Physician groups warn it will raise payment issues and other significant logistical problems.

This article was published on Thursday, March 20, 2025 in KFF Health News.

By Michelle Andrews

The routine is familiar for most people: When checking in for an appointment with a doctor or other health care provider, patients typically complete and sign a pile of paperwork, including a form that contains some version of the statement, "I agree to pay for all charges not covered by my insurance company."

Patients may not feel comfortable making that financial promise, often before they have any idea what the charges will be. But they generally sign the form anyway, because the alternative is often not to get the services they're seeking.

As a result, consumers may be responsible for unexpected bills and at risk for medical debt.

In New York, state officials, advocates, and the health care provider community have been engaged in a policy tug-of-war over efforts to protect consumers. Their advocates don't want them to get stuck signing "blank check" forms that put them in financial jeopardy. Doctors, hospitals, and other providers don't want to disrupt their practices' workflow and payment logistics with cost discussions and paperwork, especially after services have been provided. State officials' efforts to find a satisfying compromise have so far fallen short.

At the center is a state law that took effect last fall to prohibit requiring patients to sign such consent-to-pay forms before they've received treatment and discussed the costs.

Legal analysts described it as the first such law in the country. Physician groups cried foul, saying it would raise payment issues and other significant logistical problems.

Those concerns found traction. Shortly before the law's start date, the state's Department of Health delayed its implementation indefinitely. In addition, Democratic Gov. Kathy Hochul's proposed fiscal year 2026 budget would let providers go back to requiring patients to agree to pay for care in advance of receiving treatment. It also clarified that the consent requirements would not apply to emergency care.

A key provision of the new law would remain in place, however: Doctors and other providers would still be obligated to have the cost discussion with patients before the patient is asked to sign the form agreeing to pay for the service. Some consider this a significant step.

"Providers having an affirmative obligation to discuss treatment costs is unique," said Gregory Mitchell, a partner in the health and life sciences practice group at McDermott Will & Emery law firm who specializes in managed care. Clients from around the country have been reaching out to the law firm with questions.

Requiring providers to discuss costs with patients, whether before or after services are provided, would pose a "significant burden," he said. Doctors and other providers typically don't know specifics about patient deductibles, cost sharing, or other insurance coverage details until after a claim is submitted to a health plan.

Health care services are different than refrigerators or other goods that people buy, doctors say. If a patient gets a colonoscopy and doesn't want to pay for it, "it's not possible to take the service back," said Jerome Cohen, a gastroenterologist and the president of the Medical Society of the State of New York, which represents physicians. As for the proposed changes in the 2026 budget, Cohen said the medical society "very much appreciates the governor's efforts to try to fix this problematic financial consent requirement."

But patient advocates are pushing back. The current practice is "unfair and it's wrong," said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit that has successfully pushed for passage of several medical debt-related laws in recent years. No patient should ever have to preemptively agree to pay whatever a provider charges, Benjamin said.

In a written response to questions, Danielle De Souza, a spokesperson for the state Department of Health, said that the proposed law change is justified, "given the burden of this requirement on both patients and providers." De Souza didn't respond to a request for clarification about what those patient burdens are.

Helen Krim walked out of a doctor's office in the Bronx borough of New York City a few years ago rather than sign an open-ended form agreeing to pay for any services recommended by the doctor.

It was the first time that Krim, who is covered by Medicare, had visited that primary care practice. When she told them she didn't want to sign the form, she was told they wouldn't serve her unless she did.

"I'm one of those annoying people who actually reads the forms," the retired bank project manager said. "It's kind of like signing a consent to be scammed." She found another practice that didn't ask her to sign a similar form.

There are other consumer medical debt protections at the federal and state level. The federal No Surprises Act restricts providers from billing consumers for out-of-network services in certain instances. It also requires providers to give good-faith cost estimates for self-pay patients. The Consumer Financial Protection Bureau released a final rule in January that would have removed medical debt from people's credit reports, but the rule's implementation has been frozen by the Trump administration. Several states besides New York have also taken steps to protect consumers with medical debt.

