt, says the measure would reduce federal spending on Medicaid by $793 billion over 10 years, resulting in nearly 8 million more people becoming uninsured.
The bill is encountering strident opposition from the health industry, most notably hospitals that expect to see large cuts in funding as a result of millions of people losing Medicaid coverage. The House-passed legislation would increase the frequency of eligibility checks and require that most nondisabled adults regularly prove they are working, studying, or volunteering at least 80 hours a month to keep their coverage.
"This is common sense," Johnson said May 25 on the CBS News program "Face the Nation." "And when the American people understand what we are doing here, they applaud it."
Critics say the bill marks the latest attempt by Republicans to roll back the Affordable Care Act.
As the Senate moves toward a possible vote on its version of the legislation before Independence Day, the KFF poll shows Medicaid and the ACA are more popular than ever.
About 83% of adults support Medicaid, including large majorities of Democrats (93%), independents (83%), and Republicans (74%). That's up from 77% in January, with the poll finding the biggest jump in favorability among Republicans.
Medicaid and the related Children's Health Insurance Program cover about 78 million people who are disabled or have low incomes.
About two-thirds of adults hold favorable views of the ACA, the most since the law's enactment in 2010, as recorded in KFF polls. The law has only been consistently popular with a majority of adults since about 2021.
Views of the ACA remain split along partisan lines, with most Republicans (63%) holding unfavorable views and most Democrats (94%) and independents (71%) viewing it favorably.
The poll found other indications that the public may not understand key provisions of the GOP bill, including its work requirements.
The poll finds two-thirds of the public — including the vast majority of Republicans (88%) and MAGA supporters (93%) and half (51%) of Democrats — initially support requiring nearly all adults on Medicaid to prove they are working or looking for work, in school, or doing community service, with exceptions such as for caregivers and people with disabilities.
However, attitudes toward this provision shifted dramatically when respondents were presented with more information.
For example, when told most adults with Medicaid are already working or unable to work, and that those individuals could lose coverage due to the challenge of documenting it, about half of supporters changed their view, resulting in nearly two-thirds of adults opposing Medicaid work requirements and about a third supporting them.
The poll of 1,321 adults was conducted online and by telephone June 4-8 and has a margin of error of plus or minus 3 percentage points.
BRIDGEPORT, W.Va. — By the time Eric Tennant was diagnosed in 2023 with a rare cancer of the bile ducts, the disease had spread to his bones. He weighed 97 pounds and wasn't expected to survive a year with stage 4 cancer.
Two years later, grueling rounds of chemotherapy have slowed the cancer's progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant's body and his quality of life.
Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.
Early this year, Tennant's oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that's when his family began fighting another adversary: their health insurer, which decided the treatment was "not medically necessary," according to insurance paperwork.
For months, Eric Tennant's health insurance refused to cover a cancer treatment recommended by his doctor, claiming the procedure was "not medically necessary," a common reason used by health insurers to deny care. (A portion of this photo is digitally blurred to protect patient privacy.)(NBC News)
Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they've never met who may lack relevant training.
Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by KFF Health News and NBC News found.
When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn't cover it, they appealed the denial four times.
"It's a big mess," said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.
"There's literally nothing we can do to get them to change," she said in an April interview with KFF Health News. "They're, like, not accountable to anyone."
While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.
"You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment," Pickern said. Yet, once the news cycle died down, "everything went back to the status quo."
An Unintended Consequence of Health Reform?
Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.
The practice isn't new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a 2024 U.S. Senate report. By denying costly care, companies pay less for health care expenses while still collecting premiums.
For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.
But the use of prior authorization has also increased in recent years. That's partly due to the growth of enrollment in Medicare Advantage plans, which rely heavily on prior authorization compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.
"But we can't really prove this," said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes KFF Health News. Health insurers haven't been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.
Meanwhile, many states are looking to overhaul the prior authorization process.
In March, Virginia passed a law that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient's provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.
And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.
Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.
These changes were supported by AHIP, a trade group that represents health insurers.
'Sick With Little Recourse'
But the new federal rules won't prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.
For some patients, the stakes couldn't be higher.
On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It's used to treat breast cancer but has shown promise in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.
But Schrift's insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.
In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.
Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer's decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.
"Never in a million years did I think I'd end up here," Ekirch said, "sick with little recourse."
Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, introduced a bill that would eliminate prior authorization altogether. But history suggests that would create new problems.
When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department's costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General's Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.
What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.
