HELENA, Mont. — Montana's small, independent pharmacies say they're getting increasingly squeezed on reimbursements by pharmacy benefit managers — and are pushing an ambitious bill to rein in what they say are unfair practices by the powerful industry negotiators known as PBMs.
"Who in their right mind would subject themselves to this sort of treatment in a business relationship?" said Mike Matovich, a part owner of eight small-town pharmacies in Montana. "It's such a monopoly. We can be the best pharmacy in the world, and they can still put us out of business."
The bill, which sailed through the Montana House 98-1 in early March and is now before the state Senate, would set a price floor that PBMs must pay pharmacies for each prescription. Currently, there is no mandated minimum rate in contracts with pharmacies, and independent drugstores said the rates are often below what they paid for the drugs.
The measure includes a half-dozen restrictions on other PBM practices the smaller pharmacies call anticompetitive.
Pharmacy benefit managers, employed by health insurers, are powerful intermediaries in the drug-pricing chain. They determine which drugs are covered by health plans, arrange rebates from drugmakers, and dictate payments that pharmacies receive when selling covered drugs.
The six largest PBMs manage more than 90% of the nation's drug sales. Most are owned by or affiliated with health insurance giants like UnitedHealth Group, Cigna, Humana, and Aetna.
About 90 Montanan-owned pharmacies are not affiliated with national companies or PBMs, and 10 have closed in the past year, according to Josh Morris, who owns several small-town pharmacies in the state. Morris said his pharmacies lost $30,000 on underpaid drug claims last year and that they lose money on 90% of the brand-name drugs they dispense.
Representatives of independent Montana pharmacies say that without the changes provided by the legislation, more of their ranks will close, because they can't make ends meet on drug reimbursement prices imposed by what they say are "take-it-or-leave-it" contracts from PBMs.
"We're filling more prescriptions than ever before, but my employees haven't had a raise in three years," Morris said. "Our reimbursements are down 60% since 2019."
PBMs are mounting a concerted effort in the Montana Senate to kill House Bill 740, arguing it could throw a huge wrench into drug pricing in Montana that would increase consumer costs.
"Not only is it going to cost people, it's going to change fundamentally how prescription drugs are paid for in the state," said Tonia Sorrell-Neal of the Pharmaceutical Care Management Association, a trade group representing PBMs. "It takes away the options for employers who are paying for these health plans" to keep drug prices low.
The bill restricts mail-order options for drugs, limits when PBMs can audit claims, and imposes excessive reimbursements, she said.
This battle between PBMs and independent pharmacies isn't playing out just in Montana — it has roiled statehouses across the country, drawn the attention of Congress, and could end up before the U.S. Supreme Court.
New federal regulations to crack down on PBMs had been included in a 2024 post-election budget bill before Congress but were stripped out at the last minute after a lobbying push by pharmacy benefit managers.
At least 20 states have passed laws regulating PBM payments to pharmacies and several other states, including California, are considering legislation this year.
Oklahoma passed one of the most expansive laws in 2019. But PBMs sued and won a federal court ruling that said the law does not apply to self-funded health plans, thus removing about two-thirds of the insured population from the law's jurisdiction.
Oklahoma's insurance commissioner last year asked the U.S. Supreme Court to overrule the decision, but the court hasn't decided whether to take the case. Attorneys general from 31 states and the District of Columbia have asked the high court to rule in Oklahoma's favor; Montana's AG is not one of them.
In Montana, HB 740's regulations would apply to PBMs managing self-funded plans, said the state insurance commissioner's office, which so far supports the bill.
The key element of HB 740 is setting requirements on what PBMs must reimburse pharmacies for each prescription they fill, when that prescription is covered by a health plan using the PBM.
It says the reimbursement can be no less than 106% of the National Average Drug Acquisition Cost, or NADAC — which is determined by a survey of wholesale prices paid by pharmacies — plus a "dispensing fee" for each prescription.
The dispensing fee would be the same as what Montana's Medicaid program pays pharmacies — $12 to $18 per prescription, depending on the size of the pharmacy. The state Medicaid program also pays the 106% minimum reimbursement.
Montana pharmacies say the dispensing fee covers their basic costs and enables them to make a profit on most sales. Under contracts with most PBMs, the pharmacies say they get no dispensing fee.
The bill also requires other changes in PBM business practices that pharmacies say benefit PBMs and make it harder for independent pharmacies to stay in business.
For example, HB 740 says PBMs cannot offer better prices to pharmacies that they own, cannot charge after-the-fact fees that lower reimbursement rates, cannot slow-walk approval of contracts, and cannot lower payments for drugs sold past a "sell-by" date imposed by the PBMs.
