The decision by federal officials, citing authority granted under President Donald Trump’s signature tax-and-spending law, suggests the GOP-led state’s predicament could foretell other repercussions in how states are allowed to run the program under federal waivers.

Nearly every state has at least one waiver to run its Medicaid program differently than required by federal law, such as allowing the use of private managed-care plans or expanding eligibility for mental health or long-term care services. Some Medicaid waivers have stretched decades, renewed by presidential administrations of both parties, effectively making the demonstration programs they created permanent.

Arkansas is one of a dozen states with a waiver expiring Dec. 31 that face the additional restrictions the Trump administration has placed on new or renewed waivers.

Though it has yet to finalize its decision, the federal Centers for Medicare & Medicaid Services said Arkansas’ 13-year-old waiver does not comply with new “budget neutrality” rules that take effect in January, said Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services. The rules tighten a policy forbidding Medicaid waivers from increasing federal spending on the program beyond what it would have increased without the waiver.

The state is now seeking a two-year extension after hearing from CMS that its request for a five-year renewal would not be granted. If its Medicaid expansion waiver is not renewed, Arkansas officials have said they will continue offering expanded eligibility through existing Medicaid law, a change that could leave enrollees with access to fewer doctors and other health providers.

Rather than place more people in its traditional Medicaid program serving largely children, pregnant women, and disabled people, Arkansas obtained a waiver to buy Affordable Care Act marketplace policies from private insurers for adults covered by the Medicaid expansion. This “private option” gave enrollees greater choice of doctors and other health providers, because some doctors are more willing to see patients with private coverage, which generally pays more than regular Medicaid.

The move helped cut the state’s uninsured rate by nearly half, but it also ended up costing more than if beneficiaries were covered under Medicaid’s traditional, fee-for-service program.

Critics characterize the new waiver rules as part of a Trump administration effort to dramatically shrink Medicaid, the government program for those who are low-income or disabled, which grew rapidly under Presidents Barack Obama and Joe Biden.

“What we have here is a sneaky way to cut Medicaid expansion and the Medicaid program,” said Nicole Huberfeld, a professor of health law at Boston University.

Medicaid enrollees won’t know whom to blame if they lose coverage because the administration is using arcane regulatory processes to make the changes, Huberfeld said.

At issue are waivers granted by the government that allow states flexibility from existing Medicaid law in how they cover low-income residents, as long as the changes will not increase what Medicaid costs the federal government.

Pivoting from the long-standing practice of checking only retroactively whether states were keeping their budget promises, the Trump administration that it would not renew or approve any waivers unless CMS first certified that they would not increase costs to the federal government.

In its , the agency said the new waiver rules are expected to reduce federal spending.

“Characterizing enforcement of a statutory budget neutrality requirement as a cut misrepresents both the law and this guidance,” CMS spokesperson Timothy Foster said in an email to Ñî¹óåú´«Ã½Ò•îl Health News. The federal waivers are intended “to test innovative approaches to delivering care, not provide an open-ended mechanism for increasing federal spending.”

Other states with waivers expiring at the end of December include Georgia, which has added about 18,000 low-income people to Medicaid under its waiver, and California, which has used its waiver to expand coverage of social services including food and housing.

California and Georgia Medicaid officials told Ñî¹óåú´«Ã½Ò•îl Health News that they are still working with CMS in hopes of renewing their waivers. The loss of federal waiver approval could cause states to curtail benefits or eligibility expansions.

In Arkansas, it would mean redesigning the state’s Medicaid expansion program.

Arkansas’ initial waiver was granted in 2013, when its Democratic governor at the time worked with a Republican-controlled legislature to adopt a pioneering style of Medicaid expansion under the Affordable Care Act.

It was one of the first Southern states to expand Medicaid, granting coverage to many low-income residents. Forty states and Washington, D.C., have also fully expanded Medicaid to cover more low-income adults under the law also known as Obamacare.

The state’s Medicaid expansion enrollees were already facing a confusing time. Starting in January, they will need to prove they work or meet an exemption to be eligible for coverage under Trump’s law, the One Big Beautiful Bill Act. And one of the state program’s two private health insurers — Centene — announced in July that it was pulling out at the end of the year.

Sam Dubke, a spokesperson for Republican Arkansas Gov. Sarah Huckabee Sanders, told Ñî¹óåú´«Ã½Ò•îl Health News that the Sanders administration is trying to negotiate a temporary extension of its waiver “to ensure impacted Arkansans maintain access to quality, affordable healthcare during this transition period.”

“Looking ahead to the next legislative session, CMS has provided the state with an opportunity for bold, conservative healthcare reform, and the governor will work with her partners in the legislature to build a sustainable model that maintains the same high quality of care and saves taxpayer dollars,” Dubke said.

The Trump administration’s new restrictions on waivers, implemented under the same law that imposes work requirements as a condition of eligibility and reduces Medicaid spending by about $900 billion over a decade, could affect millions of enrollees and billions in spending. About a third of the almost $600 billion in federal spending on Medicaid and the Children’s Health Insurance Program in 2024 supported programs created by waivers, according to CMS.

In a , the Government Accountability Office found that the three-year spending limit the federal government approved for Arkansas’ Medicaid waiver was nearly $800 million more than what the state would have spent through its traditional Medicaid program.

Arkansas is one of several states that expanded Medicaid under the ACA using a waiver, with others including Indiana, Michigan, New Hampshire, and Iowa.

States will have to clear several more bureaucratic hurdles to retain waivers under the new CMS guidance, said Alice Lam, a managing director with consulting and legal firm Manatt. That could lead to fewer benefits or reduce the number of people eligible for Medicaid, she said.

Robert Nelb, director of policy at America’s Essential Hospitals, which represents safety net hospitals, said he and most experts believed when it passed that the One Big Beautiful Bill Act was merely codifying CMS policy on budget neutrality.

But the Trump administration has interpreted the law to restrict states’ use of waivers, he said.

Nelb said many long-standing waivers that have been renewed multiple times are now at risk and that the loss of state waivers could threaten money hospitals rely on to cover uninsured patients and improve care in their communities.

“There is a real concern that this will put added burdens on states up front and slow down new innovations in Medicaid,” Nelb said.

In 2025, the Trump administration told states it would no longer renew Medicaid waivers to help enrollees with job training or to allow continuous eligibility for adults and children for specific time periods without verifying their income eligibility.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

As a registered nurse at the University of Cincinnati Medical Center and a former Air Force medic, he knew this was a bad idea. “I made a couple of attempts to quit and they failed miserably,” said Schmidt, now 75.

Not until 2007 was he able to stop, using a newly approved prescription drug that reduced cigarette cravings. “I put them down and never went back,” he said.

Despite his years as a healthcare professional, Schmidt was unaware that lung cancer screening had become available for current and past smokers. The influential U.S. Preventive Services Task Force, an independent expert panel, recommended it in 2013.

Besides, he said, “I thought I was in the clear after all these years of not smoking.”

But in 2021, his primary care doctor, running down a list of questions at his annual Medicare wellness visit, asked whether he’d be willing to undergo a CT scan to detect lung cancer, and he agreed. A few days later, the results popped up on his patient portal: adenocarcinoma.

“It was stunning to read those words,” Schmidt recalled. “I knew what that was: cancer.”

Even with sharp declines in smoking, lung cancer remains the leading cause of cancer deaths in the United States, with  for this year, far exceeding fatal cases of colon, breast, or prostate cancer.

Yet in 2024, of the patients eligible for lung cancer screening,  — or , depending on which data researchers analyzed — were up to date on the recommended annual scans.

“Abysmally low, especially because of how deadly lung cancer is,” said Chi-Fu Jeffrey Yang, a thoracic surgeon at Mass General Brigham and the senior author of  about the screening rates.

Patients over 65 were more likely than younger people to be up to date. Still, only about a third were screened regularly, a  than received other cancer screenings. Schmidt, for instance, had dutifully undergone colonoscopies and prostate cancer tests for years.

Data from national registries shows that older adults face . “Age is a risk factor for cancer generally,” said Priti Bandi, an epidemiologist at the American Cancer Society. But seniors may also accumulate more years as smokers. About a fifth of lung cancer cases arise in people who never smoked, but smoking remains the most common cause, “even if the exposure happened much earlier in your life,” Bandi said.

Screening has been shown to save lives. In 2011,  demonstrated that annual screening with low-dose CT scans reduced lung cancer deaths by 20% compared with the chest X-rays used previously. That prompted the initial task force recommendation.

More recent European trials have found far greater reductions. In 2019, Italian researchers reported that after 10 years, patients with six years of screening had a 39% decrease in lung cancer deaths compared with those who weren’t screened.

