Pharmacists Stockpile Most Common Drugs on Chance of Targeted Trump Tariffs

KFF Health News, May 16, 2025

Pharmacists find themselves on the front lines of a tariff storm.

This article was published on Friday, May 16, 2025 in KFF Health News.

By Jackie Fortiér and Arthur Allen

In the dim basement of a Salt Lake City pharmacy, hundreds of amber-colored plastic pill bottles sit stacked in rows, one man's defensive wall in a tariff war.

Independent pharmacist Benjamin Jolley and his colleagues worry that the tariffs, aimed at bringing drug production to the United States, could instead drive companies out of business while raising prices and creating more of the drug shortages that have plagued American patients for several years.

Jolley bought six months' worth of the most expensive large bottles, hoping to shield his business from the 10% across-the-board tariffs on imported goods that President Donald Trump announced April 2. Now with threats of additional tariffs targeting pharmaceuticals, Jolley worries that costs will soar for the medications that will fill those bottles.

In principle, Jolley said, using tariffs to push manufacturing from China and India to the U.S. makes sense. In the event of war, China could quickly stop all exports to the United States.

"I understand the rationale for tariffs. I'm not sure that we're gonna do it the right way," Jolley said. "And I am definitely sure that it's going to raise the price that I pay my suppliers."

Squeezed by insurers and middlemen, independent pharmacists such as Jolley find themselves on the front lines of a tariff storm. Nearly everyone down the line — drugmakers, pharmacies, wholesalers, and middlemen — opposes most tariffs.

Slashing drug imports could trigger widespread shortages, experts said, because of America's dependence on Chinese- and Indian-made chemical ingredients, which form the critical building blocks of many medicines. Industry officials caution that steep tariffs on raw materials and finished pharmaceuticals could make drugs more expensive.

"Big ships don't change course overnight," said Robin Feldman, a UC Law San Francisco professor who writes about prescription drug issues. "Even if companies pledge to bring manufacturing home, it will take time to get them up and running. The key will be to avoid damage to industry and pain to consumers in the process."

Trump on April 8 said he would soon announce "a major tariff on pharmaceuticals," which have been largely tariff-free in the U.S. for 30 years.

"When they hear that, they will leave China," he said. The U.S. imported $213 billion worth of medicines in 2024 — from China but also India, Europe, and other areas.

Trump's statement sent drugmakers scrambling to figure out whether he was serious, and whether some tariffs would be levied more narrowly, since many parts of the U.S. drug supply chain are fragile, drug shortages are common, and upheaval at the FDA leaves questions about whether its staffing is adequate to inspect factories, where quality problems can lead to supply chain crises.

On May 12, Trump signed an executive order asking drugmakers to bring down the prices Americans pay for prescriptions, to put them in line with prices in other countries.

Meanwhile, pharmacists predict even the 10% tariffs Trump has demanded will hurt: Jolley said a potential increase of up to 30 cents a vial is not a king's ransom, but it adds up when you're a small pharmacy that fills 50,000 prescriptions a year.

"The one word that I would say right now to describe tariffs is ‘uncertainty,'" said Scott Pace, a pharmacist and owner of Kavanaugh Pharmacy in Little Rock, Arkansas.

To weather price fluctuations, Pace stocked up on the drugs his pharmacy dispenses most.

"I've identified the top 200 generics in my store, and I have basically put 90 days' worth of those on the shelf just as a starting point," he said. "Those are the diabetes drugs, the blood pressure medicines, the antibiotics — those things that I know folks will be sicker without."

Pace said tariffs could be the death knell for the many independent pharmacies that exist on "razor-thin margins" — unless reimbursements rise to keep up with higher costs.

Unlike other retailers, pharmacies can't pass along such costs to patients. Their payments are set by health insurers and pharmacy benefit managers largely owned by insurance conglomerates, who act as middlemen between drug manufacturers and purchasers.

Neal Smoller, who employs 15 people at his Village Apothecary in Woodstock, New York, is not optimistic.

"It's not like they're gonna go back and say, well, here's your 10% bump because of the 10% tariff," he said. "Costs are gonna go up and then the sluggish responses from the PBMs — they're going to lead us to lose more money at a faster rate than we already are."

Smoller, who said he has built a niche selling vitamins and supplements, fears that FDA firings will mean fewer federal inspections and safety checks.

"I worry that our pharmaceutical industry becomes like our supplement industry, where it's the wild West," he said.

Narrowly focused tariffs might work in some cases, said Marta Wosińska, a senior fellow at the Brookings Institution's Center on Health Policy. For example, while drug manufacturing plants can cost $1 billion and take three to five years to set up, it would be relatively cheap to build a syringe factory — a business American manufacturers abandoned during the covid-19 pandemic because China was dumping its products here, Wosińska said.

It's not surprising that giants such as Novartis and Eli Lilly have promised Trump they'll invest billions in U.S. plants, she said, since much of their final drug product is made here or in Europe, where governments negotiate drug prices. The industry is using Trump's tariff saber-rattling as leverage; in an April 11 letter, 32 drug companies demanded European governments pay them more or face an exodus to the United States.

Brandon Daniels, CEO of supply chain company Exiger, is bullish on tariffs. He thinks they could help bring some chemical manufacturing back to the U.S., which, when coupled with increased use of automation, would reduce the labor advantages of China and India.

"You've got real estate in North Texas that's cheaper than real estate in Shenzhen," he said at an economic conference April 25 in Washington, referring to a major Chinese chemical manufacturing center.

But Wosińska said no amount of tariffs will compel makers of generic drugs, responsible for 90% of U.S. prescriptions, to build new factories in the U.S. Payment structures and competition would make it economic suicide, she said.

Several U.S. generics firms have declared bankruptcy or closed U.S. factories over the past decade, said John Murphy, CEO of the Association for Accessible Medicines, the generics trade group. Reversing that trend won't be easy and tariffs won't do it, he said.

"There's not a magic level of tariffs that magically incentivizes them to come into the U.S.," he said. "There is no room to make a billion-dollar investment in a domestic facility if you're going to lose money on every dose you sell in the U.S. market."

His group has tried to explain these complexities to Trump officials, and hopes word is getting through. "We're not PhRMA," Murphy said, referring to the powerful trade group primarily representing makers of brand-name drugs. "I don't have the resources to go to Mar-a-Lago to talk to the president myself."

Many of the active ingredients in American drugs are imported. Fresenius Kabi, a German company with facilities in eight U.S. states to produce or distribute sterile injectables — vital hospital drugs for cancer and other conditions — complained in a letter to U.S. Trade Representative Jamieson Greer that tariffs on these raw materials could paradoxically lead some companies to move finished product manufacturing overseas.

Fresenius Kabi also makes biosimilars, the generic forms of expensive biologic drugs such as Humira and Stelara. The United States is typically the last developed country where biosimilars appear on the market because of patent laws.

Tariffs on biosimilars coming from overseas — where Fresenius makes such drugs — would further incentivize U.S. use of more expensive brand-name biologics, the March 11 letter said. Biosimilars, which can cost a tenth of the original drug's price, launch on average 3-4 years later in the U.S. than in Canada or Europe.

In addition to getting cheaper knockoff drugs faster, European countries also pay far less than the United States for brand-name products. Paradoxically, Murphy said, those same countries pay more for generics.

European governments tend to establish more stable contracts with makers of generics, while in the United States, "rabid competition" drives down prices to the point at which a manufacturer "maybe scrimps on product quality," said John Barkett, a White House Domestic Policy Council member in the Biden administration.

As a result, Wosińska said, "without exemptions or other measures put in place, I really worry about tariffs causing drug shortages."

Smoller, the New York pharmacist, doesn't see any upside to tariffs.

"How do I solve the problem of caring for my community," he said, "but not being subject to the emotional roller coaster that is dispensing hundreds of prescriptions a day and watching every single one of them be a loss or 12 cents profit?"

Jackie Fortiér: jfortier@kff.org, @JackieFortier

Arthur Allen: aallen@kff.org, @ArthurAllen202

Pain Clinic CEO Faced 20 Years for Making Patients 'Human Pin Cushions.' He Got 18 Months.