PBM and health plan lobbyists have attacked the bill for its breadth and detail, saying it's so extensive that nobody truly knows how it may affect prescription-drug markets and prices in Montana.
"This bill has too much," Bruce Spencer, an attorney for the Mountain Health Co-Op, told the House Business and Labor Committee at the bill's first hearing in February. "It has unintended consequences that are severe in the financial world."
Laura Shirtliff, a spokesperson for the state auditor's office, said the bill's provisions should be narrowed, to target assistance for smaller pharmacies.
PBM lobbyists are telling lawmakers to kill HB 740 and instead pass a bill to study the prescription-drug market in Montana, with an eye toward possible solutions to help rural pharmacies.
"I would say there are a lot of elements and factors that are impacting rural pharmacies' business," said Sorrell-Neal of the PBM trade group.
Supporters, however, said HB 740 needs to closely define exactly what's happening in the field, between PBMs and pharmacies, so those practices can be regulated.
As for waiting two years for a study? Pharmacy owners say that's too late, and that the time to fix the problem is now.
"The amount of damage that would be done in two years will never be able to be recovered from, in these communities," Matovich said. "Ten years ago, we maybe lost money on five prescriptions a month. Now, it's thousands of prescriptions a month."
HENRICO, Va. — Sheldon Ekirch spends a lot of time on hold with her health insurance company.
Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.
In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they're on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.
"I don't feel like I am the person I was a year and a half ago," said Ekirch, who was on the cusp of launching her law career, before getting sick. "Like, my body isn't my own."
Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain. But Ekirch's insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.
Patients with Ekirch's condition don't always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.
"I'm paying a lot of money for health insurance," said Ekirch, who pays more than $600 a month in premiums. "I don't understand why they won't help me, why my life means so little to them."
For patient advocates and health economists, cases like Ekirch's illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.
The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient's health insurance company before proceeding with a drug, treatment, or medical procedure.
The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven't been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.
Yet it's widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.
Some insurers' efforts to improve prior authorization practices aren't as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.
"When you really dive deep," he said, these improvements don't seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. "When we started looking into it," he said, "it was almost a PR stunt."
The ‘Tipping Point'
When Arman Shahriar's father was diagnosed with follicular lymphoma in 2023, his father's oncologist ordered a whole-body PET scan to determine the cancer's stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.
Shahriar, an internal medicine resident, said he spent hours on the phone with his father's insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father's scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.
EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is "actively developing new ways to make the submission process simpler and faster for physicians," Ziomek said.
In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of "artificially creating problems in people's lives" at the wrong time.
"If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can't," said Shahriar, who wrote about his father's case in an essay published last year by JAMA Oncology. "We're kind of reaching a tipping point where we're realizing, collectively, something needs to be done."
The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.
An Emerson College poll conducted in mid-December found 41% of 18- to 29-year-olds thought the actions of Thompson's killer were at least somewhat acceptable. In a NORC survey from the University of Chicago conducted in December, two-thirds of respondents indicated that insurance company profits, and their denials for health care coverage, contributed "a great deal/moderate amount" to the killing. Instagram accounts established in support of Luigi Mangione, the 26-year-old Maryland suspect accused of murder and terrorism, have attracted thousands of followers.
"The past several weeks have further challenged us to even more intensely listen to the public narrative about our industry," Cigna Group CEO David Cordani said during an earnings call on Jan. 30. Cigna is focused on "making prior authorizations faster and simpler," he added.
The first Trump administration and the Biden administration put forth policies designed to improve prior authorization for some patients by mandating that insurers set up electronic systems and shortening the time companies may take to issue decisions, among other fixes. Hundreds of House Democrats and Republicans signed on to co-sponsor a bill last year that would establish new prior authorization rules for Medicare Advantage plans. In January, Republican congressman Jefferson Van Drew of New Jersey introduced a federal bill to abolish the use of prior authorization altogether.
Meanwhile, many states have passed legislation to regulate the use of prior authorization. Some laws require insurers to publish data about prior authorization denials with the intention of making a confusing system more transparent. Reform bills are under consideration by state legislatures in Hawaii, Montana, and elsewhere. A bill in Virginia approved by the governor March 18 takes effect July 1. Other states, including Texas, have established "gold card" programs that ease prior authorization requirements for some physicians by allowing doctors with a track record of approvals to bypass the rules.
No one from AHIP, an insurance industry lobbying group formerly known as America's Health Insurance Plans, was available to be interviewed on the record about proposed prior authorization legislation for this article.
