But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.

“We really want people to factor that in,” said , managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”

There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.

In addition, as Medicare Advantage plan in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a in February.

“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.

For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.

But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:

• People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
• People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “.”
• If a Medicare Advantage plan leaves Medicare or in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
• If an individual and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said , a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.

There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.

Patient advocates emphasize that it’s often useful to work with a counselor at the , or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.

People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.

Beware: More Underwriting

In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.

The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a of leading insurers’ applications.

When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said , a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.

“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.

Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.

“They have access to a Medigap comparison tool in addition to what is existing on that can give you a very good estimate of what you may pay for those Medigap plans,” said , associate director of health coverage and benefits at the National Council on Aging.

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During procedures, he seemed “hesitant, not sure of how to go on to the next step without being prompted” by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.

The chief of surgery, concerned about the doctor’s cognition, “would not sign off on his credentials to practice surgery unless he went through an evaluation,” Katlic said.

Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon “did not come of his own accord,” Katlic recalled.

But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist’s report advised that the surgeon’s difficulties were “likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.”

That didn’t mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. “He retained a lifetime of knowledge that had not been impacted by cognitive changes,” Katlic said. The hospital “took him out of the OR, but he continued to see patients in the clinic.”

Such incidents are likely to become more common as America’s physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.

Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.

Yet researchers have documented “a starting in their mid-60s,” said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.

At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. “Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,” Gallagher said.

A few health organizations have responded by establishing mandating that older doctors be screened for cognitive and physical deficits.

UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor’s practice or privileges.

Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.

Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute “a vast minority,” he said.

The number may actually have shrunk. A federal lawsuit, along with the profession’s lingering reluctance, appears to have put the effort to regularly assess older doctors’ abilities in limbo.

Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.

It’s fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that “‘I’ll know when it’s time to stand down,’” said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. “It turns out not to be true.”

When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, .

That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, that were likely to impair their ability to practice medicine independently,” a study reported.

Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.

“I thought as we got the word out nationally, this would be something we could encourage across the country,” Orlando said, noting that Hartford’s program cost only $50,000 to $60,000 a year.

Instead, he has seen “zero progress” in recent years. “Probably we’ve gone backward,” he said.

A key reason: In 2020, the federal over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital’s late-career program.

But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children’s Hospital in Corpus Christi, Texas, while few new ones have emerged.

“It made lots of organizations uncomfortable about sticking their necks out,” Gallagher said.

Instituting later-career programs has always been an uphill effort. “Doctors don’t like to be regulated,” Katlic acknowledged. Late-career programs have “in some cases been very controversial, and they’ve been blocked by influential physicians,” he said.

As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.

“Neither works very well at all,” Gallagher said. “Physicians are hesitant to share their concerns about their colleagues,” which can involve “challenging power dynamics.”

As for voluntary evaluation, since cognitive decline can affect doctors’ (or anyone’s) self-awareness, “they’re the last to know that they’re not themselves,” he added.

In a recent , Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.

“How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?” he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.

“There are all sorts of accommodations” for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.

Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.

The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.

Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending “the people who have the courage to speak up.”

“If you see something, say something,” he continued, referring to health care professionals who witness doctors (of any age) faltering. “We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’”

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California, Massachusetts, Connecticut, and have set caps on health care spending in a bid to rein in the intense financial pressure felt by many families, individuals, and employers who every year face increases in premiums, deductibles, and other health-related expenses.

Hospitals and other health care providers are citing Republicans’ One Big Beautiful Bill Act, signed by President Donald Trump in July, as one more reason to challenge those limits.

The law is expected to reduce federal Medicaid spending by over a decade, which mathematically should help the overall health care system meet the caps. But the law is also expected to increase the number of uninsured Americans, mostly Medicaid beneficiaries, by an estimated . Health care analysts predict hospitals and other providers will raise prices to cover the double whammy of lost Medicaid revenue and the cost of caring for an influx of newly uninsured patients.

Whether regulators in some states will allow providers to justify higher prices and exceed the spending caps is unclear. Only can penalize providers financially if they fail to meet targets.

“Are we going to say, ‘That’s OK’? Or are we going to say, ‘Well, you exceeded the target. We’re still going to penalize you for that’?” said Richard Pan, a former state lawmaker and a member of the California Office of Health Care Affordability’s board. “That has not yet been decided.”

The California Hospital Association, the industry’s main state lobbying group, in October asking a state court to strike down the spending caps, which it argued fail to account for all the cost pressures hospitals face. Those pressures, it said, include an aging, sicker population; the of labor; expensive advances in medical technology; large capital outlays on required seismic retrofitting; and changes in federal policy, including the One Big Beautiful Bill Act. The hospital group’s lawsuit also asserted that the state affordability office, by hastily imposing ill-considered cost-cutting targets, was undermining its other key mission of improving health care access, quality, and equity.

California’s affordability office last year set a five-year target to cap statewide spending growth, starting at 3.5% in 2025 and declining to 3% by 2029. The annual caps apply to a wide range of health care entities, including hospitals, medical groups, insurers, and other payers.

Earlier this year, it imposed much lower spending growth caps — starting at 1.8% in 2026 and declining to 1.6% by 2029 — for .

“The spending caps set by politically appointed bureaucrats could force cuts that result in many Californians traveling farther for care, facing longer emergency room wait times, experiencing more overcrowding, and losing access to critical services,” Carmela Coyle, the hospital association’s president and CEO, said in an October press release.