Why, then, does screening remain so underused? “Lung cancer screening is so easy, a two-minute scan,” Yang said. “You don’t even have to put on a gown.”

One explanation: Determining eligibility gets complicated. The task force, in , recommended screening for those a) 50 to 80 years old with b) a “20 pack-year” smoking history who c) currently smoke or stopped within the past 15 years.

Both patients and doctors struggle with these criteria. Pack-year? It refers to how heavily someone smoked over time. Smoking a pack a day for 20 years creates a 20 pack-year history; so does smoking half a pack daily for 40 years.

Calculating that number is time-consuming and “challenging,” said Teva Brender, a hospitalist at the San Francisco VA Medical Center and a co-author of an  about lung cancer screening. “You might smoke a pack a day, then cut back to half a pack for two years, then stop. Then start again.”

The  probably also plays a role, sometimes making patients reluctant to disclose tobacco use. “Some people blame patients with lung cancer: ‘You did this to yourself because you smoked,’” Yang said. Screening rates also vary by state and insurance status.

Yet advances in treating lung cancer, including minimally invasive and robotic surgical procedures and increasingly effective drug therapies, mean that a diagnosis is “no longer a death sentence,” Bandi said. “The survival rate has improved dramatically.”

More than 80% of patients diagnosed in the earliest stages of the disease or more, although survival drops sharply for more advanced cancers. And screening increases the odds of finding cancer early.

Frustrated that a potentially lifesaving tool remains so underused, some doctors and organizations are calling for changes in the Preventive Services Task Force recommendations, which lead to coverage by Medicare (Medicaid coverage varies by state) and many private insurers. “The screening guidelines are too restrictive,” Yang said.

The American Cancer Society and the National Comprehensive Cancer Network have both  from their guidelines, which would make patients eligible for screening no matter how long ago they stopped smoking.

“We were disqualifying people from screening at a time when their risk was still rising,” said Robert Smith, a screening expert at the society. He and his colleagues have urged the task force to also drop the 15-year stipulation,  to back their claim.

°Õ³ó±ðÌý, dropping both the 15-year and pack-year stipulations and advocating screening for anyone who smoked for 20 years.

The task force,  from Health and Human Services Secretary Robert F. Kennedy Jr., hasn’t responded to the American Cancer Society’s analysis. Nor did it respond to a reporter’s emails asking whether it planned to revise its lung cancer screening recommendations.

Expanding eligibility so that more people can undergo screening , too. Some scans will reveal abnormalities that don’t turn out to be lung cancer, but require additional scans (or, rarely, biopsies) and cause considerable anxiety. Even with low-dose scans, repeated screenings also involve some radiation exposure.

Moreover, a recent study showed that among older adults diagnosed with metastatic lung cancer, . “If the public health goal is to reduce deaths from lung cancer through screening, it only works if you treat the people it identifies,” said Steven Woloshin, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For Schmidt, though, screening and treatment worked as intended. The mass found by his 2021 screening, diagnosed as stage 1 lung cancer, led to robotic surgery at the University of Cincinnati Cancer Center to remove the upper lobe of his right lung.

Surveillance scans followed every six months, then annually — until a 2025 scan revealed a small nodule in his lower lobe, another stage 1 cancer. Surgery removed that nodule, too. Schmidt now takes a targeted anticancer drug daily, a three-year regimen, while continuing regular scans.

“It did what it was supposed to do,” Schmidt said of his screening. “I feel blessed.” He tends his extensive gardens in Bright, Indiana, flies kites, and goes camping with his grandchildren. He still works several shifts a month as a fire department paramedic.

Experts cautioned, however, that lung cancer screening and treatment cannot substitute for the benefits of stopping smoking — or never having started. “The risk is lower the longer you are away from cigarettes,” Woloshin said. “But it doesn’t go to zero.”

The New Old Age is produced through a partnership with .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

When making the appointment, Zordani said, he’d been told the clinic was in his insurer’s network. Upon arrival, Zordani was summoned to the clinic’s financial office and told he had to make a $5,000 preservice deposit, because Mayo had since determined it did not accept his insurance. He was automatically designated “self-pay,” even though his plan had out-of-network benefits.

Not having that kind of cash on hand — and angry on principle — he refused. His appointment was canceled.

“I was so livid,” Zordani said, recalling that day in early April 2024. He later learned that Mayo had sent a message to him in his insurance carrier’s patient portal shortly before his visit with an estimate of the cost: $565, not the larger amount it later demanded.

Traditionally, patients usually receive bills for their share only after getting treatment. But what Zordani faced is becoming increasingly common — hospitals or other medical providers seeking prepayments.

“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in an emailed statement. “When prospective patients don’t have clarity that Mayo Clinic is not in-network with their health plan, unexpected pre-service deposit requests may result.”

says it requires prepayments in a variety of cases, including for “noncontracted” — also known as out-of-network — insurance plans.

The trend of hospitals asking for money up front represents a double whammy for patients.

Medical providers are collecting larger shares of what patients might owe at a time when rising deductibles mean patients are owing more for care. The preservice charge could be all or part of a remaining deductible, for example, or a sizable percentage of what the visit or treatment might cost. Those deductibles go up when hospital prices, drug costs, and labor expenses increase, as insurers try to slow premium growth by shifting more costs to patients.

People are “basically being asked to self-insure,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an organization for finance professionals.

As that happens, hospitals figure more patients will have trouble meeting those deductibles, so they want to get as much up front as possible.

“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” said Chip Kahn, a visiting senior fellow at KFF and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals. “That will make it harder on the provider, the clinician, and harder on the patients.”

The deposits can’t be viewed in isolation, Gundling said: It’s a bigger issue than just hospitals asking for money up front. The challenge, he said, is: “How do we maintain access to care when more patients can’t absorb the level of out-of-pocket costs?”

Already, consumers are increasingly worried about paying for healthcare. A recent found that lower out-of-pocket costs ranked as the top change insured adults would like to see from their coverage plans. KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

The average deductible in family coverage offered by employers is $3,762 per person, , while the average deductible in Affordable Care Act plans to a similar amount, $3,786.

A Consumer Concern

, a health insurance consumer assistance program in New York state, hears from people who are concerned about prepayments, said Diane Spicer, a supervising attorney.

“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said, “and also sometimes for care that is not covered.”

Just how many hospitals collect what are often called point-of-service payments is not known, according to Kodiak Solutions, a technology company that provides services to health systems to help manage their revenue.

“But it is becoming more and more the center of many of our conversations with health systems,” said , a vice president leading Kodiak’s revenue cycle intelligence team.

In addition to Mayo, Baltimore-based says that “it is our policy to collect all amounts owed before services are rendered” for non-emergency care. University of Texas-affiliated in Houston, one of the nation’s premier cancer treatment centers, says patients who pay for their own care “will be asked to pay an initial deposit determined by the care center, based on the type of cancer.”

On average, hospitals collect about a quarter of what they expect the patient will owe, Szaflarski said, based on what they estimate the insurer will pay — a percentage that has grown in recent years.

For example, if a person is coming in for imaging and the insurer will reimburse $1,000 for that scan, the hospital will seek $250 from the patient up front, he said. “That used to be closer to $150.”

It also varies by hospital, and sometimes by state.

“The state of Indiana has some of the lowest cash collections in the country. They are Midwest nice,” Szaflarski said. He added that California and Texas are among those that collect more.

Even as hospitals increasingly collect more upfront payments, however, their uncollected debt is also rising, according to data Kodiak collected from more than 2,300 hospitals nationwide.

said that’s because of a “fundamental shift” in coverage as plans “increasingly feature higher deductibles, greater coinsurance, and more complex cost-sharing structures: all elements that increase the nominal patient responsibility without improving—and often reducing—the probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins — and things could soon tighten further as cuts to ACA and Medicaid funding lead to more people being uninsured.

As a result, hospitals “have to be concerned” about every cost-sharing dollar, Kahn said.

After Zordani returned to Denver, he said, it took a while to find another specialist. He eventually had a procedure in late June 2024, at a Denver hospital not affiliated with Mayo, to fix a .

The following fall, he filed a in Arizona civil court. He was awarded $47,500 in economic damages and attorney fees after an arbitrator in September 2025 determined Mayo violated a state consumer fraud law because it failed to reach him to say that his plan was not in-network before he traveled. Mayo’s statement to Ñî¹óåú´«Ã½Ò•îl Health News did not include any reference to the settlement.