But changes wouldn't guarantee that the most vulnerable patients would be spared from future insurance denials or the complex appeals process set up by insurers. Some doctors and advocates for patients are skeptical that prior authorization can be fixed as long as insurers are accountable to shareholders.
Kindyl Boyer, director of advocacy for the nonprofit Infusion Access Foundation, remains hopeful the system can be improved but likened some efforts to playing "Whac-A-Mole." Ultimately, insurance companies are "going to find a different way to make more money," she said.
‘Unified Anger'
In the weeks following Thompson's killing, UnitedHealthcare was trying to refute an onslaught of what it called "highly inaccurate and grossly misleading information" about its practices when another incident landed the company back in the spotlight.
On Jan. 7, Elisabeth Potter, a breast reconstruction surgeon in Austin, Texas, posted a video on social media criticizing the company for questioning whether one of her patients who had been diagnosed with breast cancer and was undergoing surgery that day needed to be admitted as an inpatient.
The video amassed millions of views.
In the days following her post, UnitedHealthcare hired a high-profile law firm to demand a correction and public apology from Potter. In an interview with KFF Health News, Potter would not discuss details about the dispute, but she stood by what she said in her original video.
"I told the truth," Potter said.
The facts of the incident remain in dispute. But the level of attention it received online illustrates how frustrated and vocal many people have become about insurance company tactics since Thompson's killing, said Matthew Zachary, a former cancer patient and the host of "Out of Patients," a podcast that aims to amplify the experiences of patients.
For years, doctors and patients have taken to social media to shame health insurers into approving treatment. But in recent months, Zachary said, "horror stories" about prior authorization shared widely online have created "unified anger."
"Most people thought they were alone in the victimization," Zachary said. "Now they know they're not."
Data published in January by KFF found that prior authorization is particularly burdensome for patients covered by Medicare Advantage plans. In 2023, virtually all Medicare Advantage enrollees were covered by plans that required prior authorization, while people enrolled in traditional Medicare were much less likely to encounter it, said Jeannie Fuglesten Biniek, an associate director at KFF's Program on Medicare Policy. Furthermore, she said, Medicare Advantage enrollees were more likely to face prior authorization for higher-cost services, including inpatient hospital stays, skilled nursing facility stays, and chemotherapy.
But Neil Parikh, national chief medical officer for medical management at UnitedHealthcare, explained prior authorization rules apply to fewer than 2% of the claims the company pays. He added that "99% of the time" UnitedHealthcare members don't need prior authorization or requests are approved "very, very quickly."
Recently, he said, a team at UnitedHealthcare was reviewing a prior authorization request for an orthopedic procedure when they discovered the surgeon planned to operate on the wrong side of the patient's body. UnitedHealthcare caught the mistake in time, he recounted.
"This is a real-life example of why prior authorization can really help," Parikh said.
Even so, he said, UnitedHealthcare aims to make the process less burdensome by removing prior authorization requirements for some services, rendering instant decisions for certain requests, and establishing a national gold card program, among other refinements. Cigna also announced changes designed to improve prior authorization in the months since Thompson's killing.
"Brian was an incredible friend and colleague to many, many of us, and we are deeply saddened by his passing," Parikh said. "It's truly a sad occasion."
The Final Denial
During the summer of 2023, Ekirch was working full time and preparing to take the bar exam when she noticed numbness and tingling in her arms and legs. Eventually, she started experiencing a burning sensation throughout her body.
That fall, a Richmond-area neurologist said her symptoms were consistent with small fiber neuropathy, and, in early 2024, a rheumatologist recommended IVIG to ease her pain. Since then, other specialists, including neurologists at the University of Virginia and Virginia Commonwealth University, have said she may benefit from the same treatment.
There's no guarantee it will work. A randomized controlled trial published in 2021 found pain levels in patients who received IVIG weren't significantly different from the placebo group, while an older study found patients responded "remarkably well."
"It's hard because I look at my peers from law school and high school — they're having families, excelling in their career, living their life. And most days I am just struggling, just to get out of bed," said Ekirch, frustrated that Anthem continues to deny her claim.
In a prepared statement, Kersha Cartwright, a spokesperson for Anthem's parent company, Elevance Health, said Ekirch's request for IVIG treatment was denied "because it did not meet the established medical criteria for effectiveness in treating small fiber neuropathy."
On Feb. 17, her treatment was denied by Anthem for the final time. Ekirch said her patient advocate, a nurse who works for Anthem, suggested she reach out to the drug manufacturer about patient charity programs.
"This is absolutely crazy," Ekirch said. "This is someone from Anthem telling me to plead with a pharmacy company to give me this drug when Anthem should be covering it."
