On Christmas Day at the WaTiki indoor water park, Hans Wirt was getting winded from following his son up the stairs to the waterslides.
Wirt's breathing became more labored once they returned to the nearby hotel where they and Wirt's girlfriend were staying while visiting family in Rapid City, South Dakota.
Then he grew nauseated and went pale. Wirt thought the cause might have been the altitude change between his home in Deltona, Florida — 33 feet above sea level — and Rapid City, at the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.
"I could tell by the look in his eyes that there was something a little more to this," Wirt said. "So I can kind of thank my son for saving my life."
It turned out the 62-year-old was having a heart attack. A "lousy Christmas present," Wirt said.
Medics stabilized Wirt before taking him to Monument Health — the only hospital in Rapid City with an emergency room — where he was treated over two days.
Then the bill came.
The Medical Procedure
Paramedics used a defibrillator to restore a normal heart rhythm. Doctors at the hospital gave Wirt various medications, used an electrocardiograph and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.
The Final Bill
$95,523.73, including $32,998.90 for medical supplies, mostly related to the stents, and $28,879 for treatment in a cardiac catheterization lab. After unspecified hospital adjustments to the bill, Wirt owed $77,574.44.
The Billing Problem: Medicaid Across State Lines
Wirt is covered by Florida's Medicaid program through Sunshine Health, a managed-care plan. But the South Dakota hospital refused to submit the bill to his out-of-state Medicaid plan, instead sending it to Wirt and eventually threatening to send the debt to a collection agency.
Medicaid, the government health insurance program primarily for low-income people and those with disabilities, is jointly funded by the federal government and states. States are responsible for administering Medicaid, and most contract with private insurance companies like Sunshine Health.
Federal law says state Medicaid programs must reimburse out-of-state hospitals for beneficiaries' care in an emergency.
Many hospitals bill out-of-state Medicaid plans in such situations. If they don't, they risk not being reimbursed at all, since Medicaid recipients probably won't be able to afford large bills, said Katy DeBriere, who was legal director for the Florida Health Justice Project when she spoke with KFF Health News in April.
But there's no federal law that requires them to do so, she said.
Federal court opinions have noted that hospitals are not required to bill Medicaid for every individual beneficiary they treat, even if they generally accept Medicaid.
Monument Health didn't bill Wirt's insurance because the hospital isn't enrolled as a healthcare provider with Florida Medicaid, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument bills Medicaid plans only in South Dakota and four bordering states: Wyoming, Montana, Nebraska, and Minnesota.
The hospital's website says Medicaid patients who are not enrolled in one of those states "are responsible for any charges."
"Due to the significant credentialing requirements of our multiple hospitals and hundreds of physicians we do not participate with all states," a hospital representative wrote in a message to Wirt.
According to Florida's Medicaid website, out-of-state providers who have treated one of its enrollees must submit five documents to bill the program, including a six-page application, a copy of the provider's license, and a claim form.
The process is different in each state, and many Medicaid programs reimburse out-of-state providers at lower rates than those that are in-state, according to the Medicaid and CHIP Payment and Access Commission, a federal agency that advises Congress.
Provider enrollment barriers leave "beneficiaries in an untenable situation, preventing them from accessing the coverage to which they are legally entitled," Chalberg said.
Wirt decided to submit his bill to his Medicaid plan on his own. But he said Sunshine Health told him it can only process bills received directly from providers.
Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that its staff contacted the hospital on Wirt's behalf. She did not respond when asked why the plan can't process bills submitted by patients or what more it could have done to help Wirt.
The Resolution
A few days after KFF Health News emailed officials at Monument Health for this story, Wirt noticed his balance due fell from more than $77,000 to $0.
Chalberg told KFF Health News that Monument Health covered Wirt's bill through its charity care program. She said that "appropriate patients" are told about the program and that "before any bill is sent to collections, it is evaluated to determine whether the patient may qualify for our financial assistance policy."
To retain tax-exempt status, nonprofit hospitals must have programs that provide free or discounted care to patients who can't afford their bills.
But Wirt said that when he first contacted Monument Health after receiving his bill and said he couldn't afford to pay it, officials didn't mention the program. He said they didn't share any resources when he asked whether there were outside groups that could help him pay the bill. Wirt said hospital officials just recommended setting up a payment plan, but the monthly bills were still too high for him to afford. "There's a reason why I'm on Medicaid," Wirt said. "It's just beyond me how they can expect somebody who had Medicaid to come up with that kind of money. It's unrealistic."
The Takeaway
Sarah Somers, legal director at the National Health Law Program, said the various "cogs in the Medicaid system" didn't operate correctly in Wirt's situation. "Nobody's exerting themselves enough to just smooth the way for this person."
States are responsible for managing Medicaid and are therefore the main "cog," Somers said. She said Medicaid managed-care companies are also supposed to intervene.
Somers and DeBriere said Medicaid recipients who receive bills they don't think they owe should file a complaint with their state's Medicaid program and, if they have one, their managed-care plan. They can also ask whether there is a Medicaid or managed-care caseworker who can advocate on their behalf.
The attorneys said patients should also contact a legal aid clinic or a consumer protection firm that specializes in medical debt. DeBriere said those organizations can help file complaints and communicate with the hospital.
DeBriere said that, had she assisted Wirt, she would have immediately sent a letter to Monument Health ordering it to stop billing him and to either register with Florida Medicaid to submit his bill or offer him charity care.
Wirt said the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke out about the hospital's billing practices because he doesn't want others to endure the same experience.
"If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state," he joked.
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post's Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
SAN FRANCISCO — Health nonprofits and medical interpreters warn that federal cuts have eliminated dozens of positions in California for community workers who help non-English speakers sign up for insurance coverage and navigate the healthcare system.
At the same time, people with limited English proficiency have scaled back their requests for language services, which healthcare advocates attribute in part to President Donald Trump's immigration crackdown and his executive order declaring English as the national language.
Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. "People are going to have a hard time accessing benefits they're entitled to and need to live independently," said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.
Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than "very well," according to the most recent U.S. Census data available, from 2023. A KFF-Los Angeles Times survey from that year found that immigrants with limited English proficiency reported more barriers accessing healthcare and worse health than English-proficient immigrants.
Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, ProPublica reported that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, The Virginian-Pilot first reported that a Spanish translation on a state website erroneously stated that the covid-19 vaccine was not necessary.
In 2000, President Bill Clinton signed an executive order aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher patient satisfaction, as well as fewer medical errors, misdiagnoses, and adverse health outcomes. Language services also save the healthcare system money by reducing hospital stays and readmissions.
It's unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from KFF Health News.
An HHS plan implemented under President Joe Biden, including guidance during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS's Office for Civil Rights still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.
And the office added protections in July that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.
Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. "There's a process that needs to be followed," she said, about making changes with public input. "I would strongly urge them to consider the dire consequences when people don't have effective communication."
Even if the federal government ultimately doesn't offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.
Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available.
"English can be the official language and people still have a right to get language services when they go to access healthcare," Youdelman said. "Nothing in the executive order changed the actual law."
Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.
State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are considering a bill that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.
"With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential," said Jake Hofstetter, policy analyst at the Migration Policy Institute.
The Los Angeles Department of Public Health and San Francisco's Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump's executive order or federal funding cuts.
Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.
And other pockets of California have reduced language services because of the federal funding cuts.
Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.
Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.
Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.
"We can only keep them through June 30," Foo said. "We're still trying to figure it out — if we can cover people."
At one call center in the Philippines, workers help Americans with diabetes or neurological conditions troubleshoot devices that monitor their health. Sometimes they get pressing calls: elderly patients who are alone and experiencing a medical emergency.
"That's not part of the job of our employees or our tech supports," said Ruth Elio, an occupational nurse who supervised the center's workers when she spoke with KFF Health News last year. "Still, they're doing that because it is important."
Elio also helped workers with their own health problems, most frequently headaches or back pains, borne of a life of sitting for hours on end.