The California attorney general’s office, which will represent the affordability agency, has not yet filed a response to the hospital group’s complaint and did not respond to a request for comment.

Hospitals’ Pushback

California is not the only state taking a close look at hospital prices, which are widely considered a of health care costs.

“States, armed with information that points to payments to hospitals as a driver of what is way beyond affordable commercial premiums, have begun to take increasingly targeted actions focused on commercial hospital prices,” said Michael Bailit, founder of the Needham, Massachusetts-based consultancy , which has advised multiple states, including California, on ways to tame health care spending. “It is not surprising that the hospital industry is going to oppose such state actions.” 

In its lawsuit, the California Hospital Association said the affordability office’s own report showed that pharmaceutical and insurance companies are largely responsible for high costs.

Hospitals in some states with cost growth limits, including and , have expressed objections similar to the ones raised in the California lawsuit. They could follow their counterparts in California if their lawsuit succeeds, said Peter Lee, who led California’s Affordable Care Act marketplace, Covered California, for and is now a at Stanford Medicine’s Clinical Excellence Research Center.

Lee said the work of California’s affordability office and similar agencies in other states is just about the only systemwide effort being made to cut health care costs. They are basically saying, “‘Look, health care is taking money away from education, it is taking money away from the environment, it is taking money away from everything in the public sector, and in the private sector it is taking money away from wages,’” he said. “‘We don’t know how you, the health system, are going to do it, but it is your job not just to provide quality but to lower costs. Here’s the target.’”

To be sure, achieving the cost savings that California and those other states are seeking is no easy lift. It will ultimately require persuading large, financially powerful players that compete fiercely for health care dollars to adopt a different mindset and begin cooperating to reduce costs instead. And that, in many cases, will mean lower revenue.

But the status quo, as many people know all too well, means continued financial pain for millions.

In early 2020, Estevan Rodriguez, a bartender at California’s Monterey Beach Hotel, had surgery for a staph infection in his leg. The bill came to nearly $168,000. His insurance paid most of it, but he still owed $5,665, which took him two years to pay, more than $200 every month. “It may not be a lot to some people, but it was a lot to me,” Rodriguez said.

He said he dropped his Hulu subscription, switched to a lower-cost cellphone, and got cheaper car insurance. He started going to food banks rather than the grocery store, he said, and had a lot less time with his kids, because he was constantly working to pay off the hospital bill.

, where Rodriguez had his surgery, is one of the seven hospitals identified by California’s affordability office as high-cost. A attributed high hospital prices in Monterey County to a lack of market competition “rather than higher operating costs or superior quality of care.”

The Monterey hospital referred a request for comment about its “high-cost” designation to the California Hospital Association. CHA spokesperson Jan Emerson-Shea declined to comment beyond the language of the lawsuit and Coyle’s press release statement.

Reduced Competition

Health care analysts worry the One Big Beautiful Bill Act will reduce market competition even further by stressing already weak hospitals, leading some to shut services, merge with larger health systems, or close. One study estimates are at risk of closing nationwide.

Less competition, in addition to fewer Medicaid dollars and an increase in uninsured patients, will only strengthen the incentive of health systems with the requisite market clout to raise their commercial prices, increasing premiums for employers and individuals.

“We think commercial prices will continue to increase as health care providers, and hospitals in particular, will seek to preserve or increase their revenue,” said Rachel Block, a program officer at the Milbank Memorial Fund, a foundation that focuses on health equity.

That in turn could pose a challenge to state affordability regulators tasked with overseeing compliance with growth targets for health care spending.

California’s affordability office is required to consider mitigating factors, including changes in federal and state laws. But some of its board members have expressed skepticism about letting hospitals offset Medicaid losses with higher commercial prices.

“There’s a lot of talk about using HR 1 and other federal policies as an excuse to raise prices on commercial payers,” Ian Lewis, an affordability office board member and policy director for UNITE HERE Local 2, a hospitality workers union in the Bay Area, said at the agency’s , referring to the One Big Beautiful Bill. “There’s no more blood to be squeezed from this stone.”

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The ambulances frequently travel back and forth to in Asheville, the largest and most central hospital in the region. Trips can take more than two hours, according to Mark Snelson, director of , the local emergency medical service.

“When we get busy and all three of them are gone, we have no ambulances in our county,” he said.

Snelson and others in Madison County aren’t seeking more ambulances. They want a hospital closer than Mission. And the state agrees. In 2022, North Carolina Department of Health and Human Services officials said Madison and three other mountain counties needed 67 more acute care hospital beds. The state raised that to 93 beds in 2024, then to 222 by Oct. 15.

But the only indication of a new hospital thus far is a 25-acre field of graded dirt with a sign planted beside the highway reading “FUTURE HOME OF AdventHealth Weaverville.”

For the past three years, Mission Hospital’s owner has contested Florida-headquartered ’s attempt to build the hospital on land bought for $7.5 million in rural Weaverville, just minutes south of Madison County. It was , an event that would have defied the of rural hospital closures.

The irony is that the very law that calls for the new hospital — the state’s certificate of need, or CON, law — has been used to prevent further construction. Such laws are intended to cap unfettered health care expansion by allowing new hospitals and expansions only when a state can document a need for them. But the legal process has tied up the proposed Weaverville hospital in court, just as other such laws have done with projects in ; ; and .