Her only hope now lies with the Virginia State Corporation Commission Bureau of Insurance, a state agency that resolves prior authorization disputes between patients and health insurance companies. She found out through a Facebook group for patients with small fiber neuropathy that the Bureau of Insurance has overturned an IVIG denial before. In late March, Ekirch was anxiously waiting to hear the agency's decision about her case.
"I don't want to get my hopes up too much, though," she said. "I feel like this entire process, I've been let down by it."
HELENA, Mont. — Mark Nay's first client had lost the van she was living in and was struggling with substance use and medical conditions that had led to multiple emergency room visits.
Nay helped her apply for Medicaid and food assistance and obtain copies of her birth certificate and other identification documents needed to apply for housing assistance. He also advocated for her in the housing process and in the healthcare system, helping her find a provider and get to appointments.
After a year of "steady engagement," Nay said, the client has a place to live, is insured, is connected to the healthcare system, and has the resources needed to "really start to be successful and stable" in her life.
Nay is one of two community health workers in a program that St. Peter's Health of Helena started in 2022, focusing on people experiencing or at risk of homelessness who had five or more ER visits in a year. Nay and his colleague, Colette Murley, link their clients to services to meet basic needs, whether it's healthcare, food, housing, or insurance. The goal is to provide stability and, ultimately, to improve health outcomes.
Similar work is done in hospitals, community health centers, and other settings across Montana by people with titles such as case manager, outreach worker, navigator, and care manager. State Rep. Ed Buttrey, a Great Falls Republican, is sponsoring a bill in Montana's legislative session to put a common title — community health worker — to the type of work they do and define in law what the role entails. The bill also would provide for licensure and allow, but not require, Medicaid to cover the service.
"Healthcare is just a very difficult system to navigate, especially when you're trying to sign up for service and you're trying to get access to coverage for service," Buttrey said. "So that's where I see the biggest benefit."
Buttrey's HB 850 is one of several bills still alive this session that are related to Montana's healthcare workforce, which is stretched thin throughout the state, the fourth-largest by land area. According to the U.S. Health Resources and Services Administration, more than one-fourth of the state's residents live in an area with a shortage of primary care health professionals.
State Rep. Jodee Etchart, a Billings Republican and a physician assistant, is sponsoring two of the interstate compact licensure bills and one of the bills to limit noncompete clauses.
Etchart termed the compact bills "a no-brainer" because they allow people to get licensed, get a job, and start working in Montana right away.
In 2023, Etchart sponsored successful bills to allow physician assistants to practice without physician supervision and to expand the scope of practice for direct-entry midwives. Those bills, she said, helped pave the way for the progress this year's workforce bills have made this session.
"It opened a lot of people's eyes about how we can increase access to healthcare all over Montana," she said.
The 2023 bill allowing independent practice by physician assistants drew opposition from physicians, with the Montana Medical Association saying it extended their scope of practice without requiring additional training. This session, the MMA has supported the bills to remove noncompete provisions but opposed bills on expanding the scope of practice for chiropractors and optometrists. MMA CEO Jean Branscum said the group generally believes scope-of-practice changes don't fix workforce problems if the expanded practice isn't supported by evidence or training.
Buttrey said this session's bills to extend unsupervised practice and enact licensure compacts are an acknowledgment of the difficulty that small, rural communities have in attracting doctors. Physician assistants and nurse practitioners have been filling those gaps, he said.
Community health workers fill a different type of gap. They don't provide direct medical care, instead helping people find the healthcare and support services they need to become and remain healthy.
Many states have already adopted definitions for community health workers and started providing Medicaid reimbursement for their services.
The requests to add to the list of Medicaid-covered services come at a time when Congress is considering significant budget cuts that could affect the amount of funding the federal government contributes to the Medicaid program. Although the legislature this session continued Montana's Medicaid expansion program for low-income adults without disabilities, some legislators expressed concern about potential federal changes that could lower the amount of federal funds available for the program.
State Sen. Carl Glimm, a Kila Republican, was one of those legislators. He said he has similar concerns about increasing the types of services covered by Medicaid.
"The more stuff we add," he said, "the more responsibility the state has" if the federal government shifts more of the program's costs to the states.
Buttrey's bill would define a community health worker as a "frontline public health worker" who helps people obtain medical and social services, advocates for their health, and educates individuals, providers, and the community about healthcare needs. Workers could be licensed after completing training and supervision requirements.
Most medical providers don't have time to delve into all the outside factors influencing a patient's health, said Cindy Stergar, CEO of the Montana Primary Care Association, which is supporting Buttrey's bill. Community health workers can assist with that, she said, adding that research shows people with complex needs become healthier faster when their basic nonmedical needs, such as food and housing, are met.
