Sue Sheridan's baby boy, Cal, suffered brain damage from undetected jaundice in 1995. Helen Haskell's 15-year-old son, Lewis, died after surgery in 2000 because weekend hospital staffers didn't realize he was in shock. The episodes turned both women into advocates for patients and spurred research that made American health care safer.
On April 1, the Trump administration slashed the organization that supported that research — the Agency for Healthcare Research and Quality, or AHRQ — and fired roughly half of its remaining employees as part of a perplexing reorganization of the federal Health and Human Services Department.
Haskell, of Columbia, South Carolina, has done research and helped write AHRQ-published surveys and guidebooks on patient engagement for hospitals. The dissolution of AHRQ is dislodging scores of experienced patient-safety experts, a brain drain that will be impossible to rectify, she said.
Survey data gathered by AHRQ provides much of what is known about hospitalizations for motor accidents, measles, methamphetamine, and thousands of other medical issues.
"Nobody does these things except AHRQ," she said. "They're all we've got. And now the barn door's closed."
HHS Secretary Robert F. Kennedy Jr. posted on the social platform X on April 1 that layoffs at HHS, aimed at reducing the department's workforce by about 20,000 employees, were the result of alleged inefficacy. "What we've been doing isn't working," he said. "Despite spending $1.9 trillion in annual costs, Americans are getting sicker every year."
But neither Kennedy nor President Donald Trump have explained why individual agencies such as AHRQ were targeted for cuts or indicated whether any of their work would continue.
At their first meeting with the leadership of AHRQ last month, officials from Trump's Department of Government Efficiency said that they didn't know what the agency did — and that its budget would be cut by 80% to 90%, according to two people with knowledge of the meeting who were granted anonymity because of fears of retribution.
On March 28, the administration said AHRQ would merge with HHS' Office of the Assistant Secretary for Planning and Evaluation.
An AHRQ spokesperson, Rachel Seeger, said its acting chief, Mamatha Pancholi, was unavailable to answer questions.
Created on the foundation of an earlier agency in 1999, AHRQ has had two major functions: collecting survey data on U.S. health care expenditures, experiences, and outcomes; and funding research aimed at improving the safety and delivery of health care. It also has published tools and guidelines to enhance patient safety.
Its latest budget of $513 million amounts to about 0.04% of HHS spending.
"If you're going to spend $5 trillion a year on health care, it would be nice to know what the best use of that money is," said a senior AHRQ official who spoke on condition of anonymity for fear of losing his job. "To gut a 300-member, $500 million agency for no other reason than to placate a need to see blood seems really shortsighted."
Newly sworn-in FDA Commissioner Marty Makary, a surgeon who has advocated for patient safety, wrote or co-authored at least 10 research papers supported by AHRQ funding since 1998. AHRQ research and guidelines played a key role in lowering the incidence of hospital-acquired infections — such as deadly blood infections caused by contaminated IV lines, which fell 28% from 2015 to 2023, according to the Centers for Disease Control and Prevention.
Medical residents training in the 1980s were taught that such infections were an inevitable, often fatal byproduct of heart surgery, but AHRQ-funded research "showed that fairly simple checklists about preventing infections would be effective at going to zero," said Richard Kronick, a University of California-San Diego researcher who led AHRQ from 2013 to 2016.
Medical errors caused by missed diagnoses, drug errors, hospital infections, and other factors kill and maim tens of thousands of Americans each year. Makary published a controversial study in 2016 hypothesizing that errors killed 250,000 people a year in the U.S. — making medical mistakes the nation's third-leading cause of death.
"There are all kinds of terrible things about our health care system's outcomes and how we pay for it, the most expensive care in the world," Kronick said. "Without AHRQ, we'd be doing even worse."
AHRQ-funded researchers such as Hardeep Singh at Baylor College of Medicine have chipped away at patient safety risks for more than two decades. Singh devises ways to integrate technologies like telemedicine and artificial intelligence into electronic health records to alert doctors to potential prescribing errors or misdiagnoses.
Singh has 15 scholars and support staff members supported by three AHRQ grants worth about $1.5 million, he said. The elimination of the agency's office that funds outside researchers, among the cuts announced this week, is potentially "career-ending," he said. "We need safety research to protect our patients from harms in health care. No organization in the world does more for that than AHRQ."
Republicans have long been skeptical of AHRQ and the agency that preceded it. Some doctors saw it as meddling in their medical practices, while some GOP Congress members viewed it as duplicating the mission of the National Institutes of Health.