Benjamin said that simply requiring an unspecified "discussion" about costs doesn't address patients' potential unlimited financial liability. Under a bill that Benjamin's organization has drafted, providers would have to give patients a written good-faith estimate of their expected costs before the patient receives services and patients could not be held liable for unlimited or unspecified costs beyond that estimate.

"Let's be the first state to really have fair rules of engagement for both the providers and the patients about what is it that you're agreeing to be financially liable for at the point, beforehand," Benjamin said.

The measure was introduced in the Senate this month.

Providers are taking a wait-and-see attitude, Mitchell said, because the budget plan must still move through the legislative process.

Another New York medical debt-related law that took effect in October takes aim at the use of credit cards to pay for medical services. The Hochul administration has not proposed changing it. The law prohibits providers from requiring pre-authorization of credit cards or keeping a patient's card on file. It also requires providers to notify patients of the risks of paying for medical care with credit cards, which may lack medical debt protections. In addition, providers aren't allowed to help patients complete credit card applications under the law.

The laws are aimed at stopping unfair billing practices and reducing medical debt for New Yorkers. Earlier laws ban credit reporting of all medical debt and prohibit hospitals from suing patients with incomes under 400% of the poverty level, among other things.

New York providers don't like the credit card law either, though it hasn't generated the pushback seen with the consent-to-pay law.

In a statement, Brian Conway, a spokesperson for the Greater New York Hospital Association, said, "It's important to clarify that hospitals do not oppose the goals of the hospital financial assistance law reforms overall, but rather the operational burdens and patient disclosure overload that a few specific provisions create."

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

At-Risk Intervention and Mentoring program supports gun-violence patients and their families at the hospital.

This article was published on Thursday, March 13, 2024 in KFF Health News.

By Stephanie Wolf

DENVER — Seven years ago, Erica Green learned through a Facebook post that her brother had been shot.

She rushed to check on him at a hospital run by Denver Health, the city's safety-net system, but she was unable to get information from emergency room workers, who complained that she was creating a disturbance.

"I was distraught and outside, crying, and Jerry came out of the front doors," she said.

Jerry Morgan is a familiar face from Green's Denver neighborhood. He had rushed to the hospital after his pager alerted him to the shooting. As a violence prevention professional with the At-Risk Intervention and Mentoring program, or AIM, Morgan supports gun-violence patients and their families at the hospital — as he did the day Green's brother was shot.

"It made the situation of that traumatic experience so much better. After that, I was, like, I want to do this work," Green said.

Today, Green works with Morgan as the program manager for AIM, a hospital-linked violence intervention program launched in 2010 as a partnership between Denver Health and the nonprofit Denver Youth Program. It since has expanded to include Children's Hospital Colorado and the University of Colorado Hospital.

AIM is one of dozens of hospital-linked violence intervention programs around the country. The programs aim to uncover the social and economic factors that contributed to someone ending up in the ER with a bullet wound: inadequate housing, job loss, or feeling unsafe in one's neighborhood, for example.

Such programs that take a public health approach to stopping gun violence have had success — one in San Francisco reported a fourfold reduction in violent injury recidivism rates over six years. But President Donald Trump's executive orders calling for the review of the Biden administration's gun policies and trillions of dollars in federal grants and loans have created uncertainty around the programs' long-term federal funding. Some organizers believe their programs will be just fine, but others are looking to shore up alternative funding sources.

"We've been worried about, if a domino does fall, how is it going to impact us? There's a lot of unknowns," said John Torres, associate director for Youth Alive, an Oakland, California-based nonprofit.

Federal data shows that gun violence became a leading cause of death among children and young adults at the start of this decade and was tied to more than 48,000 deaths among people of all ages in 2022. New York-based pediatric trauma surgeon Chethan Sathya, a National Institutes of Health-funded firearms injury prevention researcher, believes those statistics show that gun violence can't be ignored as a health care issue. "It's killing so many people," Sathya said.