All states had certificate of need laws until 1987, when the federal government repealed a mandate requiring them. Today, North Carolina is one of with the laws still on the books. Twelve others have repealed them or let them expire, and some, and , have significantly weakened theirs amid concerns they limit health care access and boost costs. President Donald Trump’s Federal Trade Commission and Department of Justice are among those questioning the need for the laws.

In North Carolina, too, opposition to the state’s certificate of need law has surfaced in both the General Assembly, where a has been dormant since April, and more prominently in the state Superior Court.

But some , health care economists, and certificate of need lawyers argue that, though the laws create bureaucracy that can delay projects, that’s not justification to do away with them.

The principle behind certificates of need is to hold at bay what is unnecessary expansion and price inflation brought on by a free market, which makes health care more expensive for everyone.

“If the principle is worth preserving, don't abandon the principle,” said , a health care attorney with the Benesch law firm and former counsel for . “Improve the process to allow the principle to flourish.”

Who Should Fill the Need?

Mission Health is the largest health care network and the largest employer in the Tar Heel State’s share of the Appalachians. Nashville-based bought the century-old, nonprofit, six-hospital system for $1.5 billion in 2019, converting it to a for-profit operation that serves an 18-county region. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund Ñî¹óåú´«Ã½Ò•îl Health News’ coverage.)

Though AdventHealth already owns one hospital in the North Carolina mountains about a 30-minute drive from the Weaverville site, its bid to build a new one represents a threat to HCA’s stronghold. Mission argues it is best positioned to meet the needs the state says exist in the Madison County region.

“Not all acute care beds are the same,” Mission Health spokesperson Nancy Lindell said. “Instead of adding more beds at facilities that are unable to provide the complex medical and surgical care needed, the region would be better served by expanding bed capacity at Mission Hospital.”

An eastern North Carolina eye surgeon’s against the state’s health agency and top state officials alleged the state’s certificate of need law “has nothing to do with protecting the health or safety of real patients.” The ophthalmologist, Jay Singleton, has argued the law prevented him from performing surgeries at his own center because the state didn’t see a need to duplicate services already provided at the local hospital, where he was obligated to operate.

In early November, Republican state Treasurer Brad Briner, the , and several academics who study such laws nationally filed amicus briefs supporting Singleton’s case and urging a judge to reject the state’s attempt to dismiss it.

“I’ve characterized CON law as a permission slip to compete,” said , a George Mason University economics and law professor who co-authored the brief. “It’s as if, when a McDonald’s wanted to open up a shop next to Burger King, they have to go to the state regulator to ask if that’s OK.”

Stratmann argued that, instead of , more competition would give hospitals and providers greater leverage in negotiating with insurance companies.

That view aligns with a stance the federal government has held for almost 40 years. With varying degrees of fervor under Democratic and Republican leadership, the Federal Trade Commission and Department of Justice have argued that the laws are anticompetitive and bad for consumers. The Justice Department did not respond to questions about its current position, and the FTC declined to comment on the record.

“CON laws create barriers to entry and expansion, limit consumer choice, and stifle innovation,” the Federal Trade Commission wrote in an April letter to Rhode Island Gov. Dan McKee, a Democrat, as the state’s legislature considered, but ultimately abandoned, amendments to its certificate of need law. “For these reasons, the Agencies have consistently suggested that states repeal or retrench their CON laws.”

‘It’s Personal’

In a to Trump and congressional leaders, Senate Democrats named five North Carolina hospitals on a list of rural hospitals in danger of closing if the president’s then-pending spending and tax-cut legislation, called the One Big Beautiful Bill, became law, citing research from the .

Two of the five North Carolina hospitals on that list, and , are part of the Mission Health system. Both had three consecutive years of negative profit margins, like hundreds of others on the list. Lindell, the Mission Health spokesperson, said HCA is committed to keeping those two facilities open.

Even so, Madison County Health Department Director Tammy Cody said the needs in the region remain and the certificate of need appeals process has slowed down getting help.

“This isn’t theoretical — it’s personal," she said. "Every delay means a mother in labor risks a longer ride, an elder with chest pain waits longer for help, or a worker injured on the job faces unnecessary complications.”

AdventHealth spokesperson Victoria Dunkle said the hospital system supports the state’s law partly because it “protects rural access to health care and ensures the community has a voice in the process.” The legal process has kept families waiting, she said, but AdventHealth plans to move forward with the Weaverville hospital “as soon as possible.”

Snelson, the ambulance service director, voiced a question many in the region have asked since the hope of a new rural hospital surfaced.

“Why is it a bad thing for another hospital to come in here to take some of the stress off of Mission?” he asked. “Within a day of it opening, it's going to be full.”

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

Ñî¹óåú´«Ã½Ò•îl Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

Ñî¹óåú´«Ã½Ò•îl Health News South Dakota correspondent Arielle Zionts contributed to this report.

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And even well-insured patients receive unaffordable bills in this era of high-deductible health plans, narrow insurance networks, and 20% cost sharing.

Health systems, doctor groups, and insurers are merging and coalescing into ever-bigger giants. While these mergers are good for business, studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%.

