Now that the Republicans' big tax-and-spending bill has become law, new bureaucratic hurdles have emerged for millions of Americans who rely on Medicaid for health coverage. A provision in the new law dictates that, in most states, for the first time, low-income adults must start meeting work requirements to keep their coverage.
Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.
When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn't opposed to work requirements — in principle.
But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state's work requirements.
"I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I'm like, I know the process," Corporal said. "I've been in human services."
Corporal has been a social worker for more than two decades in Georgia and was familiar with the state's social service programs. For years, it had been her job to help others access benefit programs.
But her challenges with paperwork and the process had only begun.
Health advocates point to Georgia's system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.
Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.
Most states will have to set up verification systems similar to Georgia's, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.
For Corporal, 48, forgoing coverage wasn't an option. She had been diagnosed with pre-diabetes and had other medical concerns.
"I have breast cancer in my family history," she said. "So it was like, I gotta get my mammograms."
It offers Medicaid to adults — who otherwise wouldn't qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they're working, attending school, training for a job, or volunteering.
Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.
She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia's online portal.
"And we were denied. I was like, this makes no sense," said Corporal, who has a master's degree in social work. "I did everything right."
In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.
Corporal recently pulled up one of the denial notices on her cellphone to read aloud: "Your case was denied because you didn't submit the correct documents. And you didn't meet the qualifying activity requirement," she read from the email.
When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.
"Or, they'll say they called you, and we look at our call log. Nobody called me," she said. "And the letter will say, you missed your appointment, and it'll come on the same day" as it was scheduled.
Corporal's Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.
When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia's Department of Human Services, emailed this statement: "Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case."
Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants' documents. They include "rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents."
Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It's stressful, she said.
"It's still a nightmare, even once I got through the red tape and got approved," Corporal said. "Now maintaining it is bringing another level of anxiety."
But she wonders how anyone without her professional background manages to get into the program at all.
"I think the system has to be simplified," she said.
Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.
It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.
But for now, Corporal's experience remains typical. And many health advocates fear it will be replicated under Trump's budget law with its new national Medicaid work mandate.
"In Georgia, we have seen that people just can't get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn't file their paperwork or there's been some other glitch," said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.
Another state, Arkansas, tried work requirements in 2018.
But it didn't go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.
"A lot of the problems were similar to Georgia," she said, "in terms of the website closed at night, people couldn't get a hold of people."
Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse.
"What we're doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it," U.S. House Speaker Mike Johnson said during a June appearance on "The Megyn Kelly Show." "You're talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it's not being used for those purposes because it's been expanded under the last two Democrat presidents and to cover everybody. So, you've got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we're doing is restoring work requirements to Medicaid. OK, this is common sense."
National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.
"Work requirements don't work, except to cut people off of health insurance," she said.
The logistical steps required to report one's activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.
The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.
Mikell is a licensed truck driver but does not have coverage through that job. He's also an electrician who currently does property maintenance in exchange for free housing.
Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal.
"And I know it wasn't my device because I would go to the library and use the computer, I would try different devices, and I've had the same issues," he said. "Regardless of the device, it's something with the website."
Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.
"They said I was ineligible for everything because of a typo in the system or something, I don't know what it was. I eventually was able to speak to someone and she fixed it," he said.
This article is from a partnership with WABE and NPR.
A long list of Lynda Hollander's paternal relatives had heart disease, and several had undergone major surgeries. So when she hit her mid-50s and saw her cholesterol levels creeping up after menopause, she said, "I didn't want to take a chance."
A cardiologist told Hollander that based on factors like age, sex, cholesterol, and blood pressure, she faced a moderate risk of a major cardiac event, like a heart attack, within the next 10 years.
Doctors typically counsel such patients about the importance of diet and exercise, but Hollander, now 64, a social worker in West Orange, New Jersey, didn't have much room for improvement. She was already a serious runner, and although "I fall off the wagon once in a while," her diet was basically healthy. Attempts to lose weight didn't lower her cholesterol.
Her doctor explained that a coronary artery calcium test, something Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. Her doctor explained that a coronary artery calcium test, something Ms. Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. A brief and painless CT scan, it would indicate whether the fatty deposits called plaque were developing in the arteries leading to her heart.
When plaque ruptures, it can cause clots that block blood flow and trigger heart attacks. The scan would help determine whether Hollander would benefit from taking a statin, which could reduce plaque and prevent more from forming.
"The test is used by more people every year," said Michael Blaha, co-director of the preventive cardiology program at Johns Hopkins University. Calcium scans quadrupled from 2006 to 2017, his research team reported, and Google searches for related terms have risen even more sharply.
Yet "it's still being underused compared to its value," he said.
One reason is that although the test is comparatively inexpensive — sometimes up to $300, but often $100 or less — patients usually must pay for it out-of-pocket. Medicare rarely covers it, though some doctors argue that it should.
Patients with a CAC score of zero — no calcification — have lower risk than their initial assessments indicate and aren't candidates for cholesterol-lowering drugs. But Hollander's score was in the 50s — not high but not negligible.
"It was the first indication of what was going on inside my arteries," she said.
Though guidelines vary, cardiologists generally offer statins to patients with calcium scores over zero, and suggest higher intensity statins when scores exceed 100. At over 300, patients' risks approach those of people who've already had heart attacks; they may need still more aggressive treatment.
Hollander has taken a low dose of rosuvastatin (brand name: Crestor) ever since, supplemented by a non-statin drug, a shot called evolocumab (Repatha).
This is the way calcium testing is supposed to work. It's not a screening test for everyone. It's intended only for selected asymptomatic patients, ages 40 to 75, who have never had a heart attack or a stroke and are not already on cholesterol drugs.
If a doctor calculates the 10-year risk of atherosclerotic cardiovascular disease at 5% or lower, drugs are unnecessary for now. Over 20%, "there's no doubt the risk is sufficiently high to justify medication," said Philip Greenland, a preventive cardiologist at Northwestern University and co-author of a recent review in JAMA.
"It's the in-between range where it's more uncertain," he said, including "borderline" risk of 5% to 7.5% and "intermediate" risk of 7.5% to 20%.
Why add another measurement to these assessments, which already incorporate risk factors like smoking and diabetes?
"A risk score is derived from a large population, with mathematical modeling," Blaha explained. "We can say that this score describes the risk of heart disease among thousands of people. But there are lots of limitations in applying them to one individual."
A calcium scan, however, produces an image of one individual's arteries. Alexander Zheutlin, a cardiology fellow and researcher at Northwestern University, shows patients their images, so that they can see the lighter-colored calcifications.
Cardiologists tend to be fans of calcium testing, because they so regularly encounter patients who are reluctant to take statins. People who feel fine may hesitate to start drugs they'll take for the rest of their lives, despite statins' proven history of reducing heart attacks, strokes and cardiac deaths.
In 2019, a survey of almost 5,700 adults for whom statin therapy was recommended found that a quarter were not in treatment. Of those, 10% had declined a statin and 30% had started and then discontinued, primarily citing fear of side effects.
An American College of Cardiology expert consensus report recently put the rate of muscle pain, statin users' most common complaint, at 5% to 20%. Researchers consider the fear of side effects overblown, citing studies showing that reports of muscle pain were comparable whether patients took statins or placebos.
"The actual risk is much, much lower than the perceived risk," Zheutlin said.
That may be little comfort to people who are in pain, but cardiologists argue that reducing doses or switching to different statins usually solves the problem. Some patients will do better on a non-statin cholesterol drug.
Hollander, for example, suffered "muscle cramps that would wake me up at night." Her doctor advised fewer doses, so Hollander now takes Crestor three days a week and self-injects Repatha twice monthly.
(Statins also carry a very low risk of a dangerous condition, rhabdomyolysis, that causes muscle breakdown, and they slightly increase the chance of diabetes.)
Some caveats: No one has undertaken a randomized clinical trial to show whether calcium testing eventually reduces heart attacks and cardiac deaths. That's why, although several professional associations endorse calcium scans to help determine treatment, the independent U.S. Preventive Services Task Force has called the current evidence "insufficient" to recommend widespread use.
Such a trial would be expensive and difficult to mount, with many confounding variables. And pharmaceutical companies aren't eager to underwrite one, since a successful result could mean that patients with zero scores avoid cholesterol drugs altogether.
