Six months after a West Virginia man died following a protracted battle with his health insurer over doctor-recommended cancer care, the state’s Republican governor signed a bill intended to curb the harm of insurance denials.

West Virginia’s Public Employees Insurance Agency enrolls nearly 215,000 people — state workers, as well as their spouses and dependents. The new law, which will take effect June 10, will allow plan members who have been approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without the need for another approval from the state-based health plan.

“This legislation is rooted in a simple principle: if a treatment has already been approved, patients should be able to pursue a medically appropriate alternative without being forced to start the process over again — especially when it does not cost more,” Gov. Patrick Morrisey said in a statement after signing the bill into law on March 31.

“This is about common sense, compassion, and trusting patients and their doctors to make the best decisions for their care,” he said.

Delegate Laura Kimble, the Republican from Harrison County who introduced the legislation, told �������ýҕ�l Health News the measure offers “a rational solution” for patients facing “the most irrational and chaotic time of their lives.”

From Arizona to Rhode Island, at least half of all state legislatures have taken up bills this year related to prior authorization, a process that requires patients or their medical team to seek approval from an insurer before proceeding with care. These state efforts come as patients across the country await relief from prior authorization hurdles, as promised by dozens of major health insurers in a pledge announced by the Trump administration last year.

The West Virginia law was inspired by Eric Tennant, a coal-mining safety instructor from Bridgeport who died on Sept. 17 at age 58. In early 2025, the Public Employees Insurance Agency of a $50,000 noninvasive cancer treatment, called histotripsy, that would have used ultrasound waves to target, and potentially shrink, the largest tumor in his liver. His family didn’t expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life. The insurer said the procedure wasn’t medically necessary and that it was considered “experimental and investigational.”

Becky Tennant, Eric’s widow, told members of a West Virginia House committee in late February that she submitted medical records, expert opinions, and data as part of several attempts to appeal the denial. She also reached out to “almost every one of our state representatives,” asking for help.

Nothing worked, she told lawmakers, until �������ýҕ�l Health News and NBC News got involved and posed questions to the Public Employees Insurance Agency about Eric’s case. Only then did the insurer reverse its decision and approve histotripsy, Tennant said.

“But by then, the delay had already done its damage,” she said.

Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure. “The insurance company’s decision did not simply delay care. It closed doors,” his wife said.

Had the new law been in effect, Kimble said, Tennant could have undergone histotripsy without preapproval, because it was a less expensive alternative to chemotherapy, which his insurer had already authorized. The bill was passed unanimously by the state legislature in March.

U.S. health insurers argue that most prior authorization requests are quickly, if not instantly, approved. AHIP, the health insurance industry trade group, says prior authorization acts as an important guardrail in preventing potential harm to patients and reducing unnecessary health care costs. But denials and delays tend to affect patients who need expensive, time-sensitive care, .

The practice has come under intense scrutiny in recent years, particularly after the in New York City in late 2024. Americans rank prior authorization as their biggest burden when it comes to getting health care, according to a by KFF, a health information nonprofit that includes �������ýҕ�l Health News.

Samantha Knapp, a spokesperson for the West Virginia Department of Administration, would not answer questions about the law’s financial impact on the state. “We prefer to avoid any speculation at this time regarding potential impact or actions,” Knapp said.

In a fiscal note attached to the bill, Jason Haught, the Public Employees Insurance Agency’s chief financial officer, said the law would cost the agency an estimated $13 million annually and “cause member disruption.”

West Virginia isn’t an outlier in targeting prior authorization. By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books, according to a by the National Association of Insurance Commissioners.

Many states have set up “gold carding” programs, which allow physicians with a track record of approvals to bypass prior authorization requirements. Some states establish a maximum number of days insurance companies are allowed to respond to requests, while others prohibit insurance companies from issuing retrospective denials after a service has already been preauthorized. There are also a crop of new state laws seeking to regulate the use of artificial intelligence in prior authorization decision-making.

Meanwhile, prior authorization bills introduced this year across the country, including in Kentucky, Missouri, and New Jersey, have been supported by politicians from both parties.

“Republicans in conservative states see health care as a vulnerability for the midterm elections, and so, unsurprisingly, you’ll see some action on this,” said Robert Hartwig, a clinical associate professor of risk management, insurance, and finance at the University of South Carolina. “They realize that they’re not really going to get much action at the federal level given the degree of gridlock we’ve already seen.”

Last summer, the Trump administration announced a pledge signed by dozens of health insurers vowing to reform prior authorization. The insurers promised to reduce the scope of claims that require preapproval, decrease wait times, and communicate with patients in clear language when denying a request.

Consumers, patient advocates, and medical providers that companies will follow through on their promises.

Becky Tennant is skeptical, too. That’s why she advocated for the West Virginia bill.

“Families should not have to beg, appeal, or go public just to access time-sensitive care,” she told lawmakers. Tennant, who sees the bill’s passage as bittersweet, said she thought her husband would have been proud.

During Eric’s final hospital stay, Tennant recalled, right before he was discharged to home hospice care, she asked him whether he wanted her to keep fighting to change the state agency’s prior authorization process.

“‘Well, you need to at least try to change it,’” she recalled her husband saying. “‘Because it’s not fair.’”

“I told him I would keep trying,” she said, “at least for a while. And so I am keeping that promise to him.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

Do you have an experience with prior authorization you’d like to share? to tell �������ýҕ�l Health News your story.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, , told �������ýҕ�l Health News that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted , a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes �������ýҕ�l Health News. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in , but not in . Pennsylvania’s EHBs also don’t include hearing aids, but do.

But the Trump administration’s 2027 regulatory proposal : When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

Are you struggling to afford your health insurance? Have you decided to forgo coverage?��Click here��to contact �������ýҕ�l Health News and share your story.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by �������ýҕ�l Health News has found.

The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.

There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.

Medicare Advantage plans differ from traditional Medicare because private insurance companies administer them. The insurance plans enroll about members, more than half the people eligible for Medicare. The plans offer things like vision and drug coverage, but Medicare Advantage insurers restrict the hospitals and doctors that patients can use and require prior approval for various procedures.

CMS is set to announce a final decision by early next month on the rate proposal. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views.

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 comments published as of March 12.

The proposed rate plan “puts my access to care at risk,” the group’s template letter to policymakers reads in part. “If the investment made by Washington in the Medicare Advantage program is nearly flat year-over-year, I could lose benefits I rely on every day, including affordable prescriptions, capped out of pocket costs, and access to trusted doctors and specialists.”

“Medicare Advantage is not optional for me. The cost protections alone have saved me thousands of dollars and made my health care manageable. Without this program, I would face higher costs, fewer providers, and fewer benefits at a time when I can least afford it,” the letter states.

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

“There’s no way for the public to know what wealthy donors or special interests are funding dark money groups like this,” he said. “That means there’s no scrutiny of who’s really calling the shots.”

Some health care policy experts, who have long argued that the government overpays Medicare Advantage plans by tens of billions of dollars every year, believe industry groups or their surrogates routinely overstate possible negative impacts of rate decisions they don’t like.

“The plans always say that the sky is falling,” said Matthew Fiedler, a health care policy expert with the Brookings Institution. “The industry has a lot of money at stake here. They try to exert pressure on policymakers any way they can.”

At the same time, even critics concede that some of the millions of people enrolled in Medicare Advantage plans could face service cuts if insurance companies are not satisfied with government payments.