These new deals are “mutually enforced monopolization,” said Barak Richman, the Alexander Hamilton professor of business law at George Washington University. “It’s not competition. It’s more like collusion. They don’t care about price.”

Those market factors contributed to a landscape where a dose of the antiviral Paxlovid given in a hospital ; magnetic resonance imaging ; and joint replacements .

President Donald Trump has talked about the burden of health care costs since his first campaign, but he has signaled that his administration’s regulators are less inclined than his predecessor’s to intervene in health mergers.

This summer, President Joe Biden’s that all federal agencies make sure markets remain competitive, reversing course from Biden’s more expansive interpretation of antitrust law. And in a scathing statement upon taking over the Federal Trade Commission, Trump-appointed chair Andrew Ferguson , implying that she had overstepped the agency’s legal authority, as well as criticizing what he called her “clumsy” and “breathless” rhetoric and her focus on the incursion of private equity into health care.

What this will mean in practice is unclear.

In an interview with Ñî¹óåú´«Ã½Ò•îl Health News, Daniel Guarnera, the director of the FTC’s Bureau of Competition, said that the leadership at the FTC and the Justice Department has endorsed guidelines issued by the Biden administration, which he characterized as a “framing device” for companies contemplating a merger.

The expanded , issued in 2023, focused for the first time on a wide variety of new types of anti-competitive practices that had become common in health care, such as hospitals and private equity firms buying doctors’ practices and insurers owning what are known as specialty pharmacies to dispense complicated and often expensive drugs.

Guarnera noted that regulators’ strongest enforcement tool is convincing a judge that mergers violate the Clayton Antitrust Act, a statute that is the foundation of antitrust law. But administrations can interpret this statute differently, and it’s unclear what cases the Trump administration’s FTC will choose to bring.

“The Biden administration tried to be more innovative,” said a professor of health services, policy, and practice at Brown University’s School of Public Health. “The Trump administration has signaled a more traditional approach — that it’s unwilling to push the envelope.”

In the battle for profits between insurers and providers, each side insists it needs to grow bigger to hold sway in the negotiations that determine health care prices. But evidence shows the prices that make sense in industry-level dealmaking have little to do with the actual value of the services involved. Instead, they’re merely a data point in large-scale calculations that, at best, reflect the power balance between opposing parties.

Under Trump, the FTC has already sued to block two mergers of medical-device makers and has continued the Biden administration’s challenges of individual drug patents.

“Helping improve the health care system though ensuring that there is more and better competition are very, very high priorities for us at the FTC,” Guarnera said, noting that health care has “enormous effects on both Americans’ pocketbooks as well as well-being.”

But it is far more difficult to take on the more massive entities, and though the number of new mergers dipped as companies navigated the uncertain effects of tariffs and interest rates, consolidation continues.

A recent identified “28 large health systems growing bigger,” noting, “This is not an exhaustive list.”

For example, in May, Northwell Health of New York Connecticut’s Nuvance to become a 28-hospital behemoth with over 1,000 outpatient clinics. That was a more traditional merger, where hospitals in the same region joined to extend their reach and increase their market power.

Meanwhile, companies are creating powerhouses not previously seen in health care, by racking up smaller purchases that aren’t expensive enough to trigger federal review. They include what are known as vertical mergers, which combine companies that provide different functions in the same industry — most commonly, hospital systems or insurers buying doctors’ practices or specialty pharmacies.

For instance, UnitedHealth Group, the , now owns health insurance plans; physician practices and other providers; data and analytics services; payment processors; a pharmacy benefits manager; and pharmacies themselves. Jonathan Kanter, the competition czar in Biden’s Justice Department, has likened the UnitedHealth amalgamation to Amazon.

Likewise, hospital systems and private companies — often private equity firms — are increasingly expanding their reach to different regions, gobbling up hospitals, medical practices, and surgery centers. This kind of consolidation, known as a , allows companies to accumulate huge collections of doctors — and significant market power — across the country in particular specialties, such as gastroenterology, ophthalmology, pediatrics, or obstetrics.

Research shows a change in ownership means a change in prices. While pediatrics and obstetrics have traditionally been poorly paid specialties, for instance, they represent a land of opportunity to investors because parents are willing to pay more when it comes to care for their kids.

It used to be relatively simple for regulators to discern when a hospital that merged with its nearby competitor gained monopoly power, rendering it anti-competitive and driving up prices. Health researchers say these new, more complicated types of deals, creating a more complex interplay between insurers and medical providers, have made that tipping point to define.

In health care, even more traditional, vertical consolidation can be problematic, Richman said. “Economic theory says it could be innocuous, like a suit manufacturer opening a store, even though studies show in health care it’s dangerous — higher prices, poorer quality, less choice,” he said.

For example, patients who have Cigna health plans and need an array of more expensive, often injectable prescriptions must use Accredo, the specialty pharmacy in 2018, even though a different pharmacy may have a better price.

Economists have developed computer modeling to predict when patients will experience higher prices and less choice because of these new types of consolidation. But judges who could nix the transactions are so far “not convinced,” said Daniel Arnold, a health economist at Brown’s School of Public Health.

Experts such as Fuse Brown say new laws and enforcement tools are needed.

“The old laws,” she said, “are just not calibrated to the complexity and novel types of mergers.”

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In many cases, this type of community event would be unremarkable. But Irvington’s concerts stood out for their funding source: settlement money from companies accused of fueling the opioid overdose crisis.

