Opponents had alleged that California's law violates their First Amendment rights.

This article was published on Thursday, September 11, 2025 in KFF Health News.

By Ronnie Cohen

Critics of affirmative action have launched a long-shot appeal aimed at stopping California from requiring training on unconscious bias in every continuing medical education class. 

A July ruling by a three-judge panel of the 9th U.S. Circuit Court of Appeals upheld California's right to mandate that every course doctors take to remain licensed must address how bias contributes to poorer health outcomes for racial and ethnic minorities. The ruling against the nonprofit Do No Harm and Los Angeles ophthalmologist Azadeh Khatibi amounts to a victory for California as it fights the Trump administration and right-leaning advocacy and legal groups' attacks on perceived "wokeness."

In August, the Pacific Legal Foundation, which represents Do No Harm and Khatibi, asked that a panel of 11 appellate judges reconsider what attorney Caleb Trotter characterized as a "very clearly wrong" decision. Trotter, a senior attorney for the Pacific Legal Foundation, expects the court's response in October. If the appeal fails, he said, his firm would likely appeal to the U.S. Supreme Court. At stake, legal scholars say, is the latitude of states to prescribe educational content, including health equity training, for licensed professionals.

"The general recent tenor of the Supreme Court's First Amendment jurisprudence has been very speech protective, so that we would like our odds with, of course, the understanding that any attempt to get the Supreme Court to take your case is a long shot," Trotter said.

Erwin Chemerinsky, dean of the University of California-Berkeley law school, described the chances of the Supreme Court taking the case as "very unlikely" and the appellate ruling as "clearly correct" in affirming the state's authority to impose course requirements.

California began requiring implicit-bias training for physicians in 2022. From 2019 through July 2022, five other states enacted legislation mandating the training. California is the only state that requires it to be included in every course involving direct patient care.

In enacting the law, the legislature found that bias contributed to health care disparities and persisted regardless of other factors influencing care. Black women, for example, are often prescribed less pain medication than white women with the same complaints and are three to four times as likely as white women to die of pregnancy-related causes.

Bias does influence clinical care and contribute to health care disparities, a 2022 report concluded. Implicit-bias training, however, might have no impact and might even worsen care, the report noted. 

Do No Harm and Khatibi alleged that California's law violated their First Amendment rights. Khatibi acknowledges that unconscious bias might prejudice how clinicians treat patients. But the Los Angeles ophthalmologist does not believe she should be forced to carve out time to talk about it in a class she might teach on, for example, ocular tumors.

"The government is mandating doctors endorse a specific ideology or priority instead of science," she said. "I believe government should not mandate or compel the speech of doctors."

The three-judge appellate panel disagreed. No one is forcing Khatibi to teach state-accredited continuing education, the panel wrote in its opinion affirming a lower court's decision that the state had the right to mandate the training. The judges found that the curriculum requirement constitutes government speech and, therefore, is not subject to free-speech protections.  

The complaint against the California medical board does not dispute the state's authority to require physicians to learn about unconscious prejudices. Instead, it argues the state has no right to demand that all teachers discuss bias in every continuing medical education class. California physicians must take at least 50 hours of continuing education every two years. Private institutions offer the courses, and physicians generally teach them.

Rep. Sydney Kamlager-Dove (D-Calif.), who wrote the bill when she was a member of the state Assembly, defended it. "By connecting every provider to consistent and evolving training, we can help close these gaps and provide more equitable care," she said.

The Medical Board of California declined to comment.

Ashutosh Bhagwat, a UC Davis School of Law distinguished professor, said the state has a right to require implicit-bias training, although he disagrees that the training constitutes government speech. He sees it as private, but not compelled, speech because Khatibi and other instructors need only include a discussion of implicit bias if they want their classes to qualify for state licensing credit.

He likened the requirement to that of an accredited private school having to teach math. "Doesn't matter if you don't want to teach math. Doesn't matter if you don't believe in math," he said. "You have to teach math."