But a recent Australian study of asymptomatic patients with family histories of coronary artery disease found that, after three years, those who had undergone calcium scans had sustained a reduction in cholesterol and a significantly lower risk of heart disease than those who had not been tested.
The test "leads to more statin prescriptions, better adherence to statins, less progression of atherosclerosis, and less plaque growth," Greenland said of the study, in which he was not involved. "It tips the scale."
Another concern: people age 75 and older. Most will have arterial plaque, making a scan's benefit "less clear-cut," said Zheutlin, lead author of a recent JAMA Cardiology article pointing out that CAC testing can be both overused and underused.
Because older adults face more chronic diseases and medical issues, cholesterol-lowering may become a lower priority. A study now enrolling participants over 75 should answer some questions about statins, calcium scans, and dementia in a few years.
Meanwhile, cardiologists see calcium scans as a persuasive tool.
"It's incredibly frustrating," Zheutlin said. With statins, "we have cheap, safe, effective drugs available at any pharmacy" that help prevent heart attacks. If CAC test results prove more influential than traditional risk assessments alone, he said, more patients might agree to take them.
A calcium scan helped Stephen Patrick, 70, a retired tech executive in San Francisco, reach that point. "For years, I was borderline on cholesterol, and I managed to beat it back with less cheese toast" and lots of exercise, he said. "I was on no meds, and I took pride in that."
Last fall, with both his total and his LDL cholesterol higher than recommended, his doctor suggested a calcium scan. His score: 176.
He's taking atorvastatin (Lipitor) daily, and his cholesterol levels have dropped dramatically. "I might have tried it anyway," he said. "But the calcium score meant I had to pay more attention."
The New Old Age is produced through a partnership with The New York Times.
Cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years.
This article was published on Tuesday, July 29, 2025 in KFF Health News.
A few days after a harrowing cosmetic surgery procedure, Erin Schaeffer said, she woke up with fluid leaking from an open wound in her stomach.
Schaeffer went on to spend a week in a Florida hospital battling a severe infection after a type of tummy tuck and liposuction at the Jacksonville branch of Sono Bello, a national cosmetic surgery chain.
More than a year later, scars remain on her lower body — and in a lawsuit she is accusing Sono Bello of using an obstetrician-gynecologist who was inadequately trained to remove her excess skin and fat, a procedure she says caused excruciating pain.
"I literally felt like I was skinned alive," said the 37-year-old, who works as a training manager for United Parcel Service.
Schaeffer and her husband, Jonathan, are suing Sono Bello and Manuel Herrera in Duval County Circuit Court. The suit accuses Herrera, a board-certified OB-GYN, of "performing procedures that he was not trained or qualified to perform."
Sono Bello and Herrera denied the allegations in a joint court filing. And in an interview with KFF Health News and NBC News, Robert Centeno, Sono Bello's medical director for the East region, said its surgeons undergo "very rigorous training."
Backed by private-equity financing, Sono Bello is the largest of a breed of cosmetic surgery chains vying for a slice of the growing body-contouring market in the U.S. One research firm estimated that the market, which includes procedures ranging from wrinkle removal to liposuction, topped $22 billion in 2024.
The chains sell an array of body-reshaping operations, such as "Mommy Makeovers" and liposuction, targeting customers willing to pay up to $20,000 out-of-pocket for a new figure, often on credit with steep interest rates from companies specializing in credit for elective medical procedures. Sono Bello boasts it is "America's top cosmetic surgery specialist."
But a joint investigation by KFF Health News and NBC News found that Sono Bello and other cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years.
Injured patients have accused the chains of hiring doctors with minimal cosmetic surgery training, of failing to recognize and treat life-threatening infections and other dangerous surgical complications, and of high-pressure sales tactics that minimized safety risks, court records show. Sono Bello and the other companies have denied the allegations in court.
"These people promise to turn you into the fairest person in the land, and the risks aren't often worth the reality," said Sean Domnick, a Florida attorney who heads the American Association for Justice, a trial lawyers' group.
Sono Bello's Centeno disagrees. He said the company's mission is to "help each and every one of our patients live their best lives now." Sono Bello offers "life-changing transformations" that enhance a person's "appearance as well as their quality of life," said Centeno, a surgeon himself at the company's Troy, Michigan, office.
The doctors who perform such surgeries, court records show, are sometimes paid more for taking on patients with a high body mass, as obesity raises the risk of devastating complications.
And as the chains grow, there's little regulatory oversight. While the FDA maintains a database of complaints about drugs or medical devices, there's nothing similar for cosmetic surgeries.
Schaeffer had liposuction at Sono Bello in January 2024 and was satisfied with the results. On the morning of March 29, 2024, she went in for more liposuction and a mini-tummy tuck that Sono Bello calls AbEX. The medical staff gave her Xanax, a tranquilizer, and the painkiller oxycodone in pill form, according to medical records Sono Bello turned over to Schaeffer's attorney. During the procedure, she received an infusion of lidocaine to numb the area but remained awake. Sono Bello says the local anesthesia is safer and promotes faster healing with "minimal discomfort," so patients may return to work or other normal activities within a week.
That didn't happen for Schaeffer, who said she felt so much pain during the operation that she began to cry and "begged" the doctor to stop near the end.
"I said, ‘I don't care what I look like,'" she said in an interview. "‘I can't handle the pain.'"
Two days later, she spiked a fever, and a day after that her pubic area swelled up "severely," she said. Sono Bello medical staff told her that was normal and that she was fine, she said. Two days later, however, blood and fluid spilled out of her stomach when she got up.
On one visit to the office, Herrera told her she required surgery at a hospital to treat her wounds. But, Schaeffer recounted, Herrera said he couldn't arrange that because he was an obstetrician, not a plastic surgeon, and didn't have hospital privileges locally. Herrera has hospital privileges in the Orlando area, about 140 miles southwest of Jacksonville.
"I was just in utter shock," Schaeffer said.
Sono Bello spokesperson Mark Firmani said the company does not require its doctors to have local hospital privileges, though many do have them.
Centeno said Schaeffer's painful experience is not common.
"The reality is that over 90% of our patients who have our procedures completed are extremely comfortable during the procedure and they do quite well," he said. Patients of Sono Bello and some other clinics also have complained to the Better Business Bureau of unexpectedly painful procedures.
Centeno said that Herrera still works for the company, but the doctor's name does not appear on the company's Jacksonville website. Herrera runs an OB-GYN and aesthetics practice, which includes skin care treatments, in Winter Garden, Florida, near Orlando, and is board-certified by the American Board of Obstetrics & Gynecology.
Sono Bello has considered him a rising star; Herrera's work in 2023 won Sono Bello's annual "New Talent Award," given to a company doctor who exhibits "exceptional technical skills, productivity, and off-the-charts brand loyalty."
Herrera completed a Sono Bello fellowship program that teaches a "suite of aesthetic procedures" in a six- to eight-week course under the direction of a company surgeon. The company says the fellowship offers "patient-focused training in awake total body contouring and skin excision procedures." Sono Bello allows physicians who have completed formal residencies in more than half a dozen types of surgery to apply for its fellowship.
In a post on a Sono Bello website, Herrera said that before taking the fellowship course, he "had been a skilled surgeon for over 13 years with extensive experience in other areas but limited knowledge on body sculpting." Herrera did not respond to calls and emails requesting comment and directed Sono Bello to respond on his behalf. Company spokesperson Firmani said Herrera is still a member of the Sono Bello team.
Many established plastic surgeons who spoke with KFF Health News and NBC News worry that chain surgery groups may be inclined to spend more effort on marketing and sales than on making sure their doctors are properly credentialed and capable of handling any complications that arise.
Medical practices owned by private equity or investment firms have more money to spend drawing in patients and "the ability to operate and provide quality patient care is now less important," said Mark Domanski, a plastic surgeon in Northern Virginia.
Doctor Entrepreneurs
Formed in 2008 by entrepreneurial physician Tom Garrison, Sono Bello now runs more than 100 centers nationwide. Private equity investors have pumped $816 million into the company, most of it since 2023, according to PitchBook, which tracks the industry. Sono Bello advertises widely on television and online, aimed at what one major investor termed the "everyday woman and man." It has advertised having "150+ board-certified surgeons who have performed over 300,000 laser lipo & body contouring procedures."