Research shows that a violent injury puts someone at heightened risk for future ones, and the risk of death goes up significantly by the third violent injury, according to a 2006 study published in The Journal of Trauma: Injury, Infection and Critical Care.

Benjamin Li, an emergency medicine physician at Denver Health and the health system's AIM medical director, said the ER is an ideal setting to intervene in gun violence by working to reverse-engineer what led to a patient's injuries.

"If you are just seeing the person, patching them up, and then sending them right back into the exact same circumstances, we know it's going to lead to them being hurt again," Li said. "It's critical we address the social determinants of health and then try to change the equation."

That might mean providing alternative solutions to gunshot victims who might otherwise seek retaliation, said Paris Davis, the intervention programs director for Youth Alive.

"If that's helping them relocate out of the area, if that's allowing them to gain housing, if that's shifting that energy into education or job or, you know, family therapy, whatever the needs are for that particular case and individual, that is what we provide," Davis said.

AIM outreach workers meet gunshot wound victims at their hospital bedsides to have what Morgan, AIM's lead outreach worker, calls a tough, nonjudgmental conversation on how the patients ended up there.

AIM uses that information to help patients access the resources they need to navigate their biggest challenges after they're discharged, Morgan said. Those challenges can include returning to school or work, or finding housing. AIM outreach workers might also attend court proceedings and assist with transportation to health care appointments.

"We try to help in whatever capacity we can, but it's interdependent on whatever the client needs," Morgan said.

Since 2010, AIM has grown from three full-time outreach workers to nine, and this year opened the REACH Clinic in Denver's Five Points neighborhood. The community-based clinic provides wound-care kits; physical therapy; and behavioral, mental and occupational health care. In the coming months, it plans to add bullet removal to its services. It's part of a growing movement of community-based clinics focused on violent injuries, including the Bullet Related Injury Clinic in St. Louis.

Ginny McCarthy, an assistant professor in the Department of Surgery at the University of Colorado, described REACH as an extension of the hospital-based work, providing holistic treatment in a single location and building trust between health care providers and communities of color that have historically experienced racial biases in medical care.

Caught in the Crossfire, created in 1994 and run by Youth Alive in Oakland, is cited as the nation's first hospital-linked violence intervention program and has since inspired others. The Health Alliance for Violence Intervention, a national network initiated by Youth ALIVE to advance public health solutions to gun violence, counted 74 hospital-linked violence intervention programs among its membership as of January.

The alliance's executive director, Fatimah Loren Dreier, compared medicine's role in addressing gun violence to that of preventing an infectious disease, like cholera. "That disease spreads if you don't have good sanitation in places where people aggregate," she said.

Dreier, who also serves as executive director of the Kaiser Permanente Center for Gun Violence Research and Education, said medicine identifies and tracks patterns that lead to the spread of a disease or, in this case, the spread of violence.

"That is what health care can do really well to shift society. When we deploy this, we get better outcomes for everybody," Dreier said.

The alliance, of which AIM is a member, offers technical assistance and training for hospital-linked violence intervention programs and successfully petitioned to make their services eligible for traditional insurance reimbursement.

In 2021, President Joe Biden issued an executive action that opened the door for states to use Medicaid for violence prevention. Several states, including California, New York, and Colorado, have passed legislation establishing a Medicaid benefit for hospital-linked violence intervention programs.

Last summer, then-U.S. Surgeon General Vivek Murthy declared gun violence a public health crisis, and the 2022 Bipartisan Safer Communities Act earmarked $1.4 billion in funding for a wide array of violence-prevention programs through next year.

But in early February, Trump issued an executive order instructing the U.S. attorney general to conduct a 30-day review of a number of Biden's policies on gun violence. The White House Office of Gun Violence Prevention now appears to be defunct, and recent moves to freeze federal grants created uncertainty among the gun-violence prevention programs that receive federal funding.

AIM receives 30% of its funding from its operating agreement with Denver's Office of Community Violence Solutions, according to Li. The rest is from grants, including Victims of Crime Act funding, through the Department of Justice. As of mid-February, Trump's executive orders had not affected AIM's current funding.