"At the end of the day, the patient is better," Stergar said. "That's first and foremost."
The Area Health Education Center at Montana State University has been offering community health worker training since 2018, and the University of Montana's Center for Children, Families and Workforce Development began a training program in 2023. Together, the programs have trained nearly 500 people in how to identify the medical and social factors influencing a person's health and in strategies for connecting the person with the right community resources.
"Ideally, what community health workers are doing is getting out of the clinic walls, meeting people where they are, and addressing the priorities of the client to get to the root cause of their health conditions and health needs," said Mackenzie Petersen, project director for the training program at the University of Montana.
Supporters of the community health worker role say the workers are uniquely positioned to observe, understand, and address the barriers preventing a person from getting and staying healthy.
The barriers might be a lack of transportation or insurance or, for a homeless person, the inability to refrigerate a prescribed medication. A community health worker can arrange rides to appointments, help with insurance applications, or make sure a healthcare provider prescribes a medication that doesn't need refrigeration.
Murley, with the St. Peter's Health program, recalled that one of her clients was making frequent trips to the ER with suicidal ideation. Murley learned that he faced bullying in his apartment building and helped him relocate. The ER visits dropped off.
As Nay put it: "It's really about helping the people that we work with create a path to their health."
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."
Union Health is making a new bid to Indiana regulators to buy its rival hospital in Terre Haute as the door looks poised to close on such deals.
The nonprofit health system is trying to leverage an existing state law to acquire Terre Haute Regional Hospital, the only other acute care hospital in Vigo County. After withdrawing its initial application in November amid pushback, Union has shifted its pitch to emphasize what it describes as Regional's "declining position" while offering more concrete promises, such as limits on price increases.
Union submitted its new application on Feb. 5 as Indiana lawmakers were attempting to nix such mergers in their state. Lawmakers then watered down a bill that threatened to forbid Union's deal altogether, with the amended legislation now barring mergers sought after Feb. 15, leaving an opening for Union. That means the proposed merger will next face a showdown with the administration of Indiana's new governor, which has signaled opposition to such deals.
Indiana is among the latest states reconsidering Certificate of Public Advantage laws that greenlight hospital monopolies. This year, Tennessee lawmakers introduced a bill to restructure state oversight of these mergers after an attempt last year to repeal its COPA law. In 2023, Maine repealed its COPA law, joining Minnesota, Montana, North Carolina, and North Dakota.
"I would hope that they are reconsidering the laws because of the research on the long-run harms of COPAs," said Christopher Garmon, a University of Missouri-Kansas City economist who has studied COPA mergers.
Indiana is one of 19 states that still have COPA laws, which allow mergers that the Federal Trade Commission otherwise considers illegal because they reduce competition and often create monopolies.
In exchange for approval of these deals, the merging hospitals typically agree to meet conditions imposed by their state to mitigate the harms of a monopoly. But health care economists and the FTC have said that state oversight cannot replace competition and that these mergers ultimately harm patients.
Union Health's first application faced pushback. The state's Department of Health received hundreds of comments, with most opposing the deal, according to a review of documents KFF Health News obtained through a state public records request. Doctors, health economists, and the FTC were among those who called on state regulators to deny Union's proposal.
Union pulled its application in November, just days before the state was due to rule on the deal.
When Union filed its new application in early February, this time it promised a slew of concrete commitments and pledges to improve residents' health in the largely rural communities that surround Terre Haute. Among them were promises to keep both hospitals' emergency rooms open and inpatient services in operation, and to tie increases in hospital charges to the consumer price index for medical care, essentially establishing a cap so charges don't exceed medical inflation.
It also recast its pitch to describe Regional as a hospital in decline, which Union said puts the region at risk of losing access to services if the merger is not approved. Tennessee-based HCA Healthcare owns Terre Haute Regional.
In that scenario, Union warned, if Regional were to close, the health system would essentially have a monopoly anyway, "without any oversight, terms, or conditions" of a COPA. Instead, it argued, a green light from state regulators could avert a hospital closure and guarantee state oversight of the combined hospital system.
Union's first application did not argue that the merger was necessary for Regional to remain viable. In public comments submitted in September and March, the FTC argued to state regulators that both hospitals are "financially stable," adding that Regional is "part of the largest hospital system in the country with tremendous financial resources." It also cited hospital financial reporting that showed Terre Haute Regional Hospital's profits were better than those of most other hospitals in the country.
"This repackaged COPA application presents the same problems as before," Clarke Edwards, acting director of the FTC's Office of Policy Planning, said in a statement on March 17 after the commission unanimously opposed the merger.