Sono Bello limits its offerings to services such as liposuction and its version of tummy tucks, which it believes its surgeons have mastered. It does not perform Brazilian butt lifts, or fat transfers, though many other cosmetic surgery chains do.
While Sono Bello boasts that the vast majority of its patients are satisfied, court records show that allegations of substandard medical care have trailed its rapid growth.
Sono Bello and its corporate affiliates and surgeons have defended more than 60 medical malpractice cases, including four suits involving patient deaths, since April 2013, court records show. Sono Bello has settled three of four wrongful death cases filed since May 2018, while one is pending, court records show.
Schaeffer's suit in Jacksonville is among at least 19 filed since the start of March 2023. Many are pending in the courts, and the company has denied the allegations.
Other physicians who have extended their brands to multiple cities and relied heavily on social media and splashy websites to bring in patients have also faced lawsuits.
Mia Aesthetics, formed in 2017 by Texas surgeon Sergio Alvarez, runs a dozen cosmetic surgery clinics from Miami to Las Vegas. Mia Aesthetics provides "the highest quality plastic surgery at affordable prices proving that being beautiful and saving money are two realities that can exist simultaneously," its website says. Alvarez is a board-certified plastic surgeon.
Patients filed at least 30 medical negligence cases against Mia Aesthetics and its affiliates from November 2020 through March of this year, court records show. A dozen suits target its Miami surgery center. The company has sought, and often won, dismissal of malpractice suits because patients signed contracts agreeing to arbitration of any disputes, court dockets show. Alvarez did not respond to requests for comment.
Owned by New York physician Sergey Voskin since 2016, Goals Aesthetics and Plastic Surgery has branched out from a small cosmetic surgery office in the Brooklyn borough of New York City to a network of a dozen surgery centers it manages in eight states.
Goals clinics and affiliated surgeons have been named as defendants in at least 40 malpractice suits filed from October 2018 through March, court records show. The Atlanta branch accounted for more than 20 such cases in Georgia courts from September 2022 through June 2024. Most are pending. Goals defended two lawsuits brought by the families of New York patients who died shortly after having liposuction procedures, court records show. Goals denied the allegations and won dismissal of some cases by invoking arbitration agreements, according to court dockets. The company says these agreements are commonly used throughout the medical industry.
Voskin declined to be interviewed. In a statement, Goals lawyer Joshua Lurie said the medical offices it manages have performed more than 10,000 procedures and have "one of, if not the highest track records of safety among similar types of medical practices."
Lurie said the "vast majority" of malpractice claims are "meritless." These "bad faith filings create an implication of risk when none exist and when, again, there is a very negligible negative outcome from surgery compared to the total procedures performed," he wrote.
No Guarantees
Malpractice suits by themselves are not proof of wrongdoing. Nobody tracks the outcome of these lawsuits, which often are settled under confidential terms that keep key details out of public view and prohibit patients from discussing their experiences. Surgeons often argue that complications are a risk of surgery and that a poor outcome doesn't mean the doctor was negligent. To prove negligence, injured patients generally must show their care fell below what a reasonably prudent doctor with similar training would have done.
That can be a challenge. Typically, the surgery chains fight back by arguing that complications are a risk of any surgical procedure and that they never guarantee results.
Before their procedures, patients must sign consent forms acknowledging that their expectations must be "realistic" and that complications or dissatisfaction with the result does not necessarily mean the surgeon botched the job. The American Society of Plastic Surgeons investigates ethics complaints against its members, but not allegations of competence or malpractice.
Some pre-surgery contracts allow for low-cost "revisions" for disgruntled patients. Sono Bello has offered a "satisfaction commitment," which states: "If your surgeon's evaluation determines your results to be deficient, we will touch up the area at no cost to you."
Other contracts contain disclaimers, such as reminding patients that dramatic "before and after" photos widely shown in online advertisements and other solicitations may not reflect typical results.
Demonstrating the influence of social media in driving sales, Goals once required patients to sign a non-disparagement clause. The contract stated that patients who bad-mouth the company on social media without first giving the company "an opportunity to remedy any alleged issues" agree to pay damages of $10,000 for each violation.
In a civil investigation of Goals' marketing tactics, Georgia Attorney General Chris Carr alleged that policy, and others, violated state consumer protection laws. In September 2022, Goals agreed to stop using the non-disparagement clause and to pay the state $119,480 to settle the matter, without admitting any wrongdoing.
Both Goals and Mia Aesthetics have clauses in their service contracts that require arbitration of any disputes in lieu of court action, a process many consumer advocates believe favors the industry. These agreements are becoming more common among plastic surgeons. The arbitration clauses have prevented some aggrieved patients from getting their day in a courtroom.
That happened in a wrongful death case filed by the family of Angela Mendez, 57, who was found dead in her apartment a day after liposuction at a Goals office in New York City in March 2021. She died from a pulmonary thromboembolism, a blood clot in her lung, as a complication of cosmetic surgery, according to an autopsy report.
Her family sued the company alleging negligence. But, in June 2024, a judge ruled that Mendez had signed a form requiring the case to be heard in arbitration and the lawsuit was dismissed.
Attorney Gary Zucker, who represents the family, is appealing. "It's been a one-two punch for the family," Zucker said.
Goals attorney Lurie called arbitration "a common practice throughout the industry and many industries" that is "intended to speed the process to come to resolutions in a more expedited fashion." In a 2023 deposition, Lurie said patients can opt out of the arbitration agreement, which "has happened multiple times."
‘A Hard Sell'
When Erin Schaeffer first visited Sono Bello, a sales agent told her she was a "perfect candidate" for a tummy tuck procedure, she said in an interview with KFF Health News and NBC News.
Though she wanted to think about it and talk it over with her family, she said, the salesperson persuaded her to go ahead. Because cosmetic surgery is elective, insurance doesn't cover it. Schaeffer made a down payment and signed up for a credit plan through outside companies to repay most of the $19,838 bill over a five-year period, according to her medical records. She said she's now paying $420 a month.
"I definitely felt like it was a hard sell," Schaeffer said. "She didn't want me to leave out of there without putting money down on it."
Schaeffer said she didn't meet the doctor until about a week before the procedure, and only briefly. Some patients suing other companies have argued in court filings that they didn't meet the surgeon until the day of their operations, a practice that draws sharp criticism from more traditional surgeons.
Scott Hollenbeck, president of the American Society of Plastic Surgeons, said patients need time with their doctor to fully understand the pros and cons of surgery and shouldn't be pressured into quick decisions.
"It is not possible to do that when you see the doctor an hour before surgery for the first time," he said. "You should have time to process what they told you, think about it, and make a decision."
"That is best done with a surgeon, not a marketer," Hollenbeck said.
Good Candidates
Many plastic surgeons discourage people with obesity from undergoing liposuction and other cosmetic procedures because of an elevated risk of infections and other serious medical complications. Candidates are considered obese at a body mass index of 30 or above. Sono Bello patients have an average BMI of 31, according to Centeno. At the time of her surgery, Schaeffer had a BMI of 36.
But there's no consensus over who should be turned away because of their size — and policies vary.
Sono Bello says its AbEX tummy tuck can be done safely with a body mass index as high as 42, well beyond the body mass limits for a traditional abdominoplasty done using general anesthesia. The AbEX removes loose and sagging skin around the stomach "to achieve a more toned and sculpted look," according to the company.
Centeno said that high BMI "does confer additional risk, which can be managed." But he said it would be "discriminatory, unethical, and inappropriate for Sono Bello or any other medical practice to deny care to a patient based solely on their BMI."
Yet high BMI patients have alleged they suffered devastating complications, according to KFF Health News' review of the court cases filed against Sono Bello and other companies.
One patient is Marissa Edwards, then 45, a California medical receptionist with three children. At 5 feet 3 inches tall, she weighed 237 pounds, with a body mass index of 41.
She had AbEX and liposuction at a Sono Bello clinic in San Diego on Oct. 11, 2022, according to court filings. During an office visit eight days later, she complained of swelling and pain in her abdomen, but a nurse "dismissed her complaints," according to the suit. On Nov. 4, Edwards noticed the incision was opening, while a rash formed around her belly button. In a text to Sono Bello, she attached a photo of her wound which, the suit alleges, should have alerted the staff that it needed "immediate evaluation by a qualified medical professional."