KFF Health News, May 16, 2025

A federal judge described Kestner as a 'ruthless businessman' who funded a 'lavish lifestyle' by turning medical professionals into 'puppets.'

This article was published on Thursday, May 15, 2025 in KFF Health News.

By Brett Kelman

NASHVILLE, Tenn. — Federal prosecutors sought a maximum prison sentence of nearly 20 years for the CEO of Pain MD, a company found to have given hundreds of thousands of questionable injections to patients, many reliant on opioids. It would have been among the longest sentences for a health care executive convicted of fraud in recent years.

Instead, he got 18 months.

Michael Kestner, 73, who was convicted of 13 fraud felonies last year, faced at least a decade behind bars based on federal sentencing guidelines. He was granted the substantially lightened sentence due to his age and health Wednesday during a federal court hearing in Nashville.

U.S. District Judge Aleta Trauger described Kestner as a "ruthless businessman" who funded a "lavish lifestyle" by turning medical professionals into "puppets" who pressured patients into injections that did not help their pain and sometimes made it worse.

"In the court's eyes, he knew it was wrong, and he didn't really care if it was doing anyone any good," Trauger said.

But Trauger also said she was swayed by defense arguments that Kestner would struggle in federal prison due to his age and medical conditions, including the blood disorder hemochromatosis. Trauger said she had concerns about prison health care after considering about 200 requests for compassionate release in other court cases.

"The medical care at these facilities," defense attorney Peter Strianse said, "has always been dodgy and suspect."

Kestner did not speak at the court hearing, other than to detail his medical conditions. He did not respond to questions as he left the courthouse.

Pain MD ran as many as 20 clinics in Tennessee, Virginia, and North Carolina throughout much of the 2010s. While many doctors were scaling back their use of prescription painkillers due to the opioid crisis, Pain MD paired opioids with monthly injections into patients' backs, claiming the shots could ease pain and potentially lessen reliance on pills, according to federal court documents.

During Kestner's October trial, the Department of Justice proved that the injections were part of a decade-long scheme that defrauded Medicare and other insurance programs of millions of dollars by capitalizing on patients' dependence on opioids.

The DOJ successfully argued at trial that Pain MD's "unnecessary and expensive injections" were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead. During closing arguments, the DOJ argued Pain MD had turned some patients into "human pin cushions."

"They were leaned over a table and repeatedly injected in their spine," federal prosecutor Katherine Payerle said during the May 14 sentencing hearing. "Over and over, month after month, at the direction of Mr. Kestner."

At last year's trial, witnesses testified that Kestner was the driving force behind the injections, which amounted to roughly 700,000 shots over about eight years, with some patients receiving up to 24 at once.

Four former patients testified that they tolerated the shots out of fear that Pain MD otherwise would have cut off their painkiller prescriptions, without which they might have spiraled into withdrawal.

One of those patients, Michelle Shaw, told KFF Health News that the injections sometimes left her in so much pain she had to use a wheelchair. She was outraged by Kestner's sentence.

"I'm disgusted that all they got was a slap on the wrist as far as I'm concerned," Shaw said May 14. "I hope karma comes back to him. That he suffers to his last breath."

Brett Kelman: bkelman@kff.org, @BrettKelman

Dead Zone: Flawed Federal Programs Maroon Rural Americans in Telehealth Blackouts

KFF Health News, May 14, 2025

Years of Republican and Democratic administrations have tried to fix the nation's broadband woes.

This article was published on Wednesday, May 14, 2025 in KFF Health News.

By Sarah Jane Tribble and Holly K. Hacker

BRANCHLAND, W.Va. — Ada Carol Adkins lives with her two dogs in a trailer tucked into the timbers off Upper Mud River Road.

"I'm comfortable here, but I'm having health issues," said the 68-year-old, who retired from her job as a school cook several years ago after having a stroke. "Things are failing me."

Her trailer sits halfway up a ridge miles from town and the local health clinic. Her phone and internet are "wacky sometimes," she said. Adkins — who is fiercely independent and calls herself a "Mountain Momma" — worries she won't be able to call for help if service goes out, which happens often.

To Frontier Communications, the telecommunications company that owns the line to her home, Adkins says: "Please come and hook me right."

But she might be waiting years for better service, frustrated by her internet provider and left behind by troubled federal grant programs.

A quarter of West Virginia counties — including Lincoln, where the Mud River bends its way through hollows and past cattle farms — face two barriers to health care: They lack high-speed internet and have a shortage of primary care providers and behavioral health specialists, according to a KFF Health News analysis.

Years of Republican and Democratic administrations have tried to fix the nation's broadband woes, through flawed attempts. Bad mapping, weak standards, and flimsy oversight have left Adkins and nearly 3 million other rural Americans in dead zones — with eroded health care services and where telehealth doesn't reach.

Blair Levin, a former executive director of the Federal Communications Commission's National Broadband Plan, called one rural program rollout during the first Trump administration "a disaster."

It was launched before it was ready, he said, using unreliable federal maps and a reverse-auction process to select internet carriers. Locations went to the lowest bidder, but the agency failed to ensure winners had the knowledge and resources to build networks, said Levin, who is now an equity analyst with New Street Research.

The fund initially announced awards of $9.2 billion to build infrastructure in 49 states. By 2025, $3.3 billion of those awards were in default and, as a result, the program won't connect 1.9 million homes and businesses, according to a recent study.

A $42 billion Biden-era initiative still may not help Adkins and many others shortchanged by earlier federal broadband grants. The new wave of funding, the Broadband Equity, Access, and Deployment Program, or BEAD, has an anti-waste provision and won't provide service in places where previous grants were awarded — even if companies haven't delivered on their commitments.

The use of federal money to get people connected is "really essential" for rural areas, said Ross DeVol, CEO and chairman of the board of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

"Internet service providers look at the economics of trying to go into some of these communities and there just isn't enough purchasing power in their minds," DeVol said, adding that broadband expansion is analogous to rural electrification. Without high-speed internet, "you're simply at a distinct disadvantage," he added. "I'll call it economic discrimination."

'I Got Books Full'

Adkins keeps spiral-bound notebooks and calendars filled with handwritten records of phone and internet outages.

In January, while bean soup warmed on the stove, she opened a notebook: "I got books full. Hang on."

Her finger traced the page as she recounted outages that occurred about once a month last year. Adkins said she lost connectivity twice in November, again in October, and in July, May, and March. Each time she went for days without service.

Adkins pays Frontier Communications $102.13 a month for a "bundle" that includes a connection for her house phone and wireless internet access on her cellphone. Frontier did not respond to requests for comment on Adkins' and other customers' service.

Adkins, a widow, spends most of her time at home and said she would do video calls with her doctors if she could. She said she still has numbness on one side of her body after the stroke. She also has high blood pressure and arthritis and uses over-the-counter pain patches when needed, such as after she carries 30-pound dog food bags into the house.

She does not own a four-wheel-drive truck and, for three weeks in January, the snow and ice were so severe she couldn't leave. "I'm stranded up here," she said, adding that neighbors check in: "'Do you have electric? Have you got water? Are you OK?'"

The neighbors have all seen Adkins' line. The pale-yellow cord was tied off with green plastic ties around a pole outside her trailer. As it ran down the hill, it was knotted around tree trunks and branches, frayed in places, and, finally, collapsed on the ground under gravel, snow, and ice at the bottom of the hill.

Adkins said a deer stepping on the line has interrupted her phone service.

David and Billi Belcher's double-wide modular home sits near the top of the ridge past Adkins' home. Inside, an old hunting dog sleeps on the floor. Belcher pointed out a window toward where he said Frontier's cable has remained unrepaired for years: "It's laying on the ground in the woods," he said.

Frontier is West Virginia's legacy carrier, controlling most of the state's old landlines since buying them from Verizon Communications in 2010. Twelve years later, the company won nearly $248 million to install high-speed internet to West Virginia through the Rural Digital Opportunity Fund, an initiative launched during President Donald Trump's first term.

"Big Daddy," as local transit driver Bruce Perry called Trump, is popular with the people of Lincoln County. About 80% of the county's voters picked the Republican in the last election.

The Trump administration awarded Frontier money to build high-speed internet to Upper Mud River Road residents, like Adkins, according to state mapping. Frontier has until Dec. 31, 2028, to build.