HCA did not respond to questions about Union's characterization that Regional is a hospital in decline.
Despite Union's assurances that the merger would benefit the region, an analysis of the first proposal found the opposite. Zack Cooper, a health economist and an associate professor at Yale University, estimated that the price of care would rise by at least 10%, 500 jobs would be lost, and nurses' pay would decline by at least 7%.
Despite the new application and new promises, "the nature of the deal hasn't changed," Cooper said. He said that his findings remain unchanged and that Union stands to benefit — not the community.
"Life is easier for a firm if you face less competition," he said. "There's less pressure to compete on quality. There's less pressure to compete on price."
In January, state Sen. Ed Charbonneau, a Republican and a key architect of Indiana's 2021 COPA law, introduced the legislation to repeal the law, which would have foreclosed Union's chance at a possible second attempt at the merger.
In February, seated side by side at a state Senate health committee hearing, Union Health CEO Steve Holman, Terre Haute Chamber of Commerce President Kristin Craig, and state Sen. Greg Goode, a Republican representing the region, testified against the bill.
Holman told lawmakers the merger would improve the health of the region. He also noted that the hospital system had already spent $3 million on legal fees pursuing the deal. He said it seemed like lawmakers were attempting to cripple Union's chances. "Why has this come up now?" Holman asked.
The bill to repeal the COPA law advanced out of committee by a 7-4 vote. State Sen. Mike Bohacek, a Republican who represents a region a three-hour drive north of Terre Haute, said he voted against repealing the law out of deference to local officials.
"I have no dog in this fight," Bohacek said.
Charbonneau later amended his bill, winning support from Union and Goode. The new version sailed through the Senate. It is now backed by two powerful Republican representatives in the House: Brad Barrett, chair of the Public Health Committee, and Bob Heaton, House majority whip. Heaton represents parts of Vigo County.
Union Health spokesperson Amanda Scott said in an email to KFF Health News that Union and Regional Hospital "recognize the significance of a final approval" and that Union views this as its last chance to acquire its rival.
But Indiana's new governor, Republican Mike Braun, took office in January vowing to crack down on consolidation, especially in health care.
Earlier this year, Braun tapped Gloria Sachdev to lead a newly created Cabinet position overseeing the state's health care agencies, including the state Department of Health, which will decide on the merger.
As CEO of the Employers' Forum of Indiana, a coalition of businesses that has combated high hospital prices, Sachdev was an outspoken critic of the proposed merger in Terre Haute. In an October opinion piece in The Indianapolis Star, she urged regulators to consider how these mergers can crush communities.
Sachdev, now the state's secretary of health and family services, didn't answer questions on the new bid. After KFF Health News asked the governor's office whether Braun has final authority over the fate of Union's merger request, Department of Health spokesperson Greta Sanderson provided a joint statement from the agency and the office of the governor: "Gov. Braun will expect to be informed, ask questions, and ensure that whatever decision is made is thoughtful and objective with the best interests of Hoosiers in mind."
The state has until June 21 to review the merger application before rendering a decision, according to the Department of Health. The public can comment on the proposal through March 23.
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.
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.
"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.
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."
Rebecca Smith-Bindman, a professor at the University of California-San Francisco medical school, has spent well over a decade researching the disquieting risk that one of modern medicine's most valuable tools, computerized tomography scans, can sometimes cause cancer.
Smith-Bindman and like-minded colleagues have long pushed for federal policies aimed at improving safety for patients undergoing CT scans. Under new Medicare regulations effective this year, hospitals and imaging centers must start collecting and sharing more information about the radiation their scanners emit.
About 93 million CT scans are performed every year in the United States, according to IMV, a medical market research company that tracks imaging. More than half of those scans are for people 60 and older. Yet there is scant regulation of radiation levels as the machines scan organs and structures inside bodies. Dosages are erratic, varying widely from one clinic to another, and are too often unnecessarily high, Smith-Bindman and other critics say.
"It's unfathomable," Smith-Bindman said. "We keep doing more and more CTs, and the doses keep going up."
One CT scan can expose a patient to 10 or 15 times as much radiation as another, Smith-Bindman said. "There is very large variation," she said, "and the doses vary by an order of magnitude — tenfold, not 10% different — for patients seen for the same clinical problem." In outlier institutions, the variation is even higher, according to research she and a team of international collaborators have published.
She and other researchers estimated in 2009 that high doses could be responsible for 2% of cancers. Ongoing research shows it's probably higher, since far more scans are performed today.