“Had they notified me in timely fashion as required, I would not have flown there,” Zordani said. He’s still angry that the clinic didn’t ask his permission before designating his care as self-pay, which meant he wasn’t going to use his insurance, and he’s still unclear on how they calculated the $5,000 preservice amount.

When Do Consumers Have to Make Preservice Payments?

There is one clear rule: In emergency situations, hospitals that accept federal Medicare financing cannot, , demand upfront payment before stabilizing a patient who arrives at an ER, said , a senior fellow and health policy researcher at the Brookings Institution.

Other consumer protections are less clear.

Patients who get in-network care may have some recourse in their contracts with their insurers, so they should check the fine print, experts told Ñî¹óåú´«Ã½Ò•îl Health News.

“In out-of-network settings, I’m not aware of any barriers that would prevent a provider from doing this,” Fiedler said of preservice deposits.

How those amounts are calculated also appears widely up to the provider and can be opaque.

“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” said , senior director of healthcare campaigns at PIRG, a national federation of independent consumer advocacy groups.

Yet, she added, the patient might be scheduling three months in advance, so the provider wouldn’t know how much was left on the deductible. She recommends consumers ask for an itemized bill and call their insurer to find out whether it has rules regarding the charges.

Also unclear are how and when patients get their money back if they overpay.

Overpayments can happen if patients don’t require the services originally estimated or when insurers pay other bills first, such as the anesthesiology cost or a surgeon’s fees. If those payments are counted toward a patient’s deductible, yet the patient had already made a prepayment to the hospital for the expected deductible, to the hospital.

How soon they get their money back can vary and can depend on state laws, though a small number of states directly address the issue. As of this year, medical providers to reimburse patients within 30 days of a determination of an overpayment. Some states, including Maryland, prohibit certain hospitals from requiring prepayment simply to avoid offering financial assistance.

After alleging that some patients had to wait more than a year to get reimbursed, Arizona Attorney General Kris Mayes recently under state consumer protection laws against SimonMed Imaging, which has 170 locations in 10 states.

, SimonMed agreed to issue refunds within an average of 60 days.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Health secretary Robert F. Kennedy Jr. that AI nurses can provide “concierge care” to rural patients. Mehmet Oz, who leads the Centers for Medicare & Medicaid Services, “the best way to help some of these communities is going to be AI-based avatars” that connect rural patients to mental health services.

And many state health leaders agree. They are using some of their funding from the $50 billion federal Rural Health Transformation Program to expand AI among rural health organizations.

AI is computer technology that performs tasks that typically rely on human intelligence by finding patterns or generating words. It has the potential to improve the healthcare system by automating back-office work or identifying patients at risk, but several reports contend there’s little evidence AI can improve access to care and patient health in rural areas. It’s unclear how well states will track and share outcomes of the tech they invest in.

Meanwhile, some rural Americans are skeptical, according to interviews with people in Hot Springs, South Dakota, a city of about 3,400 residents at the southern end of the Black Hills.

“I get artificial intelligence for certain things, but for personal healthcare — no,” Tara Haffner said while standing outside the American Legion.

Haffner said she’s worried about AI making mistakes and wants healthcare to stay between her and her doctor.

But Phillip Mues, who oversees technology at Cherry County Hospital and Clinic in rural Valentine, Nebraska, said AI is already helping clinicians save time, reduce burnout, and focus more on patient care.

“I think it will help reduce burden on actual staffing,” he said. “It won’t replace people, but I think it will help in rural communities.”

Still, Mues said, AI can’t fix every challenge. Rural hospitals at risk of closing or ending certain services probably can’t use AI to save enough money to prevent those consequences, he said.

Congressional Republicans created the five-year Rural Health Transformation Program last summer as a last-minute sweetener to President Donald Trump’s signature One Big Beautiful Bill Act. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is by more than $900 billion over a decade.

The Word on the Street

Hot Springs, which has a 25-bed independent hospital and a Department of Veterans Affairs hospital, is known for its sandstone buildings, veterans’ services, and, yes, hot springs. Residents must drive at least an hour for more advanced care.

Six people interviewed there by Ñî¹óåú´«Ã½Ò•îl Health News said the biggest problem in rural healthcare is the cost or long wait times caused by staffing shortages.

Doug Nikkila, a heavy equipment operator, said AI and other technology come with benefits and risks.

“If it’s not utilized correctly, it becomes a burden,” he said.

Nikkila, who’s concerned about nursing home residents being neglected amid staffing shortages, said he thinks AI should send reminders to staff when their residents are due for diaper changes or other care. He also wondered whether AI-powered video monitors could send alerts when they detect falls or illness symptoms.

The healthcare industry is rapidly adopting AI despite the tools being “poorly evaluated,” according to a , a Stanford- and Harvard-led group that evaluates health-related AI. The report says that while some AI has been successful in controlled settings, there’s less evidence it can perform in the real world. It also said few studies track patient outcomes.

Evidence is especially lacking in rural areas. A found that only 26 peer-reviewed studies about AI in rural healthcare were published from 2010 through April 29, 2025. Few analyzed implementation or outcomes.

Despite the dearth of results, some states appear interested in bold experiments — such as using AI to suggest diagnoses or recommend treatments. Utah officials said in their application to the rural health program that they are interested in funding a in AI-powered prescription refill requests.

Even tools proven to work in urban settings may not work in rural ones, said Qian Huang, an assistant professor at the Center for Rural Health and Research at East Tennessee State University.

She said the technology is usually tested at large, academic hospitals and trained on data from urban patients, who may not have the same health issues and obstacles — such as a lack of transportation — as rural patients.

A Ñî¹óåú´«Ã½Ò•îl Health News review of states’ plans for the Rural Health Transformation Program shows they’re interested in using AI to automate time-consuming, behind-the-scenes tasks, such as medical charting, coding, referrals, and prior authorization requests. Some states also mentioned ways AI can save money, such as Washington, which discussed tools that “identify and recover” money it’s owed.

Mues said the Valentine clinic has been using AI scribes that record appointments and generate notes describing the visit. He said surveys of clinicians before and after they started using the technology show the scribes have helped reduce burnout by letting providers focus on patient care with “eye contact on the patient, not the computer.”

States also mentioned funding AI that directly affects patient care, such as tools that recommend possible diagnoses and treatment options to clinicians. Mississippi wants to use predictive AI algorithms to “guide” emergency medics with “triage, routing, and treatment decisions.”

Several states want to use AI to analyze patients’ medical charts and remote monitoring devices to identify immediate or future health risks. North Dakota’s plans mention AI to “detect early signs of chronic disease and behavioral health conditions,” while New Hampshire’s discusses AI that identifies patients “at high risk of adverse drug events.”

Some states plan to give patients access to chatbots or wearable devices that transmit data to their clinicians. Utah is interested in funding AI-powered fetal-monitoring devices, while Kentucky will explore using AI chatbots to “deliver personalized nudges and education” through “health coaching, gamified incentives, and rewards.”

Whether the technology appeals to consumers is another matter. Hot Springs resident Stephanie Keller wears a smartwatch to track her fitness but has no interest in an AI chatbot using her data to encourage her to reach her health goals.

“I don’t have the time to chat with AI every day. I mean, are you kidding me? I don’t want to spend my time on a cellphone,” she said.

Rural health facilities also face challenges in implementing AI.

Huang, who has AI in rural healthcare, said rural hospitals and clinics may not have the hardware or IT staff needed to support the technology. She said clinicians and staff may already be doing three jobs at once and not have time to go through AI training.

Rural health facilities may not have fast-enough internet to use AI, while patients may have slow connections at home — if they have internet at all — or may not feel comfortable using AI, Huang said.

“In rural communities, trust and a personal relationship is essential,” she said.

Roy Ehlers, a Hot Springs resident, said he doesn’t trust AI in healthcare, or anywhere else.

“I’m old-fashioned. I don’t believe in it. Technology is not my forte,” Ehlers said.

Mues said that while some rural patients are “scared of AI,” most have let their clinicians at the Valentine facility use the scribing technology to record patients’ visits.

Will States Share AI Results?

Despite questions about implementation, the boom is on. Jordan Everson, an assistant professor at the Georgetown University Department of Family Medicine, said both urban and rural health facilities are rushing to use AI.

“The risk of signing contracts that rural healthcare organizations come to regret is pretty high,” said Everson, who previously worked in the information technology office at the U.S. Department of Health and Human Services.

Several states are addressing that risk by using their rural health funding to create groups that will help rural health facilities vet, select, or monitor AI tools while offering training, ongoing assistance, or funding for upfront costs.

CMS spokesperson Timothy Foster said the agency doesn’t have any AI-specific reporting requirements but is working on a form for states to report their overall progress and outcomes.