Some who work with the hospital-linked violence prevention programs in Colorado are hoping a new voter-approved firearms and ammunition excise tax in the state, expected to generate about $39 million annually and support victim services, could be a new source of funding. But the tax's revenues aren't expected to fully flow until 2026, and it's not clear how that money will be allocated.

Trauma surgeon and public health researcher Catherine Velopulos, who is the AIM medical director at the University of Colorado hospital in Aurora, said any interruption in federal funding, even for a few months, would be "very difficult for us." But Velopulos said she was reassured by the bipartisan support for the kind of work AIM does.

"People want to oversimplify the problem and just say, ‘If we get rid of guns, it's all going to stop,' or ‘It doesn't matter what we do, because they're going to get guns, anyway,'" she said. "What we really have to address is why people feel so scared that they have to arm themselves."

UMass Chan Medical School in Worcester, Mass. is testing the concept of 'SNF at home'

This article was published on Wednesday, March 12, 2025 in KFF Health News.

By Felice J. Freyer

After a patch of ice sent Marc Durocher hurtling to the ground, and doctors at UMass Memorial Medical Center repaired the broken hip that resulted, the 75-year-old electrician found himself at a crossroads.

He didn't need to be in the hospital any longer. But he was still in pain, unsteady on his feet, unready for independence.

Patients nationwide often stall at this intersection, stuck in the hospital for days or weeks because nursing homes and physical rehabilitation facilities are full. Yet when Durocher was ready for discharge in late January, a clinician came by with a surprising path forward: Want to go home?

Specifically, he was invited to join a research study at UMass Chan Medical School in Worcester, Massachusetts, testing the concept of "SNF at home" or "subacute at home," in which services typically provided at a skilled nursing facility are instead offered in the home, with visits from caregivers and remote monitoring technology.

Durocher hesitated, worried he might not get the care he needed, but he and his wife, Jeanne, ultimately decided to try it. What could be better than recovering at his home in Auburn with his dog, Buddy?

Such rehab at home is underway in various parts of the country — including New York, Pennsylvania, and Wisconsin — as a solution to a shortage of nursing home and rehab beds for patients too sick to go home but not sick enough to need hospitalization.

Staffing shortages at post-acute facilities around the country led to a 24% increase over three years in hospital length of stay among patients who need skilled nursing care, according to a 2022 analysis. With no place to go, these patients occupy expensive hospital beds they don't need, while others wait in emergency rooms for those spots. In Massachusetts, for example, at least 1,995 patients were awaiting hospital discharge in December, according to a survey of hospitals by the Massachusetts Health & Hospital Association.

Offering intensive services and remote monitoring technology in the home can work as an alternative — especially in rural areas, where nursing homes are closing at a faster rate than in cities and patients' relatives often must travel far to visit. For patients of the Marshfield Clinic Health System who live in rural parts of Wisconsin, the clinic's six-year-old SNF-at-home program is often the only option, said Swetha Gudibanda, medical director of the hospital-at-home program.

"This is going to be the future of medicine," Gudibanda said.

But the concept is new, an outgrowth of hospital-at-home services expanded by a covid-19 pandemic-inspired Medicare waiver. SNF-at-home care remains uncommon, lost in a fiscal and regulatory netherworld. No federal standards spell out how to run these programs, which patients should qualify, or what services to offer. No reimbursement mechanism exists, so fee-for-service Medicare and most insurance companies don't cover such care at home.

The programs have emerged only at a few hospital systems with their own insurance companies (like the Marshfield Clinic) or those that arrange for "bundled payments," in which providers receive a set fee to manage an episode of care, as can occur with Medicare Advantage plans.

In Durocher's case, the care was available — at no cost to him or other patients — only through the clinical trial, funded by a grant from the state Medicaid program. State health officials supported two simultaneous studies at UMass and Mass General Brigham hoping to reduce costs, improve quality of care, and, crucially, make it easier to transition patients out of the hospital.