But when the Trump administration proposed merging it with NIH in 2018, a House-ordered study into health research priorities validated AHRQ's valuable role.
Now, the naysayers have triumphed.
Gordon Schiff, a Harvard Medical School internist who has received AHRQ funding since 2001, was among the first to learn about policy changes there when in February he got an email from the editors of an AHRQ patient-safety website informing him "regretfully" that a 2022 case study on suicide prevention he co-authored had been removed "due to a perception that it violates the White House policy on websites ‘that inculcate or promote gender ideology.'"
The article was not about gender issues. It briefly mentioned that LGBTQ men were at a higher risk for suicide than the general population. Schiff was offered the option of removing the LGBTQ reference but refused. He and Harvard colleague Celeste Royce have sued AHRQ, HHS, and the Office of Personnel Management over removal of the article.
"All we were doing was presenting evidence-based risk factors from the literature," he said. "To censor them would be a violation of scientific integrity and undermine the trustworthiness of these websites."
PSNet, the AHRQ publication where Schiff and Royce's article appeared, has been dissolved, although its website was still up as of April 2. Roughly half of AHRQ's 300 staffers resigned following the initial DOGE warning; 111 staff members were fired April 1, according to an email that a top executive, Jeffrey Toven, sent to employees and was shown to KFF Health News. AHRQ's remaining leadership was in the dark about Kennedy's plans, he said.
HHS spokespeople did not respond to requests for comment. Stephen Parente, a University of Minnesota finance professor who said he consults informally with Trump health officials, said much of AHRQ's work could be done by others. Its most vital services have been surveys that Westat, a private research company, performs for AHRQ on contract, said Parente, who was chief economist for health policy in the first Trump administration.
At the height of the covid pandemic, he said, data produced by AHRQ and other government sources were outclassed by private sources. To track covid, he relied on daily feeds of private insurance data from around the country.
Still, Parente said, the virtual disappearance of AHRQ means "we're going to lose a culture of research that is measured, thoughtful, and provides a channel for young investigators to make their marks."
A climate of deep depression has settled over the agency's Rockville, Maryland, headquarters, the unnamed AHRQ official said: "Almost everyone loves their job here. We're almost all PhDs in my center — a very collegial, talented group."
The official said he was "generally skeptical" that AHRQ's merger with the assistant secretary's office would keep its mission alive. The Centers for Medicare & Medicaid Services and the CDC conduct some health system quality research, but they are also losing staff, Harvard's Schiff noted.
One of Schiff's current AHRQ projects involved interviewing late-stage cancer patients to determine whether they could have been diagnosed earlier.
"The general public, I think, would like cancer to be diagnosed earlier, not when it's stage 4 or stage 3," he said. "There are things we could learn to improve our care and get more timely diagnosis of cancer."
"Medical errors and patient safety risks aren't going to go away on their own," he said.
With input from Sheridan and other mothers of children who suffered from jaundice-related brain damage, AHRQ launched research that led to a change in the standard of care whereby all newborns in the U.S. are tested for jaundice before discharge from hospitals. Cases of jaundice-related brain damage declined from 7 per 100,000 to about 2 per 100,000 newborns from 1997 to 2012.
The misfortune of Lewis, Haskell's son, led to a change in South Carolina law and later to a national requirement for hospitals to enable patients to demand emergency responses under certain circumstances.
Singh, a leading researcher on AI in health care, sees bitter irony in the way the Elon Musk-led DOGE has taken an ax to AHRQ, which recently put out a new request for proposals to study the technology. "Some think AI will fix health care without a human in the loop," Singh said. "I doubt we get there by dismantling people who support or perform patient safety research. You need a human in the loop."
Five years ago, the CEO of one of the largest pain clinic companies in the Southeast was sentenced to more than three years in prison after being convicted in a $4 million illegal kickback scheme.
But after just four months behind bars, John Estin Davis walked free. President Donald Trump commuted Davis' sentence in the last days of his first term. In a statement explaining the decision, the White House said that "no one suffered financially" from Davis' crime.
In court, however, the Trump administration was saying something very different. As the president let him go, the Department of Justice alleged in a civil lawsuit that Davis and his company defrauded taxpayers out of tens of millions of dollars with excessive urine drug testing. The DOJ alleged that Comprehensive Pain Specialists made such a "staggering" sum from cups of pee that employees had given the testing a profit-minded nickname: "liquid gold."