In a different call center, Kevin Asuncion transcribed medical visits from half a world away, in the United States. You can get used to the hours, he said in an interview last year: 8 p.m. to 5 a.m. His breaks were mostly spent sleeping; not much is open then.
Health risks and night shifts aside, call center workers have a new concern: artificial intelligence.
Startups are marketing AI products with lifelike voices to schedule or cancel medical visits, refill prescriptions, and help triage patients. Soon, many patients might initiate contact with the health system not by speaking with a call center worker or receptionist, but with AI. Zocdoc, the appointment-booking company, has introduced an automated assistant it says can schedule visits without human intervention 70% of the time.
The medically focused call center workforce in the Philippines is a vast one: 200,000 at the end of 2024, estimates industry trade group leader Jack Madrid. That figure is more than the number of paramedics in the United States at the end of 2023, according to the Bureau of Labor Statistics. And some employers are opening outposts in other countries, like India, while using AI to reshape or replace their workforces.
Still, it's unclear whether AI's digital manipulations could match the proverbial human touch. For example, a recent study in Nature Medicine found that while some models can diagnose maladies when presented with a canned anecdote, as prospective doctors do in training, AI struggles to elicit information from simulated patients.
"The rapport, or the trust that we give, or the emotions that we have as humans cannot be replaced," Elio said.
Sachin Jain, president and CEO of Scan Health Plan, an insurer, said humans have context that AI doesn't have — at least for now. A receptionist at a small practice may know the patients well enough to pick up on subtle cues and communicate to the doctor that a particular caller is "somebody that you should see, talk to, that day, that minute, or that week."
The turn toward call centers, while creating more distance between a caller and a health provider, preserved the human touch. Yet some agents at call centers and their advocates say the ways they are monitored on the job undermine care. At one Kaiser Permanente location, it's a "very micromanaging environment," said one nurse who asked not to provide her name for fear of reprisal.
"From the beginning of the shift to your end, you're expected to take call after call after call from an open queue," she said. Even when giving advice for complex cases, "there's an unwritten rule on how long a nurse should take per call: 12 minutes."
Meanwhile, the job is getting tougher, she said. "We're the backup to the health care system. We're open 24/7," she said. "They're calling about their incision sites, which are bleeding. Their child has asthma, and the instructions for the medications are not clear."
One nurses union is protesting a potential AI management tool in the call centers.
"AI tools don't make medical decisions," Kaiser Permanente spokesperson Vincent Staupe told KFF Health News. "Our physicians and care teams are always at the center of decision-making with our patients and in all our care settings, including call centers."
Kaiser Permanente is not affiliated with KFF, a health information nonprofit that includes KFF Health News.
Some firms cite 30% to 50% turnover rates — stats that some say make a case for turning over the job to AI.
Call centers "can't keep people, because it's just a really, really challenging job," said Adnan Iqbal, co-founder and CEO of Luma Health, which creates AI products to automate some call center work. No wonder, "if you're getting yelled at every 90 seconds by a patient, insurance company, a staff member, what have you."
To hear business leaders tell it, their customers are frustrated: Instead of the human touch, patients get nothing at all, stymied by long wait times and harried, disempowered workers.
One time, Marissa Moore — an investor at OMERS Ventures — got a taste of patients' frustrations when trying to schedule a visit by phone at five doctors' offices. "In every single one, I got a third party who had no intel on providers in the office, their availability, or anything."
These types of gripes are increasingly common — and getting the attention of investors and businesses.
Customer complaints are hitting the bottom lines of businesses — like health insurers, which can be rewarded by the federal government's Medicare Advantage policies for better customer service.
When Scan noticed a drop in patient ratings for some of the medical providers in its insurance network, it learned those providers had switched to using centralized call centers. Customer service suffered, and the lower ratings translated into lower payments from the federal government, Jain said.
"There's a degree of dissatisfaction that's bubbling up among our patients," he said.
So, for some businesses, the notion of a computer receptionist seems a welcome solution to the problem of ineffectual call centers. AI voices, which can convincingly mimic human voices, are "beyond uncanny valley," said Richie Cartwright, the founder of Fella, a weight loss startup that used one AI product to call pharmacies and ask if they had GLP-1s in stock.
Prices have dropped, too. Google AI's per-use price has dropped by 97%, company CEO Sundar Pichai claimed in a 2024 speech.
Some boosters are excited to put the vision of AI assistants into action. Since the second Trump administration took office, policy initiatives by the quasi-agency known as the Department of Government Efficiency, led by Elon Musk, have reportedly explored using artificial intelligence bots for customer service at the Department of Education.
Most executives interviewed by KFF Health News — in the hospital, insurance, tech, and consultancy fields — were keen to emphasize that AI would complement humans, not replace them. Some resorted to jargon and claimed the technology might make call center nurses and employees more efficient and effective.
But some businesses are signaling that their AI models could replace human workers. Their websites hint at reducing reliance on staff. And they are developing pricing strategies based on reducing the need for labor, said Michael Yang, a venture capitalist at OMERS.
Yang described the prospect for businesses as a "we-share-in-the-upside kind of thing," with startups pitching clients on paying them for the cost of 1½ hires and their AI doing the work of twice that number.
But providers are building narrow services at the moment. For example, the University of Arkansas for Medical Sciences started with a limited idea. The organization's call center closes at 5 p.m. — meaning patients who try to cancel appointments after hours left a phone message, creating a backlog for workers to address the next morning that took time from other scheduling tasks and left canceled appointments unfilled. So they started by using an AI system provided by Luma Health to allow after-hours cancellations and have since expanded it to allow patients to cancel appointments all day.
Michelle Winfeld-Hanrahan, the health system's chief clinical access officer, who oversees its deployment, said UAMS has plenty of ideas for more automation, including allowing patients to check on prior authorizations and leading them through post-discharge follow-up.
Many executives claim AI tools can complement, rather than replace, humans. One company says its product can measure "vocal biomarkers" — subtle changes in tone or inflection — that correlate with disease and supply that information to human employees interacting with the patient. Some firms are using large language models to summarize complex documents: pulling out obscure insurance policies, or needed information, for employees. Others are interested in AI guiding a human through a conversation.
Even if the technology isn't replacing people, it is reshaping them. AI can be used to change humans' behavior and presentation. Call center employees said in interviews that they knew of, or had heard omnipresent rumors of, or feared, a variety of AI tools.
At some Kaiser Permanente call centers, unionized employees protested — and successfully delayed — the implementation of an AI tool meant to measure "active listening," a union flyer claimed.
And employees and executives associated with the call center workforce in the Philippines said they'd heard of other software tools, such as technology that changed Filipino accents to American ones. There's "not a super huge need for that, given our relatively neutral accents, but we've seen that," said Madrid, the trade group leader.
"Just because something can be automated doesn't mean it should be," he said.
Since President Donald Trump released his 2026 budget blueprint in early May, calling for $163 billion in federal spending cuts, much of the attention has focused on his slashing of foreign aid and boosting of border security. But the proposal also holds important clues — amid some mixed messages — about the administration's approach to two pressing public health issues: mental health and addiction.
There are about 80,000 overdose deaths in the United States each year, recent data shows, and nearly 50,000 deaths by suicide. Trump's proposal includes heavy cuts, totaling more than $22.6 billion, to three federal agencies that address these issues and suggests eliminating programs aimed at suicide and overdose prevention. The administration says this will streamline its efforts, but advocates, researchers, and public health practitioners worry this could make the death toll even worse.
Of course, a proposal is far from a final budget.
And this isn't even a full budget proposal. It's what people on Capitol Hill call a "skinny budget." It covers only discretionary spending that Congress authorizes each year, not larger entitlement programs like Medicare, Medicaid, and Social Security. Those big-ticket items and many other details will be addressed in the administration's full budget, expected in the coming months.
"You don't have it in enough detail to be able to really make assessments" about specific policies, said Rodney Whitlock, a vice president at the McDermott+ consulting firm and a longtime Republican Senate staffer. But "even in a skinny budget, you have to take it seriously and think that, 'Oh yeah, they're going to try to accomplish this.'"