Abraham Pritzker, who works at Julota, a company that helps health organizations track data, said states should measure more than how often AI programs are used.

For example, states can measure whether the tech reduces falls, 911 calls, or hospital admissions, said Pritzker, a former paramedic. Huang said it’s also important to ask clinicians and patients about their experiences using AI.

Yet many states’ applications to the rural health program mention tracking only AI adoption metrics, not what happens after facilities deploy the tech. Some of these states may add further reporting requirements down the road.

Vermont spokespeople did not respond when asked why their state’s requires organizations to report only how many clinicians and patients are served by the tech, not how much time they save.

States requiring recipients to report outcomes include , which will track how often AI-powered patient monitoring devices trigger accurate alerts. organizations to track cost savings, while Wisconsin lists “patient outcomes” and “productivity and efficiencies” as possible metrics.

Huang said that after collecting results, states need to share them so other states and healthcare organizations can learn from their experiences.

“We do not have a lot of resources to waste on tools that don’t work in rural areas,” she said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

While knee replacement procedures have become standard, however, the prices charged have not.

At Catawba Valley Medical Center in Hickory, North Carolina, for example, the cost of the procedure under a Blue Cross Blue Shield health plan this year was about $16,000, according to data from Serif Health, a San Francisco startup that collects recently released data from hospitals and insurers. Little more than an hour’s drive west, however, at Mission Hospital in Asheville, the cost of the procedure under the same health plan was around $40,000, or more than double, the data showed.

Formed by the merger of the two largest hospitals in the region, Mission has little competition and more power to demand the higher price.

This comparison between these two hospitals illuminates how large hospital systems created by a in recent decades can dominate the competition and push up healthcare costs.

While many factors affect the price of a medical procedure, hospitals with few competitors can charge more, health economists say.

The hospital price hikes mean patients and their insurers must pay more for an episode of healthcare. But there is an important side effect, too, even for people who don’t require medical care. When insurers face higher hospital prices, they pass the costs on and raise the prices they charge for everyone’s health insurance.

Using Serif Health’s pricing data, it is possible to see how mergers like the one that created Mission Hospital influence costs. For years, it was difficult to determine how much hospital monopolies boosted charges. But since 2021, the Centers for Medicare & Medicaid Services to disclose prices, making it possible to gather comprehensive data such as Serif Health’s.

The connection between market power and prices exists across the country. In Melbourne, Florida, Holmes Regional Medical Center is part of a health system, Health First, that dominates surrounding Brevard County. The center has charged Cigna two times what a hospital two hours north did for a knee replacement this year, the Serif Health data shows.

Banner North Colorado Medical Center, which ranks as the leading healthcare provider in Weld County, Colorado, charged a UnitedHealthcare patient $20,000 more for the surgery in Greeley than a health system an hour’s drive south in Denver, according to Serif’s figures.

The American Hospital Association that hospital mergers can improve quality and reduce healthcare costs by creating “a fiscally sustainable environment.” A Mission Hospital spokesperson said comparing hospitals’ prices was unfair or misleading because their practices and constraints vary so much.

For years, economists suspected that the run of mergers beginning in the late 1990s was a main driver of the rising costs of U.S. healthcare. From 2002 to 2020 alone, unfolded in the United States.

But until the recent federal disclosure rule, the effect of healthcare monopolies on pricing was often overlooked or harder to detect. Hospitals do not advertise their prices, and even when they are revealed on a bill, patients scarcely notice the bottom line because they don’t pay most of it — their insurers do.

“What the data shows pretty clearly is that when hospitals have bargaining leverage, they tend to have higher prices,” said Zack Cooper, an associate professor of public health and economics at Yale University who has spent more than a decade studying hospital monopolies.

Over the last quarter century, Cooper said, hospital prices have risen faster than those for any other economic sector, and “hospital consolidation is one of the primary drivers.”

Federal and state officials have wavered over when to intervene when hospitals are proposing to merge. Last summer, former President Joe Biden’s that urged federal agencies to challenge mergers that could harm consumers, reversing course from Biden’s more aggressive enforcement of antitrust law. In a , however, Federal Trade Commission Chairman Andrew Ferguson called for a task force on healthcare mergers that are leading to “higher prices” and “decreased quality” of care.

Several states have sought to curb healthcare monopolies. In 2023, Minnesota banning anticompetitive healthcare mergers and bolstering state oversight. In 2022, requiring healthcare businesses to give the state a 90-day notice of large mergers and to investigate their effects on competition. And in 2021 enabling the state health department to block acquisitions and mergers of hospitals.

Nothing has stopped the overall trend, however, as hospitals seek to grow and gain leverage over insurers and competitors. Last year alone, hospital and health systems announced 46 mergers and acquisitions, , a healthcare business consulting firm. Five ranked as “mega-mergers,” meaning they were valued at more than $1 billion. One across Connecticut and New York into a powerful interstate health system. Another linked , a deal that created a 56-hospital system across the Midwest — including Iowa, Michigan, Minnesota, Wisconsin, and Wyoming — with combined revenue of about $10 billion.

Other mergers have been proposed in , , and Minnesota.

Asheville’s Dominant Hospital

Few places in the United States better exemplify how hospital mergers reshape healthcare than Asheville.

In 1998, the state authorized a deal that joined the city’s two acute-care hospitals, St. Joseph’s Hospital and Memorial Mission Medical Center, . Ever since, its effects have been studied and its prices fiercely contested.

Marcelle Crago, a nurse and lactation consultant, is one of many patients who have accused Mission Health, which operates Mission Hospital, of gouging consumers. Last year, she tweaked her knee while cross-country skiing.

“My knee went ‘pop, pop, pop,’” she recalled. She had torn her meniscus, the rubbery cartilage around the knee that acts as a shock absorber. A doctor advised her to have a portion of it removed.

Two days before the surgery, Mission Health told her the total charge would be over $9,000, according to paperwork on her case filed with the state’s Consumer Protection Division.

“I was shocked at the number,” she said.

Crago’s insurance policy from UnitedHealth Group had a high deductible, so she would have had to pay most of the cost. She decided to postpone the surgery and shop around, eventually arranging to have it done at an outpatient center not affiliated with Mission. There, the bill came to less than a third of the price Mission Health charged, according to paperwork she kept.

“The way Mission Health handled the whole thing felt predatory,” Crago recalled, noting that when she balked at the $9,000 figure, the hospital offered a 20% discount if she paid up-front. “It makes you wonder how much they are playing with prices.”

In responding to Crago’s complaint with the state, an attorney for Mission and HCA Healthcare, which owns the hospital, wrote that hospital charges “represent the cost for supporting the entire episode of care” and must cover the hospital’s investments in advanced technology, training, staff, and other critical needs.

“Patients are certainly entitled to ‘shop around’ for surgical procedures,” wrote the attorney, Phillip Jackson.

It is not just patients who bear the burden of rising hospital prices.

Over time, anyone who pays for health insurance pays a price for hospital monopolies, as insurers boost premiums as medical costs rise. The full cost for an employer to pay for an average family health insurance plan rose to more than $27,000 in 2025, up from $21,000 just six years ago, according to .

Around Asheville, employers and employees complain that their insurance premiums are higher because Mission’s prices are so high.

As the chef and co-founder of Cúrate restaurant in Asheville, a business with about 100 employees, Katie Button provides employee health coverage and believes she has been paying for Mission Hospital’s excessive prices, according to a pending class-action lawsuit she filed in 2021 with five residents who say the monopoly has harmed them.

Any insurance plan in Asheville must include Mission Hospital, she said, because it is the only one around. This makes the burden of its prices unavoidable.

“We are where we are because we don’t have a choice of hospitals,” Button said. “There is no other option.”

The steady creep of healthcare costs is top of mind not just in Asheville but for most U.S. voters, according to . Nearly two-thirds of U.S. adults were worried about being able to afford healthcare, the poll found.

Yet while federal law allows regulators to step in and block mergers deemed to create monopolies, the FTC intervened in only from 2002 to 2020 to stop a hospital merger, according to a Yale University study. The FTC has since announced challenges to five other hospital mergers.

Birth of a Monopoly

When Mission Health was formed by a merger in 1998, state officials recognized that Asheville’s new dominant hospital system would have the power to raise prices and required Mission to sign an agreement to limit spending and profit margins.

Even with these restrictions, the hospital , according to economic research cited by the FTC. But Mission’s prices were about to go up even more. In 2015, Mission Health lobbied the state legislature to drop the state restrictions, abandoning the profit limits.