“It is legitimate for people to be worried,” said Julie Carter, counsel for federal policy at the Medicare Rights Center, a group that advocates for older adults and people with disabilities.

Her group argues that Medicare Advantage plans have never attained expected cost savings and instead have been overpaid for years at least partly due to “actions to maximize profits.” She said the health plans “are supposed to be saving money, not taking extra.”

People struggling to pay health care bills may have little use for the policy debate in Washington.

“If it wasn’t for being able to have this program, I really wouldn’t be able to afford any kind of medical services, to be honest,” said EsterAlicia Rose, 75, who works at the front desk of a hotel in Pagosa Springs, Colorado. She said she signed the Medicare Advantage Majority form letter to reach policymakers.

Kathy Lovely-Marshall, 66, a retired nurse who lives in Brookville, Ohio, did too. She said she receives “a lot of perks” from her plan, such as dental care, eyeglasses, and prescriptions.

“All those things are a big plus as far as I am concerned,” she said. “I’m very happy with the plan I have.”

But Corenia Branham, 90, a widow and cancer survivor who lives in Alum Creek, West Virginia, said she wants nothing to do with Medicare Advantage plans run by private health insurance companies. She said she didn’t turn in any of the four form letters under her name, which were posted online by CMS on Feb. 23 and signed, “Miss Corenia Branham Branham.” It’s not clear why her last name is signed twice.

Branham said she’s not on Medicare Advantage and doubts she could count on it for needed care.

“I wouldn’t recommend it to nobody,” she said. “I sure don’t want anything to do with it.”

Grubb, the Medicare Advantage Majority spokesperson, disputed that account. He said Branham responded to an ad on Facebook. On Feb. 6, she “completed the form with her information and chose to send her comment to CMS as well as to her representatives in Congress and the White House,” he said.

Other Medicare Advantage advocacy groups have stepped up ad campaigns as the rate decision looms.

The Better Medicare Alliance, whose “allies” include a range of health insurers, health care providers, and consumers, is urging seniors to “Tell Washington to Stand Up for Medicare Advantage.”

“We’ve mobilized beneficiaries to write letters and make phone calls, and we’ve run digital ads on streaming platforms,” spokesperson Susan Reilly said.

Reilly said that this year roughly 3 million seniors “were forced to find new coverage” because plans either shuttered operations or left some areas.

She also said Medicare Advantage plans have “scaled back” benefits such as offering transportation to medical appointments, nutrition support, and dental and vision coverage, while over the past two years beneficiaries have faced an average $900 increase in out-of-pocket maximums.

“We do view this as especially serious,” Reilly said. “This isn’t a single bad year; it’s the cumulative effect of years of underfunding and policy disruption from the previous administration that has left the program increasingly vulnerable.”

As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.

CMS spokesperson Catherine Howden said the agency would make more comments public “as soon as practicable.”

“The agency focuses on reviewing the substance of timely submissions and does not speculate on volume, sentiment, or potential impact of comments while the comment period is open/under review,” she said in a statement.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

Engineered quartz countertops have surged in popularity in the home renovation market, with industry analysts estimating the global engineered stone market at . It’s continuing to expand as quartz surfaces replace natural stone in kitchens in the United States and worldwide.

When González was working, the dust that rose from his saw didn’t look extraordinary. It settled on his clothes, in his hair, across the shop floor. In a small countertop fabrication shop, he cut marble and granite before shifting to engineered stone after the 2008-09 recession, when demand for cheaper quartz countertops surged.

But the crystalline silica released while the engineered stone was cut and polished also settled into his lungs, scarring them beyond repair. What began as breathlessness hardened into silicosis, an irreversible disease that stiffens the lungs until even ordinary movement becomes effort.

A lung transplant was his path forward. The procedure can extend survival, but it redraws the boundaries of a life: anti-rejection drugs every day, constant monitoring, vulnerability to infection, the knowledge that breathing depends on the fragile acceptance of another person’s donated organ.

González, who was diagnosed with silicosis in 2023, is not alone in dealing with a disease that once was associated with miners at the end of long careers. It’s now prevalent among the much younger, often Hispanic men who work in this industry, physicians and public health officials say.

In the United States, cases are appearing in countertop fabrication shops from California to Texas, Florida, and the Northeast. Because silicosis is not a nationally reportable disease and surveillance varies by state, no comprehensive national count exists. But clinicians who treat occupational lung disease say the number of workers — often men in their 30s and 40s — diagnosed after cutting engineered stone has risen sharply over the past decade.

As of , California had identified 519 confirmed cases of engineered-stone-associated silicosis and 29 deaths since 2019. The median age at diagnosis is 46; at death, 49.

Doctors don’t debate whether working with engineered stone can scar lungs.

Manufacturers argue, though, that proper ventilation, wet cutting, and respirators can make fabrication safe. Workers, physicians, and plaintiffs’ attorneys counter that a material composed almost entirely of crystalline silica may be impossible to handle safely at scale.

“This is comparable to the tobacco industry saying cigarettes are safe,” said epidemiologist David Michaels, an assistant labor secretary under President Barack Obama who led the Occupational Safety and Health Administration.

More than 370 lawsuits have been filed by workers who say engineered stone manufacturers failed to warn employees about the risks or sold a product that cannot be fabricated safely. At the same time, members of Congress are that would largely shield manufacturers from liability in those cases, turning a workplace health crisis into a national debate over regulation, responsibility, and the limits of civil litigation.

Gustavo Reyes, 36, is part of that debate. Like González, he spent the early years of his career cutting marble and granite before shifting to engineered stone, a quartz-based material that can contain up to 95% silica and generates far more hazardous dust when cut.

In the shop, he said, cutting was done with water to control the dust. But finishing work — sanding and shaping — generated heavy dust. He said he wore disposable respirator masks or a reusable elastomeric respirator with filters. A door was kept open. Fans ran overhead.

When he was diagnosed in 2021, he did not know what silicosis meant. The doctor told him that there was no medication and that he had three to five years to live. He received a lung transplant in 2023.

Asked who he believes is responsible, Reyes answered: “The industries who created the artificial stone, the product.” Manufacturers dispute that characterization. Major companies say engineered stone can be fabricated safely when employers follow OSHA dust controls, including wet cutting, ventilation, and respirator use.

An Old Disease, Reengineered

Silicosis is not new. It was synonymous with mining disasters and sandblasting, most notoriously in the , when hundreds of workers drilling through silica-rich rock in West Virginia in the early 1930s developed acute silicosis after months of unprotected exposure to dust. In 1938, advised that the disease could be prevented if dust controls were conscientiously applied.

What is new is the industry in which it has resurfaced.

Engineered stone, often marketed as “quartz,” is typically composed of crushed quartz bound with resins and pigments. Unlike marble, which contains little crystalline silica, engineered slabs contain very high levels of the substance.

Cutting changes the material.

“When you grind it, when you cut it, you’re pulverizing it,” said Robert Blink, an occupational and environmental medicine specialist who treats patients with advanced silicosis in Chicago and is a member of the Western Occupational and Environmental Medical Association. “You’re weaponizing the silica.”

Power tools fracture the surface into respirable particles small enough to lodge deep in the lungs. Repeated exposure triggers inflammation and fibrosis. Once scarring begins, it doesn’t reverse.