Bhagwat sees Khatibi's case as "very weak." But he said he could not predict anything the Supreme Court, with its six-justice conservative majority, might do.

"If Khatibi wins in the Supreme Court, or at any level, then chaos reigns because now every single requirement in any licensure that says you must teach this to qualify for continuing education is up for grabs," he said.

Trotter fears the opposite outcome. If allowed to stand, the implicit-bias training mandate could be extended to continuing education for 50 trades and professions in California alone, he said. "Then all kinds of governments based on all kinds of views can start requiring private speakers to say all kinds of things that, depending on where you are, are going to be controversial in all different kinds of ways," he said.

While Khatibi's lawsuit and others like it have had little success in the courts, said Joan Williams, a distinguished professor emerita at UC Law-San Francisco, they have chilled the creation of laws deemed "woke" or those favoring diversity, equity, and inclusion, known as DEI.

"There's been this huge attack on DEI, and it's been extraordinarily effective in creating regulatory risk such that people are apprehensive and self-editing because they don't want to put a target on their backs," said Williams, who directs the Equality Action Center.

Still, some supporters of bias training say California could refine its approach. Cristina Gonzalez, an internist and a New York University Grossman School of Medicine professor, designs and evaluates interventions to help recognize, prevent, and repair clinicians' prejudices. She described implicit-bias training as "a science" and California's approach as misguided because it requires all instructors, regardless of their knowledge of implicit bias, to teach the material.

Finger-wagging and blaming in implicit-bias training can lead doctors to become defensive and avoid patients, but done correctly, by experts, it does work, Gonzalez said. "The messaging has to be, ‘You're not a bad person,'" she said.

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

The new tax-and-spending law signed by President Donald Trump in July mandates a vast expansion of Medicaid work requirements.

This article was published on Friday, September 5, 2025 in KFF Health News.

By Kate Wells, Michigan Public

It was March 2020, and Robert Gordon was about to kick some 80,000 people off health insurance.

As the Michigan state health director, he had spent the past year, and some $30 million in state tax dollars, trying to avoid that very thing.

Gordon was a Democrat, a veteran of the Obama administration, and he did not want people to lose the Medicaid coverage they had recently gained through the Affordable Care Act.

But Gordon and his boss, Democratic Gov. Gretchen Whitmer, had reluctantly inherited a law passed two years earlier, when Republicans led the state. And that law mandated that Michigan institute a work requirement for Medicaid on Jan. 1, 2020.

Gordon and his team determined that most enrollees were already meeting the law's requirements, either because they were already working or had an exemption. Thousands more reported their status through the newly built phone and online systems.

But even so, estimates suggested 80,000 to 100,000 Michiganders were going to be booted off the rolls within the year.

"That's the population of the city of Flint who were on track to lose their insurance," said Gordon, who led the state health department until 2021. "We're implementing this about as well as this thing can be implemented, and it is still going to be pretty catastrophic."

The new tax-and-spending law signed by President Donald Trump in July mandates a vast expansion of Medicaid work requirements to most states.

These systems will lead to 5.3 million more people being uninsured in 2034, according to an estimate from the Congressional Budget Office.

The law applies to 40 states and Washington, D.C., because they expanded Medicaid in recent years to cover more working-age adults.

About 18 million people will be affected once the work mandate is fully implemented nationally, according to the CBO. Unless their state gets an exemption till 2028, by 2027, these enrollees will need to prove they're working, volunteering, getting job training, or doing other qualifying activities at least 80 hours a month to keep their coverage.

Republicans say this is a commonsense way to weed out "freeloaders." Democrats argue that's just political cover for slashing a program that saved some 27,000 lives starting in 2010, when the Affordable Care Act was signed, through 2022.

The number of people who lose coverage, either temporarily or permanently, could vary widely by state, depending on how each state implements and maintains its reporting system.

Michigan's experience illustrates how challenging it can be to stop large numbers of people from inadvertently losing coverage, even when leaders try their best to prevent that.

"We were very committed to implementing a law that we didn't agree with, in a way that reduced the number of people who lost insurance just because the government screwed something up," Gordon said. 