The American Health Care Association, the trade group of for-profit nursing homes, calls "SNF at home" a misnomer because, by law, such services must be provided in an institution and meet detailed requirements. And the association points out that skilled nursing facilities provide services and socialization that can never be replicated at home, such as daily activity programs, religious services, and access to social workers.

But patients at home tend to get up and move around more than those in a facility, speeding their recovery, said Wendy Mitchell, medical director of the UMass Chan clinical trial. Also, therapy is tailored to their home environment, teaching patients to navigate the exact stairs and bathrooms they'll eventually use on their own.

A quarter of people who go into nursing homes suffer an "adverse event," such as infection or bed sore, said David Levine, clinical director for research for Mass General Brigham's Healthcare at Home program and leader of its study. "We cause a lot of harm in facility-based care," he said.

By contrast, in 2024, not one patient in the Rehabilitation Care at Home program of Nashville-based Contessa Health developed a bed sore and only 0.3% came down with an infection while at home, according to internal company data. Contessa delivers care in the home through partnerships with five health systems, including Mount Sinai Health System in New York City, the Allegheny Health Network in Pennsylvania, and Wisconsin's Marshfield Clinic.

Contessa's program, which has been providing in-home post-hospital rehabilitation since 2019, depends on help from unpaid family caregivers. "Almost universally, our patients have somebody living with them," said Robert Moskowitz, Contessa's acting president and chief medical officer.

The two Massachusetts-based studies, however, do enroll patients who live alone. In the UMass trial, an overnight home health aide can stay for a day or two if needed. And while alone, patients "have a single-button access to a live person from our command center," said Apurv Soni, an assistant professor of medicine at UMass Chan and the leader of its study.

But SNF at home is not without hazards, and choosing the right patients to enroll is critical. The UMass research team learned an important lesson when a patient with mild dementia became alarmed by unfamiliar caregivers coming to her home. She was readmitted to the hospital, according to Mitchell.

The Mass General Brigham study relies heavily on technology intended to reduce the need for highly skilled staff. A nurse and physician each conducts an in-home visit, but the patient is otherwise monitored remotely. Medical assistants visit the home to gather data with a portable ultrasound, portable X-ray, and a device that can analyze blood tests on-site. A machine the size of a toaster oven dispenses medication, with a robotic arm that drops the pills into a dispensing unit.

The UMass trial, the one Durocher enrolled in, instead chose a "light touch" with technology, using only a few devices, Soni said.

The day Durocher went home, he said, a nurse met him there and showed him how to use a wireless blood pressure cuff, wireless pulse oximeter, and digital tablet that would transmit his vital signs twice a day. Over the next few days, he said, nurses came by to take blood samples and check on him. Physical and occupational therapists provided several hours of treatment every day, and a home health aide came a few hours a day. To his delight, the program even sent three meals a day.

Durocher learned to use the walker and how to get up the stairs to his bedroom with one crutch and support from his wife. After just one week, he transitioned to less-frequent, in-home physical therapy, covered by his insurance.

"The recovery is amazing because you're in your own setting," Durocher said. "To be relegated to a chair and a walker, and at first somebody helping you get up, or into bed, showering you — it's very humbling. But it's comfortable. It's home, right?"

These underserved people tend to live sicker and die younger than others in America.

This article was published on Monday, March 10, 2025 in KFF Health News.

By Sarah Jane Tribble and Holly K. Hacker

BOLIGEE, Ala. — Green lights flickered on the wireless router in Barbara Williams' kitchen. Just one bar lit up — a weak signal connecting her to the world beyond her home in the Alabama Black Belt.

Next to the router sat medications, vitamin D pills, and Williams' blood glucose monitor kit.

"I haven't used that thing in a month or so," said Williams, 72, waving toward the kit. Diagnosed with diabetes more than six years ago, she has developed nerve pain from neuropathy in both legs.

Williams is one of nearly 3 million Americans who live in mostly rural counties that lack both health care and reliable high-speed internet, according to an analysis by KFF Health News, which showed that these people tend to live sicker and die younger than others in America.