What Happens When You Look for It

In California, physicians say the pattern emerged gradually.

Robert Harrison, an occupational medicine physician at the University of California-San Francisco, helped identify the of engineered stone silicosis cases in California in 2019 after several workers from the same countertop fabrication shop died or were diagnosed with the disease. He described the crisis as “the largest outbreak of silicosis in decades.” What initially appeared as isolated cases of unexplained lung scarring in young men resolved into a recognizable occupational epidemic once work histories were examined.

Jane Fazio, a pulmonologist at UCLA, recalls seeing advanced fibrosis in otherwise healthy workers. “They have families. They were working full-time,” she said. Some experienced respiratory failure within a few years.

When doctors compared work histories, the pattern became unmistakable: Many of the men had worked in small shops cutting and polishing engineered stone countertops.

Sheiphali Gandhi, an occupational and environmental pulmonologist at UCSF, warned that the true burden remains uncertain. “We’re missing cases,” she said. “There’s no national surveillance system for this.”

California designated silicosis a reportable disease . Since 2019, statewide surveillance has identified hundreds of cases linked to engineered stone. The numbers probably underestimate the toll, though makes the illness visible.

Outside California, there is no comparable tracking.

Early Warnings

California was not the first place this happened.

The earliest modern alarm came from Israel. Caesarstone, a company founded on a kibbutz in the late 1980s, helped popularize quartz countertops globally.

Israeli physicians began in young countertop workers as early as 1997.

“We had never seen this before,” said Mordechai Kramer, a retired pulmonologist who previously worked at Rabin Medical Center in Israel. “In classic silicosis, you expect long exposure, decades. Here, it was much shorter.”

Several patients required lung transplantation.

Despite the warning signs, the market continued to expand.

Australia confronted the same pattern in the late 2010s.

Rather than wait for sporadic diagnoses, Australian regulators launched systematic CT-based screening of artificial-stone workers. Disease prevalence was far higher than anticipated.

Ryan Hoy, a respiratory physician and occupational health researcher at Australia’s Monash University, described severe disease in workers with relatively short exposures.

Authorities examined whether wet cutting, ventilation, and respirators could reduce exposure sufficiently. They ultimately concluded that even with controls, fabrication of high-silica engineered stone posed unacceptable risk.

In 2024, Australia prohibited the manufacture, supply, and installation of engineered stone containing high levels of crystalline silica. Manufacturers pivoted toward lower- and zero-silica formulations.

In the United States: Who’s To Blame?

Fabrication in the U.S. continues under OSHA’s silica standard, which relies on exposure limits, wet cutting, ventilation, and respiratory protection. Manufacturers argue that compliance works and that the problem lies with shops that fail to follow the rules.

OSHA first adopted silica limits based on research from mining, quarrying, and foundry work. Although the agency updated the rule , it regulates crystalline silica broadly and does not distinguish between natural stone and high-silica engineered quartz.

The regulatory debate has now spilled into Congress. , introduced in September by Rep. Tom McClintock (R-Calif.), would largely shield manufacturers and distributors of engineered stone from civil lawsuits arising from the manufacture or sale of their products. McClintock’s office did not respond to a request for comment.

The bill was the subject of a January .

Supporters of the measure argue that manufacturers should not be held liable for injuries caused by employers who fail to follow OSHA standards. Opponents warn that removing litigation pressure would eliminate one of the few mechanisms capable of driving product reform if the material itself cannot be safely handled.

Michaels, the former OSHA official, sees the stakes as historical. “Litigation drives change,” he said, pointing to past battles over asbestos and tobacco.

Plaintiffs’ attorneys argue that compliance with the OSHA silica standard does not eliminate risk.

“It’s not a few bad actors,” said Raphael Metzger, a product liability attorney who has filed roughly 200 silicosis-related injury cases and a class action seeking medical monitoring. He said the issue is the product’s composition, not isolated regulatory noncompliance.

James Nevin, a tort attorney representing workers in silicosis cases, framed the congressional debate as a fight over accountability. “When it comes to causation, there’s no question,” he said, arguing that the wave of cases explains why manufacturers are now seeking what he calls “a manufacturer bailout.”

In mid-2025, Caesarstone US introduced its first products containing less than 1% silica. In response to questions, Irene Williams, a spokesperson for Caesarstone, said, “The company is not responding as these are matters of pending litigation.”

The U.S. engineered stone market is dominated by a handful of large brands — including Caesarstone, Spain-based Cosentino, and U.S.-based Cambria — while the volume of slabs imported from Asian manufacturers is growing.

Cosentino, too, is moving to low-silica products: “One third of the portfolio, including most new collections, contain less than 10% of crystalline silica,” said Kamela Kettles, a Cosentino spokesperson. “Cosentino will not be providing additional commentary at this time,” she said.

Commenting on behalf of Cambria, Mark Duffy, a communications consultant for the company, wrote, “Reckless employers are criminally violating the law, exposing workers to deadly working conditions.” He added that engineering and administrative controls, when properly used, are effective in reducing exposures below OSHA limits and said Cambria maintains exposures below the OSHA Action Level in its own facilities.

While Caesarstone and Cosentino are headquartered overseas, Cambria is based in Minnesota. Its chief executive, Marty Davis, has been a major Republican political donor, to President Donald Trump’s election campaigns as well as to other Republican candidates and political action committees, according to federal campaign finance records. Davis has also contributed to the campaign of Rep. Brad Finstad (R-Minn.), a co-sponsor of the legislation. Finstad’s office did not respond to a request for comment.

Nevin, the attorney, said the bill would give manufacturers “free rein” from civil liability.

He also questions whether regulatory enforcement alone can address the problem. Even before the Trump administration’s funding and staffing cuts, “you had a better chance of being struck by lightning than being visited by OSHA,” he said, arguing that inspections are too infrequent to prevent disease in an industry composed largely of small shops.

Breathing on Borrowed Time

For González, the debate arrives after the fact. The dust he inhaled has already reshaped his life.

And Reyes’ transplanted lungs may last years, but not decades. The median survival time for transplanted lungs is about eight years, UCSF’s Gandhi said.

Reyes said he hopes people shopping for countertops understand that buying artificial stone “will harm the worker. The one who cuts it, the one who manufactures it.”

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

To ensure it tastes good and is safe to drink, a small team of scientists and technicians is constantly testing the water for pH, odors, heavy metals, and microbes.

But unlike many smaller municipal utilities in the U.S., regularly checks for PFAS — per- and polyfluoroalkyl substances.

That’s a class of chemicals used by manufacturers for decades to make things like nonstick pans, cosmetics, raincoats, food wrappers, and firefighting foam.

����have linked PFAS to����like cancer, reduced immune system functioning, high cholesterol, and developmental delays in children.

They’re also known as “forever chemicals” because their strong chemical structures make them degrade incredibly slowly in the environment.

Today, they litter����and����sources around the world and can be found����of almost everyone in the U.S.

One type of PFAS that the Louisville water technicians are tracking is HFPO-DA, also known by a trade name,��.

Just over a year ago, workers noticed an unexpected increase in the level of GenX detected in a sample of the raw, untreated water drawn from the Ohio River for filtering and processing.

The GenX levels Louisville found in December 2024 were 15 times the reading from the previous month: 52 parts per trillion versus 3.4 ppt.

“A part per trillion is like one second in 32,800 years. Put your head around that, right?” said��, the city utility’s director of water quality and research.