A Year of High-Stakes Work

In 2013, then-Gov. Rick Snyder, a Republican, waged a fierce battle within his own party to expand Michigan's Medicaid program.

To Snyder, it was an opportunity to simultaneously save money and expand access: By slashing the rate of uninsured Michiganders by almost half, the state could reduce the burden of uncompensated care on the health system and boost the economy by improving the physical health of the workforce.

But opponents saw it as an expansion of "Obamacare" that would shift massive new costs onto state and federal taxpayers. A work requirement became a point of compromise and a way for Snyder to mollify some of that opposition.

From a coverage perspective, Michigan's expansion of Medicaid was a success. Low-income adults signed up, ballooning new enrollment beyond what even supporters had initially estimated.

By 2019, there were nearly 700,000 new Medicaid recipients in Michigan, and the state was responsible for an increasing share of their health care costs. (Medicaid is paid for jointly by states and the federal government.)

Fiscal hawks were worried. "It's now become the largest budget problem in Michigan," said Jarrett Skorup of the Mackinac Center for Public Policy, a free-market think tank

Snyder signed the bill creating the 80-hour-a-month work requirement in 2018, but it wouldn't go into effect until 2020, after he left office.

That left newly elected Democratic governor Whitmer's administration holding the bag. She tapped Gordon, who'd held senior roles in the federal Office of Management and Budget and Department of Education during the Obama administration, to lead the sprawling state health department.

Gordon was terrified that Michigan would become another Arkansas, which was the first state to implement a work requirement, in 2018. The change led more than 18,000 Arkansas residents to lose their coverage.

People in Arkansas were disenrolled "because computers went down, because forms weren't clear, because they just never heard about it," Gordon said. "Maybe they got sicker, maybe they died because of this decision."

If Michiganders lost coverage at the same rate as Arkansans, as many as 160,000 people would have lost their health insurance within a year, according to one estimate.

Trying To Make Medicaid Work Requirements … Work

In some ways, Michigan was better positioned than other states to implement a work requirement, Gordon said: The unemployment rate was the lowest it had been in two decades and the state was already pretty good at collecting and tracking employment and wage data.

"If the state can figure out on its own, without having to ask you if you're working, that's great, because then you don't have to do anything," Gordon said. "You're just exempted."

Michigan eventually changed its law to allow people more time to report their work activities and to automatically determine their compliance or exemption by cross-checking data from other assistance programs, like food benefits.

To see if recipients were students or had health-related exemptions, Gordon and his team also tried to capture data from community college enrollment and medical insurance claims.

Dozens of staffers reprogrammed the state's outdated benefits enrollment portal, created full-time call centers, set up audit and appeals processes, hired compliance review teams, and trained hundreds of local organizers to provide tech and enrollment assistance.

Forms and letters alerting hundreds of thousands of enrollees to the new policy were redesigned to be attention-grabbing and easier to understand.

The sheer amount of effort and time required meant other public health efforts had to take a back seat, Gordon said. "Your first job is going to suffer, and that is a consequence of work requirements."

In Michigan, Black infant mortality rates were some of the highest in the nation. Thousands of people were still dying from overdoses.

Yet at the state health department, "all of the oxygen in the room was dedicated — almost all, I should say — to the work requirement implementation," said Renuka Tipirneni, an internal medicine physician at the University of Michigan who studies Michigan's Medicaid expansion.

Even after all that work, Gordon and his team had no illusions the system they'd spent $30 million creating was flawless.

"There was a real sense that everyone was doing everything they could," he said. But they still worried that "huge numbers of people were going to fall through the cracks. Because that's just what happens with systems like this."

A 'Waste' of $30 Million

By the time the work requirement went into effect on Jan. 1, 2020, the state had been able to determine that the vast majority of the nearly 700,000 Medicaid expansion recipients already met the work requirement or were exempt.

That left about 100,000 people whose status was unknown and who therefore still had to go through the reporting process. By March, around 80,000 of those had failed to report and were on track to lose coverage.