On Nov. 5, she woke up "feeling extremely hot," and "nearly fainted," according to her complaint. Her husband drove her to an urgent care center, which diagnosed her with sepsis and rushed her to a hospital by ambulance.
When she awoke the next morning, her bedsheets were soaked with body fluid. As she stood up, "fluid began to pour out of her stomach and hit the floor," according to the complaint. She spent six days in the hospital.
Edwards alleges in her lawsuit that Sono Bello's medical staff failed to recognize and respond to early signs of trouble.
"I have sepsis and could have died," she texted to Sono Bello's office line, according to court documents. "I am very upset."
In one text that was included in her lawsuit, she wrote: "So I would appreciate some type of empathy from you!! If you only knew what I have been through and you went through this I'm sure you wouldn't be giving me this snotty attitude."
Sono Bello denies any negligence. In a court filing, the company noted that infections are a risk of surgery, and that Edwards had signed a consent form that stated in part: "The practice of medicine and surgery is not an exact science and results are not guaranteed." Sono Bello filed a motion for summary judgment that argued her care was not negligent and "not a substantial factor" in causing her alleged injuries. The case was settled earlier this month under confidential terms.
Value Units
While patients with high BMI are riskier, they also are more lucrative for Sono Bello surgeons, court records show.
The company pays its surgeons for procedures based in part on the patient's BMI, using a formula it calls a "surgical value unit."
The compensation plan surfaced in a lawsuit filed in December 2023 by Shirley Webb, then a 79-year-old Nevada woman. Hoping to slim down for a dream cruise, she paid $14,703 for an AbEX tummy tuck and liposuction of her stomach at the Sono Bello branch in Las Vegas.
Eighteen days after her operation, she was "oozing and bleeding" from her surgical wounds, and her son rushed her to a hospital, where doctors diagnosed "severe sepsis with shock," according to the complaint. She spent several months in hospitals and rehabilitation care, running up medical bills of more than $2.6 million, her lawyer stated during a deposition.
Lloyd Krieger, a California plastic surgeon who served as a medical expert for Webb's legal team, said the operations never should have happened because she was at "very high risk for multiple procedures given her advanced age and high BMI," according to the suit.
In a court deposition, Sono Bello surgeon Charles Kim testified that operating on Webb earned him "surgical value units" that boosted his pay to about $2,000 for the procedure.
Sono Bello and Kim denied Webb's negligence claims and the parties settled the case in early 2025 under confidential terms, court records show.
Centeno said Sono Bello surgeons are paid more for higher BMI patients because they "require additional work and additional complexity in terms of decision-making." He added that "our high BMI patients routinely undergo our procedures safely with an extremely high patient satisfaction rate."
Schaeffer said people hoping to reshape their bodies need to do a lot of research before plunging ahead with plastic surgery. She said she was hoping to get rid of excess skin and fat after dropping 100 pounds.
Instead, she missed seven weeks of work recovering from her tummy tuck in Jacksonville. "I went into this procedure to try to make myself feel better after losing the weight, and I came out with something even worse," she said.
"I trusted. I believed in what they told me, which I think most people do," Schaeffer said.
If you want to create a perfect storm at Covered California and other Affordable Care Act marketplaces, all you have to do is make enrollment more time-consuming, ratchet up the toll on consumers' pocketbooks, and terminate financial aid for some of the youngest and healthiest enrollees.
And presto: You've got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.
The Trump administration and congressional Republicans have just checked that achievement off their list.
They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.
Among the many provisions, there's this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.
Wait. What?
I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It's an echo of the federal immigration raids in Los Angeles and elsewhere.
"It's creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences," says Arturo Vargas Bustamante, a professor of health policy and management at UCLA's Fielding School of Public Health. "For those who believe health care is a human right, this is like excluding that population from something that should be a given."
In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.
It's not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.
The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And "Dreamers" will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.
The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.
Supporters of the policy changes enshrined in the CMS rule and budget law think it's high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.
"It's about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program," says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.
But Blase doesn't have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.
Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. "If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered," she says.
Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California's 1.9 million enrollees. That's because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.
Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.
Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.
The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.
And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.
Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.
"Who are the people who are going to decide to go through hours and hours of onerous paperwork?" says Morse Gasteier. "They're people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks."
California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect "unreasonable barriers to coverage." California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.
"The Trump administration claims that their final rule will prevent fraud," Bonta said. "It's obvious what this is really about. It's yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act."
A Georgia woman declared brain-dead and kept on life support for more than three months because she was pregnant was removed from a ventilator in June and died, days after doctors delivered her 1-pound, 13-ounce baby by emergency cesarean section. The baby is in the neonatal intensive care unit.
The case has drawn national attention to Georgia's six-week abortion ban and its impacts on pregnancy care.
Adriana Smith was put on life support at Emory University Hospital in Atlanta in February. The then-30-year-old Atlanta nurse was more than eight weeks pregnant and suffering dangerous complications.
Her condition deteriorated as doctors tried to save her life, Smith's mother told Atlanta TV station WXIA.
"They did a CT scan, and she had blood clots all in her head," April Newkirk said. "So they had asked me if they could do a procedure to relieve them, and I said yes. And then they called me back and they said that they couldn't do it."
She said doctors declared Smith brain-dead and put her on life support without consulting her.
"And I'm not saying that we would have chose to terminate her pregnancy," Newkirk said, "but what I'm saying is, we should have had a choice."
Emory Healthcare declined to comment on the specifics of Smith's case. After doctors removed Smith from life support, Emory issued a statement.
"The top priorities at Emory Healthcare continue to be the safety and wellbeing of the patients and families we serve," the health system said. "Emory Healthcare uses consensus from clinical experts, medical literature and legal guidance to support our providers as they make medical recommendations. Emory Healthcare is legally required to maintain the confidentiality of the protected health information of our patients, which is why we are unable to comment on individual matters and circumstances."
In a previous statement, Emory Healthcare said it complies "with Georgia's abortion laws and all other applicable laws."
Abortion Laws and Fetal Personhood
Georgia's HB 481 — the Living Infants Fairness and Equality, or LIFE, Act — passed in 2019. It took effect shortly after the U.S. Supreme Court overturned Roe v. Wade with its ruling in Dobbsv. Jackson Women's Health Organization on June 24, 2022.
The law bans abortion after the point at which an ultrasound can detect cardiac activity in an embryo. Typically, this occurs about six weeks into pregnancy, often before women know they're pregnant.
The law also gave fetuses the same rights as people.
It says that "unborn children are a class of living, distinct persons" and that the state of Georgia "recognizes the benefits of providing full legal recognition to an unborn child."
Nineteen states now ban abortion at or before 19 weeks of gestation; 13 of those have a near-total ban on all abortions with very limited exceptions, according to the Guttmacher Institute, a nonpartisan research group that supports abortion rights.
Like Georgia, some of these states built their abortion restrictions around the legal concept of "personhood," thus conferring legal rights and protections on an embryo or fetus during pregnancy.
Smith's case has represented a major test of how this type of law will be applied in certain medical situations.
Despite mainly being unified in their opposition to abortion, conservatives and politicians in Georgia do not publicly agree on the scope of the law in cases like Smith's.
For example, Georgia Attorney General Chris Carr, a Republican, said that the law should not restrict the options for care in a case like Smith's and that removing life support wouldn't be equivalent to aborting a fetus.
"There is nothing in the LIFE Act that requires medical professionals to keep a woman on life support after brain death," Carr said in a statement. "Removing life support is not an action ‘with the purpose to terminate a pregnancy.'"
But Republican state Sen. Ed Setzler, who authored the LIFE Act, disagreed. Emory's doctors acted appropriately when they put Smith on life support, he told The Associated Press.
"I think it is completely appropriate that the hospital do what they can to save the life of the child," Setzler said. "I think this is an unusual circumstance, but I think it highlights the value of innocent human life. I think the hospital is acting appropriately."