But the Belchers needed better internet access for work and could afford to pay $700 for a Starlink satellite internet kit and insurance, they said. Their monthly Starlink bill is $120 — a price many cannot manage, especially since Congress sunset an earlier program that helped offset the cost of high-speed plans for consumers. 

Meanwhile, the latest broadband program to connect rural Americans is ensnared in Trump administration policy shifts.

The National Telecommunications and Information Administration, which administers the program, in April announced a 90-day extension for states to finalize their plans during a "comprehensive review" of the program.

West Viriginia Gov. Patrick Morrisey, a Republican, announced his state would take an extension. The move, though, doesn't make a lot of sense, said Evan Feinman, who left the agency in March after directing the broadband program for the past three years.

Calling the work already done in West Virginia an "incredible triumph," Feinman said the state had completed the planning, mapping, and the initial selection of companies. The plan that was in place would have brought high-speed fiber lines to homes ahead of schedule and under budget, he said.

"They could be building today, and it's just deeply disappointing that they're not," Feinman said.

When Feinman resigned in March, he sent a lengthy email stating that the new administration wants to take fiber away from homes and businesses and substitute it with satellite connections. The move, he said, would be more expensive for consumers and hurt rural and small-town America.

Morrisey, whose office declined to respond to requests for comment, said in his announcement that he wants to ensure West Virginia spends the money in a manner "consistent with program changes being proposed by the Trump Administration" and "evaluate a broader range of technology options."

Commissioners from Grant County responded with a letter supporting fiber-optic cables rather than satellite-based connections like those provided by Elon Musk's Starlink. Nationwide, 115 lawmakers from 28 states sent a letter to federal leaders stating that changes could "delay broadband deployment by a year or more."

For Adkins and others, the wait has been long enough.

While legislators in Washington and across the country bickered over the broadband program, Adkins went without phone and internet. By late March, she said, her 42-year-old son was increasingly worried, noting "you're getting up in age." He told her: "Mom, move out, get off of that hill."

Worst-Case Scenario

A few miles from Upper Mud River Road, past the McDonald's and across the road from the local library, Brian Vance sat in his downtown Hamlin, West Virginia, office. He said his company has been trying to "build up there for a while."

Vance is a general manager for Armstrong Telephone and Cable, a regional telecommunications provider that competes with Frontier. He grew up in the community, and parents of a high school friend live off Upper Mud River. But he said "it's very difficult" to build fiber along the rocky terrain to homes where "you are hoping that people will hook up, and if they don't, well, you've lost a lot of money."

A 2022 countywide broadband assessment found that stringing fiber-optic lines along telephone poles would cost more than $5,000 per connection in some areas — work that would need big federal subsidies to be feasible.

Yet Vance said Armstrong cannot apply for the latest BEAD funding to help finance connections. And while he likes that the federal government is "being responsible" by not handing out two federal grants for the same area, Vance said, "we want to see people deliver on the grants they have."

If Frontier hadn't already gotten federal funds from the earlier Trump program, "we definitely would have applied to that area," Vance said.

The 2022 assessment noted the community's economy would not be sustainable without "ubiquitous broadband."

High-speed internet brings more jobs and less poverty, said Claudia Persico, an associate professor at American University. Persico, who is also a research associate with the National Bureau of Economic Research, co-authored a recent paper that found increased broadband internet leads to a reduction in the number of suicides as well as improvements in self-reported mental and physical health.

More than 30% of Lincoln County's population reports cases of depression, according to data from the Centers for Disease Control and Prevention. The rate of opioid prescriptions dispensed in Lincoln County is down about 60% from 2014 to 2024 — but still higher than the state average, according to the West Virginia Board of Pharmacy.

Twenty percent of the county's population lives below the poverty line, and residents are also more likely than the national average to experience heart disease, diabetes, and obesity.

Lincoln Primary Care Center offers telehealth services such as electronic medical records on a patient portal and a pharmacy app, said Jill Adkins, chief quality and risk officer at Southern West Virginia Health System, which operates the clinic.

But because of limited access, only about 7% of patients use telehealth, she said.

Della Vance was a patient at the clinic but said she has never used a patient portal. If she could, Vance said, she would check records on the baby she is expecting.

"You can't really get on if you don't have good service and no internet," she said. "It makes me angry, honestly."

Vance and her husband, Isaiah, live off a gravel road that veers from Upper Mud River. There is a tall pole with black wires dangling across the road from their small home. Pointing to the cables, Isaiah Vance said he couldn't get phone service anymore.

Verizon announced plans last year to buy Frontier for an estimated $20 billion. The deal, which must be approved by federal and state regulators, is expected to be completed in early 2026, according to an investor's press release.

In its federal merger application, Frontier stated that it had taken on too much debt after emerging from bankruptcy and that debt would make it difficult to finish the work of installing fiber to customers in 25 states.

In West Virginia, Frontier's Allison Ellis wrote in March 3 testimony, seeking approval for the merger from state regulators, that Verizon will honor the rural program commitments. The previous month, in February, Frontier filed a motion with the state public service commission to keep the number of customers using copper lines and the faster fiber-optic lines confidential.

Kelly Workman, West Virginia's broadband director, said during a November interview that her office has asked federal regulators for "greater visibility" into Frontier's rural program construction, particularly because those locations cannot win the Biden-era infrastructure money when it's available.

"The worst-case scenario would be for any of these locations to be left behind," Workman said.

'Money Cow'

Frontier's progress installing fiber-optic lines and its unreliable service have frustrated West Virginians for years. In a 2020 letter to the FCC, U.S. Sen. Shelley Capito (R-W.Va.) cited "the failure of Frontier to deliver on promises to federal partners" and its "mismanagement" of federal dollars, which forced the state to pay back $4.7 million because of improper use and missed deadlines.

Michael Holstine, a longtime member of the West Virginia Broadband Enhancement Council, said the company has "just used West Virginia as a money cow." Holstine has been fighting for the construction of fiber-optic lines in Pocahontas County for years. "I really just hope I get it before I die."

Across the state, people like Holstine and Adkins are eager for updated networks, according to interviews as well as letters released under a public records request.

Chrissy Murray, vice president of Frontier's external communications, acknowledged that the company was "building back our community efforts" in West Virginia after a bankruptcy filing and reorganization. She said there has been a "notable decline" in consumer complaints, though she did not provide specific numbers.

Murray said Frontier built fiber-optic cables to 20% of its designated rural funds locations as of the end of 2024. It has also invested in other infrastructure projects across the state, she said in a January email, adding that the company donated high-speed fiber internet to West Virginia University's rural Jackson's Mill campus.

According to data tracked by a federal agency, Frontier has connected 6,100 — or fewer than 10% — of the more than 79,000 locations it was awarded in the Rural Digital Opportunity Fund program.

The FCC oversees the rural fund. The agency did not respond to a request for comment. Frontier expects to receive $37 million annually from the agency through 2032, according to a federal filing.

In April, a new batch of letters from West Virginia residents filed as "support" for Frontier's merger with Verizon appeared in the state regulatory docket:

"My support for this case depends on whether Verizon plans to upgrade or replace the existing Frontier infrastructure," wrote one customer in Summers County, in the far southern corner of the state, adding, "West Virginians in my neck of the woods have been held hostage by Frontier for a generation now because no other providers exist."

A customer from Hardy County, in the state's northeastern corner, wrote: "This is [a] move by frontier to to [sic] escape its responsibility to continue services."

'Deep-Rooted'

Adkins moved to Upper Mud River with her husband, Bobby, decades ago.

For years, Bobby and Ada Carol Adkins ran a "carry-out" on Upper Mud River Road. The old building is still at the rock quarry just down the hill and around the curve from where her trailer sits.

It was the type of store where locals kept a tab — which Bobby treated too much like a "charity," Adkins said. They sold cigarettes, beer, bread, bags of chips, and some food items like potatoes and rice. "Whatever the community would want," she said.

Then, Bobby Adkins' "health started deteriorating and money got tighter," Adkins said. He died at 62 years old.

Now, Adkins said, "I'm having kidney problems. I got arthritis, they're treating me for high blood pressure."

Her doctor has begun sending notes over the internet to refill her blood pressure medicine and, Adkins said, "I love that!"