“After 20 years of the hospital behaving itself, the state decided to terminate its oversight,” said Mark Hall, a professor emeritus at Wake Forest University who of the hospital’s merger history. Then, three years later, HCA, the largest hospital corporation in the country, bought Mission Health. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund Ñî¹óåú´«Ã½Ò•îl Health News’ coverage.)

“This put a prepackaged monopoly into the hands of the world’s largest for-profit hospital corporation,” Hall said.

Across a range of services, Mission Hospital charges more than other North Carolina hospitals, according to figures from Serif Health.

Consider the prices that Mission negotiated with UnitedHealthcare compared with those the insurer pays at Catawba Valley Medical Center. For a breast biopsy, UnitedHealth pays $7,500 at Mission and $1,700 at Catawba, according to Serif. For a hernia repair, it pays $17,700 at Mission and $9,600 at Catawba.

“The prices hospitals charge are one of the leading drivers of rising healthcare costs,” according to a UnitedHealthcare statement sent by spokesperson Cole Manbeck.

Mission spokesperson Katie Czerwinski, in a statement, said that it can be misleading to compare one hospital with another.

Mission Hospital is almost three times as large as Catawba Valley Health and is a Level 1 trauma center serving a different population, Czerwinski said. She also said that pulling individual rates for comparison paints an incomplete picture.

But other figures indicate that prices at Mission Hospital are relatively high, even when viewed collectively.

A team at the think tank Rand, led by Christopher Whaley, now a Brown University health economist, uses commercial insurance records to compare average hospital prices across the U.S. relative to those paid by Medicare. , Mission Hospital in 2024 charged prices that were 334% of prices set by Medicare. Catawba Valley Medical Center charged 237%. The state benchmark for prices is 280% of Medicare, Rand figures showed.

“The prices we pay for healthcare vary tremendously and are uncorrelated to the value we receive,” according to the Rand website.

For many in Asheville, the primary complaints about Mission Hospital focus on the quality of patient care. This is consistent with showing that the quality of care declines when hospitals have little competition.

Amid rising complaints about hospital services, North Carolina state Sen. Julie Mayfield, a Democrat, helped launch a nonprofit organization two years ago called Reclaim Healthcare WNC to hold Mission “accountable for its harmful practices.”

“Within a year of the HCA sale, I started hearing stories from physicians and other friends about all the terrible things that were happening there,” Mayfield said, most of them caused by severe staff cuts and physicians leaving.

Three times since 2024, state health inspectors working on behalf of CMS have issued “immediate jeopardy” findings to Mission Hospital, indicating problems so severe that they posed an imminent risk of serious injury or death to patients.

In the most , an 88-year-old woman recovering from a fall and hip surgery at Mission Hospital died after going a night without receiving a blood transfusion.

Czerwinski, the Mission Hospital spokesperson, said a proposed plan of correction “allows Mission to address the findings from the survey and complete a comprehensive review of operations.”

As more hospitals across the United States plan to merge, Mayfield said, the experience in Asheville represents a cautionary tale.

“Unregulated monopolies have never gone well for the public.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

More than 900 people in Washtenaw County, Michigan, have been sickened with cyclosporiasis since mid-June. Linda Kim, a public health nurse, has called more than 100 of them. Almost everyone has said the same thing: It’s excruciating, and one of the worst illnesses they’ve experienced.

But on a Wednesday in July, she called one man who said he wouldn’t mind having it again, actually.

“You’re enjoying the weight loss?” Kim said, laughing as she took notes in a small conference room at the Washtenaw County Health Department building, just outside Ann Arbor. “Well, I’m glad to hear that. At least you got something good out of it!”

Normally, Kim’s supposed to be working downstairs in the clinic, where families wait in gray plastic chairs in the lobby for free or low-cost immunizations. But she hasn’t been there in months.

In March, Kim was transferred to a different department to help deal with a measles outbreak that sickened seven people in the county, five of them children. It was an all-hands-on-deck situation; everyone worked overtime. The state issued an advisory urging families in Washtenaw and surrounding counties to get babies 6 months or older vaccinated ahead of schedule, if possible.

The contact-tracing calls for measles could be contentious, Kim said. People were suspicious, asking her how she knew they had tested positive, or why they should give her any information.

“People were like, ‘Oh, you’re just trying to restrict my life,’ or ‘You’re just trying to get information out of me and get me in trouble,’” she said. “It’s like, no, we’re actually not doing that at all.”

As she tried to explain to them, tracing the spread of the virus and publicizing possible exposure sites was an effort to “keep it contained, so it doesn’t become something huge.”

The county’s measles outbreak ended in late May. Then in June, reports of cyclosporiasis cases started pouring in — so far in Michigan, including two deaths. Both people who died had “significant underlying health conditions that may have been impacted by cyclosporiasis and dehydration,” the state health department said on its website Aug. 3. Health officials aren’t providing more details, department spokesperson Lynn Sutfin said in an email, but are stressing that cyclosporiasis generally isn’t life-threatening and that deaths from it are uncommon in the U.S.

Kim said the cyclosporiasis surveillance has been very different from her experience with the measles outbreak. Now, people seem eager to divulge even the most graphic details, such as “pooping their beds, and, like, putting down towels and it’s not enough.”

Since she’s a nurse, such confessions don’t faze her, she said. Still, staffers have hundreds of these calls to make, so they try to keep each conversation under an hour.

But foodborne illness investigations are complex. Especially for this parasite, cyclospora. Symptoms can take as long as two weeks to appear after people have eaten contaminated food. And no one remembers what they ate two weeks ago, public health staffers said.

The interview process can be extremely detailed. Kim and her colleagues ask people to pull up their restaurant receipts, scroll through purchases on their grocery store apps, even try to recall details such as the exact brand of bagged salad mix they bought, or the type of taco they got at Taco Bell.

“Is that the crunchy one or the soft one?” Kim asked on a recent call, typing on a laptop decorated with cat and vaccine-themed stickers.

Kim has been working with the health department for two years, a period defined by federal funding cuts.

Laina Stebbins, a spokesperson for the Michigan Department of Health and Human Services, said the Trump administration’s sweeping cuts to public health grants eliminated a contract between the state health department and 44 of the state’s 45 local departments that funded 123 full-time employees.

Those cuts also affected the state’s disease surveillance labs, “reducing funding for equipment maintenance contracts, data modernization, and the ability to innovate laboratory processes during emerging disease response,” Stebbins said.

Some of that funding was restored after Michigan against the Trump administration. But Washtenaw’s health department still had to scale back some disease surveillance and outbreak response work. Currently, employees who leave or retire aren’t replaced, except for those on the nursing team, which is hiring but still understaffed.

The county’s , which aims to reduce health disparities, including in mental health, was shuttered suddenly in early 2025. Nearly a year later, it resumed its work, with funding at least through this September.

An employee from the Centers for Disease Control and Prevention had been stationed at the department. During the funding chaos, the worker was fired, then rehired, then furloughed.

The federal response to cyclosporiasis has felt frustratingly slow, according to Christina Zilke, a nursing supervisor at the Washtenaw health department.

“It took them forever to say that this was lettuce, and fast-food restaurants were taking it off the shelves before the CDC ever said what it was,” she said.

During a July 14 press call, the deputy director of the CDC’s Division of Foodborne, Waterborne, and Environmental Diseases, Gwen Biggerstaff, said it’s not unusual for it to take a specific source for cyclosporiasis — if it’s identified at all. That’s partly due to the lag time between exposure and the appearance of symptoms, and the complexity of tracing this particular parasite.

Meanwhile, Zilke’s been stocking the coffee station and bringing in pizza, trying to keep up staff morale. It’s not a reward, she said. “It’s more like: ‘Here’s some food for survival. Here’s a break so you don’t quit.’”

Kim, for her part, remains enthusiastic about the job but said it’s been a surreal introduction to a public health career — first measles, now cyclospora.

“If nationally they don’t know what’s going on, how are we locally expected to know what’s going on?” she said. “And also just frustrating to be, like, ‘Wow, I don’t think even our government knows how important public health is.’”

But there’s no time to dwell. She has to move on to the next call, as soon as she can wrap up this one. She gives each person her work number, so people can call or text with any follow-up questions.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Afterward, though, use of Sturgis Hospital’s emergency department fell, according to data collected at the state level. In June, three years after taking the federal lifeline, the hospital closed, leaving residents of Sturgis, a town of about 11,000 people, without critical healthcare. Its leaders had tried “every reasonable option” to remain open, including seeking a buyer, according to a

The closure “could be kind of a canary in the coal mine” for rural healthcare, said Lauren LaPine-Ray, the vice president of policy and rural health at the Michigan Health & Hospital Association.