As part of national settlements, more than a dozen companies that sold prescription painkillers are expected to pay state and local governments over nearly two decades. Governments are supposed to spend most of the windfall combating addiction. Officials who negotiated the settlements even and established other guardrails to avoid a repeat of the Tobacco Master Settlement Agreement of the 1990s, from which went to anti-smoking programs.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

In Irvington, township officials said they used the money appropriately because the concerts reduced stigma around addiction and connected people to treatment. But acting state Comptroller called the concerts a “waste” and “misuse” of the settlements, which resulted from the overdose deaths of hundreds of thousands of Americans.

Similar disputes are intensifying nationwide as officials begin spending settlement money in earnest — all while grappling with slashed federal grants and looming cuts to Medicaid, the state-federal public insurance program that is for addiction treatment.

To shed light on these discussions, Ñî¹óåú´«Ã½Ò•îl Health News and researchers at the and , a national nonprofit focused on addiction, conducted a yearlong effort to document settlement spending in 2024. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories such as treatment or prevention.

The result is a database of more than 10,500 ways settlement cash was used (or not) last year — the most comprehensive national resource of its kind. Some highlights include:

• States and localities spent or committed nearly $2.7 billion in 2024, according to public records. The bulk went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement gear, such as night vision equipment, and prevention efforts that experts called questionable, such as hiring a drug awareness magician.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including expenditures and untrackable percentages, should not be compared with the one Ñî¹óåú´«Ã½Ò•îl Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract a tendency toward in charge of settlement money and confusion among people trying to track it.

More than $237 million — about 9% of all trackable spending in 2024 — went to efforts broadly aimed at preventing addiction, according to public records. These ranged from putting on community awareness events, like the concerts in Irvington, to hiring mental health counselors in schools.

Many of the examples raised red flags for researchers, including:

• Suffield, Connecticut, held a , at which kids and seniors , posed with inflatable guitars, and pledged to remain drug-free.
• Vernon, Connecticut, , at which a fighter spoke about his experience with addiction.
• Hardy County, West Virginia, to repair a school track.

“There is no evidence” to back those efforts, said , who leads prevention-oriented research at the nonprofit Partnership to End Addiction.

Elected officials like the events because “you can announce to the community that you did something,” she said. But unless they’re part of larger initiatives that incorporate other approaches, such as screening students for mental health concerns or supporting parents struggling with addiction, they’re unlikely to have lasting impact.

And when settlement funds pay for those one-offs, there’s less left “that we do know work,” Richter added.

School assembly speakers were also popular, with three Connecticut towns spending more than $30,000 total for former Boston Celtic Chris Herren to with students.

“You get 1,200 kids in the gym and you can hear a pin drop when he talks,” said Joe Kobza, superintendent of schools in Monroe. He described Herren’s talks to students and parents as “pretty impactful.”

But emotional impact isn’t necessarily effective, Richter said. Speakers often talk about drugs messing up their lives even though they’ve become wealthy celebrities. “The messages are so mixed,” she said.

Many local officials admitted their spending decisions weren’t evidence-based. But they meant well, they said. And they received little to no guidance on how to use the money.

Kelly Giannuzzi, Suffield’s former director of youth services, who organized the sock hop, said the goal was to raise awareness and combat loneliness.

Hardy County Commissioner said spending money on track repairs made sense, since he’d seen the positive impact the sport had on his son’s life. He wanted other kids to have the same opportunity.

David Owens, a spokesperson for Vernon, said the town’s mixed martial arts event was to , meant to show people that athletics can help them build connections and avoid drugs. The event brought out young men, who are often difficult to reach, he said.

But the town has no way of knowing if the event had lasting traction.

In New Jersey, acting Comptroller Walsh this summer calling on Irvington township officials to repay the settlement money spent on the concerts.

“If they’re going to hold big parties, that’s up to them and the taxpayers,” Walsh told Ñî¹óåú´«Ã½Ò•îl Health News. “But they can’t use opioid money for that.”

He also suggested the concerts were political rallies for the mayor, Tony Vauss.

Irvington officials strongly objected to the report and unsuccessfully sued Walsh to try to block its release. Vauss told Ñî¹óåú´«Ã½Ò•îl Health News it was “misleading and flat-out wrong.”

Vauss said the township distributed overdose reversal medications at the concerts and spread messages about seeking help. At least four people sought treatment on-site, the township said in .

“We felt as though we did everything correctly,” Vauss said.

However, some of the research Irvington cited in the lawsuit to support its case appeared irrelevant, such as a and a graduate thesis.

Irvington officials did not respond to questions about those citations.

As this dispute — and others like it nationwide — continue, people affected by the crisis say it’s crucial to remember the moral weight of these settlements.

It’s “blood money,” said , an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits.

He’s seen many family members lose parents, children, and siblings.

“I don’t know how I would look a family in the face” if this money isn’t used to prevent more losses, he said.

Read the methodology behind this project.

Ñî¹óåú´«Ã½Ò•îl Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create , which have been endorsed by over 60 organizations.

is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. Ñî¹óåú´«Ã½Ò•îl Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Some of these community health centers may have to cut medical and administrative staff or reduce services. Some could eventually close. The result, their advocates warn, may be added pressure on already crowded hospital emergency rooms.