But Adkins' internet was out again in early April, and she can't afford Starlink like her neighbors. Even as Adkins said she is "deep-rooted," her son's request is on her mind.

"I'm having health problems," Adkins said. "He makes a lot of sense."

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

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

Lydia Zuraw: lzuraw@kff.org, @lydiazuraw

Honey, Sweetie, Dearie: The Perils of Elderspeak

KFF Health News, May 13, 2025

Studies in nursing homes show how commonplace such speech is.

This article was published on Friday, May 9, 2025 in KFF Health News.

By Paula Span

A prime example of elderspeak: Cindy Smith was visiting her father in his assisted living apartment in Roseville, California. An aide who was trying to induce him to do something —  Smith no longer remembers exactly what — said, "Let me help you, sweetheart."

"He just gave her The Look — under his bushy eyebrows — and said, 'What, are we getting married?'" recalled Smith, who had a good laugh, she said. Her father was then 92, a retired county planner and a World War II veteran; macular degeneration had reduced the quality of his vision, and he used a walker to get around, but he remained cognitively sharp.

"He wouldn't normally get too frosty with people," Smith said. "But he did have the sense that he was a grown-up and he wasn't always treated like one."

People understand almost intuitively what "elderspeak" means. "It's communication to older adults that sounds like baby talk," said Clarissa Shaw, a dementia care researcher at the University of Iowa College of Nursing and a co-author of a recent article that helps researchers document its use.

"It arises from an ageist assumption of frailty, incompetence, and dependence."

Its elements include inappropriate endearments. "Elderspeak can be controlling, kind of bossy, so to soften that message there's 'honey,' 'dearie,' 'sweetie,'" said Kristine Williams, a nurse gerontologist at the University of Kansas School of Nursing and another co-author of the article.

"We have negative stereotypes of older adults, so we change the way we talk."

Or caregivers may resort to plural pronouns: Are we ready to take our bath? There, the implication "is that the person's not able to act as an individual," Williams said. "Hopefully, I'm not taking the bath with you."

Sometimes, elderspeakers employ a louder volume, shorter sentences, or simple words intoned slowly. Or they may adopt an exaggerated, singsong vocal quality more suited to preschoolers, along with words like "potty" or "jammies."

With what are known as tag questions — It's time for you to eat lunch now, right? — "You're asking them a question but you're not letting them respond," Williams explained. "You're telling them how to respond."

Studies in nursing homes show how commonplace such speech is. When Williams, Shaw, and their team analyzed video recordings of 80 interactions between staff and residents with dementia, they found that 84% involved some form of elderspeak.

"Most of elderspeak is well intended. People are trying to show they care," Williams said. "They don't realize the negative messages that come through."

For example, among nursing home residents with dementia, studies have found a relationship between exposure to elderspeak and behaviors collectively known as resistance to care.

"People can turn away or cry or say no," Williams explained. "They may clench their mouths shut when you're trying to feed them." Sometimes, they push caregivers away or strike them.

She and her team developed a training program called CHAT, for Changing Talk: three hourlong sessions that include videos of communication between staff members and patients, intended to reduce elderspeak.

It worked. Before the training, in 13 nursing homes in Kansas and Missouri, almost 35% of the time spent in interactions consisted of elderspeak; that share dropped to about 20% afterward.

Furthermore, resistant behaviors accounted for almost 36% of the time spent in encounters; after training, that proportion fell to about 20%.

A study conducted in a Midwestern hospital, again among patients with dementia, found the same sort of decline in resistance behavior.

What's more, CHAT training in nursing homes was associated with lower use of antipsychotic drugs. Though the results did not reach statistical significance, due in part to the small sample size, the research team deemed them "clinically significant."

"Many of these medications have a black box warning from the FDA," Williams said of the drugs. "It's risky to use them in frail, older adults" because of their side effects.

Now, Williams, Shaw, and their colleagues have streamlined the CHAT training and adapted it for online use. They are examining its effects in about 200 nursing homes nationwide.

Even without formal training programs, individuals and institutions can combat elderspeak. Kathleen Carmody, owner of Senior Matters Home healthcare and Consulting in Columbus, Ohio, cautions her aides to address clients as Mr. or Mrs. or Ms., "unless or until they say, 'Please call me Betty.'"

In long-term care, however, families and residents may worry that correcting the way staff members speak could create antagonism.

A few years ago, Carol Fahy was fuming about the way aides at an assisted living facility in suburban Cleveland treated her mother, who was blind and had become increasingly dependent in her 80s.

Calling her "sweetie" and "honey babe," the staff "would hover and coo, and they put her hair up in two pigtails on top of her head, like you would with a toddler," said Fahy, a psychologist in Kaneohe, Hawaii.

Although she recognized the aides' agreeable intentions, "there's a falseness about it," she said. "It doesn't make someone feel good. It's actually alienating."

Fahy considered discussing her objections with the aides, but "I didn't want them to retaliate." Eventually, for several reasons, she moved her mother to another facility.

Yet objecting to elderspeak need not become adversarial, Shaw said. Residents and patients — and people who encounter elderspeak elsewhere, because it's hardly limited to healthcare settings — can politely explain how they prefer to be spoken to and what they want to be called.

Cultural differences also come into play. Felipe Agudelo, who teaches health communications at Boston University, pointed out that in certain contexts a diminutive or term of endearment "doesn't come from underestimating your intellectual ability. It's a term of affection."

He emigrated from Colombia, where his 80-year-old mother takes no offense when a doctor or healthcare worker asks her to "tómese la pastillita" (take this little pill) or "mueva la manito" (move the little hand).

That's customary, and "she feels she's talking to someone who cares," Agudelo said.

"Come to a place of negotiation," he advised. "It doesn't have to be challenging. The patient has the right to say, 'I don't like your talking to me that way.'"

In return, the worker "should acknowledge that the recipient may not come from the same cultural background," he said. That person can respond, "This is the way I usually talk, but I can change it."

Lisa Greim, 65, a retired writer in Arvada, Colorado, pushed back against elderspeak recently when she enrolled in Medicare drug coverage.

Suddenly, she recounted in an email, a mail-order pharmacy began calling almost daily because she hadn't filled a prescription as expected.

These "gently condescending" callers, apparently reading from a script, all said, "It's hard to remember to take our meds, isn't it?" — as if they were swallowing pills together with Greim.

Annoyed by their presumption, and their follow-up question about how frequently she forgot her medications, Greim informed them that having stocked up earlier, she had a sufficient supply, thanks. She would reorder when she needed more.

Then, "I asked them to stop calling," she said. "And they did."

The New Old Age is produced through a partnership with The New York Times.

Medicaid Payments Barely Keep Hospital Mental Health Units Afloat. Federal Cuts Could Sink Them.

KFF Health News, May 12, 2025

The U.S. already faces a deep shortage of inpatient mental health services.

This article was published on Monday, May 12, 2025 in KFF Health News.

By Tony Leys

SPENCER, Iowa — This town's hospital is a holdout on behalf of people going through mental health crises. The facility's leaders have pledged not to shutter their inpatient psychiatric unit, as dozens of other U.S. hospitals have.

Keeping that promise could soon get tougher if Congress slashes Medicaid funding. The joint federal-state health program covers an unusually large share of mental health patients, and hospital industry leaders say spending cuts could accelerate a decades-long wave of psychiatric unit closures.

At least eight other Iowa hospitals have stopped offering inpatient mental healthcare since 2007, forcing people in crisis to seek help in distant facilities. Spencer Hospital is one of the smallest in Iowa still offering the service.

CEO Brenda Tiefenthaler said 40% of her hospital's psychiatric inpatients are covered by Medicaid, compared with about 12% of all inpatients. An additional 10% of the hospital's psychiatric inpatients are uninsured. National experts say such disparities are common.

Tiefenthaler vows to keep her nonprofit hospital's 14-bed psychiatric unit open, even though it loses $2 million per year. That's a significant loss for an organization with an overall annual budget of about $120 million. But the people who use the psychiatric unit need medical care, "just like people who have chest pains," Tiefenthaler said.