Mary Ziegler, a law professor at the University of California-Davis and author of "Personhood: The New Civil War Over Reproduction," said the problem is that Georgia's law "isn't just an abortion ban. It's a ‘personhood' law declaring that a fetus or embryo is a person, that an ‘unborn child,' as the law puts it, is a person."
The legal concept of "personhood" has implications beyond abortion care, such as with the regulation of fertility treatment, or the potential criminalization of pregnancy complications such as stillbirth and miscarriage.
Under Georgia's law, extending rights of personhood to a fetus changes how child support is calculated. It also allows an embryo or fetus to be claimed as a dependent on state taxes.
But the idea of personhood is not new, Ziegler said.
"It has been the goal for virtually everyone in the anti-abortion movement since the 1960s," she said. "That doesn't mean Republicans like that. It doesn't necessarily mean that that's what's going to happen. But there is no daylight between the anti-abortion movement and the personhood movement. They're the same."
The personhood movement has gained more traction since the Dobbs ruling in 2022. Laws granting rights to unborn children have spread in the decades since the U.S. and Missouri supreme courts allowed Missouri's definition of life as beginning at conception to stand. Now, a wrongful death lawsuit involving a workplace accident shows how sprawling those laws — often intended to curb abortion — have become.
In Alabama, after the state's Supreme Court ruled that frozen embryos are people, the state legislature had to step in to allow fertility clinics to continue their work.
"This is sort of the future we're looking at if we move further in the direction of fetal personhood," Ziegler said. "Any state Supreme Court, as we just saw in Alabama, can give them new life," she said referring to personhood laws elsewhere.
Fetal Personhood Laws Can Delay Care
In Georgia, dozens of OB-GYNs have said that the law interferes with patient care — in a state where the maternal mortality rate is one of the worst in the U.S. and where Black women are more than twice as likely to die from a pregnancy-related cause than white women.
Members of Georgia's Maternal Mortality Review Committee — who were later dismissed from the panel — linked the state's abortion ban to delayed emergency care and the deaths of at least two women in the state, as ProPublica reported.
The personhood provision is having a profound effect on medical care, said Atlanta OB-GYN Zoë Lucier-Julian.
"These laws create an environment of fear and attempt to coerce us as providers to align with the state, as opposed to aligning with our patients that we work so hard to serve," Lucier-Julian said.
Lucier-Julian said that's what happened to Emory Healthcare in Smith's case.
Cole Muzio, president of the Frontline Policy Council, a conservative Christian group, said the state's abortion law shouldn't have affected how Emory handled Smith's care.
"This is a pretty clear-cut case, in terms of how it's defined in the language of HB 481," he said. "What this bans is an abortion after a heartbeat is detected. That is the scope of our law."
"Taking a woman off life support is not an abortion. It just isn't," Muzio said."Now, I am incredibly grateful that this child will be born even in the midst of tragic circumstances. That is a whole human life that will be able to be lived because of this beautiful mother's sacrifice."
A suit challenging Georgia's law and its impact on public health is working its way through the courts. A coalition of physicians, the American Civil Liberties Union of Georgia, Planned Parenthood, the Center for Reproductive Rights, and other groups filed the suit.
Newkirk said her daughter had initially gone to a different Atlanta-area hospital for help with severe headaches, was given some medicine, and was sent home, where her symptoms quickly worsened.
"She was gasping for air in her sleep, gargling," she told WXIA in May. "More than likely, it was blood."
Now, Newkirk said, the family is praying for her grandson to make it after the stress from months of life support.
He is fighting, she said.
"My grandson may be blind, may not be able to walk, wheelchair-bound," she said. "We don't know if he'll live."
She added that the family will love him no matter what.
This article is from a partnership with WABE and NPR.
Patient advocates warn that the erosion of federal health care protections since Trump took office threatens to undermine Americans' financial security.
This article was published on Friday, July 25, 2025 in KFF Health News.
President Donald Trump rode to reelection last fall on voter concerns about prices. But as his administration pares back federal rules and programs designed to protect patients from the high cost of health care, Trump risks pushing more Americans into debt, further straining family budgets already stressed by medical bills.
Millions of people are expected to lose health insurance in the coming years as a result of the tax cut legislation Trump signed this month, leaving them with fewer protections from large bills if they get sick or suffer an accident.
At the same time, significant increases in health plan premiums on state insurance marketplaces next year will likely push more Americans to either drop coverage or switch to higher-deductible plans that will require them to pay more out-of-pocket before their insurance kicks in.
Smaller changes to federal rules are poised to bump up patients' bills, as well. New federal guidelines for covid-19 vaccines, for example, will allow health insurers to stop covering the shots for millions, so if patients want the protection, some may have to pay out-of-pocket.
The new tax cut legislation will also raise the cost of certain doctor visits, requiring copays of up to $35 for some Medicaid enrollees.
And for those who do end up in debt, there will be fewer protections. This month, the Trump administration secured permission from a federal court to roll back regulations that would have removed medical debt from consumer credit reports.
That puts Americans who cannot pay their medical bills at risk of lower credit scores, hindering their ability to get a loan or forcing them to pay higher interest rates.
"For tens of millions of Americans, balancing the budget is like walking a tightrope," said Chi Chi Wu, a staff attorney at the National Consumer Law Center. "The Trump administration is just throwing them off."
White House spokesperson Kush Desai did not respond to questions about how the administration's health care policies will affect Americans' medical bills.
The president and his Republican congressional allies have brushed off the health care cuts, including hundreds of billions of dollars in Medicaid retrenchment in the mammoth tax law. "You won't even notice it," Trump said at the White House after the bill signing July 4. "Just waste, fraud, and abuse."
But consumer and patient advocates around the country warn that the erosion of federal health care protections since Trump took office in January threatens to significantly undermine Americans' financial security.
"These changes will hit our communities hard," said Arika Sánchez, who oversees health care policy at the nonprofit New Mexico Center on Law and Poverty.
Sánchez predicted many more people the center works with will end up with medical debt. "When families get stuck with medical debt, it hurts their credit scores, makes it harder to get a car, a home, or even a job," she said. "Medical debt wrecks people's lives."
For Americans with serious illnesses such as cancer, weakened federal protections from medical debt pose yet one more risk, said Elizabeth Darnall, senior director of federal advocacy at the American Cancer Society's Cancer Action Network. "People will not seek out the treatment they need," she said.
About 6 in 10 adults — Democrats and Republicans — say they are worried about being able to afford health care, according to one recent survey, outpacing concerns about the cost of food or housing. And medical debt remains a widespread problem: As many as 100 million adults in the U.S. are burdened by some kind of health care debt.
Despite this, key tools that have helped prevent even more Americans from sinking into debt are now on the chopping block.
Medicaid and other government health insurance programs, in particular, have proved to be a powerful economic backstop for low-income patients and their families, said Kyle Caswell, an economist at the Urban Institute, a think tank in Washington, D.C.
Caswell and other researchers found, for example, that Medicaid expansion made possible by the 2010 Affordable Care Act led to measurable declines in medical debt and improvements in consumers' credit scores in states that implemented the expansion.
"We've seen that these programs have a meaningful impact on people's financial well-being," Caswell said.
Trump's tax law — which will slash more than $1 trillion in federal health spending over the next decade, mostly through Medicaid cuts — is expected to leave 10 million more people without health coverage by 2034, according to the latest estimates from the nonpartisan Congressional Budget Office. The tax cuts, which primarily benefit wealthy Americans, will add $3.4 trillion to U.S. deficits over a decade, the office calculated.
The number of uninsured could spike further if Trump and his congressional allies don't renew additional federal subsidies for low- and moderate-income Americans who buy health coverage on state insurance marketplaces.
This aid — enacted under former President Joe Biden — lowers insurance premiums and reduces medical bills enrollees face when they go to the doctor or the hospital. But unless congressional Republicans act, those subsidies will expire later this year, leaving many with bigger bills.
Federal debt regulations developed by the Consumer Financial Protection Bureau under the Biden administration would have protected these people and others if they couldn't pay their medical bills.
The agency issued rules in January that would have removed medical debts from consumer credit reports. That would have helped an estimated 15 million people.
But the Trump administration chose not to defend the new regulations when they were challenged in court by debt collectors and the credit bureaus, who argued the federal agency had exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.