On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.
On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.
Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.
Hall said that after he was forced to "step down" to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company's coverage limits set his recovery back by months — and, ironically, cost the insurer more. His wife, Julie, estimated Jeff's medical bills have exceeded $5 million, and most of his care has been covered by his insurer.
"Getting better is not always the goal of an insurance company. It's a business," Jeff Hall said. "They don't care."
In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands "it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment." He encouraged members affected by coverage limits to contact their health care providers to "explore service and treatment options."
A 'Rare and Exceptional' Reversal
Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric's prognosis.
They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.
As a safety instructor with the West Virginia Office of Miners' Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia's Public Employees Insurance Agency.
As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer's decision in March, citing that histotripsy is "unproven in this case and is not medically necessary."
None of their appeals worked. After KFF Health News and NBC News reached out to West Virginia's Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.
"This decision reflects a rare and exceptional situation" and does not represent a change in the Public Employees Insurance Agency's overall coverage policies," Director Brent Wolfingbarger said in a prepared statement to KFF Health News.
In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with "anyone navigating through life-threatening care decisions."
"Currently, there is no evidence that histotripsy is as effective as alternative treatment options available," he said in late May, after the earlier insurance denials were reversed, "and its impact on survival or cancer recurrence is unknown."
MES Peer Review Services did not respond to a request for an interview.
Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.
Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband's insurance plan for wasting months of their time.
"Time is precious," she said. "They know he has stage 4 cancer, and it's almost like they don't care if he lives or dies."
NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.
Major changes could be in store for the more than 24 million people with health coverage under the Affordable Care Act, including how and when they can enroll, the paperwork required, and, crucially, the premiums they pay.
A driver behind these changes is the "One Big Beautiful Bill," the name given to spending and tax legislation designed to advance the policy agenda of President Donald Trump. It passed the House on May 22 and is pending in the Senate.
Combined, the moves by Trump and his allies could "devastate access" to ACA plans, said Katie Keith, director of the Center for Health Policy and the Law at the O'Neill Institute, a health policy research group at Georgetown University.
States that run their own Obamacare marketplaces and the National Association of Insurance Commissioners have also raised concerns about added costs and reduced access. But House Republicans and some conservative think tanks say the ACA needs revamping to rein in fraud, part of which they pin on certain Biden administration changes the measures would undo.
Senate Republicans must now weigh whether to include the House's proposals in their own bill, with the aim of getting it through the chamber by July 4.
Here are four key ways Trump's policies could undermine Obamacare enrollment and coverage.
More than 90% of ACA enrollees receive tax credits to defray monthly premiums for their coverage. There are two key provisions for them to watch.
One would end automatic reenrollment for most ACA policyholders each year. More than 10 million people were automatically reenrolled in their coverage for the 2025 plan year, with their eligibility for tax credits confirmed via a system that allows ACA marketplaces to check government or other data sources.
The House bill would instead require every new or returning policyholder each year to provide information on income, household size, immigration status, and other factors, starting in 2028. If they don't, they won't get a premium tax credit, which could put the price of coverage out of reach.
"Everyone who wants to either purchase or renew a marketplace plan will have to come with a shoebox filled with documents, scan in and upload them or mail them in, and sit and wait while someone reviews and confirms them," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
She and other policy experts fear that many consumers will become uninsured because they don't understand the requirements or find them burdensome. If too many young and healthy people, for example, decide it's not worth the hassle, that could leave more older and sicker people for ACA insurers to cover — potentially raising premiums for everyone.
But supporters of the House bill say the current approach needs changing because it is vulnerable to waste, fraud, and abuse.
"This would ensure that enrollees need to return to the exchange to update their information and obtain an updated eligibility determination for a subsidy — best protecting the public against excess subsidies paid to insurers that can never be recovered," the conservative Paragon Institute wrote in an April letter to top Department of Health and Human Services officials.
Having a Baby? Getting Married? Expect Coverage Delays
Today, people who experience life changes — losing a job, getting married or divorced, or having a baby, for instance — are considered provisionally eligible for tax credits to reduce their premiums if they sign up or change their ACA plans. That means they would be eligible to receive these subsidies for at least 90 days while their applications are checked against government data or other sources, or marketplaces follow up with requests for additional information.
The House bill would end that, requiring documentation before receiving tax credits. That could create particular hardship for new parents, who can't confirm that babies are eligible for premium subsidies until they receive Social Security numbers weeks after they're born.