Medicaid covers healthcare for about 72 million Americans with low incomes or disabilities. Tiefenthaler predicts that if some of them are kicked off the program and left without insurance coverage, more people would delay treatment for mental health problems until their lives spin out of control.

"Then they're going to enter through the emergency room when they're in a crisis," she said. "That's not really a solution to what we have going on in our country."

Republican congressional leaders have vowed to protect Medicaid for people who need it, but they also have called for billions of dollars in cuts to areas of the federal budget that include the program.

The U.S. already faces a deep shortage of inpatient mental health services, many of which were reduced or eliminated by private hospitals and public institutions, said Jennifer Snow, director of government relations and policy for the National Alliance on Mental Illness. At the same time, the number of people experiencing mental problems has climbed.

"I don't even want to think about how much worse it could get," she said.

The American Hospital Association estimates nearly 100 U.S. hospitals have shuttered their inpatient mental health services in the past decade.

Such closures are often attributed to mental health services being more likely to lose money than many other types of healthcare. "I'm not blaming the hospitals," Snow said. "They need to keep their doors open."

Medicaid generally pays hospitals lower rates for services than they receive from private insurance or from Medicare, the federal program that mostly covers people 65 or older. And Medicaid recipients are particularly likely to need mental healthcare. More than a third of nonelderly Medicaid enrollees have some sort of mental illness, according to a report from KFF, a nonprofit health policy organization that includes KFF Health News. Iowa has the highest rate of mental illness among nonelderly Medicaid recipients, at 51%.

As of February, just 20 of Iowa's 116 community hospitals had inpatient psychiatric units, according to a state registry. Iowa also has four freestanding mental hospitals, including two run by the state.

Iowa, with 3.2 million residents, has a total of about 760 inpatient mental health beds that are staffed to care for patients, the state reports. The Treatment Advocacy Center, a national group seeking improved mental healthcare, says the "absolute minimum" of such beds would translate to about 960 for Iowa's population, and the optimal number would be about 1,920.

Most of Iowa's psychiatric beds are in metro areas, and it can take several days for a slot to come open. In the meantime, patients routinely wait in emergency departments.

Sheriff's deputies often are assigned to transport patients to available facilities when treatment is court-ordered.

"It's not uncommon for us to drive five or six hours," said Clay County Sheriff Chris Raveling, whose northwestern Iowa county includes Spencer, a city of 11,000 people.

He said Spencer Hospital's mental health unit often is too full to accept new patients and, like many such facilities, it declines to take patients who are violent or charged with crimes.

The result is that people are held in jail on minor charges stemming from their mental illnesses or addictions, the sheriff said. "They really shouldn't be in jail," he said. "Did they commit a crime? Yes. But I don't think they did it on purpose."

Raveling said authorities in many cases decide to hold people in jail so they don't hurt themselves or others while awaiting treatment. He has seen the problems worsen in his 25 years in law enforcement.

Most people with mental health issues can be treated as outpatients, but many of those services also depend heavily on Medicaid and could be vulnerable to budget cuts.

Jon Ulven, a psychologist who practices in Moorhead, Minnesota, and neighboring Fargo, North Dakota, said he's particularly worried about patients who develop psychosis, which often begins in the teenage years or early adulthood. If they're started right away on medication and therapy, "we can have a dramatic influence on that person for the rest of their life," he said. But if treatment is delayed, their symptoms often become harder to reverse.

Ulven, who helps oversee mental health services in his region for the multistate Sanford Health system, said he's also concerned about people with other mental health challenges, including depression. He noted a study published in 2022 that showed suicide rates rose faster in states that declined to expand their Medicaid programs than in states that agreed to expand their programs to cover more low-income adults. If Medicaid rolls are reduced again, he said, more people would be uninsured and fewer services would be available. That could lead to more suicides.

Nationally, Medicaid covered nearly 41% of psychiatric inpatients cared for in 2024 by a sample of 680 hospitals, according to an analysis done for KFF Health News by the financial consulting company Strata. In contrast, just 13% of inpatients in those hospitals' cancer programs and 9% of inpatients in their cardiac programs were covered by Medicaid.

If Medicaid participants have mental crises after losing their coverage, hospitals or clinics would have to treat many of them for little or no payment. "These are not wealthy people. They don't have a lot of assets," said Steve Wasson, Strata's chief data and intelligence officer. Even though Medicaid pays hospitals relatively low rates, he said, "it's better than nothing."

Birthing units, which also have been plagued by closures, face similar challenges. In the Strata sample, 37% of those units' patients were on Medicaid in 2024.

Spencer Hospital, which has a total of 63 inpatient beds, has maintained both its birthing unit and its psychiatric unit, and its leaders plan to keep them open. Amid a critical shortage of mental health professionals, it employs two psychiatric nurse practitioners and two psychiatrists, including one providing care via video from North Carolina.

Local resident David Jacobsen appreciates the hospital's efforts to preserve services. His son Alex was assisted by the facility's mental health professionals during years of struggles before he died by suicide in 2020.

David Jacobsen knows how reliant such services are on Medicaid, and he worries that more hospitals will curtail mental health offerings if national leaders cut the program. "They're hurting the people who need help the most," he said.

People on Medicaid aren't the only ones affected when hospitals reduce services or close treatment units. Everyone in the community loses access to care.

Alex Jacobsen's family saw how common the need is. "If we can learn anything from my Alex," one of his sisters wrote in his obituary, "it's that mental illness is real, it doesn't discriminate, and it takes some of the best people down in its ugly swirling drain."

Tony Leys: tleys@kff.org, @tonyleys

Seeking Spending Cuts, GOP Lawmakers Target a Tax Hospitals Love to Pay

KFF Health News, May 8, 2025

The CBO estimates eliminating provider taxes would save the federal government more than $600 billion over a decade.

This article was published on Thursday, May 8, 2025 in KFF Health News.

By Phil Galewitz

On the eastern plains of Colorado, in a county of less than 6,000 people, Lincoln Health runs the only hospital within a 75-minute drive. The facility struggles financially, given its small size and the area's tiny population.

But for over a decade, the Hugo, Colorado-based health system has remained afloat partially thanks to a surprising source: special taxes on the state's hospitals.

The taxes Lincoln pays help cover the state's Medicaid costs and — because the federal government matches a portion of what states spend on Medicaid — enable Colorado to claim more federal money. That generally leads to more dollars for the hospital. The tax proceeds also have helped Colorado expand Medicaid under the Affordable Care Act to cover 400,000 more low-income adults, significantly reducing the number of people showing up at hospital doors without insurance.

Last year, Lincoln paid $500,000 in provider taxes but netted more than $3.6 million extra from Medicaid, accounting for about 15% of its budget, said Lincoln CEO Kevin Stansbury.

"These dollars allow me to care for patients who are enrolled in Medicaid and to break even rather than lose money," he said. "Without them, it would significantly impact our ability to survive."

Every state except Alaska uses at least one provider tax to boost its federal Medicaid dollars.

But Republicans who control Congress are looking for potential cuts in the nearly $900 billion Medicaid program to help fund an extension of President Donald Trump's tax cuts — and have sought to portray provider taxes as malicious, sometimes even deriding them as "money laundering." Lawmakers say they may curtail or eliminate provider taxes as part of legislation to enact Trump's domestic agenda.

"It's infuriating," Stansbury said.

Medicaid and the closely related Children's Health Insurance Program together cover roughly 79 million low-income and disabled people and are jointly financed by states and the federal government.

Federal dollars match state payments with no limit. While the split varies based on a state's per capita income, the federal match ranges from 50% to 77% for children, pregnant women, and people with disabilities, who make up most of the enrollment.

States started using provider taxes in the 1980s to help pay their share and gain additional Medicaid funds from the federal government.

Brian Blase, a former Trump health policy adviser who leads the conservative Paragon Health Institute, sees provider taxes as one of the highest forms of waste in Medicaid. States and their hospitals, nursing homes, and other providers aren't held accountable for how the tax money is used, reducing incentives for states to control Medicaid spending, he said.

"This has been a feature of the program for four decades, and it is a feature that is getting worse," Blase said.

The Congressional Budget Office estimates eliminating provider taxes would save the federal government more than $600 billion over a decade.

Rep. Brett Guthrie (R-Ky.), who chairs the House committee that oversees Medicaid, has said provider taxes are on the menu for potential cuts.