On the one hand, it was a lower rate of coverage loss than Arkansas had. But it was still "an enormous number of people" set to lose coverage, Gordon said.

Before that could happen, a federal judge issued a ruling on March 4, 2020, blocking Michigan's policies from going forward. That same day, Gordon was scheduled to testify before a Republican-led subcommittee about how the rollout was going.

Instead, he found himself explaining to legislators that the state's work requirement was essentially dead in the water, and that "we had, on the demand of the people holding the hearing, spent tens of millions of dollars for no purpose."

Given how brief Michigan's experiment with a Medicaid work requirement was — only about two months of the policy's being in effect, with no one losing coverage in the end — the Mackinac Center's Skorup doesn't see a lot of takeaways about the real-life impacts of work requirements.

"If you have an administration that is not sold on these being necessary at all, then I think they're more likely to drag their feet on implementing this, which is what I think they did," Skorup said, referring to the Whitmer administration.

Skorup is concerned because Medicaid costs keep rising, with 2.6 million Michiganders (1 in 4 residents) now covered by the program or the related Children's Health Insurance Program. Skorup believes Medicaid spending is "crowding out" teacher pay, pensions, and roads in the state budget.

Supporters of Medicaid expansion say the program's growth has benefited Michigan, pointing to research that Medicaid expansion helped boost employment and school enrollment and was a net positive for the state financially.

Court Ruling Comes Days Before Covid Hits

Only days after the court ruling stopped the work requirement in Michigan, officials announced the state's first cases of covid-19. The 80,000 Michiganders who might have lost Medicaid were spared, so their health coverage continued as the pandemic unfolded. Gordon continued as health director until 2021, when he resigned over "differences of opinion" with Whitmer about some pandemic restrictions.

These days, Gordon is experiencing a sense of déjà vu, with new predictions showing as many as 500,000 Michiganders could lose coverage within the first year of federally mandated work requirements, according to state estimates.

"We would have a more honest and more efficient policy if Republicans just kick people off Medicaid," he said.

That would be "incredibly harmful," he said. "But this thing they're doing isn't any less harmful. It's just more wasteful administratively, and more confusing to everyone."

This article is from a partnership that includes Michigan Public, NPR, and KFF Health News.

Research suggests GLP-1s must be used indefinitely to maintain weight loss and related health benefits.

This article was published on Thursday, September 4, 2025 in KFF Health News.

By Jamie Ducharme

After losing 50 pounds on the injectable weight loss medication Zepbound, Kyra Wensley received a surprising letter from her pharmacy benefit manager in April. 

Her request for coverage had been denied, the letter said, because she'd had a body mass index of less than 35 when she started Zepbound. The 25-year-old who lives in New York had been taking Zepbound without incident for months, so she was confused: Why was her BMI, which had been around 32 when she started, becoming an issue only now?

Wensley had no interest in quitting an effective drug. "Going right off like that, it's easier said than done," she said. 

Her doctor fought to keep her on the GLP-1 agonist, the category that includes weight loss and Type 2 diabetes drugs Ozempic, Wegovy, Mounjaro, and Zepbound. But Wensley ultimately had to switch from Zepbound to Wegovy to meet her plan's requirements. She said she doesn't like Wegovy as much as her old medication, but she now feels lucky to be on any GLP-1.

Lots of research suggests such medications must be used indefinitely to maintain weight loss and related health benefits. But with list prices of roughly $1,000 a month, public and private payers are struggling to keep up with ballooning demand for GLP-1 weight loss drugs and in some cases are eliminating or restricting their coverage as a result.

North Carolina Medicaid plans to end GLP-1 coverage for weight loss on Oct. 1, just over a year after starting the coverage. Pennsylvania is planning to limit Medicaid coverage to beneficiaries at the highest risk of complications from obesity. And despite recent reports of a potential federal pilot program to extend coverage of GLP-1 obesity drugs under Medicaid and Medicare, all state Medicaid programs are likely to be under pressure due to steep spending cuts in the budget reconciliation package recently signed into law by President Donald Trump.

