If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Nearly every Tuesday for a decade, Steve Siple attended a bar trivia night with friends in Birmingham, Alabama. After moving to North Carolina, he developed a new ritual — on Saturdays to pick up trash along the city’s light rail.

These are more than fun outings to Siple. They help keep him alive.

Siple has battled suicidal thoughts in the past. He lost his father to suicide, and one of his sons has struggled with thoughts of hurting himself.

That’s made Siple vigilant about protecting himself and his family. In addition to seeing a counselor regularly and speaking openly about mental health, he prioritizes social connection.

“Loneliness was, over my lifetime, one of the greatest risk factors” for suicide, said Siple, a for the American Foundation for Suicide Prevention.

To some, this concept may seem obvious. Yet in the overall approach to suicide prevention, it’s often overlooked. Treatment of a serious mental illness that can lead to suicide, such as major depressive disorder, often centers on medication and talk therapy with little or no consideration of factors such as social isolation or financial duress. Now, there’s a growing movement to address loneliness not just through personal choices but also through public policy.

The research is clear: Among the various complex issues that contribute to suicide, is a . It’s a for older adults, who have and for youths, for whom .

Humans are social animals. When we feel cut off from one another, our , our , and ultimately we’re (by suicide or ). An concluded that being socially disconnected is as harmful to one’s health as smoking up to 15 cigarettes a day.

And it’s getting worse.

Mental health researchers and clinicians say a variety of factors are in America, including the , such as smartphones and ; increased ; the since the covid pandemic; and .

With suicide rates remaining stubbornly high — often ranking among the in America — some advocates and people who have lost loved ones to suicide say increasing pathways to social connection could be a new frontier.

In this ongoing series, Ñî¹óåú´«Ã½Ò•îl Health News is examining new approaches to suicide prevention that shift the focus from stopping harm in moments of crisis to efforts that give people reasons to live well before they make fateful choices.

“If we want to reduce suicide rates in our country, which is absolutely essential, then a key part of that has to be fostering social connection,” said who served as surgeon general under Presidents Barack Obama and Joe Biden. “We have more than enough data to support this as being an important area of focus.”

In 2023, Murthy released the first on loneliness as a public health issue, with more than 300 supporting citations. He’s also on the topic and is touring the country discussing the value of social connection.

“To help someone else feel less alone, to help them feel seen and understood and valued,” he told Ñî¹óåú´«Ã½Ò•îl Health News, “that can be one of the most powerful interventions that we make.”

A Role for Elected Officials

Curing loneliness may seem like the responsibility of families and neighbors, people making one-to-one connections. But Murthy says elected officials have work to do, too.

They can use their bully pulpits to turn this into a mainstream issue, he said. They can create microgrants to support grassroots ideas from community entrepreneurs and invest in “social infrastructure,” he added.

That term refers to things in the community that support the development of social connection, from physical spaces, such as libraries and parks, to policies and programs, such as building public transportation and fostering volunteer groups.

“These all matter and impact whether people gather,” Murthy said.

However, investing in public institutions and infrastructure is a costly endeavor that can seem unreasonable when local officials are struggling to balance budgets without increasing tax burdens.

That’s where creativity can kick in.

A health system and a museum in Charlotte have teamed up to for people to attend art classes or live performances together. In Tennessee, the city of Chattanooga is funding community ideas to increase connection and time in nature, where people can speak with volunteer listeners. And across the country, have popped up as places where men can work on projects side by side and discuss their mental health.

Meal Deliveries and Valentines

Marcie O’Neal knew she wouldn’t have much money at her disposal. She was hired in 2024 to lead suicide prevention efforts in the rural of western Kentucky after local leaders saw a rise in suicides among the elderly. Her grant was about $280,000 — less than .

But she knew the nine-county area had other strengths, such as dedicated meal delivery programs and high school clubs.

Drivers who drop off prepared meals to homebound residents “can be the only person that an older adult sees in the week,” O’Neal said.

The state had already been training some of those drivers to recognize warning signs of suicide among older people and alert county agencies to follow up with them. O’Neal thought there could be another component.

She reached out to high school , which focus on fostering leadership skills and volunteerism, across the nine counties and asked them to write cards that could be distributed to older residents along with meals. The response was swift, O’Neal said.

About 1,200 cards were delivered last May. They repeated the gesture in February for Valentine’s Day and again this May.

O’Neal said one of the older residents told her, “I don’t remember the last time I got a Valentine’s card.”

The students also enjoyed feeling as if they made a difference, O’Neal said. She’s helping one school set up an ongoing pen pal program with a nearby retirement community.

Locals affectionately call O’Neal “the suicide lady” — a term she considers “a badge of honor.”

Suicide prevention “doesn’t have to be sweeping huge things,” she said. “It’s a little thing you can do that can kind of snowball into more things.”

‘The Secret Sauce’

Siple, who has prioritized social connection through the trivia nights and volunteer clean-ups, felt most alone when he transitioned from a job at a commercial bank to working at home.

He spent most of his day analyzing Excel sheets, drafting grant proposals, and compiling recommendations for clients. The work felt important, but it was isolating, Siple said.

“If my wife or kids were around during the evening, I was safe,” he said. Holding meetings at coffee shops helped, too.

But when it was just him at his desk, “that’s where I got the darkest lonely feelings,” he said, including thoughts of suicide.

Breaking out of that required seeking new connections.

Siple said church was a great anchor for him and his wife — not just on Sundays but throughout the week at Bible studies and potlucks. They also go to see a variety of live music, including bluegrass and alternative rock.

“Being with folks that are into the same type of music that we’re into for a concert feels like connection,” he said.

Research suggests sports can play a similar role in some instances. At least two studies have found are associated with . The authors posit it’s because people coming together to support their team or to enjoy the event creates a sense of belonging, which is protective.

That concept resonates with , who has worked on suicide prevention efforts at the state and and helps run Sources of Strength, an upstream prevention program. Fostering that sense of belonging has played a central role in each of those initiatives, she said.

“We can’t eliminate hard stuff in our lives,” said Brummett, who lost five friends to suicide, starting in middle school.

“Belonging is really the secret sauce,” she said, “for how we, as humans, can navigate really hard things.”

This <a target="_blank" href="/mental-health/suicide-prevention-loneliness-social-connection-mental-health-eleven-minutes/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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HealthQ’s Cara Anthony and Blake Farmer share know-how for parents navigating the decision to seek out mental healthcare for a child.

Divorce rocked the lives of Marcela Cabay and her daughter, who was a preschooler at the time. But counseling didn’t come until years later, when Cabay noticed her daughter was tensing up every time a storm rolled through or whenever they were preparing to be apart.

“She was experiencing just a lot of anxiety, really starting to think worst-case scenarios all the time, just really struggling in her daily life,” said Cabay, who is a life insurance broker outside Austin, Texas.

At first, Cabay attempted to help her daughter herself. She suggested coping strategies for the 8-year-old to regulate her emotions. She hoped the behavior would pass. But, over time, the anxiety got worse.

“That’s when I finally was like, ‘I think it would be really good for her to talk to a licensed third-party person — that’s not me,’” Cabay said.