He offered another way to think of it: One part per trillion would be a single drop of water in 20 Olympic swimming pools.

Goodmann told �������ýҕ�l Health News and NPR he wasn’t worried about local customers’ safety, because the increased levels were still pretty low.

Risks posed by low PFAS concentrations are measured over a lifetime of exposure, he said. And recent data from Louisville shows the����fell back within planned federal safety limits.

Plus, water is just one way people can be exposed to PFAS, Goodmann added. “Because you get a lot more of these pollutants from packaging, from prefixed food, cake mixes, weird things, you know, popcorn boxes,” he said.

Louisville Water’s data showed that the elevated levels of GenX in the water sample drawn in December 2024 fell once the water underwent typical treatment and filtering.

Federal Regulation Fight

The federal government has long regulated the levels of����in drinking water, such as arsenic, E. coli, and lead.

But the Environmental Protection Agency didn’t issue regulations regarding PFAS until 2024, during the final year of the Biden administration. The new limits applied to����in drinking water. Starting in 2029, utilities that exceeded the limits would have been required to treat the water to reduce the contamination.

But after Donald Trump’s reelection, new EPA administrator������the agency will keep the rules for only two types of PFAS, called PFOA and PFOS, but drop the restrictions on the other four types, including GenX.

In addition, the EPA announced it will give water utilities two additional years, until 2031, to comply with the remaining rules, attributing the change in part to the financial burden on rural water plants.

Many utilities, large and small, may need to��.

A����estimated about 45% of U.S. tap water contains at least one type of PFAS.

When it announced the final PFAS limits, the Biden administration anticipated that of the estimated 66,000 U.S. public drinking water systems affected by these regulations might have PFAS levels high enough to require them to take action to reduce the contamination.

Finding the Source

Goodmann’s team traced the increased levels of PFAS up the Ohio River, past Cincinnati, and through Appalachian forests, all the way to a West Virginia factory about 400 miles upstream.

There, the����uses GenX��, a plastic critical to the semiconductors that power phones.

Its Washington Works facility near Parkersburg, West Virginia, has a��.

A lawyer,��, fought the plant’s previous owner,��, in court,����the company knew that a type of PFAS it was using, PFOA, was toxic but didn’t disclose that information.

DuPont went on to��������that claimed it contaminated local environments with forever chemicals. The company has repeatedly denied wrongdoing.

Chemours was����from DuPont in 2015.

The Louisville Water team’s calculations eventually showed that the December 2024 spike in GenX levels corresponded to publicly available data from Chemours about its chemical discharges into the Ohio River.

In Chemours’ responses to����filed by a West Virginia environmental group, the company denied its discharges were connected to Louisville’s GenX spike. (Louisville is not a party in the lawsuit.)

The company also contended that sampling data showed levels of GenX in the river and in downstream utilities’ treated drinking water are “indisputably safe.”

PFAS Removal Will Challenge Water Utilities

Under current federal environmental regulations, Chemours can release some chemicals into the Ohio River. But it has exceeded the legal limits repeatedly over several years, according to court filings and��.

That’s why the����filed its lawsuit in 2024.

The EPA����in 2023, when it said it found Chemours’ West Virginia factory had repeatedly exceeded permit limits for two types of forever chemicals, GenX and PFOA.

But the West Virginia Rivers Coalition said in a court filing that the EPA’s consent order for Chemours “is not being diligently prosecuted.”

Chemours declined to answer questions from �������ýҕ�l Health News and NPR, citing ongoing litigation, except to point out that Louisville’s “finished drinking water is safe for consumption,” with PFAS levels below the EPA’s regulatory limits, as stated on and in the����from Cincinnati, which also draws from the Ohio River.

As research into the health effects of PFAS exposure continues, environmental advocates say it’s imperative for companies to meet the limitations set by government permits.

“Environmental regulatory permitting is a license to pollute,” said��, the water policy director for the��.

“You’re permitting someone to put something into the atmosphere, into water, into soil that would not be there otherwise. And so when we talk about the safe levels,” he said, “stop using the word ‘safe,’ right? This is the maximum allowable limit.”

It is possible to remove PFAS from drinking water. For example, Louisville’s utility is spending about $23 million to redesign its powdered activated carbon system, which is one method used to take out PFAS.

But PFAS removal can get expensive, especially for small, rural towns, Hart said. Preventing contaminants such as PFAS from getting into a community’s drinking water supply is easier and less costly compared with removing it on the back end, he added.

In Chemours’ responses to the lawsuit, the company acknowledged that its violating its current permit but noted it’s working with government regulators on an eventual fix.

The federal judge in the case,��, decided that wasn’t fast enough.

In August, he�� overpolluting. The company quickly filed an appeal.

The West Virginia Rivers Coalition declined to speak with �������ýҕ�l Health News and NPR but did point to its����on the judge’s ruling.

“This is a victory for public health and the Ohio River,” Autumn Crowe, the organization’s deputy director, said in the statement. “The Court recognized what communities have known for years: Chemours has been polluting our water and ignoring its legal obligations.”

In a court filing for the case, Goodmann said that elevated levels of GenX could make it more challenging for water utilities such as Louisville’s to comply with federal rules for safe drinking water.

In regard to Chemours specifically, Goodmann told �������ýҕ�l Health News and NPR that when government regulators issue the company’s next��permit, he wants them to take into account the water treatment plants downstream.

“So what we do is manage risk, and we start that at the river,” he said. “It sounds weird, but source water protection — keeping the stuff out of the river — is a big deal.”

This article is from a partnership that includes��,��, and���������ýҕ�l Health News.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

But two years ago, he heard about Peak Health, a new Advantage plan started by the West Virginia University Health System, where his doctors practice. It was cheaper and offered more personal attention, plus extras such as an allowance for over-the-counter pharmacy items. Those benefits are more important than ever, he said, as he’s treated for cancer.

“I decided to give it a shot,” said Wilkewitz, 79. “If I didn’t like it, I could go back to Humana or whatever after a year.”

He’s sticking with Peak Health. Members of Medicare Advantage plans, a privately run alternative to the government’s Medicare program, can change plans through the end of March.

Now entering its third year, Peak Health has tripled its enrollment since last year, to “north of 10,000,” said Amos Ross, its president. It expanded from 20 counties to 49, he said, and moved into parts of western Pennsylvania for the first time.

Although hospital-owned plans are only a sliver of the Medicare Advantage market, their enrollment continues to grow, reflecting the overall increase in Advantage members. Of the 62.8 million Medicare beneficiaries eligible to join Advantage plans, , according to KFF, the health information nonprofit that includes �������ýҕ�l Health News. While the number of Advantage plans owned by hospital systems is relatively stable, Mass General Brigham in Boston and others are expanding their service areas and types of plan offerings.

Health systems have dabbled in the insurance business for years, but it’s not for everyone. MedStar Health, serving the greater Washington, D.C., area, said it closed its Medicare Advantage plan at the end of 2018, citing financial losses.

“It’s a ton of work,” said Ross, who spent more than a decade in the commercial health insurance industry.

Like any other health insurer, hospitals entering the business need a back-office infrastructure to enroll patients, sign up providers, fill prescriptions, process claims, hire staff, and — most importantly — assure state regulators they have a reserve of money to pay claims. Once they get a state insurance license, they need approval from the federal Centers for Medicare & Medicaid Services to sell Medicare Advantage policies. Some systems affiliate with or create an insurance subsidiary, and others do most of the job themselves.