Already, many GLP-1 users quit within a year, studies suggest — often due to side effects, high costs, or insurance issues. Now a growing number of researchers, payers, and providers are exploring deliberate "deprescription," which aims to taper some patients off their medication after they have taken it for a certain amount of time or lost a certain amount of weight.

The U.K.'s National Institute for Health and Care Excellence, which creates guidance for the National Health Service, recommends two-year limits on the use of some weight loss medications, such as Wegovy. And the concept was raised in a recent Institute for Clinical and Economic Review report on affordable access to obesity drugs.

A. Mark Fendrick, who directs the Center for Value-Based Insurance Design at the University of Michigan, has argued that if some people using GLP-1s to lose weight were eventually transitioned off, more people could take advantage of them.

"If you're going to spend $1 billion or $100 billion, you could either spend it on fewer people for a long period of time, or you can spend it on a lot more people for a shorter period of time," he said.

Fendrick's employer, the University of Michigan, indeed does that. Its prescription drug plan caps coverage of GLP-1 drugs at two years if they're used solely for weight loss.

Jamie Bennett, a spokesperson for Wegovy and Ozempic maker Novo Nordisk, declined to comment on the concept of deprescription, noting that its drugs are intended for chronic conditions. Rachel Sorvig, a spokesperson for Zepbound and Mounjaro manufacturer Eli Lilly, said in a statement that users should "talk to their health care provider about dosage and duration needs."

Studies have shown that people typically regain a substantial amount of weight within a year of stopping GLP-1 medications, and that many people who quit ultimately go back on the drugs.

"There's no standard of care or gold standard on how to wean right now," said Allison Adams, an obesity and internal medicine doctor with UK HealthCare in Kentucky.

But the math shows why time-limited coverage is appealing to payers that struggle to pay for beneficiaries' GLP-1 prescriptions, said Michelle Gourdine, chief medical officer for the pharmacy benefit manager CVS Caremark.

And states are "between a rock and a hard place," said Kody Kinsley, who until January led North Carolina's Health and Human Services Department. "They're going to have to look at every single thing and trim dollars everywhere they can."

Pennsylvania was looking for cost-saving strategies even before the new federal tax-and-spending law, according to Brandon Cwalina, press secretary for the state's Department of Human Services. Pennsylvania projects it will spend $1.3 billion on GLP-1 drugs this year.

Plans could see real savings, Fendrick said, if they covered GLP-1s for initial weight loss then moved people to cheaper options — such as more affordable drugs or behavioral health programs — to maintain it.

Plenty of companies are eager to sell insurers, employers, and individuals on behavioral alternatives. One is Virta Health, which advertises its nutrition-focused weight management program as "a proven approach for deprescribing GLP-1s when clinically appropriate." A Virta-funded study assessed 154 people with Type 2 diabetes who stopped using GLP-1 medications but continued following Virta's program, concluding that their weight did not significantly increase after a year.

Researchers affiliated with a European weight management company also recently reported that slowly tapering off the medications may help maintain weight loss.

For employers and insurers, the "initial question" was whether to cover GLP-1s for obesity, said Virta CEO Sami Inkinen. "Now, basically, everyone's coming to the middle and asking, ‘How do we responsibly cover these drugs?'"

Part of responsible coverage, Inkinen said, is providing other forms of support to patients who stop using GLP-1 medications, by choice or otherwise.

For some people, however, maintaining weight loss without a GLP-1 remains a challenge, even with other options available.

Lily, who lives in Michigan, lost almost 80 pounds in roughly 18 months on Wegovy. But she had to quit the drug when she turned 26 and left her parents' insurance plan this year. The plan her employer offers stopped covering GLP-1s for weight loss right around the time she joined.

Lily, who asked to be identified by only her first name because she is not out to her family as transgender, has tried other medications since then, and previously tried lifestyle programs to control her weight. But she said nothing works as well for her as Wegovy.