“This is the worst time in all the years I have been working in health care,” said , president and CEO of , a network of that serves more than 144,000 patients in Los Angeles, Riverside, and San Bernardino counties in California. “We are facing federal cuts and extreme state cuts that will impact services.”

St. John’s and other federally qualified health centers offer primary care and a wide range of other services free of charge or on a sliding fee scale. Nationwide, they see in the country’s most underserved areas.

The federal funds come through two primary routes, both of which face challenges: grants paid in part through the and reimbursements for patients’ care through programs like Medicaid, which provides health insurance for low-income people and people with disabilities. Medicaid is jointly funded by states and the federal government.

Congress has approved the grant money in dribs and drabs recently. In March, lawmakers extended the funds until Sept. 30. That money expired after the Republican-controlled Congress did not pass a funding law, leading to a government shutdown.

Advocates say the health centers need long-term funding to help them plan with more certainty, ideally through a multiyear fund. received $4.4 billion in grants in early 2024. The National Association of Community Health Centers is advocating for in grants annually for two years to keep the centers fully functional.

The health center safety net faces “multiple layers of challenges,” said , vice president of policy and regulatory affairs for the association.

that Republicans call the “One Big Beautiful Bill Act” will significantly cut Medicaid, raising the second set of threats for health centers.

Medicaid of the $46.7 billion in health center revenue in 2023.

Advocates said lower Medicaid payments will exacerbate a gap between funding and operational costs.

Funding for workforce programs also is needed to support the delivery of health care services as centers struggle to hire and retain workers, said , director of the Geiger Gibson Program in Community Health at George Washington University.

The of this type opened in places such as Massachusetts in the 1960s. Congress typically has funded them with bipartisan support, with minor fluctuations.

The struggle this year began when the Trump administration through a January memo, which prevented some centers from receiving already approved grant money. As a consequence, some health centers in states such as Virginia .

The upcoming cuts also are set to arrive at a time when patients will face new demands and challenges. The Medicaid changes in President Donald Trump’s tax-and-spending law include requirements for Medicaid enrollees to report their work or other service hours to keep their benefits.

Meanwhile, the Biden administration and Congress provided consumers to help pay for Affordable Care Act health insurance are set to expire at the end of the year. Some consumers’ costs will spike if Congress doesn’t renew them.

One reason the government shut down is that Democrats want to extend the tax credits, which protect consumers from higher insurance costs. The Republican funding bill did not include an extension; Republican congressional leaders say the issue should be addressed separately.

Consumers “will need more support than ever,” said Jacobs, noting that Medicaid cuts and the expiration of the higher tax credits will both “potentially throw people out of coverage.”

Ninety percent of the centers’ patients have incomes that are twice the or less, and .

“We are also receiving 300 calls per day from patients concerned about their coverage,” said Mangia, from St. John’s.

Republicans are not directly targeting the centers, although they supported the Medicaid cuts that will affect the clinics’ finances. Many Republicans say Medicaid spending has ballooned and that reducing the program’s growth will make it more sustainable.

State and Local Support

While advocating for longer-term federal funding, the centers also are looking to their community and local governments for backing.

Some states already took action while finalizing their annual budgets. , and allocated money for centers. , , and also provided support for the health centers.

The question is how long the money will last.

While some states boosted their support of the centers, others are going in the opposite direction. Anticipating the impact of Medicaid cuts, states such as California made to the program.

California Gov. Gavin Newsom’s office, the federal Department of Health and Human Services, and the federal Health Resources and Services Administration did not respond to requests for comment.

In Los Angeles, Mangia said, one potential solution is to work with partners at the county level, noting that L.A. County has about 10 million residents.

“We can tax ourselves to increase funding for health care services,” he said.

Health center leaders are building a coalition that “hopefully” will include the main stakeholders in the county’s health care system — community health centers, clinics, hospitals, doctors, health plans, unions — to begin the process to fill out a ballot petition, Mangia said. The goal: Put the question about taxes for health centers on the ballot and let voters decide.

“We are learning that the federal government and the state government are not reliable when it comes to continuing to fund health care,” Mangia said.

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A pesar de algunos avances este año, especialmente en estados con mayoría demócrata, los recientes reveses en las legislaturas más conservadoras dejan claro lo difícil que es proteger a los pacientes.

Este año fracasaron proyectos de ley para proteger a los consumidores de deudas médicas en Indiana, Montana, Nevada, Dakota del Sur y Wyoming, debido a la oposición de la industria. Y defensores advierten que los estados deben actuar, ya que se espera que millones de personas pierdan su seguro médico debido a la ley fiscal y de gasto del presidente Donald Trump.

“Este ya era un tema clave incluso antes del cambio de administración en Washington”, dijo Kate Ende, directora de políticas de la organización Consumers for Affordable Health Care, con sede en Maine. “La retirada a nivel federal hizo aún más urgente movilizarse”.

Este año, Maine se unió a una creciente lista de estados que han prohibido que la deuda médica aparezca en los reportes de crédito de sus residentes, una protección que puede facilitar el acceso a una vivienda, un auto o incluso un empleo. La y con apoyo bipartidista.

Se estima que 100 millones de personas en Estados Unidos tienen algún tipo de deuda relacionada con la atención médica.

El gobierno federal estaba a punto de prohibir que la deuda médica apareciera en los reportes de crédito, gracias a una normativa emitida en los últimos días del mandato del ex presidente Joe Biden. Esa medida habría beneficiado a unas 15 millones de personas en todo el país.