Davis and the company denied all allegations in court filings and settled the DOJ's fraud lawsuit without any determination of liability. Davis declined to comment for this article.
Since returning to the White House, Trump has said he will target fraud in Medicare, Medicaid, and Social Security, and his Republican allies in Congress have made combating fraud a key argument in their plans to slash spending on Medicaid, which provides health care for millions of low-income and disabled Americans. During an address to Congress last month, Trump said his administration had found "hundreds of billions of dollars of fraud" without citing any specific examples of fraud.
"Taken back a lot of that money," Trump said. "We got it just in time."
But Trump's history of showing leniency to convicted fraudsters contrasts with his present-day crackdown. In his first and second terms, Trump has granted pardons or commutations to at least 68 people convicted of fraud crimes or of interfering with fraud investigations, according to a KFF Health News review of court and clemency records, DOJ press releases, and news reports. At least 13 of those fraudsters were convicted in cases involving more than $1.6 billion of fraudulent claims filed with Medicare and Medicaid, according to the Department of Justice.
And as one of the first actions of his second term, Trump fired 17 independent inspectors general responsible for rooting out fraud and waste in government.
"It sends a really bad message and really hurts DOJ efforts at creating deterrence," said Jacob Elberg, a former assistant U.S. attorney and law professor at Seton Hall University in New Jersey. "In order to reduce health care fraud, you need people both to be afraid of getting in trouble, but also for people to believe in the legitimacy of the system."
Elberg said considerable fraud in Medicare and Medicaid exists largely because the programs' "pay-and-chase models" prioritize paying for patient care first and tracking down stolen dollars second. To prevent more fraud, the programs would likely need to be redesigned in ways that would be slower and more cumbersome for all patients, Elberg said.
Regardless, Elberg said the president's claimed focus on fraud appears to be a pretext for slashing spending that has been legally appropriated by Congress. Trump has empowered the Elon Musk-led Department of Government Efficiency, which he established and named by executive order, to make deep cuts in federal budgets, halting some medical research and aid programs in addition to cutting spending on climate change, transgender health, and diversity, equity, and inclusion programs.
"What's been the focal point to date of the administration is not what anybody has ever referred to as health care fraud," Elberg said. "There is a real blurring — a seemingly intentional blurring — between what is actually fraud and what is just spending that they are not in favor of."
Jerry Martin, who served as a U.S. attorney for the Middle District of Tennessee under President Barack Obama and now represents health care fraud whistleblowers, also said Trump's focus on fraud appeared to be "just a platform to attack things that they don't agree with" rather than "a genuine desire to root out and combat fraud."
Even so, Martin said some of his whistleblower clients have been emboldened.
"I've had clients repeat back to me 'President Trump says fraud is a priority,'" Martin said. "People are listening to it. But I don't know that what he's saying translates into what they believe."
The White House did not respond to requests for comment for this article.
A Billion-Dollar Fraud Case and Needless Eye Injections
Presidents enjoy the unique authority to erase federal convictions and prison sentences with pardons and commutations. In theory, the power is intended to be a final bulwark against injustice or overly harsh punishment. But many presidents have been accused of using the pardon power to reward powerful allies and close associates as they leave the White House.
Trump issued about 190 pardons and commutations in the final two months of his first term, including for some health care fraudsters convicted of schemes with astonishing costs.
For example, Trump granted a commutation to Philip Esformes, a Florida health care executive convicted in 2019 of a $1.3 billion Medicare and Medicaid fraud scheme. After he was sentenced, DOJ announced in a press release that "the man behind one of the biggest health care frauds in history will be spending 20 years in prison." Trump freed him 14 months later.
Trump also granted a commutation to Salomon Melgen, a Florida eye doctor who was serving a 17-year prison sentence for defrauding Medicare of $42 million. Melgen falsely diagnosed patients with eye diseases, then gave them unnecessary care, including laser treatments and painful eye injections, according to DOJ and court documents.
"Salomon Melgen callously took advantage of patients who came to him fearing blindness," said a DOJ news release after Melgen was sentenced in 2018. "They received medically unreasonable and unnecessary tests and procedures that victimized his patients and the American taxpayer."
DOJ: $70M Spent on 'Excessive' Urine Testing
Despite the flurry of pardons and commutations at the end of Trump's first term, the leniency he showed Davis was unique. Davis was the only convicted health care fraudster to receive clemency while the Trump administration was simultaneously accusing him of more fraud.
As CEO of Comprehensive Pain Specialists from 2011 to 2017, Davis oversaw a rapid expansion to more than 60 locations across 12 states, according to federal court documents.