She has regained 20 pounds since going off the drug at the beginning of the year and worries that number will continue to rise, potentially contributing to future health problems.

"Just give people the drugs," she said. "It seems cheaper and safer in the long run."

Nearly one-in-five hospitals faced at least one case of public brinksmanship with payers over the past five years.

This article was published on Tuesday, September 2, 2025 in KFF Health News.

By Bram Sable-Smith

Amy Frank said it took 17 hours on the phone over nearly three weeks, bouncing between her insurer and her local hospital system, to make sure her plan would cover her husband's post-surgery care. 

Many of her calls never got past the hold music. When they did, the hospital told her to call her insurer. The insurer told her to have the hospital fax a form to a special number. The hospital responded that they'd been instructed to send faxes to a different number.

"It was just a big loophole we were caught in, going around and around," Frank said.

Frank and her husband, Allen, faced that ellipse of frustration because they were among 90,000 central Missouri patients caught in the middle of a contract dispute between University of Missouri, or MU, Health Care, a Columbia, Missouri-based health system, and Anthem, the couple's health insurance provider. The companies let their contract expire in April after failing to strike a deal to keep the hospital system and its clinics in-network.

A growing number of Americans find themselves in a similar pinch. In New York City, negotiations between UnitedHealthcare and Memorial Sloan Kettering Cancer Center missed a June 30 deadline, briefly leaving some patients in limbo until a deal was reached the next day. In North Carolina, Duke Health recently announced it could leave the Aetna network unless the insurance company agreed to pay more favorable rates to the health system. And the Franks were nearly caught out-of-network previously, when a 2023 contract dispute between Anthem and a primary care group in Jefferson City, Missouri, prompted the couple to switch some providers to MU Health Care.

Indeed, 18% of non-federal hospitals experienced at least one documented case of public brinksmanship with an insurance company from June 2021 to May 2025, according to preliminary findings by Jason Buxbaum, a health policy researcher at the Brown University School of Health. Over the same period, 8% of hospitals ultimately went out-of-network with an insurer, at least for a time.

Industry observers say long-standing trends like hospital consolidation and rising health care costs contribute to the disputes, and Trump administration policies could make them more frequent as hospitals brace for about $1 trillion in cuts to federal health care spending as part of President Donald Trump's sweeping budget law.

"They're going to be more hard-nosed at negotiating with the health plans because they're going to be in a survival mode," said John Baackes, a retired insurance executive and former board member of America's Health Insurance Plans, the national trade group representing the health insurance industry.

During the three-month stalemate between the insurer and the health system in Missouri, patients with Anthem plans lost in-network coverage with the region's largest — and, for some specialties, only — medical provider.

Most people were unable to switch insurance midyear and faced the choice of paying higher prices upfront, delaying care, finding new providers, or running a paperwork gauntlet in hopes their medical conditions qualified for a 90-day coverage extension.

The dispute came at a particularly inconvenient time for the Franks. Allen Frank was recovering from complications from falling off the roof while cleaning the siding of the couple's home in Rich Fountain in October. When it happened, Amy drove him 24 miles to the nearest emergency room. The facility in Jefferson City had recently been taken over by MU Health Care, and Allen was soon transferred 30 miles farther by ground ambulance to the system's main hospital in Columbia for surgery to insert two metal plates and several screws to repair his collarbone. 

Health care consolidation has been booming nationwide for 30 years, with over 2,000 hospital mergers announced since 1998, including 428 from 2018 to 2023. Mergers may lead to some efficiencies and benefits for consumers, but they also reduce market competition and strengthen the hand of hospitals in negotiations with insurers.

"Insurer markets have been consolidated for a long time," Brown's Buxbaum said. "What's changed is how consolidated the hospital markets have become."

Now if a hospital system drops out of a network, he said, "it's not just going to be one key hospital. It's much more likely to be all the key facilities, or many of the critical mass of providers" in an area.