Compared with those in other regions, patients across the rural South, Appalachia, and remote West are most often unable to make a video call to their doctor or log into their patient portals. Both are essential ways to participate in the U.S. medical system. And Williams is among those who can do neither.

This year, more than $42 billion allocated in the 2021 Infrastructure Investment and Jobs Act is expected to begin flowing to states as part of a national "Internet for All" initiative launched by the Biden administration. But the program faces uncertainty after Commerce Department Secretary Howard Lutnick last week announced a "rigorous review" asserting that the previous administration's approach was full of "woke mandates."

High rates of chronic illness and historical inequities are hallmarks of many of the more than 200 U.S. counties with poor services that KFF Health News identified. Dozens of doctors, academics, and advocates interviewed for this article unanimously agreed that limited internet service hinders medical care and access.

Without fast, reliable broadband, "all we're going to do is widen health care disparities within telemedicine," said Rashmi Mullur, an endocrinologist and chief of telehealth at VA Greater Los Angeles. Patients with diabetes who also use telemedicine are more likely to get care and control their blood sugar, Mullur found.

Diabetes requires constant management. Left untreated, uncontrolled blood sugar can cause blindness, kidney failure, nerve damage, and eventually death.

Williams, who sees a nurse practitioner at the county hospital in the next town, said she is not interested in using remote patient monitoring or video calls.

"I know how my sugar affects me," Williams said. "I get a headache if it's too high." She gets weaker when it's down, she said, and always carries snacks like crackers or peppermints.

Williams said she could even drink a soda pop — orange, grape — when her sugar is low but would not drink one when she felt it was high because she would get "kind of goozie-woozy."

'This Is America'

Connectivity dead zones persist in American life despite at least $115 billion lawmakers have thrown toward fixing the inequities. Federal broadband efforts are fragmented and overlapping, with more than 133 funding programs administered by 15 agencies, according to a 2023 federal report.

"This is America. It's not supposed to be this way," said Karthik Ganesh, chief executive of Tampa, Florida-based OnMed, a telehealth company that in September installed a walk-in booth at the Boligee Community Center about 10 minutes from Williams' home. Residents can call up free life-size video consultations with an OnMed health care provider and use equipment to check their weight and blood pressure.

OnMed, which partnered with local universities and the Alabama Cooperative Extension System, relies on SpaceX's Starlink to provide a high-speed connection in lieu of other options.

A short drive from the community center, beyond Boligee's Main Street with its deserted buildings and an empty railroad depot and down a long gravel drive, is the 22-acre property where Williams lives.

Last fall, Williams washed a dish in her kitchen, with its unforgiving linoleum-topped concrete floors. A few months earlier, she said, a man at the community center signed her up for "diabetic shoes" to help with her sore feet. They never arrived.

As Williams spoke, steam rose from a pot of boiling potatoes on the stove. Another pan sizzled with hamburger steak. And on a back burner simmered a mix of Velveeta cheese, diced tomatoes, and peppers.

She spent years on her feet as head cook at a diner in Cleveland, Ohio. The oldest of nine, Williams returned to her family home in Greene County more than 20 years ago to care for her mother and a sister, who both died from cancer in the back bedroom where she now sleeps.

Williams looked out a window and recalled when the landscape was covered in cotton that she once helped pick. Now three houses stand in a carefully tended clearing surrounded by tall trees. One belongs to a brother and the other to a sister who drives with her daily to the community center for exercise, prayers, and friendship with other seniors.

All the surviving siblings, Williams said, have diabetes. "I don't know how we became diabetic," she said. Neither of their parents had been diagnosed with the illness.

In Greene County, an estimated quarter of adults have diabetes — twice the national average. The county, which has about 7,600 residents, also has among the nation's highest rates for several chronic diseases such as high blood pressure, stroke, and obesity, Centers for Disease Control and Prevention data shows.