More states are passing laws to protect information generated by a person's brain and nervous system as technology improves the ability to unlock the sensitive details of a person's health, mental states, emotions, and cognitive functioning.
Colorado, California, and Montana are among the states that have recently required safeguarding brain data collected by devices outside of medical settings. That includes headphones, earbuds, and other wearable consumer products that aim to improve sleep, focus, and aging by measuring electrical activity and sending the data to an app on users' phones.
A report by the Neurorights Foundation, an advocacy group that aims to protect people from the misuse of neurotechnology, found that 29 of 30 companies with neurotechnology products that can be purchased online have access to brain data and "provide no meaningful limitations to this access." Almost all of them can share data with third parties.
In June, the American Medical Association called for greater regulation of neural data. In April, several Democratic members of the U.S. Senate Committee on Commerce, Science, and Transportation asked the Federal Trade Commission to investigate whether companies are exploiting consumers' brain data. Juliana Gruenwald Henderson, a deputy director of the FTC's Office of Public Affairs, said the agency had received the letter but had no additional comment.
Although current devices gather relatively basic information like sleep states, advocates for brain data protection caution that future technologies, including artificial intelligence, could extract more personal and sensitive information about people's medical conditions or innermost thoughts.
"If you collect the data today, what can you read from it five years from now because the technology is advancing so quickly?" said Democratic state Sen. Cathy Kipp, who sponsored Colorado's 2024 neural data protection bill when she was in the state House of Representatives.
As both excitement and trepidation about AI build, at least 28 states and the U.S. Virgin Islands have enacted some type of AI regulation separate from the privacy bills protecting neural data. President Donald Trump's "One Big Beautiful Bill" included a 10-year halt on states passing laws to regulate AI, but the Senate stripped that provision out of the budget reconciliation bill before voting to approve it on July 1.
The spirit of laws in Colorado, California, and Montana is to protect the neural data itself, not to regulate any algorithm or AI that might use it, said Sean Pauzauskie, medical director for the Neurorights Foundation.
But neurotechnology and AI go hand in hand, Pauzauskie said. "A lot of what these devices promise is based on pattern recognition. AI is really driving the usability and significance of the patterns in the brain data."
Cristin Welle, a professor of neurosurgery at the University of Colorado School of Medicine, said that AI's ability to identify patterns is a game changer in her field. "But contribution of a person's neural data on an AI training set should be voluntary. It should be an opt-in, not a given."
Chile in 2021 became the first country to adopt a constitutional amendment for neurorights, which prioritize human rights in the development of neurotechnology and collection of neural data, and UNESCO has said that neurotechnology and artificial intelligence could together pose a threat to human identity and autonomy.
Neurotechnology can sound like science fiction. Researchers used a cap with 128 electrodes and an AI model to decode the brain's electric signals from thoughts into speech. And two years ago, a study described how neuroscientists reconstructed the Pink Floyd song "Another Brick in the Wall" by analyzing the brain signals of 29 epilepsy patients who listened to the song with electrodes implanted in their brains.
The aim is to use neurotechnology to help those with paralysis or speech disabilities, as well as treat or diagnose traumatic brain injuries and brain disorders such as Alzheimer's or Parkinson's. Elon Musk's Neuralink and Synchron, funded by Bill Gates and Jeff Bezos, are among the companies with clinical trials underway for devices implanted in the brain.
Pauzauskie, a hospital neurologist, started worrying four years ago about the blurring of the line between clinical and consumer use of neural data. He noted that the devices used by his epilepsy patients were also available for purchase online, but without protections afforded by the Health Insurance Portability and Accountability Act in medical settings.
Pauzauskie approached Kipp two years ago at a constituent meetup in his hometown of Fort Collins to propose a law to protect brain data in Colorado. "The first words out of her mouth that I'll never forget were, ‘Who would be against people owning their own brain data?'" he said.
Brain data protection is one of the rare issues that unite lawmakers across the political aisle. The bills in California, Montana, and Colorado passed unanimously or nearly unanimously. Montana's law will go into effect in October.
Neural data protection laws in Colorado and California amend each state's general consumer privacy act, while Montana's law adds to its existing genetic information privacy act. Colorado and Montana require initial express consent to collect or use neural data and separate consent or the ability to opt out before disclosing that data to a third party. A business must provide a way for consumers to delete their data when operating in all three states.
"I want a very hard line in the sand that says, you own this completely," said Montana state Republican Sen. Daniel Zolnikov, who sponsored his state's neural data bill and other privacy laws. "You have to give consent. You have the right to have it deleted. You have complete rights over this information."
For Zolnikov, Montana's bill is a blueprint for a national neural data protection law, and Pauzauskie said support of regulatory efforts by groups like the AMA pave the way for further federal and state efforts.
Welle agreed that federal regulations are needed in addition to these new state laws. "I absolutely hope that we can come up with something on a national level that can enshrine people's neural rights into law, because I think this is going to be more important than we can even imagine at this time."
"Almost 5 million able-bodied Medicaid recipients 'simply choose not to work' and 'spend six hours a day socializing and watching television.'" — Scott Jennings on CNN NewsNight with Abby Phillip.
This article was published on Tuesday, July 22, 2025 in KFF Health News.
Republicans defended the GOP megabill's Medicaid changes as targeting a group of people they believe shouldn't qualify: people who can work but instead choose to stay home and chill.
Several Republican politicians and pundits, including CNN senior political commentator Scott Jennings, pegged that group's size at about 5 million people.
"There are like almost 5 million able-bodied people on Medicaid who simply choose not to work," Jennings said July 1 on "CNN NewsNight with Abby Phillip." "They spend six hours a day socializing and watching television. And if you can't get off grandma's couch and work, I don't want to pay for your welfare."
Centers for Medicare & Medicaid Services Administrator Mehmet Oz picked up on some of these points during a July 14 appearance on Fox News. "When the program was created 60 years ago, it never dawned on anyone that you would take able-bodied individuals who could work and put them on Medicaid. Today the average able-bodied person on Medicaid who doesn't work, they watch 6.1 hours of television or just hang out," Oz said.
Medicaid is a federal-state health insurance program that covers medical care for lower-income people.
Jennings cited two pieces of data: an estimate of how many fewer people would have coverage because of the work requirement and an analysis of how nonworking Medicaid recipients spend their time. But he made assumptions that the data doesn't support.
Jennings Misrepresents CBO Estimate
The 4.8 million figure stems from a June 24 Congressional Budget Office analysis of a preliminary House version of the massive tax and spending package. The office, Congress' nonpartisan research arm, projected that provisions of the bill would cause 7.8 million fewer people to have health coverage by 2034. They would include 4.8 million people previously eligible for Medicaid described as "able-bodied" adults 19 to 64 years old who have no dependents and who "do not meet the community engagement requirement" of doing "work-related activities" at least 80 hours a month.
Apart from working, doing community service and attending school also fulfill the community engagement requirement.
Jennings paired that statistic with a separate analysis of how nondisabled adult Medicaid recipients without dependent children spend their time.
But the CBO estimate was a projection — it doesn't represent the current number of nondisabled Medicaid recipients, nor does it say 4.8 million people in this group "choose not to work." The figure represented how many fewer people would have coverage because of the bill's community engagement requirement.
"The challenge with Jennings' comments — and they've been echoed elsewhere by elected Republicans — is that CBO never said that 4.8 million people were out of compliance with the proposed work requirements; they said that 4.8 million people would lose coverage because of the work requirements," said Adrianna McIntyre, an assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health.
Among the Medicaid expansion population, the law requires most adults without dependent children and parents of children older than 13 to work or participate in other qualifying activities 80 hours every month. States will need to verify that applicants met the work requirement for one to three months before they applied. States will also be required to verify that existing enrollees met the work requirement for at least a month between eligibility determinations, which will be required at least twice a year.
Research into Medicaid work requirements imposed at the state level has shown that people found it difficult to fulfill them and submit documentation, contributing to coverage losses.
In Arkansas, which added a work requirement to Medicaid in 2018, a study based on nearly 6,000 respondents found that about 95% of the target population were already working or qualified for an exemption, but a third of them did not hear about the work requirements. As a result, nearly 17,000 Medicaid recipients subject to work requirements lost coverage.