Pero la administración Trump no defendió la normativa ante las demandas legales de agencias de cobro y burós de crédito, que argumentaban que la Oficina para la Protección Financiera del Consumidor (CFPB, en inglés) se había excedido en su autoridad.

Un juez federal de Texas, designado por Trump, falló que la normativa debía anularse.

Ahora, solo los pacientes que viven en estados que han aprobado sus propias normas sobre reportes de crédito podrán beneficiarse de esta protección. Más de una docena de estados tienen estas restricciones, entre ellos California, Colorado, Connecticut, Minnesota, Nueva York y Vermont, que al igual que Maine, adoptaron una prohibición este año.

En los últimos años, más estados han aprobado otras protecciones contra la deuda médica, como límites a la tasa de interés que se puede cobrar y restricciones al uso del embargo de salarios o la incautación de bienes para cobrar facturas médicas impagas.

En muchos casos, estas medidas han recibido apoyo bipartidista, lo que refleja la popularidad de las protecciones al consumidor. En Virginia, el gobernador republicano este año que limita el embargo de salarios y establece un tope a los intereses.

Y varios legisladores republicanos en California se unieron a los demócratas para que facilita el acceso a ayuda financiera de los hospitales para quienes enfrentan facturas elevadas.

“Este es el tipo de asunto de sentido común que afecta al bolsillo de las personas y que atrae tanto a republicanos como a demócratas”, señaló Eva Stahl, vicepresidenta de Undue Medical Debt, una organización sin fines de lucro que compra y perdona deudas médicas, y que ha trabajado para que se amplíen protecciones para pacientes.

Pero en varias legislaturas estatales, el impulso por nuevas protecciones se topó con barreras.

Proyectos de ley para prohibir que las deudas médicas aparecieran en los reportes de crédito fracasaron en y , a pesar del apoyo de algunos legisladores republicanos. Y las medidas para limitar los cobros agresivos contra residentes con deuda médica fueron rechazadas en , y .

En algunos estados, las propuestas enfrentaron una fuerte oposición de agencias de cobro, burós de crédito y bancos, que argumentaron ante los legisladores que sin información sobre deudas médicas podrían terminar otorgando a los consumidores préstamos de alto riesgo.

La representante estatal Lana Greenfield (republicana de Dakota del Sur), repitió las objeciones de la industria al pedir a sus colegas que votaran en contra de la prohibición. “Los bancos pequeños de comunidades pequeñas no podrían obtener información sobre una factura médica muy, muy grande. Y entonces, podrían otorgar un préstamo de buena fe a alguien sin saber realmente cuál era su crédito”, dijo Greenfield en el pleno de la Cámara.

Durante el gobierno de Biden, los encontraron que, a diferencia de otros tipos de deuda, la médica no era un buen indicador de la solvencia crediticia.

Pero el representante estatal Brian Mulder (republicano de Dakota del Sur), presidente del comité de salud que redactó la legislación, destacó el poder del sector bancario en el estado, donde regulaciones favorables lo han convertido en un imán para las instituciones financieras.

En Montana, una propuesta para proteger parte de los bienes de los deudores frente al embargo avanzó fácilmente en el comité. Sus defensores esperaban que fuera especialmente útil para pacientes nativos americanos, quienes enfrentan de forma desproporcionada la carga de la deuda médica.

Pero cuando el proyecto de ley llegó al pleno de la Cámara, los opositores “aparecieron en masa” y hablaron personalmente con los legisladores republicanos una hora antes de la votación, contó Ed Stafman, legislador demócrata y autor de la propuesta.

“Juntaron el número de votos suficientes para derrotar el proyecto por poco”, dijo.

Tanto defensores de los pacientes como legisladores que respaldaron estas medidas dijeron que son optimistas respecto a superar la oposición de la industria en el futuro.

Y hay señales de que algunas propuestas para ampliar las protecciones a los pacientes podrían avanzar en otros estados conservadores, como Ohio y Texas.

, una propuesta que obligaría a los hospitales sin fines de lucro a ampliar la ayuda financiera para quienes enfrentan facturas altas ha recibido el respaldo de organizaciones conservadoras influyentes.

“Estas cosas a veces toman tiempo”, dijo Lucy Culp, quien lidera el cabildeo estatal de Blood Cancer United (anteriormente conocida como Leukemia & Lymphoma Society). Esta organización ha impulsado leyes estatales de protección contra la deuda médica en años recientes, incluso en Montana y Dakota del Sur.

Lo más preocupante, dijo Culp, es la ola de pacientes sin seguro que se espera debido a los recortes en la cobertura médica derivados de la nueva ley fiscal aprobada por los republicanos. Esto agravará aún más el problema de la deuda médica en el país.

“Los estados no están preparados para eso”, advirtió Culp.

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The two hospitals that treated Cochran-Zipp at the time determined that she qualified for 100% financial assistance, since her income as a college student was extremely low. Not having to worry about the roughly $100,000 in bills she racked up for her care was an enormous relief, she said.

Then she started receiving unexpected bills from doctors who worked at the hospitals but, because they weren’t on staff there, didn’t have to abide by the facilities’ financial assistance policies.