Her daughter’s counseling journey started off shaky because she was seeing a counselor weekly for two months with no results, while paying out-of-pocket. So they found a counselor who was a much better fit. Within six months, Cabay’s daughter had made so much progress that Cabay decided to suspend her weekly visits.

Determining when it’s time for professional help can be hard, especially because counseling can require a significant commitment of time and money. Therapists offer three easy-to-remember criteria to help assess challenging behavior: frequency, duration, and intensity.

1. Frequency: Is the behavior happening over and over?

Frequency is the easiest of the three to measure. Say you roll up to the park to find a hive of activity on the playground, but your child refuses to get out of the car because they’re anxious about playing with other kids. If it happens once or twice, it could be because they had a hard day and weren’t ready to be with other kids, said licensed clinical social worker and play therapist Paris Goodyear-Brown. But avoidance behavior that occurs regularly indicates a child may need extra support.

2. Duration: Does the behavior last a long time?

Goodyear-Brown is clinical director of Nurture House in Franklin, Tennessee, where parents often come with concerns when their children start preschool and are anxious about saying goodbye to them, she said. Some amount of separation anxiety is developmentally appropriate. If it regularly lasts hours, however, she generally recommends pulling in professional support.

“The child may be crying, ‘Mommy, don’t leave me,’ but as soon as the parent has departed, they enjoy the day and they’re engaged with their teachers,” she said. “That’s a really different presentation than the child who cries for three hours at school, is inconsolable, and isn’t able to learn.”

3. Intensity: Does the behavior disrupt everyday life?

Intensity can be harder to quantify because it’s less likely to be measured in hours or days. Goodyear-Brown offers obsessive-compulsive behaviors as an example: If a child won’t leave the house without making sure all their toys are lined up just right or checking 10 times to make sure the doors are locked before bed, their behavior signals a need for professional help.

Children can also show intensity in their lack of emotions. “To be numbed out, shut down, dissociated, it’s just as big,” she said. “It’s just quieter.”

Goodyear-Brown said some life events are intense enough to merit counseling even if a child isn’t behaving differently, including those considered one of the 10 “.” ACEs, as they’re more commonly known, include child abuse, neglect, suicide or depression in the household, or divorce.

Guidance, Not Certainty

Ultimately, the three criteria help parents assess whether behavior is overly disruptive to daily life. Becky Evans, a licensed professional counselor supervisor in Fort Worth, Texas, advised being on alert for the times when “you are not able to go and do what you would normally go and do because of whatever is happening with them emotionally.”

But whether the verdict points to counseling also depends on household dynamics and family history.

“It is kind of subjective to the person. What feels frequent? What feels intense? And how long is too long for this to have been going on?” Evans said.

When in doubt, she said, therapy is usually helpful. And parents can also benefit from having a “teammate,” to ensure they’re not inadvertently reinforcing the anxiety, Goodyear-Brown said.

However, some psychologists have raised concerns about or . Parents can be quick to think developmentally appropriate behavior is abnormal, said Christina Confroy, a licensed marriage and family therapist in Nashville, Tennessee. During consultation calls, she’s grown comfortable telling parents when she doesn’t see a need for counseling while also urging them to “trust their sense.”

People and Policy

Like , Confroy has stopped accepting health insurance. For her, the decision hinged on the requirement to make an official diagnosis in order to get paid. The administrative burden and low reimbursement rates have driven many others to leave insurance networks behind.

Paying for counseling out-of-pocket averaged in 2023, according to research published in Health Affairs Scholar. Confroy charges $195 per 50-minute session. She lowers the fee when the need arises, she said.

“People don’t plan for counseling the way they plan for groceries. It’s an enormous responsibility financially and time-wise,” said Confroy, who often recommends school-based counseling and other lower-cost first steps.

“You might not want another podcast to listen to or a book to read,” she said. “But I’m really big on accessing existing support.”

This installment is part of HealthQ’s reporting on caregiving among the sandwich generation. For more, check out the series archive.

Katherine Ruppelt and Emily Siner at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable healthcare system. It’s a collaboration between Nashville Public Radio and Ñî¹óåú´«Ã½Ò•îl Health News.

This <a target="_blank" href="/mental-health/healthq-children-therapy-experts-help-parents-decide/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

In the days that followed, the nurse failed a drug test and was fired, the order states. The nurse later admitted that for months he had pilfered and abused fentanyl left over after surgeries, sometimes daily, according to the order.

Under most circumstances, this would be a routine case of what is known as “drug diversion,” the unlawful taking of controlled substances from healthcare facilities — believed to be so widespread that it occurs at just about every U.S. hospital.

But the Erlanger case stands out because a high-tech watchdog was supposed to be on guard.

The hospital uses the newest line of defense against drug diversion: Sentri7, powered by artificial intelligence and designed to detect missing drugs faster than any human can. But for months at Erlanger, Sentri7 failed to raise alarms, overlooking missing drugs and other “inconsistencies” that “should have been flagged,” the nursing board’s order states.

The Erlanger case, which has not been previously reported, offers a rare glimpse at an apparent failure of AI drug diversion software used in hundreds of U.S. hospitals with little transparency or oversight. Healthcare facilities are not required to disclose their implementation of this kind of software or report malfunctions to anyone, so there is no full account of how widely these programs are used or how often they fail.

Erlanger Baroness, also referred to as Erlanger Medical Center, declined to comment on its use of Sentri7 or on the diverted drugs. André Rebelo, a spokesperson for the health division at Wolters Kluwer, the Dutch technology company behind Sentri7, declined to answer questions about what happened at Erlanger but said the company remained “confident in our software.”

Little Transparency

David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said that because AI technology is heavily proprietary and hospital officials often don’t understand how it works, this lack of transparency allows for errors to be buried rather than fixed. That means errors could be repeated at other hospitals, he said.

“The ideal for patients, caregivers, and hospital systems would be,” Rastall said, “when an AI is found to be making some type of error, that becomes very transparent and public.”

The Drug Enforcement Administration mandates that hospitals confidentially report lost or stolen drugs. Hospitals can also report stolen drugs to state health agencies, which license medical professionals and investigate wrongdoing.

But these reports are not required to include details about any AI software involved, according to interviews with three drug diversion prevention experts. In interviews, all said they had never seen an AI failure publicly documented like the apparent one at Erlanger.

“I’ve never myself seen these technologies be called out in that specific way,” Jacob Smith, a pharmacist in charge of drug security at Johns Hopkins Medicine, said of the apparent Sentri7 failure. “It doesn’t make sense to me how you could miss it.”

Smith and other experts said the Erlanger case also raises questions because the theft of leftover drugs is one of the most well-known methods of diversion. And fentanyl, a painkiller that can be 50 times as strong as heroin, is one of the most common targets.

Terri Vidals, the founder of , questioned whether the Erlanger case was the result of user error instead of malfunction.

“This is the most basics of basics for this software,” Vidals said. “I find it interesting that they’re saying it wasn’t flagged by the software. I think there’s maybe more to that story.”