Kaiser Permanente, the nation’s largest nonprofit health system by revenue, started an experimental Medicare plan in 1981 and now has nearly 2 million people enrolled in dozens of Advantage plans in eight states and the District of Columbia. The Justice Department announced Jan. 14 that KP had agreed to pay $556 million to settle accusations that its Advantage plans fraudulently billed the government for about $1 billion over a nine-year period.

Last year, UCLA Health introduced two Medicare Advantage plans in Los Angeles County, the most populous county in the United States. Other new hospital-owned plans have cropped up in less profitable rural areas.

“These are communities that have been very hard for insurers to move into,” said Molly Smith, group vice president for public policy at the American Hospital Association.

But Advantage plans offered by hospitals have a familiar, trusted name. They don’t have to move into town, because their owners — the hospitals — never left.

Bad Breakups

Medicare Advantage plans usually restrict their members to a network of doctors, hospitals, and other clinicians that have contracts with the plans to serve them. But if hospitals and plans can’t agree to renew those contracts, or when disputes flare up — often spurred by payment delays, denials, or burdensome prior authorization rules — the health care providers can drop out.

These breakups, plus planned terminations and service area cuts, forced more than 3.7 million Medicare Advantage enrollees to make a tough choice last year: find new insurance for 2026 that their doctors accept or, if possible, keep their plan but find new doctors.

About 1 million of these stranded patients had coverage from UnitedHealthcare, the country’s largest health insurer. In a July earnings update for financial analysts, chief financial officer John Rex blamed the company’s retreat on hospitals, where “most encounters are intensifying in services and costing more.”

The turbulence in the commercial insurance market has upset patients as well as their providers. Sometimes contract disputes have been fought out in the open, with anxious patients in the middle receiving warnings from each side blaming the other for the imminent end to coverage.

When Fred Neary, 88, learned his doctors in the Baylor Scott & White Health system in central and northern Texas would be leaving his Medicare Advantage plan, he was afraid the same thing could happen again if he joined a plan from another commercial insurer. Then he discovered that the 53-hospital system had its own Medicare Advantage plan. He enrolled in 2025 and is keeping the plan this year.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

“We saw a turnaround in his behavior, and our other children,” said Burkhammer, who has adopted or fostered 10 kids with his wife. “There are real impacts on real kids.”

The Republican turned his experience into legislation, sponsoring a bill to from food sold in the state. It became law in March, making West Virginia the first state to institute such a ban from all food products.

The bill was among a slew of state efforts to regulate synthetic dyes. In 2025, roughly 75 bills aimed at food dyes were introduced in 37 states, according to .

Chemical dyes and nutrition are just part of the broader “Make America Healthy Again” agenda. Promoted by Health and Human Services Secretary Robert F. Kennedy Jr., MAHA ideas have made their deepest inroads at the state level, with strong support from Republicans — and in some places, from Democrats. The $50 billion — created last year as part of the GOP’s One Big Beautiful Bill Act to expand health care access in rural areas — offers incentives to states that implement MAHA policies.

Federal and state officials are seeking a broad swath of health policy changes, including rolling back routine vaccinations and expanding the use of drugs such as ivermectin for treatments beyond their approved use. State lawmakers have introduced dozens of bills targeting vaccines, fluoridated water, and PFAS, a group of compounds known as “forever chemicals” that have been linked to cancer and other health problems.

In addition to West Virginia, six other states have targeted food dyes with new laws or executive orders, requiring warning labels on food with certain dyes or banning the sale of such products in schools. California has had a law regulating food dyes since 2023.

Most synthetic dyes used to color food have been . Some clinical studies have found a link between their use and . And in early 2025, in the last days of President Joe Biden’s term, the Food and Drug Administration known as Red No. 3.

Major food companies including have gotten on board, pledging to eliminate at least some color additives from food products over the next year or two.

“We anticipate that the momentum we saw in 2025 will continue into 2026, with a particular focus on ingredient safety and transparency,” said John Hewitt, the senior vice president of state affairs for the Consumer Brands Association, a trade group for food manufacturers.

This past summer, the group called on its members to from their products by the end of 2027.

“The state laws are really what’s motivating companies to get rid of dyes,” said , regulatory counsel for the Center for Science in the Public Interest, a nonprofit health advocacy group.

, the senior director of state health policy for the Association of State and Territorial Health Officials, said the bipartisan support for bills targeting food dyes and ultraprocessed food struck him as unusual. Several red states have proposed legislation modeled on California’s 2023 law, which bans four food additives.

“It’s not very often you see states like California and West Virginia at the forefront of an issue together,” Baker-White said.

Although Democrats have joined Republicans in some of these efforts, Kennedy continues to drive the agenda. He appeared with Texas officials when the state enacted a package of food-related laws, including one that bars individuals who participate in the Supplemental Nutrition Assistance Program — SNAP, or food stamps — from using their benefits to buy candy or sugary drinks. In December, the U.S. Department of Agriculture approved similar . Eighteen states will block SNAP purchases of those items in 2026.

There are bound to be more. The Rural Health Transformation Program also offers incentives to states that implemented restrictions on SNAP.

“There are real and concrete effects where the rural health money gives points for changes in SNAP eligibility or the SNAP definitions,” Baker-White said.

In October, California Gov. Gavin Newsom signed a bill that sets a and will phase them out of schools. It’s a move that may be copied in other states in 2026, while also providing fodder for legal battles. In December, San Francisco City Attorney David Chiu , accusing them of selling “harmful and addictive” products. names specific brands — including cereals, pizzas, sodas, and potato chips — linking them to serious health problems.

Kennedy has also for chronic diseases. But even proponents of the efforts to tackle nutrition concerns don’t agree on which foods to target. MAHA adherents on the right haven’t focused on sugar and sodium as much as policymakers on the left. The parties have also butted heads over some Republicans’ championing of , which can spread harmful germs, and the consumption of , which contributes to .

Policymakers expect other flash points. Moves by and the in October. Meanwhile, more red states may eliminate vaccine mandates for employees; . And Florida Gov. Ron DeSantis is pushing to .

Even as Kennedy advocates eliminating artificial dyes, the Environmental Protection Agency has on chemicals and pesticides, leading MAHA activists to calling on President Donald Trump to fire EPA Administrator Lee Zeldin.

Congress has yet to act on most MAHA proposals. But state lawmakers are poised to tackle many of them.

“If we’re honest, the American people have lost faith in some of our federal institutions, whether FDA or CDC,” said Burkhammer, the West Virginia lawmaker. “We’re going to step up as states and do the right thing.”

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

Hunt died five days later. Her death certificate said the foot injury was a “significant” factor. Genesis denied wrongdoing but agreed to pay $3.5 million in a settlement Hunt’s son signed in August 2024.

Yet Genesis hasn’t paid most of that debt, court records show. It may never have to.

Once the nation’s largest nursing home chain, it was spending $8 million a month defending and settling lawsuits over resident injuries and deaths in recent years. But the company is now poised to wipe the liability slate clean by seeking refuge in the most protective corner of the legal system for the nursing home industry: bankruptcy court.

The Genesis case, one of 11 large senior care bankruptcies this year, illustrates how health care companies can dodge public and financial accountability for alleged negligence through delays, confidentiality clauses, and bankruptcy maneuvers, a �������ýҕ�l Health News investigation found.