He was indicted in 2018 for using his CEO position to refer Medicare patients in need of medical equipment to a conspirator in return for kickbacks paid through a shell company, according to court documents. He was convicted at trial in April 2019 of defrauding Medicare.
Three months later, the DOJ filed a fraud lawsuit against Davis and CPS that piggybacked on the claims of seven whistleblowers. The lawsuit alleged that CPS collected more than $70 million from federal insurance programs for urine drug testing, most of which was "excessive," and that an audit of a sampling of the tests had found at least 93% "lacked medical necessity."
Typically, government insurance programs pay for urine testing so pain clinics can verify that patients are taking their prescriptions properly and not abusing any other drugs, which could contribute to an overdose. Patients could be tested as little as once a year or as often as monthly depending on their level of risk, according to the DOJ lawsuit.
But Comprehensive Pain Specialists performed "myriad urine drug testing on virtually every CPS patient on virtually every visit" then conducted "at least 16 different types of tests" on each sample, and sometimes as many as 51, according to the lawsuit.
Trump commuted Davis' sentence for his criminal conviction in January 2021 as the DOJ was finalizing a settlement in the civil lawsuit. The commutation was supported by country music star Luke Bryan, according to a White House statement.
Months later, with President Joe Biden in office, CPS and its owners agreed to repay $4.1 million — less than 10% of the damages sought in the suit — and the case was closed.
In the settlement, Davis agreed not to take any job where he would ever again bill Medicare or other federal health care programs. He was not required to personally repay anything.
Martin, who represented one of the whistleblowers who first raised allegations against Davis and CPS, said the leniency that Trump showed to him and other health care fraudsters may discourage DOJ employees from pursuing similar investigations during his second term.
"There are a lot of rank-and-file people who are operating at the lowest point in their professional careers, where they've seen a lot of their work essentially be water under the bridge," Martin said. "That's got to be really demoralizing."
It's a holy grail of health care: forcing the industry to reveal prices negotiated between health plans and hospitals — information that had long been treated as a trade secret. And among the flurry of executive orders President Donald Trump signed during his first five weeks back in office was a promise to "Make America Healthy Again" by giving patients accurate health care prices.
The goal is to force hospitals and health insurance companies to make it easier for consumers to compare the actual prices of medical procedures and prescription drugs. Trump gave his administration until the end of May to come up with a standard and a mechanism to make sure the health care industry complies.
But Trump's 2025 order is also a symbol of how little progress the country has made since he issued a similar directive nearly six years ago. Consumers find it only partially useful, and the quality of the information is spotty.
A ‘Bold' First Step That Fizzled
The 2019 order was "pretty bold," said Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News. "They basically went at the providers and the plans and said, ‘All this data you think is confidential we're not going to make confidential anymore.'"
What followed was, to consumer advocacy groups, a disappointment. Hospitals and insurers posted on websites voluminous, complex, and confusing data about their prices. The information has been a challenge for even experts in health care pricing to navigate, let alone consumers. Some members of Congress filed legislation to put the force of law behind price transparency requirements; those bills died. And President Joe Biden's administration was criticized for not more stringently enforcing the regulations, with one consumer advocacy group even buying a Super Bowl ad featuring the rapper Fat Joe alleging that "hospitals and insurers hide their prices."
Trump's new order, signed in February, said that hospitals and health plans "were not adequately held to account when their price transparency data was incomplete or not even posted at all."
The Government Accountability Office reported in October that the Centers for Medicare & Medicaid Services didn't know whether prices reported by the health care industry were correct or complete. But CMS, which regulates hospitals, now plans to "systematically monitor compliance" and help institutions understand the requirements, said Catherine Howden, an agency spokesperson.
Howden did not answer questions about whether CMS staffers overseeing price transparency compliance have been fired as part of the Trump administration's wide-ranging effort to cut the federal workforce.
'Zombie' Rates and Other Inconsistencies
Meanwhile, independent researchers have found numerous problems with the quality of price data both hospitals and health insurers do share with consumers.
A recent report from the Peterson-KFF Health System Tracker found that data reported by four health insurers in New York City often included prices that they say they pay hospitals for services that those health providers don't — or can't — provide. These are called "ghost" or "zombie" rates. For example, the health plans reported dentists, optometrists, and audiologists receiving payments for knee replacements, gastrointestinal exams, and other procedures unrelated to their specialties.