The apparent Sentri7 failure at Erlanger was revealed by the Tennessee Department of Health in a routine release of in December. Among those records was the Board of Nursing order, which summarizes a state investigation into nurse anesthetist John Stevenson, who settled the case against him by signing the document in November.

Stevenson declined to comment through his attorney. He has not been charged with any crime related to the Erlanger case. The nursing board put his license on probation while he went to drug counseling.

Bill Christian, a spokesperson for the Department of Health and Board of Nursing, declined to comment on the Erlanger case or Sentri7. In response to public records requests, the Department of Health and the Tennessee Health Facilities Commission each said it possessed no other documents about the apparent Sentri7 failure at Erlanger.

Erlanger spokesperson Charlie Milburn said earlier this year that the hospital had prepared a written statement about its use of Sentri7 in response to questions from Ñî¹óåú´«Ã½Ò•îl Health News.

That statement was never released.

“Our legal team is debating whether this is something we want to talk about at all,” Milburn said in a March email, before later declining to answer any questions.

Kristy Drollinger, a Wolters Kluwer executive who spoke generally about Sentri7 to Ñî¹óåú´«Ã½Ò•îl Health News in March, said the software is in high demand because so many hospitals have struggled to secure their drugs.

Sentri7 monitors about 60 “attributions of risk” that identify red flags for further investigation by hospital employees, Drollinger said.

“It’s pretty scary,” Drollinger said of widespread drug theft. “Every health system, every health facility, has had diversion at some point — and probably has it now.”

‘The Way of the Future’

Drug diversion is a widespread challenge in U.S. medical facilities. It can lead to patients not receiving medication or getting drugs that are contaminated with blood-borne diseases. It’s estimated as many as 15% of all healthcare workers divert drugs at least once, according to the nonprofit .

Diversion has been linked to at least — causing more than 200 infections, mostly of hepatitis C — since 1985, according to the Centers for Disease Control and Prevention.

To prevent this, hospitals attempt to track each pill or vial from the moment it is dispensed to the moment it is given to a patient, by comparing data from electronic medication cabinets and patients’ health records.

Hospital staff once performed this painstaking process manually, but in the past decade the task has become largely automated by anti-diversion software. After years of mergers and buyouts, two programs now dominate the industry: Wolters Kluwer’s Sentri7 and Bluesight’s ControlCheck. Both incorporate AI.

“It’s definitely the way of the future,” said Luke Overmire, owner of .

More than 1,500 hospitals use ControlCheck, according to Bluesight. An additional 700 use Sentri7 Clinical Surveillance programs, which can include its drug diversion software, according to Wolters Kluwer.

Neither company publishes the price of its software. Smith, the drug safety official from Johns Hopkins, said hospitals purchase these “expensive technologies” because a disastrous diversion case could result in a multimillion-dollar fine from the DEA.

“They don’t promise a return on investment,” Smith said. “They promise cost avoidance.”

In 2022, a funded by the National Institutes of Health found that Sentri7, then known as Flowlytics, could uncover drug diversion faster than existing methods. The study’s primary author worked for Invistics, the company that previously owned Sentri7.

According to that study, researchers tested the software by having it comb through medication data spanning two years and 10 hospitals in search of 22 nurses who were already known to have diverted drugs.

The program not only found them all, the study states, but found them faster than humans by as little as a week and as much as a year and a half.

At Erlanger, the humans spotted the signs of trouble first.

According to the Board of Nursing order, co-workers reported that Stevenson appeared impaired “while on duty in the surgery center” on or around June 30, 2025.

Stevenson “had slurred speech, appeared extremely tired, was seen standing with his eyes closed and swaying, exhibited head nodding while standing upright and appeared to have difficulty keeping his eyes open,” according to the order.

When questioned by state investigators, Stevenson admitted that he began diverting “unused fentanyl that would otherwise have been wasted after surgical procedures” in March 2025, according to the order. Stevenson said he used the fentanyl waste once or twice a week at first, then “increasing to daily use” by June of that year, the order states.

Erlanger audited Stevenson’s dispensing record over those four months. It found approximately five instances when Sentri7 didn’t flag missing drugs, according to the order.

It adds that the hospital found “additional inconsistencies between drug dispensing and waste documentation that should have been flagged by the automated monitoring system.”

One possible explanation is provided by the Board of Nursing, which said in the order that Sentri7 was in its “initial learning phase” at Erlanger, though the board provided no details.

In an interview, without discussing Erlanger specifically, Drollinger said Sentri7 has no “learning phase,” because it is trained on nine to 12 months of historical data when implemented at a new hospital.

Smith, of Johns Hopkins, had another theory.

In an interview, Smith said his experience with AI drug diversion software had led him to believe that it is effective at monitoring emergency rooms and intensive care units but less so in operating rooms, where drugs are dispensed and charted differently.

These areas can be harder for AI to track, Smith said, and therefore require humans to keep a closer watch.

“We’ve got people whose entire job is to work with this software,” Smith said. “The software is a piece of it, but if you rely on the software to give you all your signals, you’ll miss stuff. It’s just not 100%.”

This <a target="_blank" href="/health-industry/ai-drug-diversion-theft-artificial-intelligence-hospitals-sentri7-software-tennessee/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The 31-year-old compliance consultant from Hendersonville, Tennessee, said she couldn’t stop vomiting.

“Sunday morning, it all hits,” McClain recalled, as she described what happened that weekend in January. “I can’t keep anything down.”

McClain said she thought the dosage the telehealth company had prescribed seemed too high. She tried to contact her doctor, but when she didn’t get an immediate response, she said she called the company and a “care team” representative confirmed the instructions — which said to inject 2.21 milligrams of the semaglutide medication once a week — were correct.

It turned out, however, that was nearly nine times the amount patients are typically told to take for their first dose.

Nearly a month after she was diagnosed with an overdose, McClain said she was “still dealing with the residual side effects,” including an elevated heart rate and vision problems she felt were tied to the medication.

Most patients who have taken a GLP-1 received their prescription through a primary care doctor or a specialist, shows. But as the uptake of telehealth has grown substantially since the start of the covid pandemic, McClain is one of millions of Americans who have used online companies to meet a variety of their medical needs.

Many of the companies have started offering GLP-1 medications for weight loss as demand for these drugs has exploded. But certain medication errors tied to GLP-1s have exploded too, according to a Ñî¹óåú´«Ã½Ò•îl Health News review of Food and Drug Administration data, and physicians and telemedicine researchers worry that adverse experiences tied to telehealth companies are becoming more common.

Bad outcomes aren’t unique to telehealth providers or to the compounded weight loss drugs many of them offer. In fact, product liability lawsuits alleging patient injuries have been filed overwhelmingly against pharmaceutical giants Eli Lilly and Novo Nordisk, which manufacture name-brand weight loss drugs, court data shows. The drugmakers have defended their products.

However, some critics are also concerned that getting a weight loss prescription online is usually much easier than getting one through an in-person appointment. Not only do many telehealth companies write quick prescriptions for GLP-1s, but they often sell the medications, too, allowing patients to bypass in-person pharmacy visits. This one-stop shopping isn’t necessarily a good thing, according to critics who say some telehealth providers are writing prescriptions for people who should not be taking GLP-1s and then providing little or no follow-up care.