When it filed for bankruptcy in Dallas in July, Genesis estimated its total liability for nearly a thousand settled and pending lawsuits at $259 million. A �������ýҕ�l Health News review of the terms of 155 settlement agreements and shows Genesis officials knew insolvency was possible yet included provisions in its settlement agreements allowing it to defer payment, often for a year or more.

As a result, Genesis paid nothing in 85 cases and only a portion in the other 70, according to civil court records and bankruptcy claims made available through people with access to them. It still owes $41 million of the $58 million it had agreed to pay in those cases, the records show.

“It just feels like they killed my mom and got away with it,” said Vanessa Betancourt, whose mother, Nellie Betancourt, a retired nurse, fractured her hip at a Genesis home in Albuquerque, New Mexico — an injury the medical examiner’s report said led to her death. Genesis agreed to a $650,000 settlement with Betancourt’s family in April under the condition it would not need to pay the first of seven installments for another year, according to the settlement document.

Genesis denied wrongdoing in all lawsuits and settlements. In a written statement, the company did not answer questions about individual personal injury cases. The statement said Genesis remained “focused on delivering high-quality, compassionate care to our patients and residents without disruption” during bankruptcy.

One lawsuit Genesis settled for nearly $1 million alleged nursing home managers ignored repeated warnings about a male resident’s behavior before he sexually assaulted a female Alzheimer’s patient, according to court records. In a case the company resolved for $500,000, a Genesis nursing home was accused of delaying the hospitalization of a resident who had vomited brown mucus. He died of a bowel obstruction. Genesis has paid nothing for either settlement, according to bankruptcy claims.

Creditors, including families of the deceased, are expected to salvage a fraction of what they were promised, if anything. On Dec. 10, the company’s owners were scheduled to seek approval by the U.S. Bankruptcy Court for the Northern District of Texas to sell its nursing homes and other assets to its largest investor, a private equity firm. In court papers, lawyers for residents and other creditors say the complex plan will from pursuing Genesis’ new ownership and other companies the company’s collapse.

John Anthony, a bankruptcy attorney representing 340 personal injury claims against Genesis, said, “They never had any intention to honor these deals.”

Low Ratings and Fines

During years of financial turmoil, Genesis has frequently struggled to provide top-notch care, federal records show. Using its five-star system, the Centers for Medicare & Medicaid Services affiliated with Genesis as below average or much below average. CMS Genesis homes $10 million for violating federal health standards over the past three years.

In 2022, a Genesis home after two deaths and multiple violations. The company this year after residents twice were evacuated over safety concerns.

In its filing, Genesis said it cared for about 15,000 residents in 165 nursing homes and 10 assisted living facilities in 18 states. They are centered in Pennsylvania, West Virginia, New Mexico, New Hampshire, New Jersey, Maine, Alabama, Maryland, and North Carolina, according to the bankruptcy filing.

The company said it owed $709 million in secured debt to lenders and the IRS. Under bankruptcy rules, those debts, backed by Genesis collateral, take precedence over the $1.6 billion in unsecured debt Genesis said it owes. Unsecured creditors include a pension fund; contractors that provided health services and equipment; Pennsylvania, New Mexico, and West Virginia for unpaid provider taxes; and former residents and their families who sued.

Dangers in Memory Care

Sandia Ridge Center, a Genesis home in Albuquerque, was repeatedly faulted by health regulators for not preventing sexual misbehavior in its memory care unit. In November 2021, CMS for lacking enough nurses to prevent sexual abuse among residents. An inspection report the following August inappropriate sexual contact. Police were called to investigate sexual assault allegations in and of 2023, police reports show; neither resulted in criminal charges.

Then in April 2023, a 61-year-old male resident with alcohol-related dementia sexually assaulted a female resident with Alzheimer’s in the dining room, according to a and an . When the resident screamed for him to stop and that he was hurting her, he responded “shut up bitch I know you like this,” according to a lawsuit brought on behalf of the woman, identified in court papers as R.S.

Sandia Ridge management had been aware of the male resident’s behavioral issues for months, according to employee depositions in the case. Police had investigated a against him the previous year without bringing charges. In one deposition, a former activities assistant testified he hit her and twice pushed her into a bathroom while announcing, “I want to have sex with you.” When she reported him to a senior Genesis manager, she said in the deposition, the manager put his finger over his lips and said, “Shhh.”

The activities worker testified that R.S. used to happily sing along with Elvis Presley songs. After the assault, the worker said, R.S. “don’t sing anymore.”

Inspectors cited the home for failing to protect R.S. The same report said the home didn’t provide a therapist for another female resident who was being sexually harassed. Medicare fined Sandia Ridge Center $91,247. Genesis denied liability but settled R.S.’ lawsuit for $925,000 in May, according to the bankruptcy claim.

“We just felt we have to hold them accountable,” R.S.’ daughter said in an interview, speaking on the condition that she and her mother not be identified, because of the nature of the assault. “Maybe I’m wrong, maybe I’m naive, but the only way to do that is to sue someone, right?”

Genesis has not paid any of the settlement, according to the family’s claim filing.

Growth and Debt

Genesis’ downfall can be , when affiliates of two private equity firms acquired the company in a $1.5 billion leveraged buyout, taking on substantial debt, according to its bankruptcy filing. Private equity also has been involved in other health care bankruptcies, including those of the nursing home chain, the prison health care contractor , and two for-profit hospital systems, and .

In 2011, Genesis raised $2.4 billion by transferring substantially all its nursing home buildings and other real estate to Welltower, a publicly traded real estate investment trust, according to Genesis’ bankruptcy filing. Genesis then rented the buildings back from Welltower, which made leasing costs a significant expense.

Genesis went on a nationwide buying spree. At its peak in 2016, it had grown to more than 500 nursing homes. In a court declaration, Louis Robichaux IV, a consultant overseeing Genesis’ bankruptcy restructuring, wrote that as the company expanded, it became harder to manage and “mired in corporate inefficiencies.” Robichaux wrote that Genesis’ financial woes were exacerbated by rapidly increasing labor costs and lawsuits, including some predating the covid pandemic.

Starting in 2021, Genesis avoided bankruptcy after from a founded by Joel Landau, the owner of a , according to Robichaux’s filing.

But Genesis continued to teeter on the edge of insolvency. In for 2022 and 2023 submitted to a California oversight agency, management and auditors said rent and debt obligations raised “substantial doubt about the company’s ability to continue as a going concern.”

In a court filing, a committee appointed by the U.S. Trustee’s Office to represent the unsecured creditors in the bankruptcy accused Landau and Welltower of that allowed Welltower to keep getting its rents while Landau could run the company and “siphon value to himself.” The committee alleged their efforts forced the company into insolvency while “staffing levels and patient care declined precipitously.” Landau and Welltower did not respond to requests for comment.

Drawn-Out Lawsuits

Erin Pearson sued Genesis over the death of her father, James Sanderson, a retired mining company executive who died in 2018 after spending less than a month at Bear Canyon Rehabilitation Center in Albuquerque. In the memory care unit, Sanderson fell repeatedly, suffered medication errors made by nursing home staff, and developed a bowel obstruction and sepsis, according to the lawsuit, filed in 2019. Pearson’s lawyers said he was not hospitalized until eight days after nurses noticed he was vomiting brown mucus.