The county's population is predominately Black. The federal CDC reports that Black Americans are more likely to be diagnosed with diabetes and are 40% more likely than their white counterparts to die from the condition. And in the South, rural Black residents are more likely to lack home internet access, according to the Joint Center for Political and Economic Studies, a Washington-based think tank.

To identify counties most lacking in reliable broadband and health care providers, KFF Health News used data from the Federal Communications Commission and George Washington University's Mullan Institute for Health Workforce Equity. Reporters also analyzed U.S. Census Bureau, CDC, and other data to understand the health status and demographics of those counties.

The analysis confirms that internet and care gaps are "hitting areas of extreme poverty and high social vulnerability," said Clese Erikson, deputy director of the health workforce research center at the Mullan Institute.

Digital Haves vs. Have-Nots

Just over half of homes in Greene County have access to reliable high-speed internet — among the lowest rates in the nation. Greene County also has some of the country's poorest residents, with a median household income of about $31,500. Average life expectancy is less than 72 years, below the national average.

By contrast, the KFF Health News analysis found that counties with the highest rates of internet access and health care providers correlated with higher life expectancy, less chronic disease, and key lifestyle factors such as higher incomes and education levels.

One of those is Howard County, Maryland, between Baltimore and Washington, D.C., where nearly all homes can connect to fast, reliable internet. The median household income is about $147,000 and average life expectancy is more than 82 years — a decade longer than in Greene County. A much smaller share of residents live with chronic conditions such as diabetes.

One is 78-year-old Sam Wilderson, a retired electrical engineer who has managed his Type 2 diabetes for more than a decade. He has fiber-optic internet at his home, which is a few miles from a cafe he dines at every week after Bible study. On a recent day, the cafe had a guest Wi-Fi download speed of 104 megabits per second and a 148 Mbps upload speed. The speeds are fast enough for remote workers to reliably take video calls.

Americans are demanding more speed than ever before. Most households have multiple devices — televisions, computers, gaming systems, doorbells — in addition to phones that can take up bandwidth. The more devices connected, the higher minimum speeds are needed to keep everything running smoothly.

To meet increasing needs, federal regulators updated the definition of broadband last year, establishing standard speeds of 100/20 Mbps. Those speeds are typically enough for several users to stream, browse, download, and play games at the same time.

Christopher Ali, professor of telecommunications at Penn State, recommends minimum standard speeds of 100/100 Mbps. While download speeds enable consumption, such as streaming or shopping, fast upload speeds are necessary to participate in video calls, say, for work or telehealth.

At the cafe in Howard County, on a chilly morning last fall, Wilderson ordered a glass of white wine and his usual: three-seeded bread with spinach, goat cheese, smoked salmon, and over-easy eggs. After eating, Wilderson held up his wrist: "This watch allows me to track my diabetes without pricking my finger."

Wilderson said he works with his doctors, feels young, and expects to live well into his 90s, just as his father and grandfather did.

Telehealth is crucial for people in areas with few or no medical providers, said Ry Marcattilio, an associate director of research at the Institute for Local Self-Reliance. The national research and advocacy group works with communities on broadband access and reviewed KFF Health News' findings.

High-speed internet makes it easier to use video visits for medical checkups, which most patients with diabetes need every three months.

Being connected "can make a huge difference in diabetes outcomes," said Nestoras Mathioudakis, an endocrinologist and co-medical director of Johns Hopkins Medicine Diabetes & Education Program, who treats patients in Howard County.

Paying More for Less

At Williams' home in Alabama, pictures of her siblings and their kids cover the walls of the hallway and living room. A large, wood-framed image of Jesus at the Last Supper with his disciples hangs over her kitchen table.

Williams sat down as her pots simmered and sizzled. She wasn't feeling quite right. "I had a glass of orange juice and a bag of potato chips, and I knew that wasn't enough for breakfast, but I was cooking," Williams said.

Every night Williams takes a pill to control her diabetes. In the morning, if she feels as if her sugar is dropping, she knows she needs to eat. So, that morning, she left the room to grab a peppermint, walking by the flickering wireless router.