“It gives a black eye to telemedicine,” said Elizabeth Krupinski, an experimental psychologist at Emory University who has conducted research on the effectiveness of telehealth.

Telemedicine stands to benefit “so many people,” Krupinski said, particularly when the technology is integrated within a larger healthcare system. That way, patients benefit from the convenience of telehealth while maintaining a connection with their in-person providers.

But some telehealth companies are marketing GLP-1s as an easy way to lose weight — sometimes with the help of paid celebrity endorsements — without emphasizing the importance of healthy eating and exercise, she said.

They may be following the letter of the law, Krupinski said. But writing prescriptions while skimping on care “is not in the Hippocratic oath.”

The Perfect Storm

Starting around 2020, many states loosened restrictions on telehealth, which allowed online companies to proliferate. This helped accommodate patients who could not, or chose not to, be seen in person at the height of covid transmission.

Expanded telehealth access was also intended to lower barriers in rural communities, as well as mitigate doctor and nurse shortages. In many places, telehealth doctors and nurses are legally allowed to treat patients across state lines. But the way telemedicine is practiced , and state laws largely dictate rules that telehealth providers must follow.

Some companies, such as Mochi Health, require patients to meet virtually with a provider, such as a doctor, nurse practitioner, or physician assistant, before they can get a GLP-1 prescription.

But others, including Ro, sometimes require nothing more of patients than an “asynchronous” evaluation, which does not include a live conversation with a healthcare provider. During this type of evaluation, customers are typically asked to fill out an intake form and answer a medical history questionnaire before they are evaluated for a prescription. Ro requires a conversation in real time when required by state law, or when requested by a patient or clinician, said Nicholas Samonas, a spokesperson for the company.

“Every patient is counseled by their provider on the potential benefits and risks of treatment based on their individual medical history,” Samonas said. Ro’s clinicians can order lab work when necessary and, when appropriate, may recommend patients seek in-person care, he said.

But some medical experts are concerned that virtual care may be insufficient for prescribing weight loss drugs.

Patients with a history of pancreatitis, for example, should be counseled about potential complications, medical studies show. The same goes for people with a condition called gastroparesis, which affects stomach nerves and muscles, and those susceptible to medullary thyroid cancer.

Some patients may also benefit from blood work or muscle mass screening before starting a GLP-1.

But not all telehealth companies are adequately evaluating patients before writing prescriptions, said Marc-Andre Cornier, an endocrinologist at the Medical University of South Carolina and the immediate past president of The Obesity Society.

When it comes to parsing the good from the bad, “whose job is it to police that?” he asked. The problem, he said, is there aren’t criteria written by a government agency or a medical society to determine which providers are treating patients appropriately and which aren’t.

While the first GLP-1 was approved by the FDA more than 20 years ago, to treat Type 2 diabetes, the use of these drugs took off in 2021 when Novo Nordisk received approval for a semaglutide drug to treat obesity, with the brand name Wegovy. In a 2025 KFF poll, said they had taken a GLP-1.

In a in The New England Journal of Medicine, physician Amanda Banks noted that the proportion of GLP-1 prescriptions written for people who were not diabetic, obese, or overweight increased from 4.5% in 2018 to 17% in 2023.

In the paper, Banks called it “troubling” how easy it is to obtain a prescription for weight loss drugs and worried they might exacerbate existing eating disorders or cause new cases, including of anorexia.

Cornier, who has received compensation from Novo Nordisk for serving as a consultant, echoed some of Banks’ concerns. “It’s not just filling out a form online and then having some random healthcare provider sign off on it,” he said. “There are concerns with some of these online programs that there’s not a proper evaluation, there’s not a baseline, and there’s not proper supervision.”

The American Telemedicine Association, which advocates for the expansion of “digitally enabled care,” has not addressed how telehealth providers prescribe GLP-1s, spokesperson Gina Cella said.

“This is a bit out of our scope,” Cella said, when asked if the association had addressed the topic of telehealth providers and GLP-1 prescriptions.

The lack of clarity makes choosing a company potentially confusing for patients, and the medical profession is partly to blame, said Jamy Ard, an obesity doctor and researcher at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

Doctors have historically done a bad job counseling patients about weight loss, and many people aren’t comfortable talking to their primary care doctor about it, Ard said. Patients think, “Why would I go to my doctor and have them say, ‘Eat less and move more,’ when I have heard that a million times and I don’t want to have that lecture again?” Ard said.

This problem, combined with past shortages of name-brand versions of GLP-1s, such as Ozempic, Mounjaro, and Trulicity, has created a “perfect storm” for telehealth companies to flourish, said Ard, who has received support from pharmaceutical and telehealth companies.

While some telehealth companies prescribe only name-brand weight loss drugs, many also offer cheaper, compounded versions. They act as intermediaries between customers and mail-order compounding pharmacies, which create GLP-1s by mixing active ingredients, such as semaglutide, with additives. The ingredients for compounded drugs are commonly sourced from overseas suppliers, and the formulations are not reviewed by the FDA for safety.

The environment is “very much uncontrolled and poorly, if at all, regulated,” Ard said. “There is just no standard of care.”

Emily Hilliard, a spokesperson for the Department of Health and Human Services, told Ñî¹óåú´«Ã½Ò•îl Health News that compounded drugs “should only be used in patients whose medical needs cannot be met by an FDA-approved drug.”

Hilliard said the agency urges “consumers to be vigilant and know the source of their medicine.”

Understanding the Risks

While weight loss drugs have helped millions of people lose weight, they’re not without risk, the data shows.

A Ñî¹óåú´«Ã½Ò•îl Health News data analysis of the FDA’s Adverse Event Monitoring System found that medication errors made by providers or patients with popular weight loss drugs exploded from just over 2,000 reports in 2020 to over 25,000 in 2025. Those self-reported events involved semaglutide, tirzepatide, dulaglutide, and liraglutide, the generic names for leading GLP-1s.

Among frequent issues cited in the adverse event reports were administration of an extra or incorrect dose, issues with communication about a product, and prescribing errors.

Since 2019, the National Poison Data System has fielded a related to overdoses or side effects from injectable weight loss drugs. The data does not distinguish between overdoses tied to a telehealth prescription and those stemming from an in-person medical appointment, but it is a reflection of how prevalent these drugs have become.

Yet data on potential medication errors and adverse reactions to GLP-1 medications is incomplete, because many issues are never reported to federal officials.

For example, in a , the FDA accused drugmaker Novo Nordisk, the maker of Wegovy and Ozempic, of failing to report some adverse events to the federal government, including suicidal ideation and death.

Nobody knows how often adverse events occur, said Kristen Nixon, a Johns Hopkins University researcher who has studied posts about weight loss drugs on Reddit, a popular online forum.

Her team analyzed hundreds of Reddit posts from 2020 through last August and identified frequent mentions of drug reactions and user errors, such as patients’ not knowing how to correctly dose and inject the medication.

But another finding also stood out to her.