About two weeks before Trump released his skinny budget, a preliminary budget document for the Department of Health and Human Services was leaked, showing deep funding cuts and lists of programs slated for elimination.
Discrepancies between those two documents — the official, skinny budget and the more detailed leaked one — have muddled the budget process even more than usual.
Here are three things that millions of Americans experiencing mental illness or addiction, and their loved ones, should watch as the process continues.
1. There is considerable confusion about the future of suicide prevention programs, including the nation's mental health crisis hotline, 988.
Trump plans to propose spending $520 million on the 988 system next year — the same amount as in the current fiscal year, said Rachel Cauley, a spokesperson for the White House Office of Management and Budget. She told KFF Health News that the president's budget will include an additional $95 million for other suicide prevention programs.
But that's far from clear when looking through the only official budget document released so far.
Trump's skinny proposal calls for more than $1 billion in cuts to the Substance Abuse and Mental Health Services Administration, the government's lead agency on all things related to mental health and addiction. The proposal says much of that comes from "eliminating inefficient funding" for SAMHSA's Programs of Regional and National Significance.
This bucket of spending includes a variety of grant programs, in areas including children's mental health and homelessness prevention. Budget documents from the current fiscal year show some of the costliest programs under this title focus on suicide prevention, including 988 grants to ensure state and regional call centers have the capacity to handle the millions of calls and texts the crisis line receives, Garrett Lee Smith grants focused on preventing youth suicide, and Zero Suicide grants that help health systems develop comprehensive suicide screening and response protocols.
Many people consider these programs vital given the country's ongoing suicide crisis. From 2000 to 2018, the national suicide rate increased 35%. Although there was a slight dip the following two years, the rate returned to its peak in 2022.
The 988 system, since launching in 2022 under the Biden administration, has fielded more than 9.8 million calls and 2.5 million texts.
"Cutting this funding is going to be disastrous," said Paul Nestadt, a psychiatrist and an associate professor at Johns Hopkins University. "A lot of suicide prevention does take place at the state or even local level, but it's funded by federal programs."
The skinny budget proposal says, "These programs either duplicate other Federal spending or are too small to have a national impact."
Cauley did not respond to questions about where she got the 988 and suicide prevention funding numbers she cited or why they differ from what's noted in the skinny budget.
Although it's fairly common to see discrepancies among an administration's various budget documents, attention to these documents — and concerns about differences — are heightened this year amid the Trump team's efforts to radically downsize the government and federal spending.
"It's very confusing," said Laurel Stine, chief advocacy and policy officer with the American Foundation for Suicide Prevention. "We want to ensure that the 988 lifeline is safeguarded," but the only officially released budget document "doesn't speak to it at all."
Another point of confusion: The skinny budget suggests that states can accomplish the work supported by the eliminated funding through separate block grants they receive from the federal government to address mental health and addiction.
However, those grants are specifically aimed at caring for people with serious mental illness and cannot be spent on suicide prevention for the general public.
2. The administration wants to cut certain tools used for preventing drug overdoses.
In the skinny budget, the Trump administration says it is "committed to combatting the scourge of deadly drugs that have ravaged American communities."
It goes on to propose eliminating the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control, which has overseen a lot of overdose prevention work, and consolidating the infectious disease and opioids program with three other programs, effectively reducing its budget and capacity.
"President Trump says that he wants to protect Americans from fentanyl," said Hanna Sharif-Kazemi, who works on federal affairs for the Drug Policy Alliance, an advocacy organization for people who use drugs. "But the plan that he has outlined in his budget proposal really doesn't match those words."
The proposal refers to "harm reduction" efforts, including providing sterile syringes to people using drugs, as "dangerous activities" and suggests federal funds should not support them.
But syringe service programs are among the most studied interventions and are proven to reduce the transmission of infectious diseases, such as HIV and hepatitis, without increasing crime or drug use.
They also "do so much more than just give syringes," Sharif-Kazemi said, adding that they typically distribute naloxone, which can reverse opioid overdoses, and connect people to resources for food, housing, and treatment, which help keep them alive.
Without these programs, infectious diseases are more likely to spread and affect the broader community, said Nestadt, the Johns Hopkins professor. "Eliminating those programs is going to have terrible effects on the population of the United States, regardless of whether they're using opiates or not."
3. Research cuts aimed at 'DEI' could worsen disparities in suicide and overdose rates.
The Trump proposal takes an axe to the National Institutes of Health, wiping out nearly $18 billion of the research agency's budget and eliminating several centers within it, including the National Institute on Minority and Health Disparities.
These actions align with Trump's ongoing attacks on "diversity, equity, and inclusion" programs, which he calls "woke" ideology.
Researchers say the proposed cuts, if enacted, could hamper efforts to address racial disparities in mental health and addiction that have become increasingly prominent.
Suicide rates have been rising faster for Black Americans than for their white counterparts. Early in the covid-19 pandemic, when suicide rates decreased for white Americans, they trended in the opposite direction for Black Americans and other communities of color.
"It might seem to the layperson that suicide is suicide, overdose is overdose," Nestadt said. But the data shows that trends are different for different groups. That means the factors that drive them to suicide — and the interventions that could save their lives — may be different.
"If I want to reach people with suicidal thoughts that are a highly educated, affluent population that has access to health care, I'm going to go to primary care doctors and pediatricians" to implement interventions, Nestadt said. But when trying to reach urban Black teens who have limited access to health care, "maybe it's a church" or barbershop, he said.
Nestadt is currently working on a CDC-funded study in which he interviews the family and friends of Black youths who died by suicide to understand what led to that point and how it could be prevented. He worries his funding could be cut any day.
What happens next?
Nothing in any Trump budget proposal is final. Lawmakers hold the power to determine federal spending.
Although some advocates worry that congressional Republicans will simply accede to Trump's demands, Whitlock, the McDermott+ consultant, said, "Congress is always going to want to express its will, and this will be no different."
Susan Collins, the Republican chair of the Senate Appropriations Committee, which oversees the budget, has stated that she has "serious objections" to some of the proposed cuts.
And when Health and Human Services Secretary Robert F. Kennedy Jr. appeared before House and Senate committees on May 14, some lawmakers pushed back on the administration's plans. Rep. Madeleine Dean (D-Pa.) held up a packet of naloxone and said the government should amplify what works to decrease overdose deaths instead of shuttering SAMHSA.
"Help us save more lives," she said. "Don't shift it and shaft it."
CHARLESTON, S.C. — When Page Campbell's doctor recommended she try an injectable prescription drug called Wegovy to lose weight before scheduling bariatric surgery, she readily agreed.
"I've struggled with my weight for so long," said Campbell, 40, a single mother of two. "I'm not opposed to trying anything."
In early April, about four weeks after she'd started taking Wegovy, Campbell said she hadn't experienced any side effects, such as nausea or bowel irritation. But she doesn't use a scale at home, she said, so she didn't know whether she'd lost any weight since her most recent medical appointment earlier this year, when she weighed 314 pounds. Still, she was confident about achieving weight loss.
"It's going to work because I'm putting in the work. I'm changing my eating habits. I'm exercising," said Campbell, a shipping manager at a Michaels store. "I'm not going to second-guess myself."
Wegovy belongs to a pricey class of drugs called GLP-1s (short for glucagon-like peptide-1 agonists) that have upended the treatment of obesity in recent years, offering hope to patients who have tried and failed to lose weight in myriad other ways.
Campbell gained access to Wegovy through South Carolina Medicaid's decision in late 2024 to cover these weight loss drugs. But the medications remain out of reach for millions of patients across the country who could benefit from them, because many public and private health insurers have deemed the drugs too expensive.
A report published in November by KFF, a health information nonprofit that includes KFF Health News, found only 13 states were covering GLP-1s for the treatment of obesity for Medicaid beneficiaries as of August. South Carolina became the 14th in November.