Other changes Republicans are considering to cut federal Medicaid spending include requiring adult enrollees to prove they're working as a condition of eligibility, as well as ending higher payments for adults enrolled as part of the Affordable Care Act's expansion of the program.

Since 2014, more than 20 million nondisabled adults in 40 states and Washington, D.C., have gained coverage under the expansion.

House Republicans have set a Memorial Day deadline to come to an agreement on spending cuts, which would help pay for extending about $4 trillion in tax cuts passed during Trump's first administration and set to expire at the end of this year.

The Government Accountability Office and the Medicaid and CHIP Payment and Access Commission, a congressional advisory board, have raised concerns about the provider taxes, which effectively saddle federal taxpayers with state expenses. Republican and Democrat presidents have criticized or proposed curtailing the use of Medicaid provider taxes — including Trump in his first term, Barack Obama, and Joe Biden while serving as vice president.

But opposition from hospitals, nursing homes, and states snuffed out any move to limit or end the arrangements.

Colorado and other states often use the money to maintain or increase payments to providers, which are often paid less by Medicaid than by Medicare, the federal program primarily for people 65 or older, or private insurers.

States have added provider taxes to help generate federal money to cope with economic downturns and budget constraints.

Hospitals in Idaho last year began paying an additional provider tax to increase pay to hospitals and home- and community-based providers. The tax came as Idaho's Republican-controlled legislature sought to add many conditions that threatened to end the state's Medicaid expansion — which would also eliminate a key source of increased federal funding.

Brian Whitlock, president and CEO of the Idaho Hospital Association, said funding from the hospital tax helps boost Medicaid payments to about 80% of Medicare's rates instead of 60%.

"We still lose money on every Medicare and Medicaid patient," he said. "The state recognizes that this money helps offset the losses we take under Medicaid reimbursement."

While hospitals and nursing homes have been the main beneficiaries of provider tax proceeds, ambulance services have also paid and benefited from Medicaid taxes. States increasingly have also approved Medicaid taxes on private insurers that operate their Medicaid programs to gain more federal funds.

California's Medicaid managed care tax began in 2009 and is expected to generate nearly $9 billion in net revenue for the 2024-25 fiscal period — or about 5% of the state's Medicaid budget, according to the California Legislative Analyst's Office.

In recent years, California has extended full Medicaid coverage to immigrants lacking permanent legal status. Federal law prohibits federal Medicaid dollars from being used to cover people in the country without authorization, but states can use their own money.

At a presentation to congressional staffers in April, Blase cited California's strategy as an example of provider tax abuse and claimed the state is effectively laundering federal funds to cover people living in the U.S. without authorization.

In practice, the tax has been a kind of fiscal pressure valve generally offsetting state spending. A ballot measure that passed in November now requires that much of the money from California's tax specifically be used to increase Medicaid reimbursement to doctors, hospitals, and other providers.

Hospital officials and state Medicaid leaders argue the term "money laundering" is an inaccurate way to describe provider taxes, since they are allowed by federal law. But Blase said calling the levies a "tax" is misleading, pointing out that most businesses don't typically advocate to pay one.

Jamie Whitney, chief legal officer for Texas-based Adelanto HealthCare Ventures, a consulting firm, said that provider taxes are a politically neutral way to help states pay for Medicaid and that curtailing their use would harm them all. "This is not a red-state, blue-state issue," she said.

Colorado is one of more than a dozen states that have funded an ACA Medicaid expansion using provider tax money. Others include Arkansas, Louisiana, Missouri, North Carolina, Ohio, and Virginia.

Colorado implemented its Medicaid provider tax effort in 2009. In the 2024 fiscal year, about $5 billion of the state's $15 billion Medicaid program was funded by provider taxes, according to the state.

The money helps the state pay higher Medicaid reimbursements to hospitals, which reduces their need to charge higher rates to private insurers, said Kim Bimestefer, executive director of the Colorado Department of Health Care Policy and Financing, which oversees Medicaid.

Some of the extra payments are dependent on hospitals meeting certain quality and patient-safety metrics, such as reducing readmission rates after patients are discharged — a requirement state officials say improves care for everyone.

The provider taxes also fund a program allowing working residents with disabilities to buy into Medicaid coverage even if their income is as high as 300% of the federal poverty level, or $46,950 for an individual. About 20,000 people are enrolled in the program.

Among them is Alison Sbrana, 31, of Fort Collins, Colorado, who has a type of chronic fatigue syndrome and relies on Medicaid to cover long-term home care.

"It would be devastating if the benefit went away," said Sbrana, who works as a researcher and activist for those with the same disorder. "I would be forced to stop working to keep my income low enough to qualify."

The state's provider taxes also pay for a $60 million fund to support rural hospitals, helping them add telehealth services, recruit surgeons, and hire paramedics, according to a state report.

Konnie Martin, CEO of San Luis Valley Health, a two-hospital system based in Alamosa, Colorado, said her nonprofit paid $5.4 million in provider taxes last year and gained about $15 million in benefits from higher Medicaid payments and the rural grants.

She said the money helps her hospital maintain obstetrical services, so residents don't have to drive 120 miles to the nearest maternity hospital. Without the birthing center, the entire region would suffer, she said.

"It also would gut the economy of the community, because young people will move away," she said.

KFF Health News senior correspondent Bernard Wolfson contributed to this report.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Podcast: An Arm and a Leg: Why 'The Pitt' Is Our Fave New Drama

KFF Health News, May 5, 2025

People who work in real-life emergency rooms have raved about how the new TV drama "The Pitt" accurately captures the complex dynamics of their workplaces and the medical details of their cases.

Host Dan Weissmann talks with Alex Janke, an emergency medicine doctor and health policy researcher, about how the show stacks up against his experiences in the ER. They also discuss its depictions of the financial forces that shape day-to-day problems inside ERs.

CA's Primary Care Shortage Persists Despite Ambitious Moves to Close Gap

KFF Health News, May 1, 2025

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care.

This article was published on Thursday, May 1, 2025 in KFF Health News.

By Bernard J. Wolfson and Vanessa G. Sánchez

Sumana Reddy, a primary care physician, struggles on thin financial margins to run Acacia Family Medical Group, the small independent practice she founded 27 years ago in Salinas, a predominantly Latino city in an agricultural valley often called "the salad bowl of the world."

Reddy can't match the salaries offered by larger health systems — a difficulty compounded by a widespread shortage of primary care doctors.

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care, making recruitment difficult. "It certainly is challenging to expose medical students early in their careers to the joys of this kind of integrated health care," Reddy said. "The relationships we build and the care we provide truly allow people to live longer with a better quality of life."

Hoping to increase revenue so Acacia can afford to pay more, Reddy has signed the practice up for alternative payment methods with health plans that offer bonuses for meeting certain primary care goals tied to child vaccinations, blood pressure control, and screenings for breast cancer, colorectal cancer, and mental health. Such pay-for-performance arrangements are among the many efforts by industry players and state officials to confront the problems plaguing primary care.

Medical students frequently opt not to go into primary care, and that's not good for patients. People with regular primary care providers are more likely to get preventive care that avoids serious illnesses and feel more empowered to advocate for themselves. They're also less likely to encounter language barriers, resort to costly emergency room visits, or forgo care.

Six years after the influential California Future Health Workforce Commission made a series of recommendations to plug a projected shortage of 4,100 primary care providers in 2030, a number of public and private initiatives have proliferated around the state to address the problem. They include new residency slots, debt forgiveness, waived medical school tuition, new ways of paying doctors, expanded nurse practitioner roles, and a statewide target to increase primary care spending. Hundreds of millions of taxpayer dollars have been allocated for some of these efforts.

But numerous academic experts and medical professionals believe those moves, while well intended, have been scattershot and insufficient. "The pieces are there," said Monica Soni, chief medical officer of Covered California, the state's Affordable Care Act health insurance marketplace. "I am worried we started a little too late, and I think it's a little too siloed."

A study published in 2022 by the California Health Care Foundation found that substantial progress had been made on some of those goals, including recruitment of students from low-income households and communities of color. A separate analysis from the foundation showed that, from 2020 to 2023, California jumped about 10 spots in a ranking of states by primary care residents and fellows per capita.