“Wow, there are a lot of people talking about telehealth,” Nixon recalled thinking. Reddit commenters said they got GLP-1 prescriptions from scores of telehealth platforms, Nixon found. Commenters also mentioned several dozen compounding pharmacies — often in the same posts about telehealth.

Pharmacies are typically required to counsel patients on medications they receive. But Nixon’s research found that telehealth companies often mail the medications directly, meaning patients do not need to go to a pharmacy.

“Anecdotally, it seems like the telehealth companies are really facilitating access to compounded medications,” Nixon said.

Leslie Gammon, 54, an office manager from Wendell, North Carolina, said she turned to a telehealth company called Amble Health for a weight loss drug prescription. She was given a GLP-1 after filling out an online form, she said.

Like McClain, when she received her mail-order compounded medication in late October, she thought the dosage that accompanied it seemed too high. She’d received a box of semaglutide earlier in the month with a much lower dose. But the refill she received was a stronger formulation, and the instructions told Gammon to inject three times the volume she had been taking in previous weeks.

Even though she injected slightly less than that recommended amount before bed on a Sunday evening, she woke up in the middle of the night “throwing up every 20 to 25 minutes,” she said. And it didn’t stop until Tuesday. She was eventually admitted to a hospital in Raleigh and now owes the hospital over $9,000, a medical bill shows.

Amble Health did not respond to questions for this article.

The delivery system for injectable versions of weight loss drugs is more complicated than for a pill. In its National Poison Data System alert, America’s Poison Centers noted that some people reported “accidentally taking 10-times the recommended dose due to confusing measurement units while using a syringe.”

And people who are eager to lose extra weight — before a wedding or a vacation, for example — may choose to self-administer a higher-than-recommended dose, said Arthur Caplan, a bioethics professor at New York University’s Grossman School of Medicine.

Some telehealth companies aren’t doing enough, he said, to make sure patients understand the risks or the complex delivery system associated with the injectable drugs.

“The consent is not adequate,” Caplan said. “There’s no probing to see if you understood anything.”

Cella, with the American Telemedicine Association, said the group has not addressed the difficulty of educating patients about the risks of injecting weight loss drugs. But she pointed to the association’s “,” which states that telehealth business models “must put the patient first.”

Proceed With Caution

Pharmaceutical companies must list potentially harmful side effects when they advertise the name-brand versions of their FDA-approved medications. Potential include nausea, vomiting, changes in vision, low blood sugar, and, in rare cases, thyroid cancer. Meanwhile, telehealth companies have not historically followed the same rules that drugmakers have in disclosing medication risks in advertisements. But the FDA has started cracking down on misleading drug ads.

A national shortage of weight loss medications in 2022 opened the door for compounding pharmacies to manufacture these drugs. But since the FDA declared the shortage over last year, companies that offer compounded drugs are increasingly facing legal and regulatory challenges related to their marketing tactics.

Mounjaro manufacturer Eli Lilly and other drugmakers are suing multiple telehealth companies for promoting compounded versions of their drugs. In one legal complaint, Eli Lilly alleged Mochi Health had engaged in “deceptive” business tactics. In a motion to dismiss the lawsuit last year, lawyers for Mochi Health called the complaint part of a “nationwide campaign to bolster Lilly’s profits by dictating patient care through the elimination of compounded drugs as a treatment option for weight management.” The lawsuit is ongoing.

Eli Lilly spokesperson Michael Jamison said in a written comment that telehealth companies sued by the drug manufacturer threaten “patient safety by falsely promoting supposedly ‘personalized’ compounded tirzepatide” and mislead “consumers about the safety, clinical testing, and effectiveness of their compounded knockoffs.”

Meanwhile, Novo Nordisk has filed 130 lawsuits against “entities engaged in unlawful marketing and sale of knockoff semaglutide drugs,” said Liz Skrbkova, a spokesperson for the drugmaker.

She said the company is committed to “protecting patients from unapproved knockoff drugs made with foreign, inauthentic active pharmaceutical ingredients that pose significant safety and efficacy risks.”

The Trump administration sent a in September and February to online companies such as , , , and . The FDA said these and other companies had made false or misleading claims related to compounded versions of weight loss drugs.

“Your claims imply that your products are the same as an FDA-approved product when they are not,” the agency’s Center for Drug Evaluation and Research on Sept. 9. HHS later referred the company to the Department of Justice after it announced the launch of a $49 version of Novo Nordisk’s Wegovy pill.

When asked about the FDA warning, Abby Reisinger-Moley, a spokesperson for Hims & Hers, pointed to a announcing a shift away from compounded weight loss drugs. The company said in the press release that it had entered into an agreement with Novo Nordisk to sell name-brand versions.

Alex Smith, CEO of Join Josie, an online platform that helps women in menopause lose weight by prescribing GLP-1s, said his company also made changes in response to an FDA letter, to include removing Join Josie’s name from medication vials. “Which I agree with,” Smith said, “because you don’t want patients thinking you’re the compounding pharmacy.”

SkinnyRx and Genesis Health International did not respond to requests for comment.

But these warnings aren’t the first time the federal government has stepped in to ensure that telemedicine is being used appropriately, said Mei Wa Kwong, executive director of the Center for Connected Health Policy.

Prior cases involved attention-deficit/hyperactivity disorder medications and other controlled substances prescribed by telehealth providers, she said. While those drugs pose more risk to patients than GLP-1s, the companies were also accused of improperly screening potential customers.

The onus still falls on consumers to research companies before signing up for their services, Kwong said.

“Always approach anything on the internet with a hint of skepticism,” Kwong said.

‘Keeps Getting Worse’

McClain, the Tennessee woman hospitalized this year after a GLP-1 overdose, said she lost 50 pounds a few years ago by taking a name-brand GLP-1 prescribed by her doctor.

At the time, the medication was covered by her health insurance. This year, when she was ready to take a GLP-1 again following a pregnancy, the drug was no longer covered for weight loss.

To save money by obtaining a cheaper, compounded GLP-1, McClain signed up for Mochi Health after doing her own research. “That was just the most affordable option,” she said.

But within hours of her first dose, she said, she found herself on the phone with poison control.

After her overdose, McClain said, she spoke to a clinical director at Mochi Health, once by phone but mostly via email, about her lingering symptoms before communication paused.

David Pilip, a spokesperson for Mochi Health, said in a statement that the company would not discuss individual patients due to privacy obligations. But he said adverse events are “immediately flagged” and “investigated with extreme precision.”

“Mochi Health takes patient safety extremely seriously,” Pilip wrote in an email. “We promptly initiated a review and have been in direct and ongoing communication with the patient to reach a resolution. We remain committed to doing so.”

McClain anticipates her healthcare bills related to the hospital stay will total at least $900. She said that to get the $159 refund for her three-month membership and reimbursement for the hospital expenses, she has been asked to sign a document saying she won’t take legal action against the company. Her experience, she said, “just keeps getting worse.”

NBC News producer Jessica Herzberg and Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Fred Schulte contributed to this report.

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LISTEN: After a guilty verdict for negligent homicide, a former nurse has found receptive audiences on the speaking circuit. She says she hopes her story can help shed light on problems in the healthcare industry.