Liz Williams, one of the report's authors and a senior policy manager for the Program on Medicaid and the Uninsured at KFF, said she was not aware of any other state Medicaid programs joining the list since then. Looking ahead, the remaining states may be reluctant to add a new, expensive drug benefit while they brace for potential federal cuts coming from Congress, she said.
"As the budget debate, federally, is developing, that may impact how states are thinking about this," Williams said.
The federal government won't be helping anytime soon, either. Medicare covers GLP-1s to treat diabetes and some other health conditions, including obstructive sleep apnea and cardiovascular disease, but not obesity. In early April, the Trump administration announced it will not finalize a rule proposed by the Biden administration that would have allowed an estimated 7.4 million people covered by Medicare and Medicaid to access GLP-1s for weight loss. Meanwhile, the FDA is poised to force less expensive, compounded versions of these drugs off the market.
And the barrier to entry remains high, even for Medicaid patients in those few states that have agreed to cover the drugs without a federal mandate.
Case in point: In South Carolina, where more than one-third of all adults, and nearly half of the African American population, qualify as obese, the state Medicaid agency estimates only 1,300 beneficiaries will meet the stringent prerequisites for GLP-1 coverage.
Under one of those requirements, Medicaid beneficiaries who wish to access these drugs to lose weight must attest to "increased exercise activity," said Jeff Leieritz, a spokesperson for the South Carolina Department of Health and Human Services.
Campbell, who is insured by Medicaid, was granted coverage for Wegovy based on her body mass index. First, though, she was required to submit six months' worth of documentation proving that she'd tried and failed to lose weight after receiving nutrition counseling and going on a 1,200-calorie-a day diet, said Kenneth Mitchell, one of Campbell's doctors and the medical director for bariatric surgery and obesity medicine at Roper St. Francis Healthcare.
Campbell's Wegovy prescription was approved for six months, Mitchell said. When that authorization expires, Campbell and her health care team will need to submit more documentation, including proof that she has lost at least 5% of her body weight and has kept up with nutrition counseling.
"It's not just, ‘Send a prescription in and they cover it.' It's rather arduous," Mitchell said. "Not a lot of folks are going to do this."
Mitchell said South Carolina Medicaid's decision to cover these drugs was met with excitement among those working in his medical specialty. But he wasn't surprised that the state anticipates relatively few people will access this benefit annually, since the approval process is so rigorous and the cost high. "The problem is the medicines are so expensive," Mitchell said.
Novo Nordisk, which manufactures Wegovy, announced in March that it was cutting the monthly price for the drug from $650 to $499 for cash-paying customers. The price that health insurance plans and beneficiaries pay for these drugs varies, but some GLP-1s cost more than $1,000 per patient per month, Mitchell said, and many people will need to take them for the rest of their lives to maintain weight loss.
"That is a tremendous price tag that someone has to foot the bill for," Mitchell said.
That's the reason California Gov. Gavin Newsom on May 14 proposed eliminating Medicaid coverage of GLP-1s for weight loss starting Jan. 1, to save an estimated $680 million a year by 2028.
And the North Carolina State Health Plan Board of Trustees voted last year to end coverage of GLP-1s for state employees, after then-North Carolina Treasurer Dale Folwell's office estimated in 2023 that the drugs were projected to cost the State Health Plan $1 billion over the next six years. The decision came only a few months after a separate North Carolina agency announced it would start covering these drugs for Medicaid beneficiaries. North Carolina Medicaid has estimated it will spend $16 million a year on GLP-1s.
South Carolina Medicaid, which insures fewer than half the number of people enrolled in North Carolina Medicaid, anticipates spending less. Leieritz estimated GLP-1s and nutrition counseling offered to Medicaid beneficiaries in South Carolina will cost $10 million a year. State funding will cover $3.3 million of the expense; the remainder will be paid for by matching Medicaid funds from the federal government.
In a recent interview, Health and Human Services Secretary Robert F. Kennedy Jr. didn't rule out the possibility that Medicare and Medicaid might cover GLP-1s for obesity treatment in the future as costs come down.
They're "extraordinary drugs" and "we're going to reduce the cost," Kennedy told CBS News in early April. He said he would like GLP-1s to eventually be made available to Medicare and Medicaid patients who are seeking obesity treatment after they have tried other ways to lose weight. "That is the framework that we're now debating."
Meanwhile, public health experts have applauded South Carolina Medicaid's decision to cover GLP-1s. Yet the new benefit won't help the vast majority of the 1.5 million adults in South Carolina who are classified as obese, according to data published by the South Carolina Department of Public Health.
"We still have some work to do," acknowledged Brannon Traxler, the public health department's chief medical officer.
But the state's new "Action Plan for Healthy Eating and Active Living," written by a coalition of groups in South Carolina, including the Department of Public Health, makes no mention of GLP-1s or the role they might play in lowering obesity rates in the state.
The action plan, underwritten by a $1.5 million federal grant, isn't meant to lay out an overarching approach for lowering obesity in South Carolina, Traxler said. Instead, it promotes physical activity in schools, nutrition, and the expansion of outdoor walking trails, among other strategies. A more comprehensive obesity plan might address the benefits of surgical intervention and GLP-1s, but those also carry risk, expense, and side effects, Traxler said.
"Certainly, I think, there is a need to bring it all together," she said.
Campbell, for one, is taking the comprehensive approach. On top of injecting Wegovy once weekly, she said, she is prioritizing protein intake and moving her body. She also underwent weight loss surgery in late April.
"Weight loss is my biggest goal," said Campbell, who expressed appreciation for Medicaid's coverage of Wegovy. "It's one more thing that's going to help me get to my goal."
Under a new executive order, prescription drug prices will be reduced 'almost immediately.' — President Donald Trump, in a May 11 post on Truth Social.
This article was published on Tuesday, May 20, 2025 in KFF Health News.
President Donald Trump expressed high hopes for an executive order to reduce drug prices.
On May 11, the day before he held a White House event to sign the executive order, Trump posted on Truth Social, "Prescription Drug and Pharmaceutical prices will be REDUCED, almost immediately, by 30% to 80%."
However, the executive order's text, unveiled May 12, undercut the president's description of how soon consumers could experience this potential boon.
The idea of the executive order, he said, was to lower high prescription drug costs in the U.S. to levels more typical in other countries.
"We're going to equalize," Trump said at the order signing. "We're all going to pay the same. We're going to pay what Europe's going to pay."
Experts said Trump's action could lower the cost of prescription drugs, perhaps by the 30% to 80% Trump said, but they cautioned that the order's required procedural steps would make it far from an immediate fix.
The executive order says that within 30 days, administration officials must determine and communicate to drugmakers "most-favored-nation price targets," to push the companies to "bring prices for American patients in line with comparably developed nations."
After an unspecified period of time, the administration will gauge whether "significant progress" toward lower pricing has been achieved. If not, the order requires the secretary of Health and Human Services to "propose a rulemaking plan to impose most-favored-nation pricing," which could take months or years to take effect.
"Executive orders are wish lists," said Joseph Antos, a senior fellow emeritus in health care policy at the conservative American Enterprise Institute. The order "hopes that manufacturers will unilaterally lower U.S. prices. The legal authority to intervene in the market is unclear if this implausible scenario doesn't happen."
When contacted for comment, the White House did not provide evidence that the executive order would provide immediate results.
Why Do Americans Pay More for Prescriptions?
There is wide agreement that drug prices are unusually high in the U.S. The prices Americans pay for pharmaceuticals are nearly three times the average among a group of other industrialized countries in the Organization for Economic Cooperation and Development.
A study by the Rand Corp., a nonpartisan research organization, found that, across all drugs, U.S. prices were 2.78 times as high as the average prices across 33 OECD countries. The gap was even wider for brand-name drugs, with U.S. prices averaging 4.22 times as much.
The U.S. has lower prices than comparable nations for unbranded, generic drugs, which account for about 90% of filled prescriptions in the U.S. But generics account for only a fifth of U.S. prescription drug spending.