However, the latest state data shows nearly 15 million Californians live in areas without enough primary care providers to meet patient needs.

State budget constraints and potential federal spending cuts, especially to Medicaid, could exacerbate shortages in areas already desperate for clinicians and dampen hopes of building a robust primary care system that state officials and virtually everyone in the industry agree would be a strong defense against serious — and costly — illnesses. Federal cuts could also hit medical training and hospital systems.

"Many of us are very scared about threats from both the Trump administration and Republicans in Congress," said Kevin Grumbach, a family community medicine professor at the University of California-San Francisco.

California's lack of primary care providers, including doctors, nurse practitioners, and physician assistants, is most acute in rural parts of the state, particularly in the north and the Central Valley. Entire rural counties, including Del Norte, Madera, Tulare, and Yuba, are designated shortage areas, according to state data. Some densely populated urban areas, including parts of Los Angeles, also confront shortages.

Many Californians face months-long waits for appointments or have to travel long distances or go to emergency rooms for nonurgent medical needs, which means hours spent in crowded waiting rooms for unnecessarily expensive care.

In Chico, 90 miles north of Sacramento, the emergency room at the only hospital in town has seen a sharp increase in patients over the past decade, due in part to a lack of primary care providers in the area.

"People who don't have a primary care provider — which is a lot, because there are not enough — end up in the ER when they need routine care," said David Alonso, a local internal medicine doctor. "The ER then says, ‘OK, you should follow up with your primary care provider,' and they're like, ‘We don't have one.'"

Yalda Jabbarpour, director of the Robert Graham Center for Policy Studies, a health policy think tank, said failure to invest robustly in primary care has robbed the public of its benefits.

The field has historically been underfunded, accounting for less than 5% of national health care spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.

The Consequences Are Clear.

The U.S. spends significantly more per capita on health care than other industrialized nations, and yet Americans aren't any healthier. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer's, as well as mental illness, account for 90% of the $4.5 trillion spent on health care every year.

Medical students, often faced with staggering educational debt, are increasingly choosing higher-paid specialties over primary care. The average salary of a family medicine physician is slightly over $300,000, compared with more than $565,000 for a cardiologist and over $763,000 for a neurosurgeon, according to one study.

"If you are going to pay over $300,000 to go to medical school, you want to be a neurosurgeon; you don't want to be a family practice doctor," said William Barcellona, executive vice president of government affairs at America's Physician Groups, a Los Angeles-based professional association representing 360 medical groups and independent practice associations nationwide.

Barcellona said the Golden State's high housing costs also make recruiting difficult.

But it's not only pay that tempers enthusiasm for primary care. It's also burnout from so many unpaid hours spent recording details of medical visits in electronic health records; haggling with insurance companies for treatment authorization; answering phone calls and emails from patients; or searching far and wide — often in a health care desert — for specialists with the right expertise.

Debby Lee, the daughter of Hmong immigrants from Laos, experienced this kind of frustration firsthand.

Cultural and linguistic barriers faced by her family motivated her to pursue internal medicine. Lee worked part of her residency at a community clinic serving Hmong in the Sacramento area. She loved the patients, as well as her co-workers. But she was burdened by outdated technology that limited the number of patients she could see. "I just saw myself kind of burning out being in that setting," Lee said.

When the clinic invited her to stay, she declined, taking a job with a bigger health system.

Solutions to the Shortage

Besides residencies, other efforts support primary care.

The Health Plan of San Mateo offers grants to help medical practices retain and add to primary care staff. In exchange, the practices — some single physicians serving patients in California's Medicaid program, Medi-Cal — must show they have increased their patient load and retained newly hired providers for five years.

The idea is to provide capital so doctors can hire the staff they need to run their practices efficiently, increase salaries, offer bonuses, and even take sabbaticals. Such efforts are consistent with one of the main thrusts of the 2019 workforce report: to increase investment in primary care.

California recently joined several other states, including Connecticut, Oklahoma, and Rhode Island, in setting a target to increase primary care spending. So far, those policies have yielded mixed results.

Late last year, California's Office of Health Care Affordability set a target to make primary care account for 15% of total health care spending by 2034, more than double the current proportion. It imposes no requirements, relying on the goodwill of health plans to work with medical providers.

Greater spending on primary care would mean better pay and more people working in the field, said Richard Kronick, a public health professor at UC-San Diego and a member of the OHCA board. "That's a big change. Will it happen? I don't think anyone can predict the future with any certainty."

Stephen Shortell, a professor emeritus of health policy and management at UC-Berkeley, said "some of that increase might occur, but at some point, it might need to be made mandatory."

In its report, the workforce commission also cited the importance of alternative forms of primary care payment that offer extra cash for quality care. The affordability office has set targets to encourage such payment methods. The aim is to transform the system from one in which every medical service has a price tag to one that treats people holistically, and in which adherence to medical standards brings more money to doctors and their office staff.

Such arrangements are common among HMOs, though less so in primary care practices. Where they do exist, different health plans and other payers generally design them differently, which means primary care practices manage multiple payment models, adding to their administrative burden.

Reddy's family practice is participating in a one-year demonstration project launched in January intended to reduce that burden by having multiple insurers work together in one payment plan.

The project brings together three large insurers — Health Net, Aetna, and Blue Shield of California — and 10 independent practices across the state with the goal of improving care while boosting revenue for the medical groups. It is administered by two industry groups, the Integrated Healthcare Association and the California Quality Collaborative.

On top of customary payments, either for services rendered or monthly per-member allotments, the medical practices receive bonuses for meeting targets or improving their performance on core measures.

Participating practices also receive monthly per-patient payments for "population health management," which means managing the collective health of their patients. And they can search a single platform to find all their patients covered by one of the three plans.

In addition to extra payments and fewer administrative hassles, the health plans pay for a "practice coach," whose job is to help primary care groups meet their targets and provide more seamless care.

The idea is to add more insurers and medical groups over time, said Todd May, Health Net's medical director for commercial health plans, who is among those driving the project. "In addition to better outcomes, we'd like to see a stronger, more robust, and more satisfied primary care workforce," he said.

Reddy hopes she can increase Acacia's revenue by 20%, using the extra money from this and other pay-for-performance arrangements. That, she said, would enable her to raise pay for her staff and hire clinicians.

For many years, her practice has limited the number of patients it has accepted. But after searching for the better part of five years, Reddy has hired a doctor on a half-time basis and another is coming on board in June.

"This is the most hopeful I have felt in decades," Reddy said.

Phillip Reese contributed to this report.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

Vanessa G. Sánchez: vsanchez@kff.org, @vanesanchez_g

The Patient Expected a Free Checkup. The Bill Was $1,430.

KFF Health News, April 30, 2025

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

This article was published on Wednesday, April 30, 2025 in KFF Health News.

By Samantha Liss and Lauren Sausser

Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and complete some blood work.

The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn't had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They'd tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

"Sounds like a good idea," Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken's appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient's health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for "professional services," which included a charge for a 40-minute "High Mdm" outpatient visit — indicating a high level of "medical decision-making" — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That's the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that's not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, "How did this happen?" They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. "Surely this is a misunderstanding."

But their insurer sided with UI Health's position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken's appeal, BlueCross BlueShield of Illinois decided that "the labs were billed correctly as diagnostic."

Under the plan's parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken's bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for "medication monitoring and to obtain a vaccine."

"Medication monitoring is not considered a wellness benefit under the Affordable Care Act," she said.

Sacco also said Aiken's labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians' offices or independent commercial labs for the same tests.

The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who's on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA's preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

"This is an outrageous bill for what should have been routine care," Corlette said. "People just don't have this kind of money lying around."

The Resolution

After the insurer denied their appeal, they "fell down a hole into despair about it for a while," Aiken said.

"And then someone really wise was like, ‘You can pay it and then just stop thinking about it.'"

So that's what Aiken did: "I put it on my credit card."

UI Health's Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

"However, it is the insurance company's sole discretion whether a service is fully covered or subject to cost sharing," she said. "In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health."

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they'd incur another large bill.

Aiken ended up paying the bill by credit card.(Jim Vondruska for KFF Health News)

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it's critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

"Get vaccinated," Hicks said. "We just do not have the same tools for many other cancers."