When RaDonda Vaught got her first speaking request, it had been a year since that day in a Nashville courtroom, when she listened as a jury read her guilty verdict for negligent homicide and neglect of an impaired adult.

That was in 2022. Vaught was sentenced to three years of probation for administering the wrong medication and killing a patient at Vanderbilt University Medical Center in 2017.

She also lost her nursing license. So Vaught became a full-time farmer. She and her husband live on a in Bethpage, Tennessee, tucked in the rolling hills north of Nashville. They sell eggs at farmers markets on Saturdays and supply meat to local butchers and restaurants.

The controversial trial had been national news, and now the healthcare industry wanted to hear from her. So Vaught started giving speeches across the country about what happened that day in the hospital. She says her hope is that others in an industry increasingly turning toward automation and artificial intelligence can understand the multiple factors that contributed to the deadly medication mix-up.

She says she’s painfully aware that it could appear she is profiting from a tragedy of her making.

“It wasn’t something that I wanted to happen. It wasn’t even something that was on my radar to think about,” Vaught said of the speaking requests. “The opportunities just kept presenting themselves.”

The speaking engagements provide her with an income that replaces what she made as a nurse, a career she can never return to. Last year, she told her story more than 20 times, and she is paid $5,000 to $10,000 per event.

But her speaking engagements also provoke criticism. After she told her story at length on Nashville Public Radio’s in March, a retired nurse, Gary Wood, fired off an email to the station. Such medical mistakes could never be justified, he wrote: “It put a stain on a proud and dedicated profession.” Yet, Vaught often finds a receptive audience, eager to hear her perspective.

“I’ve seen her a few times now in person, and I’ve never seen RaDonda tell the story and not be upset,” said Charlene Verga, who invited Vaught to be the closing speaker at the ’s clinical nursing conference last year.

“RaDonda speaking the way she is, she literally is transforming her mistake into a teaching moment,” Verga said.

Vaught expected the speaking gigs would be short-lived. But the reviews were good. And she realized she was comfortable in front of a crowd.

“It was emotionally overwhelming and a little cathartic, but I’m going to tell you, you could have heard a pin drop,” Vaught said of her first talk in 2023 to hundreds of industrial professionals at a meeting organized by , a Knoxville, Tennessee-based company that specializes in root cause analysis.

Vaught has turned her story into a cautionary tale that she hopes will make hospitals safer. She says that humans are going to make mistakes and that systems in healthcare need to be designed so people can fail without killing someone.

“This whole mockery of our healthcare system — people feeling afraid to talk about mistakes and come forward when they happen — it doesn’t save people. It kills them,” she said in a presentation to the .

Onstage, Vaught confronts the painful and embarrassing details directly, often choking back tears when talking about the patient who died — Charlene Murphey.

It wasn’t just one mistake that led to the death.

A doctor had ordered a sedative called Versed to settle Murphey’s claustrophobia before an imaging procedure. Vaught typed “VE” into the search function to retrieve Versed from the electronic medicine cabinet. When it did not dispense, she overrode the system.

In Vaught’s trial, fellow nurses testified that during a time when the hospital was upgrading some of its technology, they could use overrides to bypass delays.

When Vaught took that step, one of the drug options available was vecuronium, a powerful paralytic. Vaught overlooked multiple warnings about the danger of vecuronium, including on the bottle’s cap, which said “Warning: Paralyzing Agent,” according to court records.

Vaught administered the vecuronium and also left the patient alone.

While not disputing most of the facts, Vaught pleaded not guilty to all charges, claiming there were other factors, such as a new electronic health record system that was causing widespread problems in the hospital. A lead investigator for the prosecution testified in the criminal case that Vanderbilt also shared some responsibility.

As previously reported by Ñî¹óåú´«Ã½Ò•îl Health News, Vanderbilt did not initially report the error to regulators as required and told the medical examiner that the patient died of natural causes. The medical center fired Vaught and negotiated a settlement with the Murpheys that keeps the family from talking publicly about her death.

Once the case became a criminal matter, though, the details entered the public record. Vaught is not bound by the hospital’s settlement, allowing her to share whatever she feels comfortable sharing with whomever she wants.

Vanderbilt spokesperson Craig Boerner declined to comment about Vaught’s public speaking or what the medical center learned from the incident.

The two largest companies that make drug-dispensing cabinets, Omnicell and BD, have updated their machines with recommendations from the . One update requires the user to type in more than the first two letters of a medication to pull up a list of options.

Many hospitals also tweaked their drug administration protocols, such as by requiring wristband barcode checks anywhere a patient gets medication in a hospital.

Reacting to Vaught’s case, the state legislature in Kentucky that became law in 2024 providing immunity for on-the-job healthcare mistakes. Support wasn’t just bipartisan. It was unanimous.

Nursing consultant went to nursing school with Vaught and has worked directly with her as a nurse. Vaught’s criminal case inspired him to go to law school, he said. He now plans to help other nurses defend themselves in similar cases, even though he sees the need for accountability.

If it had been up to him, he also would have fired Vaught, Garvey said. He also thinks that the Tennessee Board of Nursing should have taken action immediately. Only after the patient’s death escalated to a criminal matter did the board revisit the case and revoke Vaught’s license.

But the defendants’ side of the story is rarely ever told, Garvey said, because they are advised by their lawyers not to talk.

Now that she has a platform, Garvey said, it’s therapeutic for Vaught. Her talks resonate with anxious nurses across the nation, he said, and promote a much-needed discussion about collective responsibility.

“We can’t change what happened. We can only change what we do moving forward,” Garvey said. “Having the individual who can tell you the play-by-play — that was there when it actually happened — is incredibly valuable.”

This article is from a partnership that includes ,Ìý, and Ñî¹óåú´«Ã½Ò•îl Health News.

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North Carolina, in late April, became the latest member of a growing group of Republican-led states to require their public health agencies to flag recipients of Medicaid to the U.S. Department of Homeland Security if their legal status is in question.

It’s a trend health policy researchers expect to spread among GOP-controlled states eager to join Trump in the federal crackdown on Medicaid fraud and illegal immigration. Already, at least four states — , , , and — have passed similar laws, and lawmakers in others, such as and , are weighing measures. In those six states, Republicans hold a power trifecta — both chambers of the legislature and the governor’s office.

“This is an issue that is very much on the political radar right now,” said , a health policy researcher at Harvard Law School.

More than 75 million people , the federal and state-run public health program for people with disabilities and low incomes, or its related Children’s Health Insurance Program, which provides low-cost coverage for people under 19. Immigrants without legal status are ineligible for Medicaid benefits, but a swath of noncitizens qualify, such as green-card holders, asylees, and refugees. A quarter of children in the U.S., most of them citizens, live with an immigrant.

Yet the new reporting laws add a layer of risk for immigrants seeking healthcare in the U.S., where the the use of to help identify and deport people.