Experts cite several reasons for this pricing discrepancy.
One is that the U.S. has more limited price negotiation with drug manufacturers than other countries do. Often, if another country fails to find the extra cost of a new drug is justified by improved results, it'll reject the drug application. Some countries also set price controls.
Another factor is patent exclusivity. Over the years, U.S. pharmaceutical companies have used strong legal protections to amass patents that can keep generic competitors from the marketplace.
Drug companies have also argued that high prices help pay for research and development of new and improved pharmaceuticals. When Trump released the executive order, Stephen J. Ubl, president and CEO of the drug industry group Pharmaceutical Research and Manufacturers of America, said in a statement, "It would mean less treatments and cures and would jeopardize the hundreds of billions our member companies are planning to invest in America." (In Trump's May 13 interview with Fox News' Sean Hannity, Trump offered a different picture of what drug company officials have told him; he said they agreed "it's time" to lower U.S. prices.)
Recent studies have cast doubt on the idea that high prices pay for research and development. A 2023 study found that from 1999 to 2018, the world's 15 largest biopharmaceutical companies spent more on selling and general administrative activities, which include marketing, than on research and development. The study also said most new medicines developed during this period offered little to no clinical benefit over existing treatments.
The long-standing reality of high U.S. drug prices has driven Democratic and Republican efforts to bring them down. Then-President Joe Biden signed legislation to require Medicare, the federal health care program that covers Americans over 65, to negotiate prices with the makers of some popular, high-cost medicines. And Sen. Bernie Sanders (I-Vt.) has made lowering drug prices a cornerstone issue during his political career.
During his first term, Trump sought to lower prices for certain drugs under Medicare, but the courts blocked the move on procedural grounds.
Trump's drug-price push could attract bipartisan support, experts said.
Jonathan Cohn, who has worked for several left-of-center media outlets and wrotetwo books on health care policy, offered measured praise for Trump's executive order in The Bulwark, a publication generally critical of Trump, calling it "a serious policy initiative, one that credible people think could bring some relief on drug prices."
Andrew Mulcahy, a Rand Corp. senior health economist, said one part of Trump's statement — the possibility of a 30% to 80% price reduction — is plausible.
"Of course, the devil's in the policy design and implementation details," Mulcahy said. "But at first blush, a savings of roughly two-thirds on what we spend now for drugs seems in line" with what Rand's research has shown.
What Would Trump's Executive Order Do?
Referring to high U.S. drug prices, Trump told Hannity that "I ended it" by issuing the executive order. But that's not how the order is structured.
The executive order makes plain that any actions will not happen quickly.
"That 'almost' in 'almost immediately' is doing a lot of work," Mulcahy said, referring to Trump's statement.
The executive order also could face court challenges, just as Trump's first-term executive order did.
"It seems unlikely that the federal government can set prices for drugs outside of the Medicare program," Antos said. If Trump wants reduced prices to benefit all U.S. consumers, experts said, Congress will likely have to pass new legislation. While executive orders direct federal agencies what to do, requiring action from privately owned companies likely would require legislation passed by Congress, experts said.
If Congress gets involved, that will not only tack on extra time, but it also could draw opposition from the Republican majority in one or both chambers. Historically, Antos said, "federal price controls are anathema for many Republicans in Congress."
Our Ruling
Trump said that, because of his new executive order, prescription drug prices would be reduced "almost immediately."
Experts said that if the goals of the executive order are achieved, price reductions would not happen "almost immediately."
The order sets out a 30-day period to develop pricing targets for drugmakers, followed by an unspecified amount of time to see if companies achieve the targets. If they don't, a formal rulemaking process would begin, requiring months or even years. And if Trump intends to lower prices for all consumers, not only those who have federal coverage such as Medicare, Congress will likely have to pass a law to do it.
Trump gives the impression that Americans will shortly see steep decreases in what they pay for prescription drugs. But even if the executive order acts as intended — which would require a lot to go right — it could take months or years.
The statement contains an element of truth but ignores evidence that would give a different impression. We rate it Mostly False.
Healthcare has proved a vulnerable target for the firehose of cuts and policy changes President Donald Trump ordered in the name of reducing waste and improving efficiency. But most of the impact isn't as tangible as, say, higher egg prices at the grocery store.
One thing experts from a wide range of fields, from basic science to public health, agree on: The damage will be varied and immense. "It's exceedingly foolish to cut funding in this way," said Harold Varmus, a Nobel Prize-winning scientist and former director of both the National Institutes of Health and the National Cancer Institute.
The blaze of cuts have yielded nonsensical and perhaps unintended consequences. Consider instances in which grant funding gets canceled after two years of a three-year project. That means, for example, that $2 million has already been spent but there will be no return on that investment.
Some of the targeted areas are not administration priorities. That includes the abrupt termination of studies on long covid, which afflicts more than 100,000 Americans, and the interruption of work on mRNA vaccines, which hold promise not just in infectious disease but also in treating cancer.
While charitable dollars have flowed in to plug some gaps, "philanthropy cannot replace federal funding," said Dustin Sposato, communications manager for the Science Philanthropy Alliance, a group that works to boost support from charities for basic science research.
Here are critical ways in which Trump administration cuts — proposed and actual — could affect American healthcare and, more important, the health of American patients.
Cuts to the National Institutes of Health: The Trump administration has cut $2.3 billion in new grant funding since its term began, as well as terminated existing grants on a wide range of topics — vaccine hesitancy, HIV/AIDS, and covid-19 — that do not align with its priorities. National Institutes of Health grants do have yearly renewal clauses, but it is rare for them to be terminated, experts say. The administration has also cut "training grants" for young scientists to join the NIH.
Why It Matters: The NIH has long been a crucible of basic science research — the kind of work that industry generally does not do. Most pharmaceutical patents have their roots in work done or supported by the NIH, and many scientists at pharmaceutical manufacturers learned their craft at institutions supported by the NIH or at the NIH itself. The termination of some grants will directly affect patients since they involved ongoing clinical studies on a range of conditions, including pediatric cancer, diabetes, and long covid. And, more broadly, cuts in public funding for research could be costly in the longer term as a paucity of new discoveries will mean fewer new products: A 25% cut to public research and development spending would reduce the nation's economic output by an amount comparable to the decline in gross domestic product during the Great Recession, a new study found.
Cuts to Universities: The Trump administration also tried to deal a harrowing blow — currently blocked by the courts — to scientific research at universities by slashing extra money that accompanies research grants for "indirect costs," like libraries, lab animal care, support staff, and computer systems.
Why It Matters: Wealthier universities may find the funds to make up for draconian indirect cost cuts. But poorer ones — and many state schools, many of them in red states — will simply stop doing research. A good number of crucial discoveries emerge from these labs. "Medical research is a money-losing proposition," said one state school dean with former ties to the Ivies. (The dean requested anonymity because his current employer told him he could not speak on the record.) "If you want to shut down research, this will do it, and it will go first at places like the University of Tennessee and the University of Arkansas." That also means fewer opportunities for students at state universities to become scientists.
Cuts to Public Health: These hits came in many forms. The administration has cut or threatened to cut long-standing block grants from the Centers for Disease Control and Prevention; covid-related grants; and grants related to diversity, equity, and inclusion activities — which often translated into grants to improve healthcare for the underserved. Though the covid pandemic has faded, those grants were being used by states to enhance lab capacity to improve detection and surveillance. And they were used to formally train the nation's public health workforce, many of whom learn on the job.
Why It Matters: Public health officials and researchers were working hard to facilitate a quicker, more thoughtful response to future pandemics, of particular concern as bird flu looms and measles is having a resurgence. Mati Hlatshwayo Davis, the St. Louis health director, had four grants canceled, three in one day. One grant that fell under the covid rubric included programs to help community members make lifestyle changes to reduce the risk of hypertension and diabetes — the kind of chronic diseases that Health and Human Services Secretary Robert F. Kennedy Jr. has said he will focus on fighting. Others paid the salaries of support staff for a wide variety of public health initiatives. "What has been disappointing is that decisions have been made without due diligence," she said.