It's a scary prospect for patients, making the public threat of a rupture a potent tool in negotiations between hospitals and insurers. That typically works in a hospital's favor, Baackes said, "because the general assumption is the insurance is being greedy and the hospital is doing God's work."

In a statement, Buddy Castellano, spokesperson for Anthem's parent company, Elevance Health, wrote, "We approach negotiations with a focus on fairness, transparency, and respect for everyone impacted. Health plan rate discussions are complex and require thoughtful collaboration to ensure long-term sustainability. Our commitment remains clear: ensuring access to care while keeping coverage affordable for the families, employers, and communities we serve."

Allen Frank needed follow-up care in the months after his initial surgery, including a second surgery in July.

A federal law dubbed the No Surprises Act, which took effect in 2022, offers protections for some patients whose provider drops out of network due to a contract dispute. People getting treatment for serious conditions can keep their in-network rates for up to 90 days with their current providers, delaying the need to find a new one or face higher rates. So Amy Frank worked the phones to get that continuity of care for her husband.

"Our deductible was already met. If we go out-of-network, we're going to have to start completely over for the out-of-network deductible," she said.

Eventually, Anthem agreed to let Allen Frank continue his care with MU Health Care. But when he showed up for an appointment to get an injection in his injured shoulder, he was told the health system didn't have a record of the approval. He refused to leave without being seen, and, eventually, a nurse was able to get through to Anthem to get a confirmation number and approval for the appointment.

"It's just very frustrating," Amy Frank said in early July, before the sides had reached a deal. "I've got my own medical issues, and I don't feel like mine are bad enough to be fighting for a continuity of care."

In an email, MU Health Care spokesperson Eric Maze wrote: "While our goal was to reach agreement prior to our contract terminating and to avoid disruption in care, we established processes and resources well in advance to facilitate continuity of care and reduce the burden for our patients. We understand and are sorry for the stress and concern being out of network created for many, and we are deeply grateful for the patience and trust placed in us during this time."

Rising health care costs are fueling contract disputes. Hospital expenses grew 5.1% in 2024, according to a recent brief from the American Hospital Association, outpacing the 2.9% inflation rate. Labor costs are the biggest driver, with advertised nursing salaries rising 26.6% faster than inflation from 2020 to 2024, the brief noted.

Hospitals want to recoup those costs by pressing insurance companies to pay more for services.

Washington University in St. Louis health economist Tim McBride said that dynamic could be further enflamed by the massive tax-and-spending law. The measure makes significant cuts to federal health care spending over the next decade, including a $911 billion drop in Medicaid spending, and is expected to cause 10 million Americans to lose their insurance.

As negotiations between MU Health Care and Anthem broke down, the insurer claimed the hospital was seeking a 39% rate increase over three years, while the hospital said the insurer wouldn't budge past 1%-2%.

On June 30, three months into the standoff, the Missouri Senate Insurance and Banking Committee called the two sides in for a hearing that broke months of deadlock and prompted new proposals from Anthem.

"Anthem doubled their rate increase offer," Missouri Senate President Cindy O'Laughlin, a Republican whose district includes parts of central Missouri, wrote in a Facebook post on July 8, encouraging a deal.

"Yes I know that I'm not on the inside nor the CEO of either but from what I've been told this seems a reasonable offer."

The sides announced an agreement one week later that was retroactive to April 1, the day the previous contract expired.

Amy Frank got several texts from friends and family about the agreement. She'd been so vocal about her frustrations, they wanted to make sure she'd seen the news. But her relief was subdued.

"So you put everybody through all of this for nothing?" she said the day after the deal was announced.

She had already sunk hours on the phone to ensure Allen's July 31 surgery to repair the plates holding his clavicle together would be covered. She was in no rush to call her doctors to reschedule the appointments she'd skipped, figuring their phone lines would be busy. The experience had her wondering if the two sides were trying to get people upset as a bargaining tactic.

"That money that they're fighting over — is that really worth all of the stress?" she said.

And after going through two disputes in three years, she can't help but wonder: How long until the next one?

Bram Sable-Smith: brams@kff.org, @besables