Policy experts following the debate "did not expect the end to provisional eligibility," Corlette said. "I don't know what the reaction in the Senate will be, as I'm not sure everyone understands the full implications of these provisions because they are so new."
It can take up to six weeks for the Social Security Administration to process a number for a newborn, and an additional two weeks for parents to get the card, according to a white paper that analyzed provisions of the House bill and was co-authored by Jason Levitis, a senior fellow at the Urban Institute, and Christen Linke Young, a visiting fellow with Brookings' Center on Health Policy.
Without a Social Security number, any application to add a newborn to an ACA policy would automatically generate a hold on premium tax credits for that family, they wrote — increasing their out-of-pocket costs, at least temporarily.
"It puts consumers on the hook for any delays the marketplace is taking," while the Centers for Medicare & Medicaid Services, which administers the ACA marketplaces, "is cutting staff and adding a lot more paperwork to burden the staff they have," Levitis said.
Provisions in the House bill that would require ACA enrollees to provide information each year that they reenroll — or when seeking to add or change a policy due to a life circumstance — would increase the number of people without health insurance by 700,000 in 2034, according to the latest CBO estimate.
Less Time To Sign Up
The House bill would turn into law a Trump proposal to shorten the ACA open enrollment period. The start date would continue to be Nov. 1. But the window would be shortened by about a month, with an end date of Dec. 15. This affects people in states that use the federal marketplace as well as the 19 states and the District of Columbia that run their own, most of which offer open enrollment into at least mid-January.
Also, as soon as the end of this year, a special enrollment period the Biden administration created would be done away with. It allowed people with lower incomes — those who earn up to 1.5 times the 2024 federal poverty level, or about $38,730 for a family of three — to sign up anytime during the year.
Critics, including the Paragon Institute, argue that this enrollment opening led to fraud, partly blaming it for a steep increase last year in instances of insurance agents seeking commissions by enrolling or switching consumers into plans without their consent, or fudging their incomes to qualify them for tax credits so large they paid no monthly premiums at all.
But supporters — including some states that run their own ACA exchange — say there are other ways to address fraud.
"We anticipate that much of the improper activity can be prevented by security and integrity upgrades to the federal marketplace, which we understand the Centers for Medicare and Medicaid Services (CMS) is implementing," the National Association of Insurance Commissioners wrote in a May 29 letter to congressional leaders.
Premiums and Out-of-Pocket Costs Will Likely Increase
The reason? Enhanced tax credits created during the pandemic expire at the end of the year. The House bill doesn't extend them. Those more generous payments are credited with helping double ACA enrollment since 2020.
The CBO estimates that extending the subsidies would cost $335 billion over 10 years. The House bill instead funds an extension of Trump's tax cuts, which largely benefit wealthier families.
If the enhanced credits are allowed to expire, not only would premium subsidies be smaller for many people, but there would also be an abrupt eligibility cutoff — an income cliff — for households above four times the federal poverty rate, or about $103,280 for a family of three for this plan year.
Taking into account the smaller subsidies and the cliff, KFF estimates a national average premium increase of 75% for enrollees if the enhanced subsidies expire. The CBO expects that about 4.2 million more people will be uninsured in 2034 as a result.
Responding to charges that President Donald Trump's tax and spending bill would cut Medicaid coverage for millions of Americans, Trump administration officials misleadingly counter that it targets only waste, fraud, and abuse.
During an interview on CNN's "State of the Union," Russell Vought, the administration's director of the Office of Management and Budget, framed Medicaid as sagging under the weight of improper payments.
An "improper" payment refers to payments made erroneously to beneficiaries and their providers or without sufficient documentation.
Pressed June 1 by CNN host Dana Bash about concerns that low-income Americans would suffer if the bill becomes law, Vought called such arguments "totally ridiculous."
"This bill will preserve and protect the programs, the social safety net, but it will make it much more commonsense," Vought said. "Look, one out of every $5 or $6 in Medicaid [payments] is improper."
That would mean Medicaid's improper payment rate is 16% to 20%.
In a 2024 report covering the years 2022, 2023, and 2024, Medicaid's parent agency — the Centers for Medicare & Medicaid Services — said the rate was about 5.1%.
One conservative group, the Paragon Health Institute, said the agency has been using an incomplete calculation method and that the percentage could be as high as 25%. Other experts told PolitiFact that the actual numbers could be higher than what the federal government reports, although not as high as Paragon's estimate.
The White House did not respond to an inquiry for this article.