The cancer risk from CT scans for any individual patient is very low, although it rises for patients who have numerous scans throughout their lives. Radiologists don't want to scare off patients who can benefit from imaging, which plays a crucial role in identifying life-threatening conditions like cancers and aneurysms and guides doctors through complicated procedures.
But the new data collection rules from the Centers for Medicare & Medicaid Services issued in the closing months of the Biden administration are aimed at making imaging safer. They also require a more careful assessment of the dosing, quality, and necessity of CT scans.
The requirements, rolled out in January, are being phased in over about three years for hospitals, outpatient settings, and physicians. Under the complicated reporting system, not every radiologist or health care setting is required to comply immediately. Providers could face financial penalties under Medicare if they don't comply, though those will be phased in, too, starting in 2027.
When the Biden administration issued the new guidelines, a CMS spokesperson said in an email that excessive and unnecessary radiation exposure was a health risk that could be addressed through measurement and feedback to hospitals and physicians. The agency at the time declined to make an official available for an interview. The Trump administration did not respond to a request for comment for this article.
The Leapfrog Group, an organization that tracks hospital safety, welcomed the new rules. "Radiation exposure is a very serious patient safety issue, so we commend CMS for focusing on CT scans," said Leah Binder, the group's president and CEO. Leapfrog has set standards for pediatric exposure to imaging radiation, "and we find significant variation among hospitals," Binder added.
CMS contracted with UCSF in 2019 to research solutions aimed at encouraging better measurement and assessment of CTs, leading to the development of the agency's new approach.
The American College of Radiology and three other associations involved in medical imaging, however, objected to the draft CMS rules when they were under review, arguing in written comments in 2023 that they were excessively cumbersome, would burden providers, and could add to the cost of scans. The group was also concerned, at that time, that health providers would have to use a single, proprietary tech tool for gathering the dosing and any related scan data.
The single company in question, Alara Imaging, supplies free software that radiologists and radiology programs need to comply with the new regulations. The promise to keep it free is included in the company's copyright. Smith-Bindman is a co-founder of Alara Imaging, and UCSF also has a stake in the company, which is developing other health tech products unrelated to the CMS imaging rule that it does plan to commercialize.
But the landscape has recently changed. ACR said in a statement from Judy Burleson, ACR vice president for quality management programs, that CMS is allowing in other vendors — and that ACR itself is "in discussion with Alara" on the data collection and submission. In addition, a company called Medisolv, which works on health care quality, said at least one client is working with another vendor, Imalogix, on the CT dose data.
Several dozen health quality and safety organizations — including some national leaders in patient safety, like the Institute of Healthcare Improvement — have supported CMS' efforts.
Concerns about CT dosing are long-standing. A landmark study published in JAMA Internal Medicine in 2009 by a research team that included experts from the National Cancer Institute, the Department of Veterans Affairs, and universities estimated that CT scans were responsible for 29,000 excess cancer cases a year in the United States, about 2% of all cases diagnosed annually.
But the number of CT scans kept climbing. By 2016, it was estimated at 74 million, up 20% in a decade, though radiologists say dosages of radiation per scan have declined. Some researchers have noted that U.S. doctors order far more imaging than physicians in other developed countries, arguing some of it is wasteful and dangerous.
More recent studies, some looking at pediatric patients and some drawing on radiation exposure data from survivors of the atomic bomb attacks on Hiroshima and Nagasaki in Japan, have also identified CT scan risk.
Older people may face greater cancer risks because of imaging they had earlier in life. And scientists have emphasized the need to be particularly careful with children, who may be more vulnerable to radiation exposure while young and face the consequences of cumulative exposure as they age.
Max Wintermark, a neuroradiologist at the MD Anderson Cancer Center in Houston, who has been involved in the field's work on appropriate utilization of imaging, said doctors generally follow dosing protocols for CT scans. In addition, the technology is improving; he expects artificial intelligence to soon help doctors determine optimal imaging use and dosing, delivering "the minimum amount of radiation dose to get us to the diagnosis that we're trying to reach."
But he said he welcomes the new CMS regulations.
"I think the measures will help accelerate the transition towards always lower and lower doses," he said. "They are helpful."
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?"
Kirk Vartan pays more than $2,000 a month for a high-deductible health insurance plan from Blue Shield on Covered California, the state's Affordable Care Act marketplace. He could have selected a cheaper plan from a different provider, but he wanted one that includes his wife's doctor.
"It's for the two of us, and we're not sick," said Vartan, general manager at A Slice of New York pizza shops in the Bay Area cities of San Jose and Sunnyvale. "It's ridiculous."
Vartan, who is in his late 50s, is one of millions of Californians struggling to keep up with health insurance premiums ballooning faster than inflation.