The router's download and upload speeds were 0.03/0.05 Mbps, nearly unusable by modern standards. Williams' connection on her house phone can sound scratchy, and when she connects her cellphone to the router, it does not always work. Most days it's just good enough for her to read a daily devotional website and check Facebook, though the stories don't always load.

Rural residents like Williams paid nearly $13 more a month on average in late 2020 for slow internet connections than those in urban areas, according to Brian Whitacre, an agricultural economics professor at Oklahoma State University.

"You're more likely to have competition in an urban area," Whitacre said.

In rural Alabama, cellphone and internet options are limited. Williams pays $51.28 a month to her wireless provider, Ring Planet, which did not respond to calls and emails.

In Howard County, Maryland, national fiber-optic broadband provider Verizon Communications faces competition from Comcast, a hybrid fiber-optic and cable provider. Verizon advertises a home internet plan promising speeds of 300/300 Mbps starting at $35 a month for its existing mobile customers. The company also offers a discounted price as low as $20 a month for customers who participate in certain federal assistance programs.

"Internet service providers look at the economics of going into some of these communities and there just isn't enough purchasing power in their minds to warrant the investment," said Ross DeVol, chief executive of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

Conexon, a fiber-optic cable construction company, estimates it costs $25,000 per mile to build above-ground fiber lines on poles and $60,000 to $70,000 per mile to build underground.

Former President Joe Biden's 2021 infrastructure law earmarked $65 billion with a goal of connecting all Americans to high-speed internet. Money was designated to establish digital equity programs and to help low-income customers pay their internet bills. The law also set aside tens of billions through the Broadband Equity Access and Deployment Program, known as BEAD, to connect homes and businesses.

That effort prioritizes fiber-optic connections, but federal regulators recently outlined guidance for alternative technologies, including low Earth orbit satellites like SpaceX's Starlink service.

Funding the use of satellites in federal broadband programs has been controversial inside federal agencies. It has also been a sore point for Elon Musk, who is chief executive of SpaceX, which runs Starlink, and is a lead adviser to President Donald Trump.

After preliminary approval, a federal commission ruled that Starlink's satellite system was "not reasonably capable" of offering reliable high speeds. Musk tweeted last year that the commission had "illegally revoked" money awarded under the agency's Trump-era Rural Digital Opportunity Fund.

In February, Trump nominated Arielle Roth to lead the federal agency overseeing the infrastructure act's BEAD program. Roth is telecommunications policy director for the Senate Committee on Commerce, Science, and Transportation. Last year, she criticized the program's emphasis on fiber and said it was beleaguered by a "woke social agenda" with too many regulations.

Commerce Secretary Lutnick last week said he will get rid of "burdensome regulations" and revamp the program to "take a tech-neutral approach." Republicans echoed his positions during a U.S. House subcommittee hearing the same day.

When asked about potentially weakening the program's required low-cost internet option, former National Telecommunications and Information Administration official Sarah Morris said such a change would build internet connections that people can't afford. Essentially, she said, they would be "building bridges to nowhere, building networks to no one."

'That Hurt'

Over a lunch of tortilla chips with the savory sauce that had been simmering on the stove, Williams said she hadn't been getting regular checkups before her diabetes diagnosis.

"To tell you the truth, if I can get up and move and nothing is bothering me, I don't go to the doctor," Williams said. "I'm just being honest."

Years ago, Williams recalled, "my head was hurting me so bad I had to just lay down. I couldn't stand up, walk, or nothing. I'd get so dizzy."

Williams thought it was her blood pressure, but the doctor checked for diabetes. "How did they know? I don't know," Williams said.

As lunch ended, she pulled out her glucose monitor. Williams connected the needle and wiped her finger with an alcohol pad. Then she pricked her finger.

"Oh," Williams said, sucking air through her teeth. "That hurt."

She placed the sample in the machine, and it quickly displayed a reading of 145 — a number, Williams said, that meant she needed to stop eating.

Sarah Jane Tribble: sjtribble@kff.org, @sjtribble

Holly K. Hacker: hhacker@kff.org, @hollyhacker