After the judge rejected Genesis’ request to force Pearson into arbitration, Genesis appealed. It took 2½ years before an appeals court affirmed the original decision to let the case go forward in court, records show.

This past May, more than five years after suing, Pearson reached a $500,000 settlement, with the first payment required by November, according to a copy of the agreement. Nothing was paid, according to the bankruptcy claim.

“It was so drawn out and for so long,” Pearson said in an interview, calling Genesis’ bankruptcy “despicable.”

Payouts Postponed

Jennifer Foote, an Albuquerque attorney who represents clients in multiple lawsuits against Genesis, including Pearson’s, said the company frequently filed appeals. “They did not usually win them on these issues,” she said, “and our sense was that they were doing it as a delay tactic.”

Genesis started using installment payments around 2018, said Dusti Harvey, Foote’s law partner. “The payments wouldn’t start for several months out,” Harvey said. Foote said Genesis’ lawyers often wanted to time the payments to start the month the trial in the case was scheduled to occur.

Families had to wait even when comparatively small amounts of money were involved, settlement agreements show. Genesis’ settlement agreements also included a confidentiality clause prohibiting discussion of the incidents.

Genesis agreed to pay $42,000 in a November 2024 settlement, but the first payment was not due until nine months later. It was not paid, according to the bankruptcy claim.

A $250,000 settlement signed in October 2023 did not start paying out until the following September. When Genesis declared bankruptcy — 21 months after the case was resolved — it still owed $100,000, according to the family’s claim.

‘We Never Found Out the Truth’

Settling cases allowed Genesis to avoid the expense and publicity of a trial, at which details of how its nursing homes functioned might have been revealed. In October 2020, Margarett Johnson, a retired school bus driver, fell out of her wheelchair at a Genesis nursing home in Waldorf, Maryland, fracturing her jawbone, nose, and neck, according to a lawsuit brought by her family. Johnson was sent to a trauma center and placed on a ventilator. She died three months later, at age 76, from ventilator-associated pneumonia, the lawsuit said.

“It looked like she was hit by a truck,” Angelina Harley, one of her daughters, said in an interview. “I knew my mom was not going to come home. I knew the Lord was not going to punish her more.”

The company denied negligence and blamed the accident on Johnson’s jacket getting tangled in the wheel of her wheelchair, according to the lawsuit. Harley and her sister Angela Swann were dubious.

“We never found out the truth,” Harley said. “They wanted to settle out of court.”

The company denied liability but agreed to a $950,000 settlement in October 2024. It never paid the final $112,500 installment, according to a letter Johnson’s five children sent to the bankruptcy judge.

“If you settle out of court, you know doggone well you did something wrong,” Harley said.

Maddening Judges

By summer 2025, judges in some civil cases had run out of patience.

Alma Brown, a retired day care manager and accordion teacher living in a Genesis nursing home in Clovis, New Mexico, suffered falls, infections, bedsores, and other neglect that hastened her death in 2023, according to her estate’s lawsuit. In Santa Fe District Court, Judge Kathleen McGarry Ellenwood castigated Genesis after it failed to pay $2 million of the $3 million settlement to Brown’s estate or explain the delay.

Genesis “obviously benefited by not having to go to trial,” McGarry Ellenwood said in one hearing, according to a court transcript. “They assure me that they’re not trying to renege on their contract, but it certainly seems like they haven’t lived up to what the bargain was.”

Genesis declared bankruptcy the day McGarry Ellenwood announced she would impose more than $100,000 in fines, plus $10,000 more each day until the settlement was paid.

In Pennsylvania, Greg Hunt petitioned a judge to punish Genesis after it stopped payments of the $3.5 million settlement after the death of his mother, Nancy, the resident with the gangrenous foot. She had spent eight months in 2019 at Brandywine Hall, a Genesis facility in West Chester that was later sold and renamed.

In a filing with the Common Pleas Court of Montgomery County, Genesis admitted it was in arrears but asked the judge for more time, citing “unforeseen and exigent financial challenges.” Genesis said care for patients at its nursing homes would suffer if it had to pay immediately.

Unswayed, Judge Richard Haaz in June ordered Genesis to pay up, along with punitive interest. But the bankruptcy court stayed that order. Genesis still owes $1.4 million of the $2 million it was supposed to pay, according to Hunt’s claim. (The rest of the $3.5 million settlement is supposed to be paid by an insurer in January 2026.) Ian Norris, Hunt’s lawyer, declined to comment, citing confidentiality provisions in the settlement.

Court records indicate Genesis lawyers never disclosed in either case that it was preparing to declare bankruptcy.

‘Bankruptcy as a Tool’

In the first nine months of 2025, 10 other senior living companies with liabilities over $10 million entered Chapter 11 bankruptcy, according to , a consulting firm.

Hamid Rafatjoo, a bankruptcy lawyer representing nursing homes who is not involved in the Genesis bankruptcy case, said filings may increase as the industry has become costlier to run and class action lawsuits have become a fixture.

“Nursing homes get sued all the time for everything,” Rafatjoo said. “A lot of operators wait too long to use bankruptcy as a tool.”

On Dec. 1, Genesis announced the , saying it had elected to to a private equity firm controlled by Landau. In a court filing, Anthony, the attorney for the personal injury claimants, in Landau’s favor despite an “objectively better and higher competing bid” from another private equity investor that would have provided more money to creditors. Genesis said in its statement that Landau’s group had increased its bid during the auction.

Sen. Elizabeth Warren (D-Mass.) and two other senators last month to intervene in the case, out of concern that “individuals who already own or control Genesis are trying to sell it to themselves, wiping away legal and other creditor debts in the process.” Lawyers representing those in charge of the auction did not respond to a request for comment.

Families of former Genesis residents said they fear the capacity to purge lawsuits through bankruptcy emboldens nursing home owners who provide deficient care.

“They can file bankruptcy again,” said Gabe Betancourt, whose wife, Nellie, died after her stay at Uptown Rehabilitation Center in Albuquerque. “And we’re the ones that will pay for it, with our memories, our lives.”

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

Brader, de 27 años y residente de Bloomington, Indiana, tiene un marcapasos y una enfermedad dolorosa en las articulaciones. Además, sufre una lesión en la columna que le fusionó las vértebras del cuello, lo que le impide girar la cabeza.

La agencia estatal de Medicaid considera a Brader como “médicamente frágil”, lo que le da acceso a un conjunto ampliado de beneficios, como terapia física.

Pero nuevas reglas federales exigirán que más de 18 millones de personas beneficiarias de Medicaid en todo el país demuestren, a partir de 2027, que trabajan, hacen voluntariado o estudian al menos 80 horas al mes para mantener su cobertura.

Brader está exenta mientras siga siendo considerada médicamente frágil.

Pero ante la falta de directrices claras a nivel federal, los estados deben llegar a un acuerdo sobre cómo definir la fragilidad médica, una decisión de gran impacto que podría hacer que muchas personas pierdan el acceso a Medicaid, según funcionarios estatales, defensores del consumidor y expertos en políticas de salud.

“Estoy aterrada”, dijo Brader. “Ya he luchado mucho para conseguir esta atención médica”.

Mucho en juego

La ley One Big Beautiful Bill Act del presidente Donald Trump recortará casi $1.000 billones de dólares a Medicaid a lo largo de la próxima década. Buena parte de esos ahorros proyectados provendrían de dejar de cubrir a quienes no califiquen bajo las nuevas reglas laborales.