In other cases, the data included different prices for the same service paid for by the same insurer at the same hospital. UnitedHealthcare, for example, reported paying New York-Presbyterian/Weill Cornell Medical Center three rates — $47,000, $64,000, and $70,000 — to treat a heart attack.
Or, the insurers reported paying the same price for vastly different services. Aetna, for example, said it paid exactly $6,292 to Mount Sinai Beth Israel hospital for the treatment of respiratory infections, heart attacks, cancers of the digestive tract, kidney and urinary tract infections, and psychosis.
Neither UnitedHealthcare nor Aetna addressed the discrepancies in the data. Cole Manbeck, a spokesperson for UnitedHealthcare, said the insurer has met price transparency requirements and urged members "to use our cost-estimator tools for exact costs based on their specific health plan." Aetna spokesperson Shelly Bendit referred questions to AHIP, a lobbying and trade association for insurers.
Health insurers have "strongly supported" price transparency, said Chris Bond, a spokesperson for AHIP. The group will work with the Trump administration to provide transparency "in a way that is meaningful for the end user, while also promoting a competitive private market," Bond said.
What's a Consumer To Do?
Estimates and total prices aren't very useful for consumers, who are mainly interested in what they'll ultimately have to pay out-of-pocket, said David Cutler, a professor of applied economics at Harvard University. That can vary by health plan, depending on deductibles, copayments, and other fees.
"Most of the price transparency information doesn't have that," he said.
It also doesn't give consumers information about the quality of care, Cutler added, which can lead to an old bias. "It's kind of like wine when you go to the restaurant," he said. "People assume that the more expensive wine is better."
Cutler said he's skeptical that price transparency will lower costs for patients. But he said it may offer insight to hospitals and health plans about what their competitors are charging and paying for services — knowledge that could inadvertently lead to price increases if hospitals that receive a lower rate than a competitor demand higher reimbursement from health plans.
Trump's recent executive order notes that the top quarter of the most expensive health service prices have dropped by 6.3% a year since his 2019 order.
However, the same research referenced in the executive order showed that the bottom quarter of services got more expensive, at a rate of about 3.4% per year, according to the analysis by Turquoise Health, a health care price data firm that examined rates at more than 200 hospitals in the 10 largest U.S. markets.
Some patients say that with research and persistence, they've been able to make price transparency work for them.
Theresa Schmotzer, 50, of Goodyear, Arizona, said she used hospital price data to save nearly $3,000 on outpatient surgery to have a fibroid removed last year.
Schmotzer, who has health insurance, said the hospital first told her she would owe $3,700 for the procedure and wanted the payment upfront. But she was skeptical.
She said her health insurer was unable to quote a price for the procedure or specify how much she would owe. The morning of the surgery, Schmotzer said, she found a spreadsheet online at PatientRightsAdvocate.org that included different prices paid by insurers, including hers. The reported price for the procedure was closer to $700, she said.
Schmotzer said she took a printout of the spreadsheet to the hospital and presented it during preadmission. She paid her $300 deductible and told the hospital to bill her for the rest.
A few months later, she said, the bill arrived in the mail for the remaining $400, which she paid.
When people go for surgery and aren't clear upfront what the cost will be, it stokes fear, she said. "Because they're going in blind."
Next Steps
Hospitals say they want to work with federal regulators and comply with reporting requirements, said Ariel Levin, director of coverage policy for the American Hospital Association, which represents about 5,000 institutions. Levin said consumers should be given the price of services and "a more comprehensive estimate" that represents an entire episode of care and the amount they'll owe out-of-pocket, based on their health plan.
CMS has developed rules since Trump's 2019 order to make price information reported by hospitals and health plans easier to understand, and the agency has fined more than a dozen hospitals for failing to comply.
Federal rules allow hospitals to report an estimate, a price range, or a historical rate for their services, while health plans can adjust prices based on factors like the severity of the case, the length of treatment, and a patient's age.
KFF's Claxton said that such flexibility doesn't allow for "apples-to-apples comparisons" and that the data must be reliable before researchers can use it to better understand health care costs. "It doesn't seem to be that yet," he said.
Much remains to be done before price transparency lives up to expectations that it will increase competition and lower costs, said Katie Martin, chief executive of the Health Care Cost Institute, a nonprofit research group.
Price transparency alone is not a silver bullet, Martin said. It's "a critical first step" for employers, lawmakers, regulators, and others to better understand how money flows through the health care system and how to make it more efficient, she said. "It's not the whole thing."
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."