Health-Related Impact of Tariffs: Though Trump has exempted prescription drugs from his sweeping tariffs on most imports thus far, he has not ruled out the possibility of imposing such tariffs. "It's a moving target," said Michael Strain, an economist at the American Enterprise Institute, noting that since high drug prices are already a burden, adding any tax to them is problematic.
Why It Matters: That supposed exemption doesn't fully insulate American patients from higher costs. About two-thirds of prescription drugs are already manufactured in the U.S. But their raw materials are often imported from China — and those enjoy no tariff exemption. Many basic supplies used in hospitals and doctors' offices — syringes, surgical drapes, and personal protective equipment — are imported, too. Finally, even if the tariffs somehow don't themselves magnify the price to purchase ingredients and medical supplies, Americans may suffer: Across-the-board tariffs on such a wide range of products, from steel to clothing, means fewer ships will be crossing the Pacific to make deliveries — and that means delays. "I think there's an uncomfortably high probability that something breaks in the supply chain and we end up with shortages," Strain said.
Changes to Medicaid: Trump has vowed to protect Medicaid, the state-federal health insurance program for Americans with low incomes and disabilities. But House Republicans have eyed the program as a possible source of offsets to help pay for what Trump calls "the big, beautiful bill" — a sweeping piece of budget legislation to extend his 2017 tax cuts. The amount of money GOP leaders have indicated they could squeeze from Medicaid, which now covers about 20% of Americans, has been in the hundreds of billions of dollars. But deep cuts are politically fraught.
To generate some savings, administration officials have at times indicated they are open to at least some tweaks to Medicaid. One idea on the table — work requirements — would require adults on Medicaid to be working or in some kind of job training. (Nearly two-thirds of Medicaid recipients ages 19-64 already work.)
Why It Matters: In 2024 the uninsured rate was 8.2%, near the all-time low, in large part because of the Medicaid expansion under the 2010 Affordable Care Act. Critics say work requirements are a backhanded way to slim down the Medicaid rolls, since the paperwork requirements of such programs have proved so onerous that eligible people drop out, causing the uninsured rate to rise. A Congressional Budget Office report estimates that the proposed change would reduce coverage by at least 7.7 million in a decade. This leads to higher rates of uncompensated care, putting vulnerable healthcare facilities — think rural hospitals — at risk.
WINNER, S.D. — Sophie Hofeldt planned to receive prenatal care and give birth at her local hospital, 10 minutes from her house. Instead, she's driving more than three hours round trip for her appointments.
The hospital, Winner Regional Health, recently joined the increasing number of rural hospitals shuttering their birthing units.
"It's going to be a lot more of a stress and a hassle for women to get the healthcare that they need because they have to go so much further," said Hofeldt, who has a June 10 due date for her first child.
Hofeldt said longer drives mean spending more on gas — and a higher risk of not making it to the hospital in time. "My main concern is having to give birth in a car," she said.
More than a hundred rural hospitals have stopped delivering babies since 2021, according to the Center for Healthcare Quality and Payment Reform, a nonprofit organization. Such closures are often blamed on shortages of staff and money.
About 58% of South Dakota counties have no birthing facilities, the second-highest rate among states, after North Dakota, according to March of Dimes. And the South Dakota health department says pregnant womenand infants in the state, especially those who are Black or Native American, experience high rates of complications and death.
Winner Regional Health serves rural communities, including parts of the Rosebud Sioux Indian Reservation, in South Dakota and Nebraska. It delivered 107 babies last year, down from 158 in 2021, said CEO Brian Williams.
The nearest birthing hospitals are in rural towns an hour or more from Winner. But several women said driving to those facilities would take them through areas without reliable cellphone service, which could be a problem if they have an emergency along the way.
KFF Health News spoke with five patients from the Winner area who planned to deliver at Avera St. Mary's Hospital in Pierre, about 90 miles from Winner, or at one of the large medical centers in Sioux Falls, 170 miles away.
Hofeldt and her boyfriend drive every three weeks to her prenatal appointments at the Pierre hospital, which serves the small capital city and vast surrounding rural area. She'll have to make weekly trips closer to her due date. Neither of their jobs provides paid time off for such appointments.
"When you have to go to Pierre, you have to take almost the whole day off," said Hofeldt, who was born at the Winner hospital.
That means forfeiting pay while spending extra money on travel. Not everyone has gas money, let alone access to a car, and bus services are scarce in rural America. Some women also need to pay for child care during their appointments. And when the baby comes, family members may need to pay for a hotel.
Amy Lueking, Hofeldt's doctor in Pierre, said when patients can't overcome these barriers, obstetricians can give them home monitoring devices and offer phone- or video-based care. Patients can also receive prenatal care at a local hospital or clinic before connecting with a doctor at a birthing hospital, Lueking said.
However, some rural areas don't have access to telehealth. And some patients, such as Hofeldt, don't want to split up their care, form relationships with two doctors, and deal with logistics like transferring medical records.
During a recent appointment, Lueking glided an ultrasound device over Hofeldt's uterus. The "woosh-woosh" rhythm of the fetal heartbeat thumped over the monitor.
"I think it's the best sound in the whole wide world," Lueking said.
Hofeldt told Lueking she wanted her first delivery to be "as natural as possible."
But ensuring a birth goes according to plan can be difficult for rural patients. To guarantee they make it to the hospital on time, some schedule an induction, in which doctors use medicine or procedures to stimulate labor.
Katie Larson lives on a ranch near Winner in the town of Hamill, population 14. She had hoped to avoid having her labor induced.
Larson wanted to wait until her contractions began naturally, then drive to Avera St. Mary's in Pierre. But she scheduled an induction in case she didn't go into labor by April 13, her due date.
Larson ended up having to reschedule for April 8 to avoid a conflict with an important cattle sale she and her husband were preparing for.
"People are going to be either forced to pick an induction date when it wasn't going to be their first choice or they're going to run the risk of having a baby on the side of the road," she said.
Lueking said it's very rare for people to give birth while heading to the hospital in a car or ambulance. But last year, she said, five women who planned to deliver in Pierre ended up delivering in other hospitals' emergency rooms after rapidly progressing labor or weather made it too risky to drive long distances.
Nanette Eagle Star's plan was to deliver at the Winner hospital, five minutes from home, until the hospital announced it would be closing its labor and delivery unit. She then decided to give birth in Sioux Falls, because her family could save money by staying with relatives there.
Eagle Star's plan changed again when she went into early labor and the weather was too dangerous to drive or take a medical helicopter to Sioux Falls.
"It happened so fast, in the middle of a snowstorm," she said.
Eagle Star delivered at the Winner hospital after all, but in the ER, without an epidural pain blocker since no anesthesiologist was available. It was just three days after the birthing unit closed.
The end of labor and delivery services at Winner Regional Health isn't just a health issue, local women said. It also has emotional and financial impacts on the community.
Eagle Star fondly recalls going to doctor appointments with her sisters when she was a child. As soon as they arrived, they'd head to a hallway with baby photos taped to the wall and begin "a scavenger hunt" for Polaroids of themselves and their relatives.
"On both sides it was just filled with babies' pictures," Eagle Star said. She remembers thinking, "look at all these cute babies that were born here in Winner."
Hofeldt said many locals are sad their babies won't be born in the same hospital they were.
Anora Henderson, a family physician, said a lack of maternity care can lead to poor outcomes for infants. Those babies may develop health problems that will require lifelong, often expensive care and other public support.
"There is a community effect," she said. "It's just not as visible and it's farther down the road."
Henderson resigned in May from Winner Regional Health, where she delivered vaginal births and assisted on cesarean sections. The last baby she delivered was Eagle Star's.
To be designated a birthing hospital, facilities must be able to conduct C-sections and provide anesthesia 24/7, Henderson explained.