Esos recortes ayudan a financiar otras prioridades del Partido Republicano, como más seguridad fronteriza y recortes de impuestos que benefician sobre todo a personas con altos ingresos.

Legisladores conservadores han argumentado que Medicaid —el programa de seguro médico del gobierno para personas de bajos ingresos o con discapacidades— ha crecido demasiado, especialmente tras su expansión a más personas adultas de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA, por sus siglas en inglés). También afirman que exigirles trabajar a los beneficiarios es una medida de sentido común.

La nueva ley fiscal y presupuestaria de Trump ofrece excepciones a varias personas que podrían tener dificultades para cumplir con las reglas laborales, incluyendo aquellas consideradas “médicamente frágiles”. La ley define ciertas condiciones como fragilidad médica, por ejemplo, ceguera, discapacidad y adicciones. Pero no incluye muchas otras.

En su lugar, la norma exime a quienes tengan una “condición médica seria o compleja”, un término cuya interpretación puede variar según el estado.

Funcionarios estatales señalan que necesitan más claridad para asegurar que las personas que no pueden trabajar por razones de salud mantengan su derecho a Medicaid. También les preocupa que, incluso con una definición clara, muchas personas enfrenten el reto burocrático de tener que probar constantemente ��que son médicamente frágiles, lo cual es difícil si no se puede acceder a una atención médica adecuada.

“Hay mucho en juego”, dijo Kinda Serafi, socia de la firma consultora Manatt Health.

Los nuevos requisitos laborales afectarán a beneficiarios de Medicaid en 42 estados y en Washington, DC. Ocho estados —Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming— no expandieron sus programas de Medicaid para incluir a más personas adultas de bajos ingresos, por lo que no tendrán que implementar estas reglas.

Según la Oficina de Presupuesto del Congreso (Congressional Budget Office), una entidad no partidista, se espera que estas reglas laborales de Medicaid sean el en la próxima década.

El 44% de las personas adultas cubiertas por los programas de Medicaid en estados que lo ampliaron tienen , según KFF.

Un desafío para los estados

Las agencias estatales de Medicaid se apresuran a implementar las nuevas reglas con poca orientación del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS, por sus siglas en inglés) que aún no ha emitido directrices específicas. Andrew Nixon, vocero de la agencia, dijo que la definición federal de “médicamente frágil” se aclarará el próximo año.

En última instancia, serán los estados los que tengan que decidir quién está lo suficientemente enfermo como para quedar exento de los requisitos laborales. Y no será fácil para el personal estatal ni para los sistemas informáticos hacer ese seguimiento.

Cada año, los sistemas estatales de elegibilidad evalúan a millones de personas solicitantes para determinar si califican para Medicaid y otros programas gubernamentales. Ahora, esos mismos sistemas también tendrán que verificar si personas nuevas o ya inscritas cumplen con los requisitos laborales.

Jessica Kahn, socia en la firma consultora McKinsey & Co., ha instado a los estados a comenzar desde ya a planear cómo adaptar sus sistemas para verificar el estatus laboral. Los estados pueden hacer “muchísimo” incluso sin esperar directrices federales, dijo Kahn —quien fue funcionaria federal de Medicaid— durante una reciente audiencia de asesoría sobre el programa. “El tiempo se acaba”.

Las personas encargadas de Medicaid a nivel estatal evalúan este reto.

“La fragilidad médica es algo muy complejo”, dijo Emma Sandoe, directora de Medicaid en Oregon, durante un panel reciente. Las condiciones que impiden trabajar, como los trastornos de salud mental, son difíciles de demostrar, explicó.

Un estado podría intentar usar información de los expedientes médicos de una persona, por ejemplo, para determinar si es médicamente frágil. Pero esa información puede no reflejar con claridad la salud de alguien, especialmente si no tiene acceso regular a servicios médicos.

Es una tarea difícil para sistemas de elegibilidad que históricamente no han tenido que revisar registros médicos para evaluar solicitudes, señaló Serafi, de Manatt Health.

“Esto es completamente nuevo para los sistemas de inscripción, y simplemente no están preparados”, añadió.

Grupos de cabildeo que representan a compañías privadas de seguros médicos que administran Medicaid en varios estados también han pedido a las autoridades federales que definan claramente qué significa ser médicamente frágil, para que se aplique de manera uniforme.

En una carta enviada el 3 de noviembre, las organizaciones Planes de Salud Medicaid de Estados Unidos (MHPA, en inglés) y la Asociación de Planes Afiliados a la Comunidad (ACAP, en inglés) recomendaron que se permita a las personas solicitantes calificar para la exención simplemente al indicar en su solicitud que tienen condiciones que las hacen médicamente frágiles. Según las dos organizaciones, implementar con éxito estas exenciones será “crucial” dada la “gravedad de los riesgos para la salud que implica perder cobertura” para estas poblaciones.

Algunos funcionarios estatales temen que haya consecuencias imprevistas por estas reglas laborales para personas con enfermedades crónicas.

Jennifer Strohecker, quien recientemente renunció como directora de Medicaid en Utah, reiteró la gravedad de este asunto, especialmente para personas con diabetes afiliadas a Medicaid.

Explicó que, si bien pueden llevar una vida funcional con insulina, eso podría cambiar si pierden la cobertura por no cumplir con los requisitos laborales.

Actualmente, el hecho de que alguien sea considerado médicamente frágil depende en gran medida del lugar donde viva.

Por ejemplo, en Arkansas, las personas deben indicar en sus solicitudes de Medicaid si tienen una discapacidad, son ciegas o necesitan ayuda para realizar actividades diarias.

Según Gavin Lesnick, vocero del Departamento de Servicios Humanos de Arkansas, aproximadamente el 6% de las 221.000 personas inscritas en el programa de expansión de Medicaid del estado se consideran médicamente frágiles.

En West Virginia, el estado acepta la designación de fragilidad médica cuando una persona la reporta por cuenta propia.

En Dakota del Norte, el proceso es más estricto. Quienes solicitan deben completar un cuestionario sobre su salud y presentar documentación adicional, como notas del historial médico y planes de tratamiento. Más de la mitad de las solicitudes fueron rechazadas el año pasado, según Mindy Michaels, vocera del Departamento de Salud y Servicios Humanos.

La Administración de Servicios Familiares y Sociales de Indiana, que gestiona Medicaid en ese estado, se negó a ofrecer entrevistas y dijo que no podía comentar sobre casos individuales, como el de Brader.

Brader teme que la burocracia adicional la haga perder otra vez su cobertura de Medicaid. Contó que en 2019 fue expulsada temporalmente del programa por no cumplir con las reglas laborales del estado, cuando Indiana determinó que su trabajo como estudiante no contaba como empleo.

“Siempre que he intentado recibir ayuda del estado de Indiana, ha sido una pesadilla burocrática”, dijo.

Mientras los estados esperan una guía federal, Kristi Putnam —miembro del conservador Instituto Cicero y ex secretaria del Departamento de Servicios Humanos de Arkansas— dijo que, incluso si un estado crea una lista extensa de condiciones que califican como fragilidad médica, siempre habrá que poner un límite.

“No se puede crear una política de exenciones que lo cubra todo”, afirmó.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).

The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from��a person’s health records, for instance, to determine medical frailty. But information from��a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).