Federal leaders have spent decades trying to prop up rural hospitals, which face persistent staffing shortages, low federal payment rates, and declining patient numbers.

About 1,700 hospitals nationwide are eligible to convert to the stripped-down Rural Emergency Hospital model. So far, more than 50 rural hospitals in over 20 states have signed on, but LaPine-Ray and other hospital leaders nationwide fear Sturgis’ failure is a sign the new model won’t be enough to keep doors open when the anticipated federal funding losses arrive from President Donald Trump’s signature One Big Beautiful Bill Act.

Last year, the survival of rural hospitals became as Congress debated the massive tax and spending law, which is expected to reduce Medicaid funding by more than $900 billion over 10 years. The reductions are expected to have a substantial impact in rural areas that often have high Medicaid enrollment. Republicans added the new $50 billion Rural Health Transformation Program to win votes from a few holdouts in their ranks.

Sturgis’ facility is the only rural U.S. hospital to in 2026. The day before it shuttered, four senators — including Maine Republican Susan Collins, an architect of the rural health fund — sent a letter to Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services. said the way his agency structured the fund “may unintentionally disadvantage many of the rural hospitals and clinics the program was intended to support.”

Congress created the emergency hospital model, which took effect in 2023, as “a whole new way of providing care,” said George Pink, a senior research fellow at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. The Sheps Center tracks rural hospital closures and conversions, and Pink recently released early research showing converted hospitals reporting improved finances, though some are not yet in the black.

Hospitals that convert to the emergency model get a 5% boost in Medicare payments plus an extra monthly facility payment, totaling about $3.6 million a year, according to the Rural Health Redesign Center. In return, the hospitals must offer emergency services and give up their inpatient beds. They can continue offering outpatient services.

Janice Walters, CEO of the Rural Health Redesign Center, which has received federal funding to help hospitals change to the new model, said dozens of hospitals had reached out about converting during the first five months of 2026. It’s reasonable, she said, to presume that 10 or 11 might convert this year.

‘No Easy Answers’

More than 40% of all rural hospitals lose money, and hundreds have eliminated obstetrics, general surgery, and chemotherapy services, the healthcare consulting group Chartis.

Sen. Chuck Grassley (R-Iowa) sponsored the legislation that created the emergency hospital model. He touted the program last fall, pointing to hospitals such as Landmann-Jungman Memorial Hospital Avera in South Dakota, which he said would be able to use the model to enhance local health services.

Melissa Gale, the chief executive of the Scotland, South Dakota, hospital, said the facility averaged less than one inpatient a day and was “a little above or below break-even year-over-year for decades.”

Today, with additional federal funding from the emergency model, Gale said, the hospital could try to draw in more patients for mammograms and may add a wound care program. In the past year, the hospital has improved employee benefits and reinvested in the building, upgrading plumbing and the heating and air conditioning, she said.

“No one wants to see rural health fail,” Gale said, adding, “There’s no easy answers.”

Federal lawmakers have tried, and thus far failed, to update the emergency hospital model. One proposal, which is expected to be reintroduced, would allow converted hospitals to offer new services, such as beds for patients who need short-term recovery and in-house obstetric labor and delivery units. Another, which is in committee, would allow hospitals to use a federal drug discount program that many facilities use to generate revenue.

The current law is a “critical start, but it must evolve,” said Carrie Cochran-McClain, the chief policy officer for the National Rural Health Association, whose members include hospitals and clinics.

Residents of the southeastern Iowa town of Keokuk continue to hope their shuttered hospital will reopen under the program. The effort has been plagued by delays.

The Keokuk hospital went out of business in 2022 and was later purchased by a Michigan company that pledged to reopen it.

“It’s been a slower process than we envisioned,” said Insight Health Systems Vice President Dayne Walling. Many of the delays have been related to improvements needed to the aging building, he said. Without the emergency hospital model, Walling said, his company would not see a realistic path to reviving the hospital.

Walling said the emergency model would be even better if Congress approved the bill that would allow hospitals to make extra income from prescription medications.

Dierdra Sorrell, the CEO of Clifton-Fine Hospital in Star Lake, New York, said converting to an emergency hospital was not a “silver-bullet, magic pill.” But it “put us in a much better place.”

The 20-bed hospital lost more than $2.5 million annually before 2024, when it became New York’s first emergency hospital, Sorrell said. While converting, the hospital shut down inpatient beds and cut 20 employees.

The first year, Clifton-Fine lost only $600,000, and its emergency patient visits were “rock solid,” Sorrell said. The hospital also won state grant money to update its two-bed emergency room and pay for additions that could house visiting specialty doctors or new lines of services, such as a dental hygienist.

If Clifton-Fine had not converted, Sorrell said, anticipated Medicaid losses could have “put us under.”

‘One Important Tool’

Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, said the emergency model is “one important tool” for rural hospitals, “but each facility must determine whether this care model is appropriate.” Foster also said that the new five-year, $50 billion rural health fund was created to support “innovative, system-wide reforms” that strengthen the rural healthcare delivery system.

Of the 56 hospitals that have converted to the rural emergency model, two have closed, and three remain open but have changed what services they offer, according to Sheps.

In Holly Springs, Mississippi, Alliance HealthCare System was one of the first to convert to the emergency hospital designation, laying off staff and shutting down inpatient beds.

Then, federal officials said they and required the hospital to recertify as a new hospital, a delay that cost an estimated $1.5 million in federal reimbursement, CEO Kenneth Williams said.

The hospital is “a shell of what it once was,” Williams said. The ER remains closed.

“We have survived, but survival has come at a tremendous cost,” he said.

Williams said he is closely watching the impact of upcoming Medicaid changes because cuts in insurance coverage or payments “ultimately affect patient access,” he said.

Sen. Josh Hawley (R-Mo.), who voted for the One Big Beautiful Bill Act — which included both the rural health fund and the Medicaid spending reductions — has asked for more support for rural hospitals. Ten full-service rural hospitals in Missouri have closed in the past 12 years, according to the Sheps Center.

Last year, Hawley introduced legislation to . This June, he to announce that he wanted to pay rural hospitals $1 million annually, or more if needed, to keep emergency rooms operating. A spokesperson said the bill would apply to all rural hospitals, including those using the emergency model.

Michigan’s Sturgis Hospital faced “some significant challenges” in 2023 when it converted to the emergency hospital model, said LaPine-Ray, of the state hospital association. In the news release, hospital officials said the closure was due to declining reimbursement rates, rising costs, and declining patient numbers. Bobby Morin, a former chief operating and financial officer at the hospital, declined to comment.

The hospital’s ER patient volume dropped 13% in the two years after it converted, LaPine-Ray said. Five rural hospitals have closed in the past 20 years in Michigan, and LaPine-Ray said she doubts the rural health fund Congress approved last year will stop the closures. The association, which worked with the governor’s office on the funding, expects less than 10% of Michigan’s $173 million in first-year rural health funding to trickle down to rural hospitals.

That money will pay for “very specific programs where rural hospitals have to create basically a new program and implement it with no funding on the front end,” LaPine-Ray said.

At the same time, she said, the association expects Michigan hospitals to lose $6 billion in Medicaid payments over the next decade because of the One Big Beautiful Bill Act.

“What’s it going to look like in the coming years?” LaPine-Ray said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The officials, all Democrats, are running at a time when the Trump administration is reducing government funding for scientific research, restricting access to some vaccines, and making it more difficult for some Americans to obtain health insurance.

Shaughnessy Naughton, president of 3.14 Action, a political action committee that recruits Democratic candidates with science and health backgrounds, said it is unusual to see so many public health leaders running for office.

“But it’s not surprising given the moment we are living in, with an arsonist running HHS working to undermine the vaccine schedule and public health at large,” she said.

Health and Human Services Secretary Robert F. Kennedy Jr. is a longtime anti-vaccine activist who disparaged public health measures implemented during the pandemic, going as far as calling the covid vaccine the “.”

Neither HHS nor the White House responded to requests for comment.

Several of the candidates benefit from name recognition built during the covid pandemic, political science scholars say, when daily news briefings from local health officials became must-see-TV for many citizens sheltering in place from the novel virus. But that cuts two ways.

While many Americans regarded public health officials as offering prudent advice and a steady voice, others criticized them for pushing school closures, mask mandates, and new, quickly created vaccines. The attacks have escalated under President Donald Trump, with Republicans targeting pandemic-era public health leaders such as Anthony Fauci and a former Fauci adviser even facing .