Williams, the hospital's CEO, said Winner Regional Health hasn't been able to recruit enough medical professionals trained in those skills.
For the last several years, the hospital was only able to offer birthing services by spending about $1.2 million a year on temporary physicians, he said, and it could no longer afford to do that.
Another financial challenge is that many births at rural hospitals are covered by Medicaid, the federal and state program serving people with low incomes or disabilities. The program typically pays about half of what private insurers do for childbirth services, according to a 2022 report by the U.S. Government Accountability Office.
Williams said about 80% of deliveries at Winner Regional Health were covered by Medicaid.
Obstetric units are often the biggest financial drain on rural hospitals, and therefore they're frequently the first to close when a hospital is struggling, the GAO report said.
Williams said the hospital still provides prenatal care and that he'd love to restart deliveries if he could hire enough staff.
Henderson, the physician who resigned from the Winner hospital, has witnessed the decline in rural maternity care over decades.
She remembers tagging along with her mother for appointments before her sister was born. Her mother traveled about 100 miles each way after the hospital in the town of Kadoka shuttered in 1979.
Henderson practiced for nearly 22 years at Winner Regional Health, sparing women from having to travel to give birth like her mother did.
Over the years, she took in new patients as a nearby rural hospital and then an Indian Health Service facility closed their birthing units. Then, Henderson's own hospital stopped deliveries.
"What's really frustrating me now is I thought I was going to go into family medicine and work in a rural area and that's how we were going to fix this, so people didn't have to drive 100 miles to have a baby," she said.
When people call large insurance brokerages seeking free assistance in choosing Medicare Advantage plans, they're often offered assurances such as this one from eHealth: "Your benefit advisors will find plans that match your needs — no matter the carrier."
About a third of enrollees do seek help in making complex decisions about whether to enroll in original Medicare or select among private-sector alternatives, called Medicare Advantage.
Now a blockbuster lawsuit filed May 1 by the federal Department of Justice alleges that insurers Aetna, Elevance Health (formerly Anthem), and Humana paid "hundreds of millions of dollars in kickbacks" to large insurance brokerages — eHealth, GoHealth, and SelectQuote. The payments, made from 2016 to at least 2021, were incentives to steer patients into the insurer's Medicare Advantage plans, the lawsuit alleges, while also discouraging enrollment of potentially more costly disabled beneficiaries.
Policy experts say the lawsuit will add fuel to long-running concerns about whether Medicare enrollees are being encouraged to select the coverage that is best for them — or the one that makes the most money for the broker.
Medicare Advantage plans, which may include benefits not covered by the original government program, such as vision care or fitness club memberships, already cover more than half of those enrolled in the federal health insurance program for seniors and people with disabilities. The private plans have strong support among Republican lawmakers, but some research shows they cost taxpayers more than traditional Medicare per enrollee.
The plans have also drawn attention for requiring patients to get prior authorization, a process that involves gaining approval for higher-cost care, such as elective surgeries, nursing home stays, or chemotherapy, something rarely required in original Medicare. Medicare Advantage plans are under the microscope for aggressive marketing and sales efforts, as outlined in a recent report from Sen. Ron Wyden (D-Ore.). During the last year of the Biden administration, regulators put in place a rule that reined in some broker payments, although parts of that rule are on hold pending a separate court case filed in Texas by regulation opponents.
The May DOJ case filed in the U.S. District Court for the District of Massachusetts alleges insurers labeled payments as "marketing" or "sponsorship" fees to get around rules that set caps on broker commissions. These payments from insurers, according to the lawsuit, added incentives — often more than $200 per enrollee — for brokers to direct Medicare beneficiaries toward their coverage "regardless of the quality or suitability of the insurers' plans." The case joins the DOJ in a previously filed whistleblower lawsuit brought by a then-employee of eHealth.
"In order to influence the market, the Defendant Insurers understood that they needed to make greater, illicit payments in addition to the permitted (but capped) commissions," the lawsuit alleges.
In one example cited, the lawsuit says insurer Anthem paid broker GoHealth "more than $230 million in kickbacks" from 2017 to at least 2021 in exchange for the brokerage to hit specified sales targets in payments often referred to as "marketing development funds."
Insurers and brokers named in the case pushed back. Aetna, Humana, Elevance, eHealth, and SelectQuote each sent emailed statements to KFF Health News disputing the allegations and saying they would fight them in court. EHealth spokesperson Will Shanley, for example, wrote that the brokerage "strongly believes the claims are meritless and remains committed to vigorously defending itself." GoHealth posted online a response denying the allegations.
The DOJ lawsuit is likely to add to the debate over the role of the private sector in Medicare with vivid details often drawn from internal emails among key insurance and brokerage employees. The case alleges that brokers knew that Aetna, for example, saw the payments as a "shortcut" to increase sales, "instead of attracting beneficiaries through policy improvements or other legitimate avenues," the lawsuit said.
One eHealth executive in a 2021 instant message exchange with a colleague that is cited in the lawsuit allegedly said incentives were needed because the plans themselves fell short: "More money will drive more sales [be]cause your product is dog sh[*]t."
The DOJ case focuses on large insurance brokerages, which often rely on national marketing efforts to gain customers, rather than mom-and-pop insurance offices.
The filing, which alleges violations under the federal False Claims Act, outlines some of the problems consumers could face because of those payments, including being enrolled or switched into plans without their express permission, and getting coverage that didn't meet their needs.
A cancer patient, for example, was switched from the original Medicare program into a private-sector managed-care plan by a large brokerage firm, according to the lawsuit, only to get hit with $17,000 in ongoing treatment costs that would have been covered without the change. Another person calling for free advice later discovered she had been enrolled without permission into a plan with a different insurer than she had previously chosen.
Meanwhile, people with disabilities looking to enroll in private-sector Medicare Advantage plans had their calls ignored or rerouted by systems designed to weed out disabled people, especially if they were under age 65, the lawsuit alleges. That's because the insurers knew that disabled beneficiaries usually cost more to cover than those without medical problems, the case alleges. Medicare plans are not allowed to discriminate against people with disabilities.
Still, private insurers are allowed to offer commissions to brokers — or not.
Congress and regulators, however, concerned about insurers' potential financial influence over beneficiaries' choice of plans, set maximum commissions and limited payments for other things, such as administrative costs, to a vaguer standard: their fair market value. (Under the Biden-era rule that's on hold, administrative fees would have been capped at $100 per enrollment.) On commissions, the national cap in 2021 — the final year cited in the lawsuit — was $539 per enrollment for the initial year, with higher amounts in some states, including California and New Jersey, the lawsuit said.
The allowed commission rates have risen to a maximum in the low $600s per person in most states this year. Those amounts are higher than what brokers earn if a client enrolls in original Medicare and buys a supplemental drug plan, for which the commission is capped at $109 for the initial year.
Some policy experts say that pay structure alone — aside from any of the allegations in the lawsuit — creates an uneven playing field between the private-sector plans and the original program.
"It's not my intent to paint all agents and brokers with the same brushstroke, but there are significant financial incentives to steer people toward Medicare Advantage in general," said David Lipschutz, co-director of law and policy at the Center for Medicare Advocacy.
While brokers can be helpful in sorting out complexities, other options are available. Lipschutz suggested that consumers seek information from their federally funded State Health Insurance Assistance Program, which can advise beneficiaries about Medicare options, are not affiliated with insurers, and don't receive commissions.
While encouraged that the Trump administration filed the case under investigations that began under the Biden administration, policy experts say Congress and insurers need to do more.
"What we see in this lawsuit highlights the terrible incentives that desperately need Congress to reform," said Brian Connell, a vice president at the Leukemia & Lymphoma Society, an advocacy group.
Right now, however, Congress is embroiled in budget battles amid calls by the Trump administration to drastically cut federal spending.