Average monthly premiums for families with employer-provided health coverage in California's private sector nearly doubled over the last 15 years, from just over $1,000 in 2008 to almost $2,000 in 2023, a KFF Health News analysis of federal data shows. That's more than twice the rate of inflation. Also, employees have had to absorb a growing share of the cost.
The spike is not confined to California. Average premiums for families with employer-provided health coverage grew as fast nationwide as they did in California from 2008 through 2023, federal data shows. Premiums continued to grow rapidly in 2024, according to KFF.
Small-business groups warn that, for workers whose employers don't provide coverage, the problem could get worse if Congress does not extend enhanced federal subsidies that make health insurance more affordable on individual markets such as Covered California, the public marketplace that insures more than 1.9 million Californians.
Premiums on Covered California have grown about 25% since 2022, roughly double the pace of inflation. But the exchange helps nearly 90% of enrollees mitigate high costs by offering state and federal subsidies based on income, with many families paying little or nothing.
Rising premiums also have hit government workers — and taxpayers. Premiums at CalPERS, which provides insurance to more than 1.5 million of California's active and retired public employees and family members, have risenabout 31%since 2022. Public employers pay part of the cost of premiums as negotiated with labor unions; workers pay the rest.
"Insurance premiums have been going up faster than wages over the last 20 years," said Miranda Dietz, a researcher at the University of California-Berkeley Labor Center who focuses on health insurance. "Especially in the last couple of years, those premium increases have been pretty dramatic."
Dietz said rising hospital prices are largely to blame. Consumer costs for hospitals and nursing homes rose about 88% from 2009 through 2024, roughly double the overall inflation rate, according to data from the Department of Labor. The rising cost of administering America's massive health care system has also pushed premiums higher, she said.
Insurance companies remain highly profitable, but their gross margins — the amount by which premium income exceeds claims costs — were fairly steady during the last few years, KFF research shows. Under federal rules, insurers must spend a minimum percentage of premiums on medical care.
Rising insurance costs are cutting deeper into family incomes and squeezing small businesses.
The average annual cost of family health insurance offered by private sector companies was about $24,000, or roughly $2,000 a month, in California during 2023, according to the U.S. Department of Health and Human Services. Employers paid, on average, about two-thirds of the bill, with workers paying the remaining third, about $650 a month. Workers' share of premiums has grown faster in California than in the rest of the nation.
Many small-business workers whose employers don't offer health care turn to Covered California. During the last three decades, the percentage of businesses nationwide with 10 to 24 workers offering health insurance fell from 65% to 52%, according to the Employee Benefit Research Institute. Coverage fell from 34% to 23% among businesses with fewer than 10 employees.
"When an employee of a small business isn't able to access health insurance with their employer, they're more likely to leave that employer," said Bianca Blomquist, California director for Small Business Majority, an advocacy group representing more than 85,000 small businesses across America.
Kirk Vartan said his pizza shop employs about 25 people and operates as a worker cooperative — a business owned by its workers. The small business lacks negotiating power to demand discounts from insurance companies to cover its workers. The best the shop could do, he said, were expensive plans that would make it hard for the cooperative to operate. And those plans would not offer as much coverage as workers could find for themselves through Covered California.
"It was a lose-lose all the way around," he said.
Mark Seelig, a spokesperson for Blue Shield of California, said rising costs for hospital stays, doctor visits, and prescription drugs put upward pressure on premiums. Blue Shield has created a new initiative that he said is designed to lower drug prices and pass on savings to consumers.
Even at California companies offering insurance, the percentage of employees enrolled in plans with a deductible has roughly doubled in 20 years, rising to 77%, federal data shows. Deductibles are the amount a worker must pay for most types of care before their insurance company starts paying part of the bill. The average annual deductible for an employer-provided family health insurance plan was about $3,200 in 2023.
During the last two decades, the cost of health insurance premiums and deductibles in California rose from about 4% of median household income to about 12%, according to the UC Berkeley Labor Center, which conducts research on labor and employment issues.
As a result, the center found, many Californians are choosing to delay or forgo health care, including some preventive care.
California is trying to lower health care costs by setting statewide spending growth caps, which state officials hope will curb premium increases. The state recently established the Office of Health Care Affordability, which set a five-year target for annual spending growth at 3.5%, dropping to 3% by 2029. Failure to hit targets could result in hefty fines for health care organizations, though that likely wouldn't happen until 2030 or later.
Other states that imposed similar caps saw health care costs rise more slowly than states that did not, Dietz said.
"Does that mean that health care becomes affordable for people?" she asked. "No. It means it doesn't get worse as quickly."
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.