KFF found that adults ages 50 to 64 are more at risk of losing Medicaid coverage because of the new work requirements. More than 1 in 10 in that age group said they had retired, and among them, 28% reported being disabled, said KFF, a health information nonprofit that includes KFF Health News.
Benjamin Sommers, a health care economics professor at the Harvard Chan school, said many of the 4.8 million "able-bodied" people in the CBO estimate "will actually be engaged in the activities they are supposed to be doing, and lose coverage because they are not able to navigate the reporting requirements with the state and lose coverage from red tape."
When Recipients Don't Work, It's Rarely From Lack of Interest
There is no universal definition for "able-bodied"; disability can be assessed in different ways. But other studies offer much smaller estimates than 4.8 million Medicaid recipients without dependents who can work but choose not to.
Millions of working-age, nondisabled adults joined the Medicaid ranks in states that expanded eligibility under the Affordable Care Act. There were about 34 million working-age nondisabled Medicaid enrollees in 2024, according to the CBO, 15 million of whom enrolled through the ACA.
A KFF analysis found a smaller figure of 26 million Medicaid-covered adults, ages 19 to 64, who don't receive Supplemental Security Income, Social Security Disability Insurance, or Medicare benefits.
Among this group, KFF estimated, 64% were working either full time or part time. The reasons the rest were not working included caregiving (12%); illness or disability (10%); retirement, inability to find work, or other reason (8%); and school attendance (7%).
Few people cited lack of interest in working as the reason for their unemployment. An Urban Institute study found 2% of Medicaid expansion enrollees without dependents who neither worked nor attended school — or 300,000 people out of a projected 15 million subject to work requirements — cited a lack of interest in working as the reason they were unemployed.
This was consistent with the Brookings Institution's June 5 analysis that found that, of 4.3 million adult enrollees who worked fewer than 80 hours a month and did not have any activity limitations or illnesses, about 300,000 reported that they "did not work because they did not want to."
Mostly Women, Mostly With a High School Degree or Less
When Republicanshave described nondisabled adult Medicaid recipients, they have often portrayed them as men in their 30s "playing video games" in their parents' basement or who "smoke weed all day." Research paints a different picture.
Jane Tavares and Marc Cohen, of the University of Massachusetts-Boston Gerontology Department, researched Medicaid recipients who are not disabled or working, have no dependent children under 18, and are not in school. They cited 2023 census data from the American Community Survey.
They found:
The average age of this population is 41, and 26% are older than 50.
Almost 80% are female.
Most, 80%, have a high school education or less.
Their median individual income is $0, and their median household income is $44,800.
About 56% worked in the past five years, and 23% worked in the prior year. About 30% are looking or available for work.
"They are not healthy young adults just hanging out," the authors, along with health law experts Sara Rosenbaum and Alison Barkoff, wrote April 30.
"It's clear based on their prior work history and family size/income that they are exceptionally poor and have likely left the workforce to care for adult children or older adults," Tavares told PolitiFact. "Even if these individuals could work, they would have very few job opportunities and it would come at the cost of the people they are providing care for."
AEI Study Not Definitively Linked to CBO Estimate
On the social platform X, Jennings posted the CBO letter and a May 29 analysis by the American Enterprise Institute, a conservative think tank, about "how nondisabled Medicaid recipients without children spend their time." PolitiFact contacted CNN to reach Jennings but did not receive a reply.
The author of that study, American Enterprise Institute senior fellow Kevin Corinth, analyzed survey data and found that Medicaid recipients who do not report working spend on average 6.1 hours a day "on all socializing, relaxing and leisure activities (including television and video games)."
But it's uncertain whether the people in the survey population he analyzed overlap with the people included in the CBO analysis, said Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured.
Corinth told PolitiFact "it is difficult to say" how the population he analyzed differs from the CBO's. Tavares, Cohen, Rosenbaum, and Barkoff said Corinth's dataset defined disability narrowly, leading to a "serious underestimation of disability" among the population of Medicaid recipients he looked into. It focused on Medicaid recipients who receive Supplemental Security Income or have a health condition that prevents them from working. The researchers said this approach is too narrow because the SSI program accounts for only those "most deeply impoverished adults with severe disabilities."
The group gave a hypothetical example of a 54-year-old woman with a serious heart condition who can work only a few hours a week. She may not be considered disabled under the SSI program, but she may be limited in the work she can do and may need time to rest.
"Using her ‘leisure time' to justify a work requirement grossly misrepresents her reality," the group wrote.
Corinth's analysis also shows that nonworking Medicaid recipients spend less time socializing, relaxing, or engaged in leisure activities than nonworking people who aren't covered by Medicaid. Nonworking Medicaid recipients also spend more time looking for work and doing housework and errands, it found.
Our Ruling
Jennings said almost 5 million nondisabled Medicaid recipients "simply choose not to work" and "spend six hours a day socializing and watching television."
The 5 million figure stems from a CBO projection that 4.8 million people would go without coverage by 2034 as a result of not fulfilling the community engagement requirements. It is not descriptive of current enrollees and does not specify that these people choose not to work.
Jennings cited an American Enterprise Institute analysis on how nondisabled Medicaid recipients with no dependents spend their time, but it is uncertain if the population in that analysis overlaps with that in the CBO estimate.
Current snapshots of the population Jennings described produce a smaller number. A survey by the Urban Institute found that 2% of Medicaid expansion enrollees without dependents who were neither working nor attending school — about 300,000 people — cited a lack of interest in working. Other research has found reasons this group doesn't work include caregiving, illness or disability, retirement, and inability to find work.
Studies of nonworking Medicaid recipients have found the majority are women and have a high school education or less. Their average age is 41, and more than half have a work history in the past five years.
We rate Jennings' statement False.
Our Sources
Email interview, Jane Tavares, University of Massachusetts-Boston adjunct instructor in gerontology, July 2, 2025
Email interview, Marc Cohen, University of Massachusetts-Boston professor of gerontology, July 2, 2025
Email interview, Sara Rosenbaum, George Washington University Milken Institute School of Public Health professor emerita of health law and policy, July 2, 2025
Email interview, Alison Barkoff, George Washington University Milken Institute School of Public Health associate professor of health law and policy, July 2, 2025
Email interview, Edwin Park, Georgetown University McCourt School of Public Policy Center for Children and Families research professor, July 2, 2025
Email interview, Benjamin Sommers, Harvard T.H. Chan School of Public Health professor of health care economics, July 2, 2025
Phone interview, Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured, July 2, 2025
Email interview, Adrianna McIntyre, Harvard T.H. Chan School of Public Health assistant professor of health policy and politics, July 2, 2025
Phone interview, Michael Karpman, Urban Institute Health Policy Division principal research associate, July 3, 2025
Email exchange, Congressional Budget Office spokesperson, July 2, 2025
Email interview, Kevin Corinth, American Enterprise Institute senior fellow, July 3, 2025
Alexander tried signing up for Pathways, the state's limited Medicaid expansion, multiple times and got denied each time, he said, even though he met the qualifying terms because he's a full-time student.
Georgia is one of 10 states that haven't expanded Medicaid health coverage to a broader pool of low-income adults. Instead, it offers coverage to those who can prove they're working or completing 80 hours a month of other qualifying activities, like going to school or volunteering. And it is the only state currently doing so.
"Why is this marketing out here?" said the 20-year-old, who lives in Conyers, east of Atlanta. "It's truly not accessible."
Each denial used the same boilerplate language, Alexander said, and his calls to caseworkers were not returned. State offices couldn't connect him with caseworkers assigned to him from the same state agency. And when he requested contact information for a supervisor to appeal his denial, he said, the number rang to a fax machine.
"It's impenetrable," Alexander said. "I've literally tried everything, and there's no way."
Millions of Americans trying to access Medicaid benefits could soon find themselves navigating similar byzantine state systems and work rules. Legislation signed into law by President Donald Trump on July 4 allocates $200 million to help states that expanded Medicaid create systems by the end of next year to verify whether some enrollees are meeting the requirements.
Conservative lawmakers have long argued that public benefits should go only to those actively working to get off of government assistance. But the nation's only Medicaid work requirement program shows they can be costly for states to run, frustrating for enrollees to navigate, and disruptive to other public benefit systems. Georgia's budget for marketing is nearly as much as it has spent on health benefits. Meanwhile, most enrollees under age 65 are already working or have a barrier that prevents them from doing so.