"It doesn't seem like it's high in the queue," said Zachary Baron, director of the Center for Health Policy and the Law at Georgetown University's O'Neill Institute. Some members of Congress may push for more changes to Medicare Advantage, Baron said, "but the real question is whether there will be bipartisan interest."
The large amounts of money that the lawsuit alleges were involved, though, might add legislative momentum.
"This is money not being spent on care, money not going to providers of health care services," Lipschutz said. "In my mind, it's a lot of wasted payment. It's pretty staggering."
In the dim basement of a Salt Lake City pharmacy, hundreds of amber-colored plastic pill bottles sit stacked in rows, one man's defensive wall in a tariff war.
Independent pharmacist Benjamin Jolley and his colleagues worry that the tariffs, aimed at bringing drug production to the United States, could instead drive companies out of business while raising prices and creating more of the drug shortages that have plagued American patients for several years.
Jolley bought six months' worth of the most expensive large bottles, hoping to shield his business from the 10% across-the-board tariffs on imported goods that President Donald Trump announced April 2. Now with threats of additional tariffs targeting pharmaceuticals, Jolley worries that costs will soar for the medications that will fill those bottles.
In principle, Jolley said, using tariffs to push manufacturing from China and India to the U.S. makes sense. In the event of war, China could quickly stop all exports to the United States.
"I understand the rationale for tariffs. I'm not sure that we're gonna do it the right way," Jolley said. "And I am definitely sure that it's going to raise the price that I pay my suppliers."
Squeezed by insurers and middlemen, independent pharmacists such as Jolley find themselves on the front lines of a tariff storm. Nearly everyone down the line — drugmakers, pharmacies, wholesalers, and middlemen — opposes most tariffs.
Slashing drug imports could trigger widespread shortages, experts said, because of America's dependence on Chinese- and Indian-made chemical ingredients, which form the critical building blocks of many medicines. Industry officials caution that steep tariffs on raw materials and finished pharmaceuticals could make drugs more expensive.
"Big ships don't change course overnight," said Robin Feldman, a UC Law San Francisco professor who writes about prescription drug issues. "Even if companies pledge to bring manufacturing home, it will take time to get them up and running. The key will be to avoid damage to industry and pain to consumers in the process."
Trump on April 8 said he would soon announce "a major tariff on pharmaceuticals," which have been largely tariff-free in the U.S. for 30 years.
"When they hear that, they will leave China," he said. The U.S. imported $213 billion worth of medicines in 2024 — from China but also India, Europe, and other areas.
Trump's statement sent drugmakers scrambling to figure out whether he was serious, and whether some tariffs would be levied more narrowly, since many parts of the U.S. drug supply chain are fragile, drug shortages are common, and upheaval at the FDA leaves questions about whether its staffing is adequate to inspect factories, where quality problems can lead to supply chain crises.
On May 12, Trump signed an executive order asking drugmakers to bring down the prices Americans pay for prescriptions, to put them in line with prices in other countries.
Meanwhile, pharmacists predict even the 10% tariffs Trump has demanded will hurt: Jolley said a potential increase of up to 30 cents a vial is not a king's ransom, but it adds up when you're a small pharmacy that fills 50,000 prescriptions a year.
"The one word that I would say right now to describe tariffs is ‘uncertainty,'" said Scott Pace, a pharmacist and owner of Kavanaugh Pharmacy in Little Rock, Arkansas.
To weather price fluctuations, Pace stocked up on the drugs his pharmacy dispenses most.
"I've identified the top 200 generics in my store, and I have basically put 90 days' worth of those on the shelf just as a starting point," he said. "Those are the diabetes drugs, the blood pressure medicines, the antibiotics — those things that I know folks will be sicker without."
Pace said tariffs could be the death knell for the many independent pharmacies that exist on "razor-thin margins" — unless reimbursements rise to keep up with higher costs.
Unlike other retailers, pharmacies can't pass along such costs to patients. Their payments are set by health insurers and pharmacy benefit managers largely owned by insurance conglomerates, who act as middlemen between drug manufacturers and purchasers.
Neal Smoller, who employs 15 people at his Village Apothecary in Woodstock, New York, is not optimistic.
"It's not like they're gonna go back and say, well, here's your 10% bump because of the 10% tariff," he said. "Costs are gonna go up and then the sluggish responses from the PBMs — they're going to lead us to lose more money at a faster rate than we already are."
Smoller, who said he has built a niche selling vitamins and supplements, fears that FDA firings will mean fewer federal inspections and safety checks.
"I worry that our pharmaceutical industry becomes like our supplement industry, where it's the wild West," he said.
Narrowly focused tariffs might work in some cases, said Marta Wosińska, a senior fellow at the Brookings Institution's Center on Health Policy. For example, while drug manufacturing plants can cost $1 billion and take three to five years to set up, it would be relatively cheap to build a syringe factory — a business American manufacturers abandoned during the covid-19 pandemic because China was dumping its products here, Wosińska said.
It's not surprising that giants such as Novartis and Eli Lilly have promised Trump they'll invest billions in U.S. plants, she said, since much of their final drug product is made here or in Europe, where governments negotiate drug prices. The industry is using Trump's tariff saber-rattling as leverage; in an April 11 letter, 32 drug companies demanded European governments pay them more or face an exodus to the United States.
Brandon Daniels, CEO of supply chain company Exiger, is bullish on tariffs. He thinks they could help bring some chemical manufacturing back to the U.S., which, when coupled with increased use of automation, would reduce the labor advantages of China and India.
"You've got real estate in North Texas that's cheaper than real estate in Shenzhen," he said at an economic conference April 25 in Washington, referring to a major Chinese chemical manufacturing center.
But Wosińska said no amount of tariffs will compel makers of generic drugs, responsible for 90% of U.S. prescriptions, to build new factories in the U.S. Payment structures and competition would make it economic suicide, she said.
Several U.S. generics firms have declared bankruptcy or closed U.S. factories over the past decade, said John Murphy, CEO of the Association for Accessible Medicines, the generics trade group. Reversing that trend won't be easy and tariffs won't do it, he said.
"There's not a magic level of tariffs that magically incentivizes them to come into the U.S.," he said. "There is no room to make a billion-dollar investment in a domestic facility if you're going to lose money on every dose you sell in the U.S. market."
His group has tried to explain these complexities to Trump officials, and hopes word is getting through. "We're not PhRMA," Murphy said, referring to the powerful trade group primarily representing makers of brand-name drugs. "I don't have the resources to go to Mar-a-Lago to talk to the president myself."
Many of the active ingredients in American drugs are imported. Fresenius Kabi, a German company with facilities in eight U.S. states to produce or distribute sterile injectables — vital hospital drugs for cancer and other conditions — complained in a letter to U.S. Trade Representative Jamieson Greer that tariffs on these raw materials could paradoxically lead some companies to move finished product manufacturing overseas.
Fresenius Kabi also makes biosimilars, the generic forms of expensive biologic drugs such as Humira and Stelara. The United States is typically the last developed country where biosimilars appear on the market because of patent laws.
Tariffs on biosimilars coming from overseas — where Fresenius makes such drugs — would further incentivize U.S. use of more expensive brand-name biologics, the March 11 letter said. Biosimilars, which can cost a tenth of the original drug's price, launch on average 3-4 years later in the U.S. than in Canada or Europe.
In addition to getting cheaper knockoff drugs faster, European countries also pay far less than the United States for brand-name products. Paradoxically, Murphy said, those same countries pay more for generics.
European governments tend to establish more stable contracts with makers of generics, while in the United States, "rabid competition" drives down prices to the point at which a manufacturer "maybe scrimps on product quality," said John Barkett, a White House Domestic Policy Council member in the Biden administration.
As a result, Wosińska said, "without exemptions or other measures put in place, I really worry about tariffs causing drug shortages."
Smoller, the New York pharmacist, doesn't see any upside to tariffs.
"How do I solve the problem of caring for my community," he said, "but not being subject to the emotional roller coaster that is dispensing hundreds of prescriptions a day and watching every single one of them be a loss or 12 cents profit?"