Keep in mind that your coverage may vary — some insurance companies won't cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through "site-neutral" payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

"Site-neutral reforms could potentially have significantly reduced Carmen's expenses," said Christine Monahan, an assistant research professor at Georgetown's Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown's Corlette said, "then we all potentially lose access to free, high-value preventive care, and that would be a real shame."

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post's Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

Samantha Liss: sliss@kff.org, @samanthann

Lauren Sausser: lsausser@kff.org, @laurenmsausser

When Hospitals Ditch Medicare Advantage Plans, Thousands of Members Get to Leave, Too

KFF Health News, April 28, 2025

In the past 15 months, CMS has quietly offered roughly three-month special enrollment periods allowing MA members in 13 states to change plans.

This article was published on Monday, April 28, 2025 in KFF Health News.

By Susan Jaffe

For several years, Fred Neary had been seeing five doctors at the Baylor Scott & White Health system, whose 52 hospitals serve central and northern Texas, including Neary's home in Dallas. But in October, his Humana Medicare Advantage plan — an alternative to government-run Medicare — warned that Baylor and the insurer were fighting over a new contract. If they couldn't reach an agreement, he'd have to find new doctors or new health insurance.

"All my medical information is with Baylor Scott & White," said Neary, 87, who retired from a career in financial services. His doctors are a five-minute drive from his house. "After so many years, starting over with that many new doctor relationships didn't feel like an option."

After several anxious weeks, Neary learned Humana and Baylor were parting ways as of this year, and he was forced to choose between the two. Because the breakup happened during the annual fall enrollment period for Medicare Advantage, he was able to pick a new Advantage plan with coverage starting Jan. 1, a day after his Humana plan ended.

Other Advantage members who lose providers are not as lucky. Although disputes between health systems and insurers happen all the time, members are usually locked into their plans for the year and restricted to a network of providers, even if that network shrinks. Unless members qualify for what's called a special enrollment period, switching plans or returning to traditional Medicare is allowed only at year's end, with new coverage starting in January.

But in the past 15 months, the Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, has quietly offered roughly three-month special enrollment periods allowing thousands of Advantage members in at least 13 states to change plans. They were also allowed to leave Advantage plans entirely and choose traditional Medicare coverage without penalty, regardless of when they lost their providers. But even when CMS lets Advantage members leave a plan that lost a key provider, insurers can still enroll new members without telling them the network has shrunk.

At least 41 hospital systems have dropped out of 62 Advantage plans serving all or parts of 25 states since July, according to Becker's Hospital Review. Over the past two years, separations between Advantage plans and health systems have tripled, said FTI Consulting, which tracks reports of the disputes.

CMS spokesperson Catherine Howden said it is "a routine occurrence" for the agency to determine that provider network changes trigger a special enrollment period for their members. "It has happened many times in the past, though we have seen an uptick in recent years."

Still, CMS would not identify plans whose members were allowed to disenroll after losing health providers. The agency also would not say whether the plans violated federal provider network rules intended to ensure that Medicare Advantage members have sufficient providers within certain distances and travel times.

The secrecy around when and how Advantage members can escape plans after their doctors and hospitals drop out worries Sen. Ron Wyden of Oregon, the senior Democrat on the Senate Finance Committee, which oversees CMS.

"Seniors enrolled in Medicare Advantage plans deserve to know they can change their plan when their local doctor or hospital exits the plan due to profit-driven business practices," Wyden said.

The increase in insurer-provider breakups isn't surprising, given the growing popularity of Medicare Advantage. The plans attracted about 54% of the 61.2 million people who had both Medicare Parts A and B and were eligible to sign up for Medicare Advantage in 2024, according to KFF, a health information nonprofit that includes KFF Health News.

The plans can offer supplemental benefits unavailable from traditional Medicare because the federal government pays insurers about 20% more per member than traditional Medicare per-member costs, according to the Medicare Payment Advisory Commission, which advises Congress. The extra spending, which some lawmakers call wasteful, will total about $84 billion in 2025, MedPAC estimates. While traditional Medicare does not offer the additional benefits Advantage plans advertise, it does not limit beneficiaries' choice of providers. They can go to any doctor or hospital that accepts Medicare, as nearly all do.

Sanford Health, the largest rural health system in the U.S., serving parts of seven states from South Dakota to Michigan, decided to leave a Humana Medicare Advantage plan last year that covered 15,000 of its patients. "It's not so much about the finances or administrative burden, although those are real concerns," said Nick Olson, Sanford Health's chief financial officer. "The most important thing for us is the fact that coverage denials and prior authorization delays impact the care a patient receives, and that's unacceptable."

The National Association of Insurance Commissioners, representing insurance regulators from every state, Puerto Rico, and the District of Columbia, has appealed to CMS to help Advantage members.

"State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care," the group wrote in September. "Lack of CMS guidance could result in unnecessary financial or medical injury to America's seniors."

The commissioners appealed again last month to Health and Human Services Secretary Robert F. Kennedy Jr. "Significant network changes trigger important rights for beneficiaries, and they should receive clear notice of their rights and have access to counseling to help them make appropriate choices," they wrote.

The insurance commissioners asked CMS to consider offering a special enrollment period for all Advantage members who lose the same major provider, instead of placing the burden on individuals to find help on their own. No matter what time of year, members would be able to change plans or enroll in government-run Medicare.

Advantage members granted this special enrollment period who choose traditional Medicare get a bonus: If they want to purchase a Medigap policy — supplemental insurance that helps cover Medicare's considerable out-of-pocket costs — insurers can't turn them away or charge them more because of preexisting health conditions.

Those potential extra costs have long been a deterrent for people who want to leave Medicare Advantage for traditional Medicare.

"People are being trapped in Medicare Advantage because they can't get a Medigap plan," said Bonnie Burns, a training and policy specialist at California Health Advocates, a nonprofit watchdog that helps seniors navigate Medicare.

Guaranteed access to Medigap coverage is especially important when providers drop out of all Advantage plans. Only four states — Connecticut, Massachusetts, Maine, and New York — offer that guarantee to anyone who wants to reenroll in Medicare.

But some hospital systems, including Great Plains Health in North Platte, Nebraska, are so frustrated by Advantage plans that they won't participate in any of them.

It had the same problems with delays and denials of coverage as other providers, but one incident stands out for CEO Ivan Mitchell: A patient too sick to go home had to stay in the hospital an extra six weeks because her plan wouldn't cover care in a rehabilitation facility.

With traditional Medicare the only option this year for Great Plains Health patients, Nebraska insurance commissioner Eric Dunning asked for a special enrollment period with guaranteed Medigap access for some 1,200 beneficiaries. After six months, CMS agreed.

Once Delaware's insurance commissioner contacted CMS about the Bayhealth medical system dropping out of a Cigna Advantage plan, members received a special enrollment period starting in January.

Maine's congressional delegation pushed for an enrollment period for nearly 4,000 patients of Northern Light Health after the 10-hospital system dropped out of a Humana Advantage plan last year.

"Our constituents have told us that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers," the delegation told CMS.

CMS granted the request to ensure "that MA enrollees have access to medically necessary care," then-CMS Administrator Chiquita Brooks-LaSure wrote to Sen. Angus King (I-Maine).

Minnesota insurance officials appealed to CMS on behalf of some 75,000 members of Aetna, Humana, and UnitedHealthcare Advantage plans after six health systems announced last year they would leave the plans in 2025. So many provider changes caused "tremendous problems," said Kelli Jo Greiner, director of the Minnesota State Health Insurance Assistance Program, known as a SHIP, at the Minnesota Board on Aging. SHIP counselors across the country provide Medicare beneficiaries free help choosing and using Medicare drug and Advantage plans.

Providers serving about 15,000 of Minnesota's Advantage members ultimately agreed to stay in the insurers' networks. CMS decided 14,000 Humana members qualified for a network-change special enrollment period.

The remaining 46,000 people — Aetna and UnitedHealthcare Advantage members — who lost access to four health systems were not eligible for the special enrollment period. CMS decided their plans still had enough other providers to care for them.

Susan Jaffe: Jaffe.KHN@gmail.com, @susanjaffe

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