Those bills, which came from specialists in emergency medicine, anesthesiology, and radiology who treated her, totaled more than $5,000. Although it was a fraction of the total cost of her care, to Cochran-Zipp it was an enormous amount. She went on payment plans and used scholarship and covid stimulus money to help cover the bills.

Cochran-Zipp, now 25 and working at a community health center, is applying to medical schools and hopes to enroll next fall. Her experience as a patient has shaped how she thinks about becoming a doctor.

“I don’t think that I could be a provider that, in good conscience, charges patients money in addition to the hospital fees,” she said.

Hospital financial assistance programs are commonplace, and many patients rely on them. Most offer varying amounts of financial help to uninsured and lower-income people. Eligibility is typically based on a sliding income scale. Some hospitals apply other tests, such as residency.

But even if people qualify for assistance, they may not get discounts. That’s because many physicians working at but not for a hospital aren’t bound by its financial assistance policies. Hospitals themselves might limit the types of services eligible for discounted or “charity care,” as it’s sometimes called.

“It’s a hole in the system,” said Caitlin Donovan, a at the , a nonprofit that helps patients with serious illnesses cover their medical bills. Case managers who work with patients report that they’ve seen these problems repeatedly, Donovan said.

In the coming years, more patients will encounter difficulties as demand for financial assistance grows. More than 14 million people are over the next decade, primarily because of changes to the federal Medicaid program and state insurance marketplaces in recently passed championed by the Trump administration. Some of these people will likely qualify for discounted care.

Nonprofit hospitals do not pay taxes on the money they make, but to maintain that tax-exempt status, they are to help patients pay for emergency and other medically necessary care. For-profit hospitals are not required to offer financial assistance to needy patients, but many do.

However, physicians and other providers who work in a hospital as independent contractors rather than as employees are often not subject to a hospital’s financial assistance policy. According to an , a health care think tank, physician services in the emergency, radiology, anesthesia, and pathology specialties are commonly excluded from hospital charity care.

For example, at , a large nonprofit health system serving Connecticut, Massachusetts, and Rhode Island, services performed by physicians, nurse practitioners, and physician assistants employed by HHC, including emergency department physicians at four of its hospitals, are covered by its financial assistance policy. But treatment by emergency physicians at three HHC hospitals is not covered by the financial assistance policy, since they are not employees. Care by doctors working in isn’t covered by the financial assistance policy at any HHC facility.

Hartford HealthCare declined to comment on the record for this article.

Health system researchers have identified another potential barrier to patients’ receiving help from hospital financial assistance policies. require that nonprofit hospitals include emergency and medically necessary care in their charity care policies, but they give hospitals substantial leeway to define what “medically necessary” care means.

Historically, excluded care has been limited to services that insurance doesn’t typically cover, like cosmetic surgery or experimental treatment. But in recent years, hospitals appear to be defining medically necessary care more narrowly, eliminating financial assistance for care that is needed but not urgently required. Care that might fall into this category could be a kidney stone removal, a cancer biopsy, or a cardiac valve replacement, published this year in The New England Journal of Medicine.

Although the study of 209 nonprofit hospitals with more than 200 beds found only isolated examples of hospitals — about 6% of them — that substantially excluded medically necessary care, researchers are concerned that it could be the leading edge of a larger trend, said Mark Hall, a professor of law and public health at Wake Forest University, who co-authored the study.

“There’s not really much in the way of regulatory guidance in what should be in or out” of a financial assistance policy, said , a clinical assistant professor at the University of South Carolina School of Medicine, who has examining hospital financial assistance policies.

The American Hospital Association declined to comment for this article. American Medical Association spokesperson Robert Mills said that the AMA doesn’t have a position on whether all contracted physicians should be required to participate in hospital financial assistance policies.

For-profit hospitals have more latitude to fashion their financial assistance policies as they wish.

At HCA Healthcare, one of the country’s largest for-profit health care systems, with nearly in 20 states and the United Kingdom, discounted or free care is available only for “.”

“Facility charity policies and uninsured discounts are typically specific to emergency services” at HCA Healthcare, said Harlow Sumerford, an HCA Healthcare spokesperson. “Any third-party providers are independent and would have their own financial policies.”

In recent years, medical debt protection laws. A few apply to some doctors and other health care providers who practice at health care facilities and bill patients separately for their care.

Colorado’s is the most expansive. Under its law that took effect in September 2022, covered hospitals have to screen all uninsured people and others who request it for eligibility for Medicaid and other health programs, and provide discounted care to people whose income is up to 250% of the federal poverty level (about ). There are limits on how much qualifying patients can be billed each month and, after three years, their debt is retired.

Under the Colorado law, licensed health care professionals who work at a covered hospital can charge qualified patients no more than the rates set by the state.

“This rule has been a game changer for folks in Colorado,” said Melissa Duncan, consumer assistance program manager at the , which helps patients access health care and cover their bills.

Unfortunately, the law didn’t pass in time to help Cochran-Zipp.

As hospitals grapple with the changes expected under the federal health care legislation passed this summer, discounted care programs may make a tempting target, say some health care financing experts. Facing higher rates of uncompensated care and trouble collecting payments from patients, facilities may reduce the financial assistance that they offer.

Hospitals may say “we are going to do all we can to protect our spending,” said , a professor of accounting and health policy and management at Johns Hopkins University. “In that environment, charity care will be a burden.”

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