Some of the state laws apply only to health agencies, such as in North Carolina. But the bill headed to Tennessee Gov. Bill Lee’s desk , requiring all state agencies to report people suspected of being in the U.S. without legal status. All seven state measures go beyond what’s federally required, which is to cooperate with enforcement officers by providing personal information of recipients when asked.

In Louisiana, families with mixed immigration statuses have reported that the state’s new law, enacted last year, for their kids with U.S. citizenship.

“I expect this law will lead to more families asking whether it is safe to seek healthcare, whether information can be shared with immigration authorities, and whether enrolling a child or seeking treatment could expose them to enforcement consequences,” said , a North Carolina immigration attorney.

North Carolina Republican lawmakers inserted their mandate for the state’s health department as part of a in Medicaid funds, which the legislature cut when it failed to pass a budget last year.

Starting in October, state employees will ask non-U.S. citizens receiving Medicaid for proof of their immigration standing and report those without “satisfactory” legal status to federal authorities. “This bill is designed not only to fund our critical needs today, but to begin looking at fraud, abuse issues we know exist within the system,” Republican state Rep. Donny Lambeth said during a House debate on the bill.

Immigrants than people born in the U.S., according to an analysis by the Cato Institute, a libertarian think tank, which also found noncitizens are much less likely to than citizens. State health agencies are already required to verify whether applicants’ immigration statuses .

Several Republican leaders responsible for the bill did not respond to requests for comment. North Carolina Department of Health and Human Services spokesperson Hannah Jones said the agency is still trying to understand the impact of the new law.

, about half of adults who “likely” lack legal status said someone in their family has avoided seeking medical care because they were concerned their information could draw the attention of immigration enforcement.

, a North Carolina discrimination attorney, said immigrants “in process,” or those waiting for legal authorization, generally already fear using government assistance for themselves.

“What I’ve learned from handling thousands of cases over the years is that most of the individuals who are in process pay for their own medical treatment out-of-pocket,” Rosa said.

Such policies essentially force children who are U.S. citizens to go without health coverage or hospital care, said , a researcher at Georgetown University’s Center for Children and Families.

“When you do policies that target an immigrant, you may think that you are just targeting this one person in the family, but it’s a really imprecise bomb that takes out the whole household,” Cuello said.

The use of states’ public health agencies to find immigrants who lack legal status is not the only strategy states have deployed. Some have passed laws looking to hospitals to collect and report such information. A 2023 Florida law that requires hospital staff to ask about patients’ immigration status has made noncitizens hesitant to seek care, separated families, and caused psychological distress, by the University of South Florida. Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida’s law in 2024.

Democratic states have pushed back against Trump administration policies that mine private medical information to target immigrants, with 21 signing on to a filed last year that attempts to prevent DHS from . recipients’ identities could be shared, but medical information could not. Litigation is ongoing.

DHS did not respond to a request for comment on the record.

After he signed the bill into law, North Carolina’s Democratic governor, Josh Stein, urging Republican lawmakers to protect Medicaid coverage for nearly 27,000 pregnant women and children who are lawfully present in the country. He did not respond to questions about the provision that requires the state to report immigrants without legal status.

Polanco-Galdamez said such laws have further eroded trust in healthcare systems among underserved families.

“At the end of the day, public health systems function best when people feel safe seeking medical care,” Polanco-Galdamez said. “Policies that blur the line between healthcare access and immigration enforcement risk pushing vulnerable families further into the shadows.”

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That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans.

“Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said.

Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a found that many returning marketplace enrollees reported higher costs this year.

In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage.

Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans.

As of this year, that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan.

Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints.

But because states have passed laws exempting from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans.

Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions.

Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be than unsubsidized marketplace plans, plan managers say.

As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins.

“We’re trying to present another option,” he said.

Sowing Choices

In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to for subsidized enrollees who retained their marketplace plan, according to KFF.

Last year, was one of four states that passed laws permitting farm bureau health plans. The others were , , and .

Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage . Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them.

In Missouri, the farm bureau offers with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network.

Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said.

It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years.

“People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said , general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.”

Staying Rooted in Coverage

Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said.

“We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said.

And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said , principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network.

Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said.

“We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said.

Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions.

Meanwhile, policy experts share Howard’s concerns.

Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said , vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans.

Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said.

Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans.

“I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said , co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.”

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It’s one of the many parts of the 25-bed rural hospital that need updating, former CEO Ron Wiens said.

He said the hospital, an essential service in its namesake town of nearly 800 residents in the state’s sprawling north-central high plains, needs at least $1 million for deferred maintenance, including a failing HVAC system. But the facility has struggled to make payroll each month and can’t afford to make all the fixes, Wiens said.

Built by farmers and ranchers in 1965, Big Sandy Medical Center began with nine beds. Today, a similar community effort — donations and grants to plug financial holes each year — keeps it afloat.

Wiens, who recently left his position at the hospital, said he wishes Big Sandy could get funding from Montana’s share of the $50 billion federal Rural Health Transformation Program to renovate the hospital and direct payments to help secure its future. The state received more than $233 million in its first-year award.

But the hospital may not get the kind of help he sought.

That’s because the five-year program focuses on new, creative ways to improve access to rural health care, not on directly funding services and renovations. And Montana is one of at least 10 states whose leaders say projects launched under the federal program could lead rural hospitals to cut services so they can continue to afford to offer emergency and other essential care.

Congressional Republicans created the fund as a last-minute sweetener to their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset disproportionate fallout anticipated in rural communities from the law, which is expected to slash Medicaid spending .

includes programs to make it easier for rural residents to get medical care and live a healthy lifestyle. For example, it says funding can be used to start community gardens, train paramedics to make home visits, open school-based clinics, or bring mobile clinics to rural areas.

rural Montana hospitals can receive payments for implementing recommendations, “including right-sizing select inpatient services” to match demand. In some cases, it says, right-sizing might mean “downsizing.” The state says hospitals will have input and recommendations will be specific to each facility.

“That’s what has all the hospitals on pins and needles, words like restructuring, reducing inpatient beds. Everybody is going, ‘What is this going to look like?’” Wiens said.

The Montana Department of Public Health and Human Services declined to answer questions about how it will carry out its right-sizing efforts.

A Lifeline of Care

Big Sandy cattle rancher Shane Chauvet doesn’t want any services cut.

He credits Big Sandy Medical Center with saving his life after a flying piece of metal nearly cut off his arm during a windstorm a few years back.

“I looked over, saw it coming, and whack!” Chauvet recalled.

His wife drove him to the hospital, where they frantically pounded on the ER door while Chauvet’s blood pooled on the ground.

Because of the storm, staffers worked on Chauvet with no power and no ability to summon a helicopter. He was then taken by ambulance 80 miles through intense rain and hail to a larger hospital.

Chauvet understands the state’s plan doesn’t call for eliminating emergency care, but he worries that reducing other services would set off a downward spiral for the hospital and his town.

In Oklahoma, realigning clinical services could mean “shutting down service lines,” to the federal program. And in Wyoming, any facility that receives funding must agree to “reduce unprofitable, duplicative or nonessential service lines,” .

Monique McBride, business operations administrator at the Wyoming Department of Health, said the department interprets right-sizing as helping rural hospitals provide essential services — such as emergency departments, ambulance services, and labor and delivery units — while maintaining long-term, financial stability.