How High Is the Medicaid Improper Payment Rate?
Medicaid and its closely related Children's Health Insurance program provides health care and long-term care to roughly 83 million lower-income beneficiaries, accounting for about one-fifth of health care spending overall. It is funded through a mix of federal and state money and is administered by states under federal government rules.
Every year, the Centers for Medicare & Medicaid Services publishes official numbers for the share of improper Medicaid payments, and in other federal health insurance programs the agency oversees.
In a 2024 review of payments made in 2022, 2023, and 2024, the agency found that 5.09% of Medicaid payments totaling $31.10 billion were improper.
The 5.09% rate represented a decrease from the 8.58% rate cited in its 2023 report, which was also based on a three-year time span. The 2024 figure represented the third consecutive annual decline.
Are These Numbers Complete?
In March 2025, Brian Blase, a conservative health policy analyst and president of Paragon Health, a health policy think tank, co-authored a report that said the official CMS improper payment rate figures were unrealistically low for eight of the past 10 years, because in some years the agency failed to undergo widespread auditing of its beneficiaries' Medicaid eligibility.
From 2017 to 2019, during Trump's first term, Blase served as Trump's special assistant for economic policy. Before that, he served as a health policy analyst for the Senate Republican Policy Committee and has worked for the Heritage Foundation, a conservative think tank.
The report said if the agency's analysis had looked at eligibility checks every year, more ineligible beneficiaries and payments on their behalf would have been discovered. The report said this might have increased the improper payment rate as high as 25%, based on the rates found in 2020 and 2021, when a high number of eligibility checks were included in the agency's methodology.
However, it's hard to confirm whether lack of eligibility auditing caused higher improper payment rates in 2020 and 2021, said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, a liberal think tank.
Wagner said Medicaid enrollment procedures have fluctuated, which could help explain the higher rates in some years rather than others. Using two years of data to generalize about trends across a decade, she said, is not necessarily valid.
Robert Westbrooks, the federal Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, told PolitiFact it's plausible that the officially reported improper payment rates for Medicaid could be too low.
However, Westbrooks said pinpointing how much higher the rate is in reality is a speculative process. "I don't believe anyone can credibly quantify the [difference]," he said.
What Is an Improper Payment?
Health care experts emphasized that improper payments are not the same thing as waste, fraud, or abuse.
Fraud: "When someone knowingly deceives, conceals, or misrepresents to obtain money or property from any health care benefit program."
Waste: "Overusing services or other practices that directly or indirectly result in unnecessary costs to any health care benefit program. Examples of waste are conducting excessive office visits, prescribing more medications than necessary, and ordering excessive laboratory tests."
Abuse: "When health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program," which can include overbilling or misusing billing codes.
By contrast, an improper payment "includes any payment to an ineligible recipient, any payment for an ineligible good or service, any duplicate payment, any payment for a good or service not received, and any payment that does not account for credit for applicable discounts," KFF, a health information nonprofit that includes KFF Health News, wrote this year.
"Although all fraudulent payments are improper, not all improper payments are fraudulent," said Jessica Tillipman, associate dean for government procurement law at George Washington University's law school. "Most providers identify the improper payments and return them knowing how aggressively enforced" the legal provisions are. "When they don't, they open the door to significant liability."
This typically involved cases in which a state or provider missed an administrative step, and it did not necessarily indicate fraud or abuse, the agency said. Instead, it could be an accidental oversight or mistake.
In other words, it was rare for ordinary beneficiaries to be scamming the government. "The vast majority of fraud in Medicaid is committed by providers or other actors, not enrollees," Wagner said.
Our Ruling
Vought said that "one out of every $5 or $6 in Medicaid [payments] is improper."
The official improper payment rate calculated by the Centers for Medicare & Medicaid Services in 2024 was about 5%, smaller than the 16% to 20% rate Vought described.
A health policy analyst and former Trump adviser said methodological shortcomings in the agency's analysis could mean the rate is as high as 25%. Although it's possible the rate is higher than the 5% the government reported, how much higher is speculative.
The statement contains an element of truth but ignores critical facts, namely the federal government's own data. We rate the statement Mostly False.
Email interviews with Tammie Smith and Craig Palosky, spokespersons for KFF, June 2, 2025.
Email interview with Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities.
Email interview with Jessica Tillipman, associate dean for government procurement law at George Washington University's law school, June 3, 2025.
Email interview with Robert Westbrooks, Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, June 3, 2025.