National polls show healthcare is for many voters this year, with Democrats most worried about costs and Republicans about fraud. But that’s no guarantee of victory. Nirav Shah, an epidemiologist who led Maine’s top public health agency through the pandemic, lost a narrow Democratic primary in the state governor’s race in June.

Here are some of the public health officials on the ballot this year:

Xavier Becerra, Running for Governor in California

Becerra, who served as HHS secretary under President Joe Biden, is the highest-ranking former health official running this cycle. He won a crowded and expensive open primary and now faces Republican Steve Hilton, a British-born former Fox News host, in the general election.

Mark Peterson, a public policy professor at the UCLA Luskin School of Public Affairs, said with the pandemic in the rearview mirror, any judgment voters may have about the federal government’s response is more likely to reflect on Biden rather than Becerra, who has no medical background and maintained a low profile as HHS secretary.

Leading the nation’s health department as the pandemic lingered, Becerra focused more on expanding access to the Affordable Care Act and Medicaid, overseeing record numbers of people enrolled in the publicly financed programs during his tenure. He did face criticism over the processing and placement of a massive influx of migrant children at the U.S.-Mexico border, as well as his agency’s response to a baby formula shortage brought on, in part, by major product recalls.

Becerra has said he now wants to be California’s “healthcare governor,” a mantle outgoing Gov. Gavin Newsom tried to claim upon taking office in 2019.

Becerra’s campaign did not respond to a request for comment.

Before becoming HHS secretary, Becerra served as California’s attorney general and sued the first Trump administration more than 100 times, leading a coalition of states against GOP efforts to gut the ACA. He also started a unit in his office focused solely on healthcare. During Becerra’s tenure, his office reached a $575 million antitrust settlement with the California hospital system Sutter Health, pursued pharmaceutical companies that delayed generic drugs, and helped block a Trump administration rule that let employers choose whether to cover .

Voters often regard decades of experience in government as a negative, Peterson said. But for the job of running the nation’s most populous state and the world’s fourth-largest economy, he added, “I think there are a lot of people out there who would like to have somebody who actually has run a big enterprise.”

In , Becerra has said California should maintain state-funded Medicaid coverage for immigrants without legal status. He is also a longtime supporter of implementing single-payer healthcare, though in recent interviews he has said it needs to be addressed at the federal level.

Amy Acton, Running for Governor in Ohio

Acton ran Ohio’s health department from February 2019 to June 2020.

During the first months of the pandemic, Acton appeared at daily news conferences with the state’s Republican governor, Mike DeWine, that were jokingly dubbed “.” She earned fans with her calm and positive demeanor while explaining her approach to keeping covid at bay.

But she also attracted critics with her recommendations to stay at home, mask up, and shut down some businesses to curb the virus’ spread. Protesters even showed up at her home.

Acton’s Republican opponent in the governor’s race, Vivek Ramaswamy, has labeled her “Dr. Lockdown” on social media. His criticism of her role in shutting down businesses could prove effective with the economy at the top of many people’s minds, said Christopher Devine, a University of Dayton political science professor.

“It’s a double-edged sword, because she also really upset some people,” Devine said of Acton’s time as the health director during the pandemic.

He said that is a tricky attack for Ramaswamy to pursue, though, because DeWine — still the sitting governor and a popular conservative figure — endorsed the covid measures Acton recommended, granting her emergency powers to sign the orders, and has since said he takes all responsibility for those actions.

For her part, Acton has done little on the campaign trail to highlight her time as the state’s public health director. Instead, she has focused more on healthcare affordability, highlighting the Trump-led cuts to Medicaid and the scaled-back subsidies for ACA plans that have resulted in dropping coverage in the state.

“I hear from families across Ohio that healthcare costs are rising and they just can’t keep up,” Acton said in an emailed statement. “That’s why I will fight to protect and expand access, reduce the price of prescription drugs, forgive medical debt holding Ohioans back, and lower premiums.”

Abdul El-Sayed, Running for U.S. Senate in Michigan

El-Sayed — who ran the health departments in the city of Detroit and Wayne County, Michigan — is one of two leading Democratic candidates for Senate. The primary is Aug. 4.

El-Sayed, a progressive, is facing off against Haley Stevens, a four-term congresswoman. They are vying to run against Republican nominee Mike Rogers, a former congressman, for the Senate seat held by retiring Democrat Gary Peters.

From 2015 to 2017, El-Sayed ran the Detroit Health Department, which and privatized as part of the city’s 2013 bankruptcy. In his role, he led efforts to test Detroit schools for lead in the wake of the Flint water crisis and provide free eyeglasses to children in public schools.

From 2022 until 2025, he ran the health department in Wayne County, the state’s most populous county, which includes Detroit. In that job, he initiated a program to retire medical debt for thousands of residents and make naloxone available in public areas to reverse the effects of opioid overdoses.

In an interview with Ñî¹óåú´«Ã½Ò•îl Health News, El-Sayed said his public health experience helped him become an effective communicator and challenge corporations and the role they play in healthcare.

“Politics have become overrun by big money and corporations, and my training and background in public health has taught me to think about that and push back against it,” he said.

El-Sayed, who did not practice medicine after completing his residency and is not licensed to do so, has faced criticism from some in his party for calling himself a doctor.  

El-Sayed, who has endorsements from Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Alexandria Ocasio-Cortez (D-N.Y.), supports “Medicare for All,” a policy favored by many progressives that would make more people eligible for the federal health program for people who are 65 and older or disabled.

David Dulio, a professor of political science at Oakland University in Rochester, Michigan, said that the broader economy, Trump’s tariffs, and trade are eclipsing healthcare this year as top concerns for voters in the state. But he added that “progressive stances such as Medicare for All are attractive in the Democratic primary electorate.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The race is in Iowa, whose Medicaid program has been plagued with controversy since 2016, when the state hired national insurance companies to manage billions of dollars’ worth of benefits.

That shift was made by then-Gov. Terry Branstad, a Republican. With his executive order, Iowa joined most other states in privatizing the management of Medicaid, which covers healthcare for more than 67 million Americans with low incomes or disabilities.

The arguments have resurfaced this year during the competition to replace Republican Gov. Kim Reynolds, who was Branstad’s protégé and continued contracting with private companies to manage Medicaid benefits. Zach Lahn, the Republican candidate to succeed the retiring governor, supports the practice. Rob Sand, the Democratic candidate, wants to end it.

“It’s been a disaster,” said Sand, Iowa’s state auditor. “The number of complaints has been catastrophic.”

Pros and Cons

Supporters of privatization say the insurers, known as managed-care organizations, make Medicaid more effective and efficient. Critics contend the companies pad their profits by denying payment for crucial health services and by shortchanging agencies and professionals who provide care.

Iowa is among 41 states, plus the District of Columbia, that contract with outside companies to run at least part of their Medicaid programs. Overall, private insurers manage the benefits of more than three-quarters of Medicaid patients. Connecticut is the only state that has fully reversed course after privatizing its Medicaid system.

Sand has criticized privatized Medicaid for years. As state auditor, he alleging that the national insurers systematically deny or delay payment for services to which Medicaid participants are entitled.

He has vowed not to renew state contracts with the three insurers managing care for more than 600,000 Iowans on Medicaid, which is jointly financed by the state and federal governments. He would rather have state employees or nonprofit agencies review and pay bills from clinics, hospitals, and other healthcare providers.

Lahn told Ñî¹óåú´«Ã½Ò•îl Health News that Sand’s pledge to resume state administration of Medicaid “is the exact wrong idea.”

Lahn is a former activist for Americans for Prosperity, a national pro-business group affiliated with the Koch family. He contends that state governments and Medicaid participants benefit when insurers compete to serve them.

“There are very few things that government does more efficiently than the private sector,” he said.

Lahn, who is a businessman and farmer, emphasized that state officials should strictly enforce contract requirements, ensuring that the insurers treat Medicaid recipients fairly and make prompt payments to care providers. He also said he would bar insurers from using artificial intelligence systems to determine whether to pay for medical claims under Medicaid. “Iowans deserve to have a human looking at their case,” he said.

Sand said in a recent interview that he doesn’t want Iowa to fully return to a “fee-for-service” Medicaid system, in which hospitals, clinics, and other healthcare agencies would effectively be paid piecemeal for whatever services they provided. Instead, he said, state employees or nonprofit organizations could take over operation of a managed-care system, in which administrators review services to help ensure Medicaid participants receive what they need without wasting public money on ineffective services.

A few months ago, Republicans controlling the Iowa Legislature considered a bill to require the state to have a privately managed Medicaid system. That proposal would have blocked future governors from unilaterally shifting back to public management of the program. But the bill

Sand, a former assistant state attorney general, said he is confident he would have legal authority as governor to stop contracting with private Medicaid managers, although he cautioned that the transition would be complicated and could take time.