“This might involve limiting some elective procedures that could be done at lower cost in higher-volume facilities. The main distinction here is time-sensitive emergencies vs. ‘shoppable’ services,” she said.

A New Lease on Life?

Seven of the 10 states — Nebraska, North Dakota, Tennessee, Kansas, Nevada, South Carolina, and Washington — where rural hospital service cuts are on the table say they’ll help pay for hospitals to convert to Rural Emergency Hospitals. The recently created federal designation requires hospitals to halt inpatient services and offers enhanced payments to help them maintain emergency and outpatient care.

At least 15 additional states wrote that they’ll use the federal funding to right-size, evaluate, or adjust services — which could mean adding or taking away services, or transitioning them to a telehealth or outpatient setting.

Brock Slabach, chief operations officer of the National Rural Health Association, said, “There’s a proper concern from rural hospital administrators that this funding is not going to where it was intended.”

He said cutting services that lose money could backfire in the long run. For example, he said, halting labor and delivery care might drive more people out of small towns, further reducing hospitals’ patient numbers and revenue.

The type of hospital services that states will assess matters, said Tony Shih, a senior adviser at the Commonwealth Fund, a nonprofit focused on making health care more equitable.

“If the end result is that high-margin services are taken away from local hospitals with nothing given back in return, it can be financially harmful,” he said.

Shih noted that states’ plans to add more outpatient care could prove beneficial for patients. It’ll take time to know which states help stabilize rural hospitals, he said.

Rural hospital leaders say they know which changes would keep their facilities open and that states shouldn’t suggest or mandate service cuts and other changes on their behalf.

Josh Hannes, who oversees rural health policy at the Colorado Hospital Association, said “top-down” directives won’t work.

He said the association’s members believe they can find efficiencies and are eager to collaborate. But “a state agency shouldn’t be making those determinations,” he said.

Hannes said members are worried Colorado’s plan to classify rural health facilities as a “hub, spoke, or telehealth node” will compel service reductions. The classification will help determine “which services are sustainable locally and which are best provided regionally or through telehealth,” .

Spokespeople for the Colorado and Oklahoma health departments said no facility will be forced to end services. But Oklahoma spokesperson Rachel Klein said some facilities might choose to do so as part of a broader effort to make sure they’re meeting community needs while remaining financially stable.

“A hospital might shift certain services to a nearby regional provider with higher patient volume and specialized staff while expanding other local services,” such as primary, outpatient, or community-based care, she said.

Wiens and Darrell Messersmith, CEO of Dahl Memorial Hospital in the southeastern Montana town of Ekalaka, said they worry the only way hospitals will get their share of funding is to cut services or become Rural Emergency Hospitals that don’t offer inpatient services.

“I would hate to see things shift toward a pack-and-ship facility,” Messersmith said. “Right now, we function quite well as an inpatient facility.”

Not all Montana health leaders are worried.

Ed Buttrey, president and CEO of the Montana Hospital Association, said he thinks his state’s plan could help rural hospitals become financially sustainable and survive Medicaid cuts. Buttrey is also a Republican state lawmaker.

Chauvet, the Big Sandy rancher, said his perspective on whether remote towns like his should have a hospital is forever changed because of his accident.

“I always would say, ‘Oh, they’re nice to have,’ but now I look at the hospital and say, ‘That’s essential to our community,’” he said.

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LISTEN: Your dental insurance might not cover what you expect.

Russell Anthony made eight trips to the dentist last year. The 65-year-old retiree in Nashville, Tennessee, hopes to go less often in 2026, but he’s already made a few visits.

“I had a root canal just last week that was like $500,” he said. “The week before that, I had a crown that cost me several hundred dollars. And as we speak, I have a broken tooth, and I have to go and see the dentist soon.”

In all, Anthony — uncle of HealthQ host Cara Anthony — expects to pay about $2,000 for dental care this year, even though he has dental insurance.

“Trying to weigh the cost of when to go to get dental care and paying for it, versus the other needs that I have, is something that’s very important,” Russell Anthony said.

The American Dental Association reported that had dental insurance in 2021. But that coverage does not necessarily protect against large bills. In fact, 1 in 4 adults with dental insurance reported costs as a barrier to care, according to a by KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Here are three things to know to better understand your insurance plan and keep your dental costs as low as possible:

1. Even With Dental Insurance, You’ll Have To Pay for Procedures

Dental plans typically cover routine care in full but pay only a portion of additional work. Benefits vary, but many plans follow the “100/80/50” rule, covering 100% of preventive care like cleanings and exams, 80% of basic procedures like fillings and root canals, and 50% of other major procedures.

Plus, dental plans often have a maximum annual payout, usually between $1,000 and $2,000. Patients are responsible for any costs above that. For example, if your plan maxes out at $1,500 and you need $4,000 of dental treatments, you will be on the hook for the difference of $2,500.

2. Facing a Big Dental Bill? You Have Options

It might feel uncomfortable to talk about finances directly with a dentist, but it’s helpful to be up-front about what you can afford.

Many dentist offices offer financial options to help patients manage the cost of care, including pretreatment estimates and payment plans. If you get an estimate that seems especially high, talk through the items and consider getting a second opinion. It never hurts to ask the office for a discount.

If you need a lower-cost alternative, consider looking into dental schools, which often offer discounted care, or , which use sliding scales based on a patient’s income.

3. Seeing Your Dentist Regularly Can Help Keep Costs Low

Sarah Olim, a general dentist in Katy, Texas, encourages her patients to come in for visits every six months.

“The best thing that you can do to mitigate the cost of going to the dentist is make sure that you are going regularly and trying to take care of things early,” she said.

Olim welcomes patients no matter how long it’s been since their last visit. But she cautioned that patients who wait a few years between visits may find their appointments are more expensive and more uncomfortable.

The reason? Dental problems often don’t resolve on their own. For example, a small cavity that needs a quick filling might cost $200. If left untreated, it could turn into a larger issue requiring a root canal and crown — and cost thousands.

Your dentist will also encourage you to follow the best preventive maintenance: brushing your teeth for two minutes twice a day. Olim tells her patients to use a timer or listen to a favorite song to make sure they brush long enough.

People and Policy

Federal lawmakers have tried to increase children’s access to dental insurance. Under the Affordable Care Act, dental care is considered , so health insurance plans on the individual marketplace must offer dental coverage for those 18 or younger. State Medicaid programs are also for children.

Emily Siner at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and Ñî¹óåú´«Ã½Ò•îl Health News.

This <a target="_blank" href="/health-care-costs/healthq-dental-care-insurance-large-bills/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

The KFF poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told Ñî¹óåú´«Ã½Ò•îl Health News.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for KFF.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both KFF polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told Ñî¹óåú´«Ã½Ò•îl Health News that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a KFF poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured. 

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

KFF pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

Are you struggling to afford your health insurance? Have you decided to forgo coverage?  to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

This <a target="_blank" href="/health-care-costs/kff-poll-aca-obamacare-higher-premiums-blame-trump-gop/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">