What Georgia shows is "just how costly setting up these administrative systems of red tape can be," said Joan Alker, executive director of Georgetown University's Center for Children and Families.
Over the past two years, KFF Health News has documented the issues riddling Georgia's Pathways program, launched in July 2023. More than 100,000 Georgians have applied to the program through March. Just over 8,000 were enrolled at the end of June, though about 300,000 would be eligible if the state fully expanded Medicaid under the terms of the Affordable Care Act.
The program has cost more than $100 million, with only $26 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a KFF Health News analysis of state reports.
"That was truly a pretty shocking waste of taxpayer dollars," Alker said.
The Government Accountability Office is investigating the costs of the program after a group of Democratic senators — including both members of the Georgia delegation — asked the government watchdog to look into the program. Findings are expected this fall.
A state report to the federal government from March said Georgia couldn't effectively determine if applicants meet the qualifying activities criteria. The report also said the state hadn't suspended anyone for failing to work, a key philosophical pillar of the program. Meanwhile, as of March, more than 5,000 people were waiting to have their eligibility verified for Pathways.
The Pathways program has strained Georgia's eligibility system for other public benefits, such as food stamps and cash assistance.
In April, the state applied to the federal government to renew Pathways. In its application, officials scaled back key elements, such as the requirement that enrollees document work every month. Critics of the program also say the red tape doesn't help enrollees find jobs.
"Georgia's experience shows that administrative complexity is the primary outcome, not job readiness," said Natalie Crawford, executive director of Georgia First, which advocates for fiscal responsibility and access to affordable health care.
Despite the struggles, Garrison Douglas, a spokesperson for Georgia's Republican governor, Brian Kemp, defended the program. "Georgia Pathways is doing what it was designed to do: provide free healthcare coverage to low-income, able-bodied Georgians who are willing to engage in one of our many qualifying activities," he said in an emailed statement.
New federal requirements in the tax and spending legislation mean that the 40 states (plus Washington, D.C.) that expanded Medicaid will need to prepare technology to process the documentation some Medicaid recipients will now have to regularly file.
The federal law includes exemptions for people with disabilities, in addiction treatment, or caring for kids under 14, among others.
The Trump administration said other states won't face a bumpy rollout like Georgia's.
"We are fully confident that technology already exists that could enable all parties involved to implement work and community engagement requirements," said Mehmet Oz, head of the Centers for Medicare & Medicaid Services, in an emailed statement.
In a written public comment on Georgia's application to extend the program, Yvonne Taylor of Austell detailed the difficulties she faced trying to enroll.
She said she tried to sign up several times but that her application was not accepted. "Not once, not twice, but 3 times. With no response from customer service," she wrote in February. "So now I am without coverage."
Victoria Helmly of Marietta wrote in a January comment that she and her family members take care of their dad, but the state law doesn't exempt caregivers of older adults.
"Georgia should recognize their sacrifices by supporting them with health insurance," she wrote. "Let's simplify this system and in the end, save money and lives."
A last-minute scramble to add a $50 billion rural health program to President Donald Trump's massive tax and spending law has left hospital and clinic leaders nationwide hopeful but perplexed.
The Rural Health Transformation Program calls for federal regulators to hand states $10 billion a year for five years starting in fiscal year 2026.
But the "devil's in the details in terms of implementing," said Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics.
"An investment of this amount and this style into rural — hopefully it goes to rural — is the type of investment that we and other advocates have been working on for a long time," said Hohman, whose organization represents 5,600 rural health clinics.
People who live in the nation's rural expanses have more chronic diseases, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services like obstetrics and mental health care.
Nearly 1 in 4 people in rural America use Medicaid, the state and federal program for low-income and disabled people. So, as Senate Republicans heatedly debated Medicaid spending reductions, lawmakers added the $50 billion program to quell opposition. But health advocates and researchers doubt it will be enough to offset expected cuts in federal funding.
Senate Majority Leader John Thune, a Republican from South Dakota, which has one of the largest percentages of rural residents in the nation, led the push to pass the budget bill. His website touts support for strengthening access to care in rural areas. But his office declined to respond on the record to questions about the rural health program included in the bill.
Sen. Susan Collins, a Republican from Maine who introduced an initial amendment to add the rural program, also did not respond to a request for comment. On July 15, Sen. Josh Hawley, a Republican from Missouri, introduced a bill to reverse future cuts to Medicaid and add to the rural program.
Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank headquartered in Washington, D.C., said the money was set aside because of politics and not necessarily for rural patients.
"As long as it's a government slush fund where politics decides where the money goes, then there's going to be a mismatch between where those funds go and what it is consumers need," Cannon said.
The nonpartisan Congressional Budget Office estimates federal Medicaid spending will be reduced by about $1 trillion over the next decade.
"These dollar amounts translate to actual people," said Fredric Blavin, a senior fellow and researcher at the Urban Institute, a Washington D.C.-based think tank that focuses on social and economic research.
Most states expanded their Medicaid programs to cover more low-income adults under the Affordable Care Act. That has lowered medical debt, improved health, and even reduced death rates, Blavin said.
By 2034, about 11.8 million people are expected to lose their health insurance from this bill, said Alice Burns, an associate director for KFF's Program on Medicaid and the Uninsured. And she said the Medicaid rollback may have an outsize impact on rural areas.
In rural areas, federal Medicaid spending is expected to decline by $155 billion over 10 years, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.
If the goal of the rural program was to transform rural health care, as its name suggests, it will fall short, Burns said. The $50 billion rural program distributed over five years won't offset the losses expected over a decade of Medicaid reductions, she said.
In Kansas, Holton Community Hospital Chief Executive Carrie Lutz said she doesn't "feel that the sky is falling right now."
Lutz, whose 14-bed hospital is on the northern plains of the state, said she is bracing for the potential loss of Medicaid-covered patients and limits to provider taxes, which nearly all states use to get extra federal Medicaid money.
The reduction in provider taxes has been delayed until fiscal year 2028, Lutz said, but she still wants her state's leaders to apply for a portion of the rural program funding, which is expected to be distributed sooner.
"Every little penny helps when you've got very negative margins to begin with," Lutz said.
The program's $50 billion will be spread over five years and may not be limited to bolstering rural areas or their hospitals. Half of the money will be distributed "equally" among states that apply to and win approval from the Centers for Medicare & Medicaid Services. The law's current language "raises the possibility" that a small state like Vermont could receive the same amount as a large state like Texas, Burns said.
States are required to submit a "detailed rural health transformation plan" by the end of this year, according to the law.
The law says states should use the funds to pursue goals including improving access to hospitals and other providers, improving health outcomes, enhancing economic opportunity for health care workers, and prioritizing the use of emerging technologies.
Mehmet Oz, a Trump appointee leading Medicare and Medicaid, will determine how to distribute the other half, or $25 billion, using a formula based on states' rural population and need. The law says the money is to be used for such things as increasing use of robotics, upgrading cybersecurity, and helping rural communities "to right size their health care delivery systems."
Spokespeople for CMS did not respond to a list of questions.
Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, said there is "a pretty significant degree of discretion" for the White House and the Medicare and Medicaid administrator in approving state plans.
"We will urge states to include robust telehealth and virtual care options within their proposals going up to the federal government," Zebley said.
Alexa McKinley Abel, government affairs and policy director for the National Rural Health Association, said that while the law calls for states to create and submit plans, it's unclear what state agencies will perform the task, McKinley Abel said.
"There are a lot of gaps around application and implementation," she said, noting that an earlier version of the bill called for state plans to be developed in consultation with federally funded state offices of rural health.
But those offices are proposed to be eliminated in Trump's federal budget, which will face congressional approval in the fall. McKinley Abel said her organization supports state offices of rural health helping develop the plans and working with states to disburse the money, "since they intimately know the rural health community."
Hohman, with the rural health clinic association, said she is not sure money from the transformation program will even reach her members. About 27% of the patients treated at rural health clinics are enrolled in Medicaid, she said.
"There's just some confusion about who actually gets this money at the end of the day," Hohman said. "What is it actually going to be used for?"
KFF Health News senior correspondent Phil Galewitz contributed to this report.