A Toss-Up Race

National political observers say the Iowa governor’s race

This June, Lahn won an underdog primary campaign to beat a sitting congressman backed by President Donald Trump. Lahn gained Trump’s endorsement after winning the Republican primary. He is a vocal supporter of the Make America Healthy Again movement, led by Health and Human Services Secretary Robert F. Kennedy Jr., which aims to improve Americans’ diets and reduce environmental poisons.

Sand noted that Lahn’s past political activism included a failed 2014 attempt to defeat a proposal to cover more people under Montana’s Medicaid program.

Lahn said that at the time he worried the federal government would reduce how much money it would contribute to such Medicaid expansions, leaving states to foot much of the bill. He said he also didn’t want to see public programs such as Medicaid giving benefits to adults capable of providing for themselves. But he said those concerns have been allayed, partly by the Trump administration’s moves to require millions of Medicaid recipients to prove they are working, volunteering, or going to school.

If elected governor, he said, he would not try to reverse Iowa’s expansion of Medicaid, which happened in 2014 under Branstad.

Branstad also is the governor who decided in 2016 to hire private insurers to manage Medicaid.

Branstad, who declined to comment for this article, did not need the legislature to approve his momentous decision. He weathered controversy over the change, including allegations that the companies systematically denied payment for care that people with disabilities needed to remain in their homes.

Andy Schneider, a who studies health policy issues, said it’s understandable that many government leaders see an advantage in hiring private Medicaid management companies. Each state’s Medicaid program pays claims for hundreds of thousands or even millions of members, and administrators must scrutinize bills from thousands of hospitals, clinics, and other healthcare organizations. “That’s a heavy lift,” said Schneider, who worked in federal Medicaid administration when Barack Obama was president.

Schneider noted that Medicaid expenses are among the biggest parts of any state’s budget. The costs can vary dramatically year to year, he said, which is hard for legislators and governors to plan for. Management companies sign contracts for set amounts of money per enrollee, depending on people’s ages and health conditions. Managed-care companies say they can improve Medicaid members’ health and reduce expenses. But Schneider said have been unable to confirm or disprove those claims.

Federal law gives states flexibility in how they run their Medicaid programs, including whether they hire private insurers to manage the programs. “Unwinding those arrangements might take a little time, but there’s no question they can do it,” Schneider said.

Connecticut of private insurers to run Medicaid in 2012. to contract only with nonprofit insurers, starting in 2025, and that state’s governor doing away with private management altogether.

Gary Jessee, a former Texas Medicaid director who helped transition that state’s program into managed care, noted that most Americans’ health coverage is managed by some kind of insurance company, whether they obtain it on their own or get it through a government or employer plan.

Jessee now helps run a whose clients include Medicaid managed-care companies. He said states rarely talk about totally scrapping contracts with such companies. Instead, he said, states have options to change the contracts, including to increase oversight or limit profits.

Overall, Jessee said, managed-care companies help Medicaid enrollees obtain the services they need to stay healthy. But it’s hard to calculate how much money the companies save states, he said, because all healthcare costs have been rising, and new members of managed-care plans may at first use more services as the insurance companies encourage them to get regular checkups instead of waiting for emergencies.

Iowa’s Medicaid program is managed by three insurers: Molina Healthcare, Elevance Health subsidiary Wellpoint, and Centene subsidiary Iowa Total Care.

None responded to requests for comment for this article.

Catherine Gray of Des Moines helps run a Facebook page for families who use Iowa’s Medicaid system. Her adult son, John, is on Medicaid because of a disability. Gray said the managed-care companies have made it much harder for people to obtain services, including mental healthcare, dental care, and transportation to health appointments. Iowa’s shift to the private system was abrupt and chaotic, she said. “We know people have died,” she said.

Gray said she probably will vote for Sand for governor, even though she doesn’t agree with every nuance of his stance on Medicaid. She suspects many other Iowans who use the program will do the same. “They’ve really been put through the wringer for 10 years, and they’re exhausted.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

That’s the concern of food safety leaders across the U.S. who are raising alarms over federal cuts they say have made it harder to detect and stop the spread of foodborne illnesses, such as the recent outbreaks of cyclospora, which has in dozens of states. And they’re especially worried the next pathogen will be much more deadly.

Food safety in the U.S. is monitored by a piecemeal system of state and federal agencies. That network is in charge of detecting, investigating, and stopping outbreaks of foodborne illnesses. Key to the system is the Centers for Disease Control and Prevention’s FoodNet program, created after four children died from E. coli in hamburgers in the early 1990s. States participating in the program, officially called the Foodborne Diseases Active Surveillance Network, contact labs to get case data that can signal when a problem is emerging.

But in President Donald Trump’s second term, his administration has slashed billions of dollars in public health funding and fired thousands of workers at federal health agencies. It has also curtailed FoodNet, stopping the program’s mandatory tracking of cyclospora and five other pathogens that together kill hundreds of people in the U.S. each year.

“You’re basically allowing for outbreaks to continue without being figured out. Invariably more people will get sick,” said Bill Marler, a Seattle-area food safety lawyer and advocate who has filed lawsuits against Taco Bell on behalf of people who allege they were sickened by cyclospora after eating there.

Under the changes to the FoodNet surveillance system, the 10 participating states — meant to represent a cross section of the broader population — no longer have to report cases of listeria, for example. That bacteria of people who are diagnosed with it.

Complications from listeria infections can include convulsions, miscarriage, and sepsis that damages organs. It’s much more rare than the type of E. coli bacteria still required to be tracked by FoodNet, but of people infected with listeria wind up hospitalized. Listeria infections result in an estimated according to numbers from the CDC and the Food and Drug Administration.

“It’s very hard to identify listeria outbreaks,” said Neal Fortin, the director of the Institute of Food Laws and Regulations at Michigan State University. Seeing it cut from FoodNet’s mandatory surveillance “really does disturb me,” he said.

Thirty-three people died and a pregnant woman had a miscarriage in 2011 after with listeria. The FDA identified the cause in .

States participating in FoodNet also no longer have to report illnesses caused by campylobacter, a bacteria often contracted from raw and undercooked poultry that afflicts an estimated 1.5 million people each year. The bacteria sickened about 60 people in Idaho this year in an outbreak linked to raw milk — a product Health and Human Services Secretary Robert F. Kennedy Jr. has championed, even though pasteurization kills harmful bacteria.

HHS denies that the changes to FoodNet or Trump administration staffing cuts have elevated the risk that future outbreaks will be harder to identify and stop.

“FDA investigators were not affected by staffing changes or force reductions, and the FY 2027 President’s Budget proposes a $33 million increase for food safety activities,” HHS spokesperson Emily Hilliard said in an email. And the CDC never stopped monitoring illnesses caused by cyclospora, she said.

The CDC has other, passive surveillance systems, but they rely on states to report problems.

“There’s no requirement of how long it takes them to do that,” said Barbara Kowalcyk, the director of the Institute for Food Safety and Nutrition Security at George Washington University.

And the FDA meets only a fraction of the number of inspections mandated by Congress. The FDA for domestic and foreign inspections since 2018, according to a report early last year by the Government Accountability Office.

Food safety by the FDA plummeted from 10,641 facilities in 2011 to about 4,500 a decade later. The agency had for domestic and foreign inspections in 2024, according to a GAO report.

That was before the Trump administration in a push to reduce federal spending.

Now, food safety leaders say the situation could get worse, because the Trump administration wants to push more routine food inspections to the states and further reduce the number of federal staffers that handle investigations and inspections.

State health departments are already overburdened from federal funding cuts and staffing shortages, forcing some to reduce or halt prevention programs so they can focus on more emergent concerns.

The cuts are being felt in Michigan, which has reported more than 7,000 cases of cyclosporiasis, the most of any state. The cyclospora parasite can cause frequent diarrhea that can last for days or even weeks, as well as abdominal pain, nausea, and fatigue.

The health department in Washtenaw County, Michigan, already pulled some staff off other work, such as immunizations and sexual health, to handle a recent measles outbreak that sickened seven people, including five kids. Now those same nurses are spending hours on the phone with hundreds of people with cyclosporiasis, trying to trace the source of their illness through weeks-old takeout receipts, bank statements, and recollections.

“We are starting to see the consequences of an underfunded public health system in 2026,” said Natasha Bagdasarian, Michigan’s chief medical executive. “Currently it’s cyclospora. Eventually, we are going to lose the ability to detect something else.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .