More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.

“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.

While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.

A Chubb spokesperson did not respond to requests for comment on the increase.

More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to KFF, meaning they could be vulnerable to large costs if they have a serious illness.

In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.

“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.

Climbing Numbers

Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to KFF. That amount has likely risen since.

“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.

In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to Ñî¹óåú´«Ã½Ò•îl Health News by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.

For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.

Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.

Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”

Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.

“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.

Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.

“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.

Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.

“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”

But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.

How This Plays Out

People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.

Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.

have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.

An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.

Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.

“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.

There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.

For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to KFF, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.

Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.

Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.

Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.

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The lawsuit, settled on confidential terms last year, blamed not only the managers of City Creek Post-Acute and Assisted Living but also the building’s owner, a real estate investment trust, or REIT.

In the year Darby died, City Creek paid CareTrust REIT more than $1 million in rent, while the Sacramento, California, nursing home ran a deficit, court records show.

Federal tax rules ban REITs from running health care facilities, but CareTrust was not an absentee landlord either, according to internal records filed in the case. It chose the nursing home’s management company and required through the lease that the home keep at least 80% of beds occupied. CareTrust granularly tracked how well the home kept to its financial plan, down to the money spent monthly on nurses and food, the records said. And the documents showed that the real estate company kept tabs on government safety inspection findings and Medicare quality ratings.

Both CareTrust and the nursing home operator denied liability for Darby’s death. CareTrust officials said in court papers that it is not involved in day-to-day nursing home decisions or patient care, and that it monitors facilities to ensure nothing jeopardizes rent payments. In a written statement, CareTrust Corporate Counsel Joseph Layne told Ñî¹óåú´«Ã½Ò•îl Health News: “We are the property owners, not the operators.”

Landlords With Influence

Over the past decade, real estate investment trusts have bought thousands of buildings that house nursing homes, hospitals, assisted living facilities, and medical offices. A Ñî¹óåú´«Ã½Ò•îl Health News examination of court filings and corporate records shows that these landlords have more influence than the health care facilities publicly acknowledge.

The documents reveal REITs often select the management who oversee the operations and leave them in place even when they are aware of threadbare staffing, floundering governance, repeated safety violations, or other problems that hamper quality of care. A California jury in March awarded $92 million in punitive damages against a former REIT over the death of a 100-year-old resident with dementia who froze to death outside her assisted living facility.

“The REITs are in charge,” said Laraclay Parker, one of the lawyers who represent Darby’s daughter.

Absence of Oversight

Despite their ubiquity, REITs remain invisible to state and federal health regulators. Hospitals and nursing homes are not required to disclose rent payments or landlord identities in the annual reports they submit to Medicare.

Under President Donald Trump, the Centers for Medicare & Medicaid Services a Biden-era requirement that nursing homes . Catherine Howden, a CMS spokesperson, said in a statement that the agency does not regulate facilities based on their tax status or corporate form and instead focuses on the quality of the care they provide.

REITs now of the nation’s senior housing, which includes assisted living, memory care, and independent living, according to an industry analysis. REITs also hold investments in nursing homes. Publicly traded REITs that focus on health care are now worth nearly a quarter of a trillion dollars, according to Nareit, an industry association.

While one research study found REIT investments were associated with , another concluded that after being bought by REITs, nursing homes frequently with less skilled nurses and aides. A concluded that health inspection results were worse after REIT investment.

Researchers also found that investor-owned hospital chains that sold buildings to REITs were or go bankrupt, with Steward Health Care. Often, private equity investors kept the sale proceeds as profits while the hospitals were burdened with new rent costs. “There were no improvements in clinical outcomes,” said Thomas Tsai, an associate professor at the Harvard T.H. Chan School of Public Health.

REITs are required to distribute most of their income and don’t have to pay the 21% federal corporate income tax on it. There is a catch: A REIT that “directly or indirectly operates or manages” a health care facility for five years. Typically, a REIT leases the property to another company that runs the nursing home or assisted living facility and maintains its tax break. Nareit said health care REITs distributed more than $7 billion in dividends in 2024.

Michael Stroyeck, head of health care analysis at Green Street, a real estate research company, said “there’s definitely a symbiotic relationship” between REITs and facility managers because they have the same goals. He said he has seen REITs replace operators that are having difficulties or go bankrupt.

John Kane, a senior vice president at the American Health Care Association and the National Center for Assisted Living, an industry group that represents nursing homes, said in a statement: “Given government funding often falls short, REITs have been valuable partners in helping to invest in long term care without influencing daily operations.”

Low Staffing at a Chain

Strawberry Fields REIT, which like CareTrust trades on the New York Stock Exchange, owns or controls the buildings of 131 nursing home facilities. The nursing home operations inside 66 of those facilities are owned by Moishe Gubin, Strawberry Fields’ chief executive, and Michael Blisko, one of its directors, according to Strawberry Fields’ for last year.

Gubin and Blisko also jointly own , which manages their nursing homes; Blisko is Infinity’s CEO. On average, Infinity-affiliated nursing homes provided an hour and a quarter less nursing care per resident per day than the national average of four hours, a Ñî¹óåú´«Ã½Ò•îl Health News analysis of federal records found.

Infinity and several of its nursing homes have recently settled 30 death and injury lawsuits in Cook County, Illinois, totaling more than $4 million, said Margaret Battersby Black, a Chicago lawyer. A jury last year awarded $12 million in a lawsuit brought against Infinity and one of its Chicago nursing homes over the 2023 death of Shirley Adams. A retired candy factory worker, Adams died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to the lawsuit.

“She had wounds that no one could explain,” one of her adult children, Leslie Adams, testified at trial. Medicare its lowest quality rating, one star out of five.

Paul Connery, a lawyer for Adams’ family, said they are still trying to collect on the judgment against the nursing home and management company, which now totals $17 million with interest and attorney fees.

“If I get caught speeding and I went to court, they issue me a ticket and I’ve got a fine to pay,” Adams said in an interview. “How are they able to still continue to move on with business like nothing has happened?”

In a phone interview and an email, Gubin said Strawberry Fields, Infinity, and the nursing homes are all legally distinct and that he has not played an active role in Infinity in more than a decade. He said nursing homes get sued all the time but that the verdict against Lakeview is so large that it will force the home to declare bankruptcy or shut down.

“The whole thing is unfortunate,” Gubin said by phone. “For 15 years they were a perfectly good guardian” and “a well-run building,” he said. “You wouldn’t think it was fair to be judged on your worst day.”

Blisko and an Infinity lawyer did not respond to requests for comment.

Strawberry Fields, which owns 10 assisted living facilities and two long-term care hospitals in addition to the nursing homes, earned net income last year of from $155 million in rent, a 21% profit margin, securities filings show. Gubin said those weren’t excessive returns.

A $110 Million Verdict

Traditionally, REIT leases make the operating companies responsible for paying property taxes, insurance premiums, and maintenance costs. In 2008, Congress gave health care REITs a new option to make money: On top of collecting rents, they could set up subsidiaries and take profits directly from health care businesses. They still must have independent management overseeing care decisions. Many REITs have embraced the role even though the subsidiaries must pay corporate taxes and risk losing money if the businesses do poorly.

Colony Capital was a REIT that through layers of shell corporations owned both the building and the operation of Greenhaven Estates, a Sacramento assisted living and memory care facility. In 2018 Greenhaven paid Colony $1.4 million in rent, nearly a third of its $4.5 million in revenue that year, according to financial records filed in court.

Greenhaven also was on the verge of losing its license, according to a revocation notice filed in November 2018 by the California Department of Social Services. Greenhaven had racked up years of health violations, including from letting untrained workers administer medications, lacking enough employees to care for people with dementia, and neglecting a resident who smeared feces over his body, bed, floor, and bathroom, the notice said.

In February 2019, a few weeks after celebrating her 100th birthday, Mildred Hernandez, a resident with Alzheimer’s, wandered out of Greenhaven in the middle of the night. Her assisted living wing had no exit door alarms even though it housed several residents with dementia, court records showed. Berta Lepe, one of Greenhaven’s caregivers, found Hernandez under a bush, wearing only a shirt and underwear. The temperature was in the 30s.

“She was talking, but I couldn’t understand what she was saying,” Lepe testified at trial over a lawsuit from Hernandez’s family. Hernandez died of hypothermia a few hours later, according to her death certificate.

Frontier Management, the company that Colony had hired to manage Greenhaven, denied liability and settled the lawsuit on undisclosed terms.

Since the lawsuit, Colony has changed its name to DigitalBridge, which no longer owns Greenhaven and gave up its REIT status. At trial earlier this year, DigitalBridge said resident care was the responsibility of Frontier and that Colony “encouraged” Frontier to address problems. Richard Welch, a former Colony executive, testified that replacing management is disruptive. “I viewed it as a last resort,” he said.

In March, a jury awarded Hernandez’s family $110 million: $10 million in compensatory damages, $92 million in punitive damages against DigitalBridge, and $8 million in punitive damages against Formation Capital, an asset management company.

“REIT money is very detached from knowing about or caring about patient or resident outcomes, because it’s not in their business model,” Ed Dudensing, a lawyer for the family, said in an interview. “Their allegiance is to their investors.”

DigitalBridge has asked the judge to delay finalizing the judgment while its legal challenges to the lawsuit and the verdict are evaluated. A DigitalBridge attorney and a corporate spokesperson did not respond to requests for comment, a Formation attorney declined comment, and a Frontier attorney and a spokesperson did not respond to a request for comment.

‘Wet From Head to Toe’

When CareTrust bought City Creek Post-Acute and Assisted Living in 2019, the Sacramento nursing home where Pearlene Darby lived had a one-star Medicare rating and was losing money. CareTrust leased the building to a management company called Kalesta Healthcare Group based on the business plan Kalesta submitted.

While CareTrust was not the operator, it held periodic phone calls with Kalesta, which provided “a full update of what’s happening at the facility,” including changes in leadership, financial progress, and health inspection survey results, according to deposition testimony by Ryan Williams, a Kalesta co-founder.

According to a state inspection report, in 2020, the year Darby died, City Creek left a resident in soiled linens “wet from head to toe lying in bed” for more than eight hours. During a different visit, a health inspector cited the home after watching a nurse put a dirty diaper back onto a resident after caring for a wound. “It was just a small stool and it is far from where the wound is,” the nurse told the inspector, according to the report.

James Callister, CareTrust’s chief investment officer, said in his deposition that CareTrust officials “review results of regulatory surveys provided to us by the tenant. We review the five-star rating.” He said, “We evaluate results of care, but we do not evaluate types of care given or how or when, no.”

Darby had been living in City Creek since 2011 after a stroke left her in a wheelchair. She needed help getting in and out of bed. From September through November 2020, Darby lost 30 pounds, her family’s lawsuit alleged. During those months, employees dropped her three times as one worker rather than the required two operated the mechanical lift, the lawsuit said.

The suit alleged City Creek failed to reposition her every two hours in bed or her wheelchair, which is the clinical standard for people at risk of bedsores, and to promptly order devices to protect her skin.

In November, the nursing home sent Darby to the hospital. A blood test found bacteria had entered her bloodstream from her feces’ touching open skin wounds, according to the lawsuit. The hospital diagnosed her with sepsis. A surgeon said she needed an operation to redirect fecal waste from her intestines but concluded she wasn’t medically stable enough for surgery, the suit said.

Darby began receiving comfort care measures and was sent back to City Creek. She died two weeks later. In court filings, CareTrust and Kalesta denied the allegations.

In a phone interview, Williams, the Kalesta co-founder, said Darby’s death occurred during the most challenging point of the covid pandemic, when California rules required any nurses testing positive for the virus to be sent home and nurses were quitting out of fear for their health. “It was the most herculean of professional efforts to secure enough staff,” he said.

While expressing sympathy for Darby and her family, he said it was “unconscionable” that personal injury lawyers sued nursing homes over care failures during “the worst of times.”

In court, CareTrust petitioned Judge Richard Miadich to dismiss it from the lawsuit before trial. “This case does not concern a property condition,” CareTrust’s lawyers wrote. “CareTrust is simply a landlord.” But the judge ruled last year a jury should decide whether CareTrust “exercised actual control over City Creek.”

The case was settled out of court a few months later. All parties declined to reveal the settlement terms.

A 67% Profit

As recently as November 2023 — four years after its acquisition — City Creek earned one star from Medicare. It was cited for failing to have the minimum nursing home staffing required by California law during five of 24 randomly selected days in 2022, according to an inspection report. Williams said in the interview that Kalesta had increased spending on nursing over the course of its ownership, including boosting wages, but that it takes a year or two to turn around a troubled nursing home. He said the home’s star rating in 2023 was dragged down by its poor inspection history from before Kalesta took over.

City Creek’s rating has climbed in the past two years, and it now has the top overall rating of five, according to Medicare. Medicare rates City Creek’s current staffing levels as average. That’s better than most nursing homes in more than 200 buildings CareTrust bought before 2025, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of federal data. On average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours.

In its statement to Ñî¹óåú´«Ã½Ò•îl Health News, CareTrust’s counsel Layne said the REIT worked to “identify quality operators as tenants,” and that the homes the REIT rents out have more nurses and aides than the minimum required for nursing homes by their state governments. “The operators are licensed by state regulators and retain sole responsibility for operations,” the statement said.

CareTrust, which now owns more than 500 senior housing and nursing home buildings, reported net income last year of $320 million from in rents and other revenue — a 67% profit margin. By comparison, HCA Healthcare, one of the nation’s largest for-profit hospital and health care chains, for last year.

Lesley Ann Clement, one of Darby’s lawyers, said cases like hers show the nursing home industry is wrong to complain it lacks financial resources for more staffing.

“There’s plenty of money,” Clement said. “They’re just not spending it on patient care.”

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Other drivers stopped, broke the car window, and pulled him to safety. A passing volunteer firefighter performed CPR until an ambulance arrived to take Masterson to UPMC Mercy hospital.

He spent 18 days in the medical intensive care unit there, 14 of them on a ventilator. He developed delirium, a common ICU condition, and needed antipsychotic drugs. Despite a feeding tube, he lost weight. “We honestly weren’t confident that he would pull through,” said Ron Dedes, his brother-in-law.

But he did. Masterson was discharged Feb. 1 and returned home with near-constant family support. Working diligently with several kinds of therapists, he has regained his ability to walk, despite lingering weakness, and to manage his personal care. His once-garbled speech has markedly improved. He can make himself a sandwich.

Now, “our biggest concern is his memory,” Dedes said. Masterson, who so recently handled complex legal matters, forgets conversations and events that happened a few hours earlier, said Patti Dedes, his sister. He can’t yet operate a microwave or place a phone call.

In an interview, he described himself, accurately, as “much, much better than I was” — but misstated his age. Screening tests after his discharge indicated cognitive impairment and depression.

Among critical-care doctors, prolonged symptoms like his are known as “post-intensive care syndrome,” or PICS. The fallout can be physical or psychological, as well as cognitive, and can persist for months or years.

More than are admitted to intensive care across about 5,000 American hospitals, and research shows that . Older age increases the odds.

Patients and families are often startled by these continuing difficulties. “The belief is that they’ll be discharged from the hospital and in two or three weeks, they’ll be back to normal,” said Brad Butcher, who was Masterson’s doctor and in the medical journal JAMA. “That doesn’t comport with reality.”

In fact, with greater ICU use and improved treatments — the Society of Critical Care Medicine estimates that their stays — the population likely to encounter the syndrome is growing.

“Everyone is grateful that the patient has survived,” said Lauren Ferrante, a pulmonary critical-care doctor and researcher at the Yale School of Medicine. “But that’s just the start of a long road to recovery.” In a study of patients 70 and older that she co-authored, within six months after discharge only about half had .

Intensive care patients face a . PICS symptoms — weakness, pain, neuropathy (tingling in arms and legs), and malnutrition — to , primarily anxiety and depression. like Masterson’s are commonplace, including problems with memory, attention and concentration, and language.

“For many people, surviving a critical illness is a life-altering experience,” Butcher said. Patients in intensive care after emergency or elective surgery also of new physical, mental, and cognitive problems a year later.

The same aggressive treatments that save lives contribute to the syndrome. Intensive care patients “have some sort of dramatic organ failure that requires immediate attention” and constant monitoring, explained Carla Sevin, a pulmonary critical-care doctor who directs the ICU Recovery Center at Vanderbilt University Medical Center.

That could mean a breathing tube attached to a ventilator, which in turn often requires sedating drugs. Sedation “can precipitate delirium, and delirium is the key factor in cognitive symptoms,” Butcher said.

It doesn’t help that constant beeps and alarms from monitors and round-the-clock bright lighting disrupt sleep, and that restrictive family visiting hours deprive patients of reassuring faces and voices.

Gregory Matthews, a retired accountant in St. Petersburg, Florida, spent nearly a month in an ICU after a lung transplant in 2014. He still vividly remembers his hallucinations, including mice running across the wall and someone trying to frame him for drug running.

“One day, I thought a doctor was an assassin — I could see the rifle,” said Matthews, now 80. “So I jumped out of bed,” he said, and yanked out his IVs. The staff put his arms in restraints for days.

But immobilization exacts its own toll as patients quickly lose muscle mass and strength. “Our bodies were not meant to lie in bed all day,” Ferrante said.

Psychologically, “PTSD is pretty common, similar to what’s seen in combat veterans or sexual assault survivors,” Sevin said, referring to post-traumatic stress disorder. Families can suffer anxiety and depression along with the patients.

Alarmed by such discoveries, doctors and administrators at about 35 U.S. hospitals have established , where teams of doctors, nurses, pharmacists, therapists (physical, occupational, cognitive, speech), and social workers screen for a host of conditions and help guide patients through them.

Vanderbilt’s clinic saw its first patient in 2012. The Critical Illness Recovery Center at the University of Pittsburgh Medical Center, which Butcher founded in 2018, works with about 100 patients a year, including Masterson. Yale opened its clinic in 2022.

They rely on six practices recommended by the Society of Critical Care Medicine that are shown to . The measures call for changes such as using lighter sedation, getting patients up and moving earlier, testing their breathing daily to wean them from ventilators sooner, and removing restrictions on family visiting.

Clinics often offer support groups for patients and families. There’s evidence that keeping an ICU diary, in which patients and caregivers record their experiences, and engaging in exercise and physical rehabilitation after discharge.

Also on the clinics’ agenda: discussions of what other options patients might prefer if they face another critical illness, as many do. Would they agree to undergo intensive care and risk its aftereffects again? Or choose palliative care, which emphasizes comfort rather than cure? Some post-ICU patients remain permanently impaired.

Butcher, although he said that the use of the new practices needed to expand dramatically, sounded optimistic about the future of critical care. “We’re going to find better diagnostic tools, better preventive strategies, and better therapies,” he said.

For now, though, the ICU experience remains disorienting and sometimes traumatic. When Butcher asked 117 patients in his post-ICU clinic those next-time questions, many wanted to place limits on further medical interventions.

About a third would want to lower the level of aggressive care. Of those, about a quarter would want “do not resuscitate” and “do not intubate” orders, and almost 7% said they never wanted to return to an ICU.

Masterson is working hard to further his recovery. “I haven’t been out and about much,” he said. “I’ve been kind of homebound.” He hopes to get strong enough to resume running — he used to log 3 to 4 miles several times a week.

The future for patients contending with post-ICU syndrome often depends on their physical, mental, and cognitive health before their admission. Masterson’s previous fitness and cognitively demanding work bode well for his further progress, Butcher said.

His family remains alternatively hopeful and worried. “Down the road, what’s it going to be like?” Dedes, his brother-in-law, wondered. “We just take it day by day.”

The New Old Age is produced through a partnership with .

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OAKLAND, Calif. — Rosa María Carranza leaned forward to hold a 3-year-old’s back as the girl climbed a rock in the forested hills of northeast Oakland.

Dressed in hiking gear and beaded necklaces, Carranza, 67, maneuvered between trees and children on a sunny morning in December. “Hold on to that branch,” she said in Spanish. “You can do it, my love!”

Carranza, a child development professional who grew up swinging through trees and swimming in rivers in El Salvador, said she feels at home in the forest at the outdoor preschool she co-founded. She has worked with children and teens as a caregiver and educator for more than three decades, long enough to know when to lean in and when to step back to let her students find their own footing.

When she transitioned to working part-time last year, Carranza counted on getting Medicare and Social Security checks — benefits given to American workers and lawfully present immigrants when they retire, work history and age or disability requirements. She’s contributed tens of thousands of dollars into Medicare and Social Security over 24 years, according to her Social Security Administration earnings record, reviewed by El Tímpano and Ñî¹óåú´«Ã½Ò•îl Health News. But Carranza and an estimated immigrants will soon be cut out of Medicare.

The GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump, barred certain categories of lawfully present immigrants — including temporary protected status holders, refugees, asylum-seekers, survivors of domestic violence, trafficking victims, and people with work visas — from Medicare.

Those already in the program, like Carranza, will be disenrolled by Jan. 4 — a move by Republican lawmakers to rein in Medicare spending, as they and Trump have argued that taxpayer dollars should not be used to pay for the health care of immigrants in the U.S. without authorization.

“The Democrats want Illegal Aliens, many of them VIOLENT CRIMINALS, to receive FREE Healthcare,” Trump two months after he signed the bill into law. “We cannot let this happen!”

However, the categories of immigrants now losing coverage do have legal status. Neither the White House nor the Department of Health and Human Services responded to a question about whether it was fair to disenroll legal residents from Medicare.

Immigrants without legal status were already ineligible for Medicare or most other federally funded public benefits.

Carranza is worried that she could also lose legal permission to live in the United States if the Trump administration ends temporary protected status for Salvadorans, as it sought to do during .

If that happened, Carranza would lose legal residency, risking time in an immigration detention center or deportation.

“This is like a horror movie, a complete nightmare,” Carranza said. “This is not how I imagined getting old.”

‘Under Constant Attack’

Carranza left El Salvador in 1991 during a brutal civil war, leaving behind three young children, to earn money to send home to her family. She overstayed her visa until 2001, when she qualified for temporary protected status, after two earthquakes struck El Salvador, and displacing 1.3 million.

Temporary protected status, or TPS, was passed by Congress and signed into law by Republican President George H.W. Bush in 1990.

It allows people such as Carranza, from select nations undergoing armed conflict, civil war, and climate disasters, to live and work in the United States if being in their home country poses a risk.

Carranza missed her youngest daughter’s graduation from kindergarten and first medal-winning performance in track. She worked overnight shifts babysitting newborns and later substitute-taught in public schools in the San Francisco Bay Area to pay for her children’s schooling in El Salvador, and for her own classes at City College of San Francisco, where she earned a degree in child development.

And she cared for dozens of 3-, 4-, and 5-year-olds who gazed in awe as they uncovered little treasures buried in the redwood forest of the Oakland park where she co-founded Escuelita del Bosque, a Spanish immersion preschool that teaches children outdoors.

The trade-off was supposed to be a peaceful retirement. But Congress narrowed Medicare eligibility to citizens, lawful permanent residents, Cuban and Haitian nationals, and people covered under the Compacts of Free Association, agreements between the United States and Pacific island nations.

The move followed Trump’s efforts to bar some lawfully present immigrants from Medicaid, marketplace insurance subsidies, and social support services, such as food assistance, housing subsidies, and medical visits in federally funded health centers. Altogether, 1.4 million lawfully present immigrants were projected to lose health insurance, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A spokesperson for House Speaker Mike Johnson, Taylor Haulsee, did not respond to requests for comment.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said Republicans wanted to enact tax cuts and eliminate health insurance for immigrants because it wouldn’t upset their base.

“They don’t want to turn the United States into a welfare magnet,” he said. “And they resent the government for making them pay for a welfare state.”

While data on lawfully present immigrants is not available, immigrants without legal status and $25.7 billion into Social Security in 2022, according to the Institute on Taxation and Economic Policy. The Congressional Budget Office estimated that the Medicare restrictions alone would reduce federal spending by 2034.

Health experts say eliminating coverage for immigrants with legal status .

“This is actually the first time that Congress has taken away Medicare from any group,” said Drishti Pillai, director of immigrant health policy at KFF. “This change is impacting immigrants who have lawful presence in the U.S., and many of whom have already worked and paid into the system for decades.”

As older adults like Carranza lose their Medicare coverage, clinicians anticipate that they will delay their care, leading to an increase in severely ill patients, especially in hospital emergency rooms.

Seniors can become sick suddenly and quickly, and they are more vulnerable to cardiovascular diseases such as heart disease and high blood pressure, especially if they put off routine care, said Theresa Cheng, an emergency physician at Zuckerberg San Francisco General Hospital and assistant clinical professor of emergency medicine at the University of California-San Francisco.

“It’s quite easy for them to fall off the cliff,” Cheng said.

Carranza hikes and considers herself healthy, but she acknowledges that she is aging and starting to struggle to keep up with the kids in the forest.

Late last year she was diagnosed with high blood pressure, and in January she woke up with a tight chest and went to urgent care because it had spiked to dangerous levels. A few weeks later, she tripped on a curb while walking and fell to the ground. She woke up the next day with a swollen foot. A doctor at the local hospital told her she had arthritis.

These were scary moments, she said, but she was grateful to have to pay only $10 for the urgent care visit and $5 to see her primary care doctor. However, that will change when she loses Medicare by early next year.

The stress of knowing she will lose health insurance coverage, and potentially her legal status, all while masked federal agents are detaining immigrants like her across the country, has taken a toll on her mental health, she said. She is searching for a therapist and acupuncture services to treat her insomnia and anxiety — and the feeling that she is “under constant attack.”

Nowhere To Turn

In California, home to the largest number of , Carranza could have enrolled in state-sponsored insurance, but this year the state for adults 19 and older who are a TPS holder, in the U.S. without authorization, or an asylum-seeker. Other states with Democratic governors such as have also scaled back their health programs for immigrants amid budget pressures.

In January, California Gov. Gavin Newsom proposed a state budget that would not backfill federal health care cuts to about 200,000 lawfully present immigrants, noting the $1.1 billion annual price tag and state budget shortfalls.

“Given these fiscal pressures, the administration cannot backfill for this change in federal policy,” California Department of Finance spokesperson H.D. Palmer said.

But some Democratic lawmakers and consumer advocates say the state should step in. State Assembly member Mia Bonta, who chairs the Assembly’s health committee, said she is working on a legislative budget solution to bring immigrants who will lose health coverage, including older adults, into Medi-Cal, the state’s version of Medicaid.

The East Bay Democrat is especially concerned for people like Carranza, “who have lived here for decades and contributed into this economy, who have given into our cultural fabric and into our communities and who built families and lives and who are now wanting to be able to retire with dignity and live with dignity and have the health care that they need.”

A Sign of the Future

Last April, Carranza got a glimpse of what losing her health coverage and retirement benefits could look like, after the Social Security Administration sent her a letter informing her that she no longer qualified for retirement benefits because she was not lawfully present in the U.S. — even though she was. Then Medicare stopped payments to her health plan, which disenrolled her as a result.

As a TPS holder with a work permit, she knew a mistake had been made. Yet, without her check, Carranza didn’t have money to pay her rent for a month. She worked off her rent by babysitting her landlords’ children. Last May, the office of U.S. Rep. Lateefah Simon, an Oakland Democrat, helped Carranza recover her retirement benefits, but it took months for her to get her health insurance back.

The experience left her reeling.

“It’s like getting slapped on the face after more than 30 years working for the system here,” Carranza said. “And in return, this is what we have now.”

She lies awake at night imagining the future: here, where she’s spent half her life, without health insurance and possibly Social Security benefits; or in El Salvador, where two of her three children remain. Her daughter, a green-card holder who lives in Texas, hopes to become a citizen so she can petition for permanent residency for Carranza, but the process can take years. Then there’s the possibility she fears most: indefinite detention or deportation.

On a recent morning in her basement studio in Oakland, Carranza pulled a box from the back of her closet. In it was a thick stack of identification cards that included old driver’s licenses, her Social Security card, and dozens of work IDs issued by the federal government.

“My life is in that box,” she said.

This article was produced in collaboration with , a civic media organization serving and covering the Bay Area’s Latino and Mayan immigrant communities.

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While taking her history and vital signs, Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148/86, above normal despite her taking two medications intended to lower it. “Clearly that was too high,” he said recently.

Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet, and a lack of regular exercise. She had also told Supiano that she typically drank a couple of glasses of wine each evening.

After Supiano discussed ways to lower her risk, the woman and her husband joined a gym. She stopped taking the anti-inflammatory and cut back on salt and alcohol, bringing her systolic blood pressure readings into the 130-to-140 range — still hypertension, according to  issued by the American Heart Association and the American College of Cardiology later that year, but more acceptable. (Systolic is the top number in the blood pressure ratio and the more clinically important number.)

By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. “I was not as aggressive as I should have been,” Supiano recalled. He added a third drug for high blood pressure to the woman’s regimen, and her readings fell to 120 or lower.

The shifting guidelines for blood pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, “How low can you go?”

For more than 25 years, a reading of 140/90 or below was considered normal, according to the AHA/ACC guidelines. But the 2017 update introduced major changes, backed by results from the , which enrolled adults over 50 who were at high cardiovascular risk.

The SPRINT trial found that intensive treatment aimed at bringing the systolic number below 120 reduced the risk of heart attacks, strokes, other cardiovascular illnesses, and overall mortality so substantially that the investigators .

It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.

°Õ³ó±ðÌý, issued last year, encourage still tighter control. They call for patients at cardiovascular risk to strive for systolic readings below 120, and they also call that target “reasonable” even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.

Blood pressure normally rises with age because “with stiffening of the arteries, the heart has to pump harder,” said Erica Spatz, the director of the preventive cardiovascular health program at the Yale School of Medicine. From 2021 to 2023, about  had hypertension, according to the operative definition at the time.

But recent revisions could “define a lot more people as having high blood pressure,” said Rita Redberg, a cardiologist at the University of California-San Francisco.

To Supiano, recent  and  that show cognitive benefit for the lower readings “have tipped the scales” for older adults. “What’s good for the heart is good for the brain,” he said, calling those findings “a lever to get people to pay more attention to their blood pressure. They may not want to live longer, but they want to hold on to their cognition longer.”

Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization’s board), have endorsed the latest guidelines.

“I used to be lenient in many of my older patients,” said John Dodson, a cardiologist and researcher at NYU Langone Health. “If I overtreated high blood pressure, bad things were going to happen.”

Blood pressure that drops too low — hypotension — can cause dizziness and fainting or injuries from falls.

Now, Dodson said, “I’m treating my older patients more aggressively.” Studies have shown that treating high blood pressure . And while older adults in the SPRINT trial had more fall injuries, the rate wasn’t higher  than in those undergoing standard treatment. Among those over 75, it was  for both groups.

Another significant change: The new guidelines recommend at-home monitoring.

“Blood pressure is tricky,” Spatz pointed out. “It varies throughout the day, depending on whether a person is just waking up or just ate or it’s hot outside.” Systolic readings can bounce around by 30 points or more in a single day.

And they’re almost always higher in a doctor’s office. “I don’t want to put much stock in one reading,” Spatz said.

“Maybe the patient has white-coat syndrome,” she added, referring to anxiety about doctors and testing, “or they had a fight with the parking attendant” on the way in.

She asks patients to record their blood pressure twice a day for a week or two before their appointments. Some doctors prescribe a 24-hour home monitor.

Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.

Price is not likely to present an obstacle. Most patients need two or three drugs to lower blood pressure, but as generics they’re “dirt cheap, about $5 a month,” and rarely interact with the other drugs that are often prescribed for older people, Supiano said. A blood pressure monitor for home use , or more for those that digitally transmit data.

Although some side effects are serious — a fall can be life-altering — most complications “thankfully are transient and reversible and rather mild,” he said.

Yet the guidelines have skeptics, too. Redberg, for example, counsels older patients about diet, exercise, and weight loss but does not urge them to start medication to reduce a 135 systolic reading to below 120.

They already seem overanxious about their blood pressure, she said, adding, “I encourage them to go out and enjoy themselves.”

“Take a class! Go to a museum!” she said. “You can’t do that if you’re at home taking your blood pressure five times a day.”

While trials and guidelines address benefits for the population as a whole — even small reductions in dementia would have an enormous impact — they are not useful for predicting individual outcomes. The , used to gauge whether someone would see cardiovascular benefit from hypertension treatment, has not been validated for people over 79 and does not factor in cognitive benefits, Supiano noted.

For people with other serious illnesses — cancer patients or frail nursing home residents with dementia, for instance — controlling blood pressure may be far down the list of concerns.

Time is also a factor in weighing risks versus benefits. A meta-analysis of older patients by Sei Lee, a geriatrician at UCSF, and colleagues found that for 200 patients in intensive treatment for hypertension, it would .

Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. “You’d have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher.”

Supiano’s 78-year-old patient did hit that target and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and eventually received an Alzheimer’s diagnosis.

Given what researchers are reporting about the cognitive benefits of treating high blood pressure, “maybe it gave her another couple of good years,” he mused. “Maybe it delayed the progression.” Or maybe, he added, he should have started intensive treatment earlier.

The New Old Age is produced through a partnership with .

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

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

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

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

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

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

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

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

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

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

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

Beware: More Underwriting

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

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

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

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

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

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

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called , a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found. 

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

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

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

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about members, more than half the people eligible for Medicare. 

CMS is set to announce a final rate decision by early next month. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online. 

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

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

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

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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“The person said he was an officer of the Department of Criminal Investigations looking into drug trafficking and money laundering,” the woman recalled. He seemed to know a lot about her: the states where she and her late husband had lived; his name and occupation; and her current address in Washington County, Rhode Island.

On her phone, he showed her a convincing badge and a photo ID with his name (“‘Frank’ something”), plus an article describing the supposed investigation. The woman, a 76-year-old retiree, denied any involvement.

“You can hire a very expensive criminal defense attorney, or you can cooperate with me,” Frank told her.

“Now, when you think about it, it doesn’t make any sense,” the woman acknowledged recently. But persuaded by the badge and ID, she agreed to cooperate. Otherwise, “I thought they were going to come and arrest me.”

Frank called each morning to learn where she was going, what she was doing. His team would be watching, he warned. The woman, feeling “petrified,” started looking around as she drove to garden club meetings. Was somebody following her?

It was all a scam.

Because victims’ sense of shame often leaves them reluctant to report such crimes, the extent of elder financial exploitation is hard to calculate. The Federal Trade Commission of $2.4 billion in 2024, largely driven by investment and and impersonations, with total losses much higher.

Americans age 60 and older lose more than $28 billion annually to financial exploitation, .

As those numbers rise, because the population is aging and predators are growing increasingly resourceful, banks and investment firms are becoming the first line of defense.

Frank’s initial target: her account at Fidelity Investments. He instructed her to shift about $250,000 into her checking account, telling the financial adviser at her local office that she and her family intended to buy real estate.

That scheme fizzled when the adviser said Fidelity could not approve the transaction without more information on the property.

So Frank sent her to her local branch of Washington Trust Company to take $70,000 in cash from a home-equity line of credit. “We don’t give out that much in cash,” the teller said, quietly messaging the branch manager, who had known the woman and her husband for years.

The manager ushered the woman into her office to talk, and the scam stopped there, with a call to the local police. The woman’s assets remained intact, but the experience proved so mortifying that she has not told even her family how close she came to losing much of her life savings. The New York Times is withholding her name to spare her embarrassment.

“I felt so stupid,” she said. “I felt like a fool.”

Financial predators targeting older adults represent “a heightened focus for us now,” said Mary Noons, president and chief operating officer of Washington Trust.

A regional community bank, Washington Trust cranked up its efforts last fall to advise older customers and their families about finances, including the dangers of elder fraud and exploitation. It published and distributed a booklet called “Age With Wisdom” and brought in an expert on dementia to speak with staff members.

And it became one of the 1,500 financial institutions to date to use BankSafe, a free AARP video program that trains front-line employees to spot the indicating possible elder exploitation and to intervene. Everyone at the branch where the 76-year-old banked had taken the training.

“Some older customers visit their bank far more frequently than they see their health care providers,” Noons pointed out.

Until recent years, financial institutions placed “more of an emphasis on the autonomy of the client,” said Pamela Teaster, director of the Virginia Tech Center for Gerontology and an elder abuse researcher. Their approach was, “an adult has the capacity to make poor choices, and we’re going to let them make them,” she added.

But changes in government and industry policies and practices have encouraged greater vigilance. Congress passed in 2018, protecting banks and financial firms from liability if they reported suspected exploitation to authorities.

That year, the Financial Industry Regulatory Authority began requiring member firms to ask for a when investors open or update accounts. (The account holder isn’t obliged to provide one, however.) And since 2022, it has on older investors’ transactions if they suspect exploitation is involved.

About half of states have enacted laws that permit financial institutions to deny suspicious transactions or impose holds for specified periods to allow investigations, said Jilenne Gunther, the director of BankSafe.

“It adds friction,” she explained. “With space and time, the criminal gets worried and might move on. And the potential mark has time to stop and think.”

Teaster’s analysis of during a six-month pilot in 82 financial institutions, found that participants were much more likely to report suspected cases and save customers money than a control group was.

Not all of older adults’ losses result from predators, however. They can, on their own, get caught up in investment fads, take on too much debt, or make otherwise unwise decisions, even without criminals pulling the strings or relatives looting their accounts.

Managing finances presents complex cognitive challenges, said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine. “It requires a lot of brain,” he said, including: “Memory, remembering that a bill is due. Executive function, the ability to manage your time. Abstraction, hypothesizing about your future.”

He added, “Financial errors are not infrequently the or a neurocognitive disorder.”

A by the Federal Reserve Bank of New York, for instance, found an increased probability of delinquent payments and deteriorating credit ratings in the five years before a dementia diagnosis. Those errors can reduce seniors’ access to credit and raise their interest rates on loans at the very point when caregiving expenses are likely to soar.

Lachs has called on fellow doctors to recognize what he calls , a syndrome that can affect even older people with normal cognition, especially if they contend with medical illnesses, sensory deficits, or social isolation.

And he remains skeptical about the financial industry’s claims of heightened attention to its oldest customers. “I still see concerning financial transactions executed that should have received far greater scrutiny,” he said.

Training more front-line staff members and increasing emphasis on establishing trusted contacts for older customers would help, Gunther said, because “once the money leaves the account, it’s near impossible to ever retrieve it.” More states could enact laws allowing financial institutions to deny suspicious transactions or impose holds.

Several related bills with bipartisan support are working their way through Congress. The would require the FBI to coordinate efforts to protect seniors. A would at least provide the consolation of excusing scam victims from paying taxes on money they no longer have.

However, new weapons like artificial-intelligence voice cloning — in which the supposed grandson four states away who urgently needs $5,000 in gift cards actually sounds like the victim’s grandson — keep advocates and bankers awake at night.

In the Washington Trust branch where the Rhode Island woman didn’t lose her money, employees just days earlier had stopped a scam similar to the one that had targeted her.

But more recently, nobody spotted any danger signs when an older woman withdrew $9,000 for a kitchen renovation, until it went to a scammer instead of a contractor.

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“I was kind of a mess,” recalled Abrams, 69. Trying to cope, “I was eating myself into oblivion.” As her weight hit 270 pounds and her blood pressure, cholesterol, and blood glucose levels climbed, “I knew I was in trouble health-wise.”

What came to mind? “Oh, oh, oh, Ozempic!” — the from television commercials that promoted the GLP-1 medication for diabetes. The ads also pointed out that patients who took it lost weight.

Abrams remembered the commercials as “joyful” and sometimes found herself humming the jingle. They depicted Ozempic-takers cooking omelets, repairing bikes, playing pickleball — “doing everyday activities, but with verve,” she said. “These people were enjoying the hell out of life.”

So, just as such ads often urge, even though she had never been diagnosed with diabetes, she asked her doctor if Ozempic was right for her.

Small wonder Abrams recalled those ads. Novo Nordisk, which manufactures Ozempic, spent an estimated $180 million in direct-to-consumer advertising in 2022 and $189 million in 2023, according to MediaRadar, which monitors advertising.

By last year, the sum — including radio and TV commercials, billboards, and print and digital ads — had reached an estimated $201 million, and total spending on direct-to-consumer advertising of prescription drugs topped $9 billion, by MediaRadar’s calculations.

Novo Nordisk declined to address those numbers.

Should it be legal to market drugs directly to potential patients? This controversy, which has simmered for decades, has begun receiving renewed attention from both the Trump administration and legislators.

The question has particular relevance for older adults, who contend with more medical problems than younger people and are more apt to take prescription drugs. “Part of aging is developing health conditions and becoming a target of drug advertising,” said Steven Woloshin, who studies health communication and decision-making at the Dartmouth Institute.

The debate over direct-to-consumer ads dates to 1997, when the FDA loosened restrictions and allowed prescription drug ads on television as long as they included a rapid-fire summary of major risks and provided a source for further information.

“That really opened the door,” said Abby Alpert, a health economist at the Wharton School of the University of Pennsylvania.

The introduction of Medicare Part D, in 2006, brought “a huge expansion in prescription drug coverage and, as a result, a big increase in pharmaceutical advertising,” Alpert added. A study she co-wrote in 2023 found that pharmaceutical ads in areas with a high proportion of residents 65 and older.

and have shown that ads influence prescription rates. Patients are more apt to make appointments and request drugs, either by brand name or by category, and doctors often comply. may ensue.

But does that benefit consumers? Most developed countries take a hard pass. Only New Zealand and, despite the decadelong , the United States allow direct-to-consumer prescription drug advertising.

Public health advocates argue that such ads encourage the use and overuse of expensive new medications, even when existing, cheaper drugs work as effectively. (Drug companies don’t bother advertising once patents expire and generic drugs become available.)

In a 2023 study in JAMA Network Open, for instance, researchers analyzed the “” of the drugs most advertised on television, based on the assessments of independent European and Canadian organizations that negotiate prices for approved drugs.

Nearly three-quarters of the top-advertised medications didn’t perform markedly better than older ones, the analysis found.

“Often, really good drugs sell themselves,” said Aaron Kesselheim, senior author of the study and director of the Program on Regulation, Therapeutics, and Law at Harvard University.

“Drugs without added therapeutic value need to be pushed, and that’s what direct-to-consumer advertising does,” he said.

Opponents of a ban on such advertising say it benefits consumers. “It provides information and education to patients, makes them aware of available treatments and leads them to seek care,” Alpert said. That is “especially important for underdiagnosed conditions,” like depression.

Moreover, she wrote in a recent , direct-to-consumer ads lead to increased use not only of brand-name drugs but also of non-advertised substitutes, including generics.

The Trump administration entered this debate last September, with calling for a return to the pre-1997 policy severely restricting direct-to-consumer drug advertising.

That position has repeatedly been urged by Health and Human Services Secretary Robert F. Kennedy Jr., who has charged that “pharmaceutical ads hooked this country on prescription drugs.”

At the same time, the FDA said it was issuing about deceptive drug ads and sending “thousands” of warnings to pharmaceutical companies to remove misleading ads. Marty Makary, the FDA commissioner, in an essay in The New York Times.

“There’s a lot of chatter,” Woloshin said of those actions. “I don’t know that we’ll see anything concrete.”

This month, however, the that the agency had found its TV spot for a new oral version of Wegovy false and misleading. Novo Nordisk said in an email that it was “in the process of responding to the FDA” to address the concerns.

Meanwhile, Democratic and independent senators who rarely align with the Trump administration also have introduced legislation to ban or limit direct-to-consumer pharmaceutical ads.

Last February, independent Sen. Angus King of Maine and two other sponsors prohibiting direct-to-consumer ads for the first three years after a drug gains FDA approval.

King said in an email that the act would better inform consumers “by making sure newly approved drugs aren’t allowed to immediately flood the market with ads before we fully understand their impact on the general public.”

Then, in June, he and independent Sen. Bernie Sanders of Vermont proposed entirely. That might prove difficult, Woloshin said, given the Supreme Court’s Citizens United ruling .

Moreover, direct-to-consumer ads represent only part of the industry’s promotional efforts. Pharmaceutical firms actually spend than to consumers.

Although television still accounts for most consumer spending, because it’s expensive, Kesselheim pointed to “the mostly unregulated expansion of direct-to-consumer ads onto the web” as a particular concern. Drug sales themselves are bypassing doctors’ practices by moving online.

Woloshin said that “disease awareness campaigns” — for everything from shingles to restless legs — don’t mention any particular drug but are “often marketing dressed up as education.”

He advocates more effective educational campaigns, he said, “to help consumers become more savvy and skeptical and able to recognize reliable versus unreliable information.”

For example, Woloshin and Lisa Schwartz, a late colleague, designed and tested a simple “,” similar to the nutritional labeling on packaged foods, that summarizes and quantifies the benefits and harms of medications.

For now, consumers have to try to educate themselves about the drugs they see ballyhooed on TV.

Abrams read a lot about Ozempic. Her doctor agreed that trying it made sense.

Abrams was referred to an endocrinologist, who decided that her blood glucose was high enough to warrant treatment. Three years later and 90 pounds lighter, she feels able to scramble after her 2-year-old grandson, enjoys Zumba classes, and no longer needs blood pressure or cholesterol drugs.

So Abrams is unsure, she said, how to feel about a possible ban on direct-to-consumer drug ads.

“If I hadn’t asked my new doctor about it, would she have suggested Ozempic?” Abrams wondered. “Or would I still weigh 270 pounds?”

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More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.

“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.

While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.

A Chubb spokesperson did not respond to requests for comment on the increase.

More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to KFF, meaning they could be vulnerable to large costs if they have a serious illness.

In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.

“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.

Climbing Numbers

Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to KFF. That amount has likely risen since.

“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.

In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to Ñî¹óåú´«Ã½Ò•îl Health News by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.

For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.

Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.

Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”

Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.

“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.

Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.

“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.

Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.

“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”

But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.

How This Plays Out

People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.

Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.

have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.

An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.

Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.

“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.

There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.

For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to KFF, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.

Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.

Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.

Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.

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The lawsuit, settled on confidential terms last year, blamed not only the managers of City Creek Post-Acute and Assisted Living but also the building’s owner, a real estate investment trust, or REIT.

In the year Darby died, City Creek paid CareTrust REIT more than $1 million in rent, while the Sacramento, California, nursing home ran a deficit, court records show.

Federal tax rules ban REITs from running health care facilities, but CareTrust was not an absentee landlord either, according to internal records filed in the case. It chose the nursing home’s management company and required through the lease that the home keep at least 80% of beds occupied. CareTrust granularly tracked how well the home kept to its financial plan, down to the money spent monthly on nurses and food, the records said. And the documents showed that the real estate company kept tabs on government safety inspection findings and Medicare quality ratings.

Both CareTrust and the nursing home operator denied liability for Darby’s death. CareTrust officials said in court papers that it is not involved in day-to-day nursing home decisions or patient care, and that it monitors facilities to ensure nothing jeopardizes rent payments. In a written statement, CareTrust Corporate Counsel Joseph Layne told Ñî¹óåú´«Ã½Ò•îl Health News: “We are the property owners, not the operators.”

Landlords With Influence

Over the past decade, real estate investment trusts have bought thousands of buildings that house nursing homes, hospitals, assisted living facilities, and medical offices. A Ñî¹óåú´«Ã½Ò•îl Health News examination of court filings and corporate records shows that these landlords have more influence than the health care facilities publicly acknowledge.

The documents reveal REITs often select the management who oversee the operations and leave them in place even when they are aware of threadbare staffing, floundering governance, repeated safety violations, or other problems that hamper quality of care. A California jury in March awarded $92 million in punitive damages against a former REIT over the death of a 100-year-old resident with dementia who froze to death outside her assisted living facility.

“The REITs are in charge,” said Laraclay Parker, one of the lawyers who represent Darby’s daughter.

Absence of Oversight

Despite their ubiquity, REITs remain invisible to state and federal health regulators. Hospitals and nursing homes are not required to disclose rent payments or landlord identities in the annual reports they submit to Medicare.

Under President Donald Trump, the Centers for Medicare & Medicaid Services a Biden-era requirement that nursing homes . Catherine Howden, a CMS spokesperson, said in a statement that the agency does not regulate facilities based on their tax status or corporate form and instead focuses on the quality of the care they provide.

REITs now of the nation’s senior housing, which includes assisted living, memory care, and independent living, according to an industry analysis. REITs also hold investments in nursing homes. Publicly traded REITs that focus on health care are now worth nearly a quarter of a trillion dollars, according to Nareit, an industry association.

While one research study found REIT investments were associated with , another concluded that after being bought by REITs, nursing homes frequently with less skilled nurses and aides. A concluded that health inspection results were worse after REIT investment.

Researchers also found that investor-owned hospital chains that sold buildings to REITs were or go bankrupt, with Steward Health Care. Often, private equity investors kept the sale proceeds as profits while the hospitals were burdened with new rent costs. “There were no improvements in clinical outcomes,” said Thomas Tsai, an associate professor at the Harvard T.H. Chan School of Public Health.

REITs are required to distribute most of their income and don’t have to pay the 21% federal corporate income tax on it. There is a catch: A REIT that “directly or indirectly operates or manages” a health care facility for five years. Typically, a REIT leases the property to another company that runs the nursing home or assisted living facility and maintains its tax break. Nareit said health care REITs distributed more than $7 billion in dividends in 2024.

Michael Stroyeck, head of health care analysis at Green Street, a real estate research company, said “there’s definitely a symbiotic relationship” between REITs and facility managers because they have the same goals. He said he has seen REITs replace operators that are having difficulties or go bankrupt.

John Kane, a senior vice president at the American Health Care Association and the National Center for Assisted Living, an industry group that represents nursing homes, said in a statement: “Given government funding often falls short, REITs have been valuable partners in helping to invest in long term care without influencing daily operations.”

Low Staffing at a Chain

Strawberry Fields REIT, which like CareTrust trades on the New York Stock Exchange, owns or controls the buildings of 131 nursing home facilities. The nursing home operations inside 66 of those facilities are owned by Moishe Gubin, Strawberry Fields’ chief executive, and Michael Blisko, one of its directors, according to Strawberry Fields’ for last year.

Gubin and Blisko also jointly own , which manages their nursing homes; Blisko is Infinity’s CEO. On average, Infinity-affiliated nursing homes provided an hour and a quarter less nursing care per resident per day than the national average of four hours, a Ñî¹óåú´«Ã½Ò•îl Health News analysis of federal records found.

Infinity and several of its nursing homes have recently settled 30 death and injury lawsuits in Cook County, Illinois, totaling more than $4 million, said Margaret Battersby Black, a Chicago lawyer. A jury last year awarded $12 million in a lawsuit brought against Infinity and one of its Chicago nursing homes over the 2023 death of Shirley Adams. A retired candy factory worker, Adams died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to the lawsuit.

“She had wounds that no one could explain,” one of her adult children, Leslie Adams, testified at trial. Medicare its lowest quality rating, one star out of five.

Paul Connery, a lawyer for Adams’ family, said they are still trying to collect on the judgment against the nursing home and management company, which now totals $17 million with interest and attorney fees.

“If I get caught speeding and I went to court, they issue me a ticket and I’ve got a fine to pay,” Adams said in an interview. “How are they able to still continue to move on with business like nothing has happened?”

In a phone interview and an email, Gubin said Strawberry Fields, Infinity, and the nursing homes are all legally distinct and that he has not played an active role in Infinity in more than a decade. He said nursing homes get sued all the time but that the verdict against Lakeview is so large that it will force the home to declare bankruptcy or shut down.

“The whole thing is unfortunate,” Gubin said by phone. “For 15 years they were a perfectly good guardian” and “a well-run building,” he said. “You wouldn’t think it was fair to be judged on your worst day.”

Blisko and an Infinity lawyer did not respond to requests for comment.

Strawberry Fields, which owns 10 assisted living facilities and two long-term care hospitals in addition to the nursing homes, earned net income last year of from $155 million in rent, a 21% profit margin, securities filings show. Gubin said those weren’t excessive returns.

A $110 Million Verdict

Traditionally, REIT leases make the operating companies responsible for paying property taxes, insurance premiums, and maintenance costs. In 2008, Congress gave health care REITs a new option to make money: On top of collecting rents, they could set up subsidiaries and take profits directly from health care businesses. They still must have independent management overseeing care decisions. Many REITs have embraced the role even though the subsidiaries must pay corporate taxes and risk losing money if the businesses do poorly.

Colony Capital was a REIT that through layers of shell corporations owned both the building and the operation of Greenhaven Estates, a Sacramento assisted living and memory care facility. In 2018 Greenhaven paid Colony $1.4 million in rent, nearly a third of its $4.5 million in revenue that year, according to financial records filed in court.

Greenhaven also was on the verge of losing its license, according to a revocation notice filed in November 2018 by the California Department of Social Services. Greenhaven had racked up years of health violations, including from letting untrained workers administer medications, lacking enough employees to care for people with dementia, and neglecting a resident who smeared feces over his body, bed, floor, and bathroom, the notice said.

In February 2019, a few weeks after celebrating her 100th birthday, Mildred Hernandez, a resident with Alzheimer’s, wandered out of Greenhaven in the middle of the night. Her assisted living wing had no exit door alarms even though it housed several residents with dementia, court records showed. Berta Lepe, one of Greenhaven’s caregivers, found Hernandez under a bush, wearing only a shirt and underwear. The temperature was in the 30s.

“She was talking, but I couldn’t understand what she was saying,” Lepe testified at trial over a lawsuit from Hernandez’s family. Hernandez died of hypothermia a few hours later, according to her death certificate.

Frontier Management, the company that Colony had hired to manage Greenhaven, denied liability and settled the lawsuit on undisclosed terms.

Since the lawsuit, Colony has changed its name to DigitalBridge, which no longer owns Greenhaven and gave up its REIT status. At trial earlier this year, DigitalBridge said resident care was the responsibility of Frontier and that Colony “encouraged” Frontier to address problems. Richard Welch, a former Colony executive, testified that replacing management is disruptive. “I viewed it as a last resort,” he said.

In March, a jury awarded Hernandez’s family $110 million: $10 million in compensatory damages, $92 million in punitive damages against DigitalBridge, and $8 million in punitive damages against Formation Capital, an asset management company.

“REIT money is very detached from knowing about or caring about patient or resident outcomes, because it’s not in their business model,” Ed Dudensing, a lawyer for the family, said in an interview. “Their allegiance is to their investors.”

DigitalBridge has asked the judge to delay finalizing the judgment while its legal challenges to the lawsuit and the verdict are evaluated. A DigitalBridge attorney and a corporate spokesperson did not respond to requests for comment, a Formation attorney declined comment, and a Frontier attorney and a spokesperson did not respond to a request for comment.

‘Wet From Head to Toe’

When CareTrust bought City Creek Post-Acute and Assisted Living in 2019, the Sacramento nursing home where Pearlene Darby lived had a one-star Medicare rating and was losing money. CareTrust leased the building to a management company called Kalesta Healthcare Group based on the business plan Kalesta submitted.

While CareTrust was not the operator, it held periodic phone calls with Kalesta, which provided “a full update of what’s happening at the facility,” including changes in leadership, financial progress, and health inspection survey results, according to deposition testimony by Ryan Williams, a Kalesta co-founder.

According to a state inspection report, in 2020, the year Darby died, City Creek left a resident in soiled linens “wet from head to toe lying in bed” for more than eight hours. During a different visit, a health inspector cited the home after watching a nurse put a dirty diaper back onto a resident after caring for a wound. “It was just a small stool and it is far from where the wound is,” the nurse told the inspector, according to the report.

James Callister, CareTrust’s chief investment officer, said in his deposition that CareTrust officials “review results of regulatory surveys provided to us by the tenant. We review the five-star rating.” He said, “We evaluate results of care, but we do not evaluate types of care given or how or when, no.”

Darby had been living in City Creek since 2011 after a stroke left her in a wheelchair. She needed help getting in and out of bed. From September through November 2020, Darby lost 30 pounds, her family’s lawsuit alleged. During those months, employees dropped her three times as one worker rather than the required two operated the mechanical lift, the lawsuit said.

The suit alleged City Creek failed to reposition her every two hours in bed or her wheelchair, which is the clinical standard for people at risk of bedsores, and to promptly order devices to protect her skin.

In November, the nursing home sent Darby to the hospital. A blood test found bacteria had entered her bloodstream from her feces’ touching open skin wounds, according to the lawsuit. The hospital diagnosed her with sepsis. A surgeon said she needed an operation to redirect fecal waste from her intestines but concluded she wasn’t medically stable enough for surgery, the suit said.

Darby began receiving comfort care measures and was sent back to City Creek. She died two weeks later. In court filings, CareTrust and Kalesta denied the allegations.

In a phone interview, Williams, the Kalesta co-founder, said Darby’s death occurred during the most challenging point of the covid pandemic, when California rules required any nurses testing positive for the virus to be sent home and nurses were quitting out of fear for their health. “It was the most herculean of professional efforts to secure enough staff,” he said.

While expressing sympathy for Darby and her family, he said it was “unconscionable” that personal injury lawyers sued nursing homes over care failures during “the worst of times.”

In court, CareTrust petitioned Judge Richard Miadich to dismiss it from the lawsuit before trial. “This case does not concern a property condition,” CareTrust’s lawyers wrote. “CareTrust is simply a landlord.” But the judge ruled last year a jury should decide whether CareTrust “exercised actual control over City Creek.”

The case was settled out of court a few months later. All parties declined to reveal the settlement terms.

A 67% Profit

As recently as November 2023 — four years after its acquisition — City Creek earned one star from Medicare. It was cited for failing to have the minimum nursing home staffing required by California law during five of 24 randomly selected days in 2022, according to an inspection report. Williams said in the interview that Kalesta had increased spending on nursing over the course of its ownership, including boosting wages, but that it takes a year or two to turn around a troubled nursing home. He said the home’s star rating in 2023 was dragged down by its poor inspection history from before Kalesta took over.

City Creek’s rating has climbed in the past two years, and it now has the top overall rating of five, according to Medicare. Medicare rates City Creek’s current staffing levels as average. That’s better than most nursing homes in more than 200 buildings CareTrust bought before 2025, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of federal data. On average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours.

In its statement to Ñî¹óåú´«Ã½Ò•îl Health News, CareTrust’s counsel Layne said the REIT worked to “identify quality operators as tenants,” and that the homes the REIT rents out have more nurses and aides than the minimum required for nursing homes by their state governments. “The operators are licensed by state regulators and retain sole responsibility for operations,” the statement said.

CareTrust, which now owns more than 500 senior housing and nursing home buildings, reported net income last year of $320 million from in rents and other revenue — a 67% profit margin. By comparison, HCA Healthcare, one of the nation’s largest for-profit hospital and health care chains, for last year.

Lesley Ann Clement, one of Darby’s lawyers, said cases like hers show the nursing home industry is wrong to complain it lacks financial resources for more staffing.

“There’s plenty of money,” Clement said. “They’re just not spending it on patient care.”

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Other drivers stopped, broke the car window, and pulled him to safety. A passing volunteer firefighter performed CPR until an ambulance arrived to take Masterson to UPMC Mercy hospital.

He spent 18 days in the medical intensive care unit there, 14 of them on a ventilator. He developed delirium, a common ICU condition, and needed antipsychotic drugs. Despite a feeding tube, he lost weight. “We honestly weren’t confident that he would pull through,” said Ron Dedes, his brother-in-law.

But he did. Masterson was discharged Feb. 1 and returned home with near-constant family support. Working diligently with several kinds of therapists, he has regained his ability to walk, despite lingering weakness, and to manage his personal care. His once-garbled speech has markedly improved. He can make himself a sandwich.

Now, “our biggest concern is his memory,” Dedes said. Masterson, who so recently handled complex legal matters, forgets conversations and events that happened a few hours earlier, said Patti Dedes, his sister. He can’t yet operate a microwave or place a phone call.

In an interview, he described himself, accurately, as “much, much better than I was” — but misstated his age. Screening tests after his discharge indicated cognitive impairment and depression.

Among critical-care doctors, prolonged symptoms like his are known as “post-intensive care syndrome,” or PICS. The fallout can be physical or psychological, as well as cognitive, and can persist for months or years.

More than are admitted to intensive care across about 5,000 American hospitals, and research shows that . Older age increases the odds.

Patients and families are often startled by these continuing difficulties. “The belief is that they’ll be discharged from the hospital and in two or three weeks, they’ll be back to normal,” said Brad Butcher, who was Masterson’s doctor and in the medical journal JAMA. “That doesn’t comport with reality.”

In fact, with greater ICU use and improved treatments — the Society of Critical Care Medicine estimates that their stays — the population likely to encounter the syndrome is growing.

“Everyone is grateful that the patient has survived,” said Lauren Ferrante, a pulmonary critical-care doctor and researcher at the Yale School of Medicine. “But that’s just the start of a long road to recovery.” In a study of patients 70 and older that she co-authored, within six months after discharge only about half had .

Intensive care patients face a . PICS symptoms — weakness, pain, neuropathy (tingling in arms and legs), and malnutrition — to , primarily anxiety and depression. like Masterson’s are commonplace, including problems with memory, attention and concentration, and language.

“For many people, surviving a critical illness is a life-altering experience,” Butcher said. Patients in intensive care after emergency or elective surgery also of new physical, mental, and cognitive problems a year later.

The same aggressive treatments that save lives contribute to the syndrome. Intensive care patients “have some sort of dramatic organ failure that requires immediate attention” and constant monitoring, explained Carla Sevin, a pulmonary critical-care doctor who directs the ICU Recovery Center at Vanderbilt University Medical Center.

That could mean a breathing tube attached to a ventilator, which in turn often requires sedating drugs. Sedation “can precipitate delirium, and delirium is the key factor in cognitive symptoms,” Butcher said.

It doesn’t help that constant beeps and alarms from monitors and round-the-clock bright lighting disrupt sleep, and that restrictive family visiting hours deprive patients of reassuring faces and voices.

Gregory Matthews, a retired accountant in St. Petersburg, Florida, spent nearly a month in an ICU after a lung transplant in 2014. He still vividly remembers his hallucinations, including mice running across the wall and someone trying to frame him for drug running.

“One day, I thought a doctor was an assassin — I could see the rifle,” said Matthews, now 80. “So I jumped out of bed,” he said, and yanked out his IVs. The staff put his arms in restraints for days.

But immobilization exacts its own toll as patients quickly lose muscle mass and strength. “Our bodies were not meant to lie in bed all day,” Ferrante said.

Psychologically, “PTSD is pretty common, similar to what’s seen in combat veterans or sexual assault survivors,” Sevin said, referring to post-traumatic stress disorder. Families can suffer anxiety and depression along with the patients.

Alarmed by such discoveries, doctors and administrators at about 35 U.S. hospitals have established , where teams of doctors, nurses, pharmacists, therapists (physical, occupational, cognitive, speech), and social workers screen for a host of conditions and help guide patients through them.

Vanderbilt’s clinic saw its first patient in 2012. The Critical Illness Recovery Center at the University of Pittsburgh Medical Center, which Butcher founded in 2018, works with about 100 patients a year, including Masterson. Yale opened its clinic in 2022.

They rely on six practices recommended by the Society of Critical Care Medicine that are shown to . The measures call for changes such as using lighter sedation, getting patients up and moving earlier, testing their breathing daily to wean them from ventilators sooner, and removing restrictions on family visiting.

Clinics often offer support groups for patients and families. There’s evidence that keeping an ICU diary, in which patients and caregivers record their experiences, and engaging in exercise and physical rehabilitation after discharge.

Also on the clinics’ agenda: discussions of what other options patients might prefer if they face another critical illness, as many do. Would they agree to undergo intensive care and risk its aftereffects again? Or choose palliative care, which emphasizes comfort rather than cure? Some post-ICU patients remain permanently impaired.

Butcher, although he said that the use of the new practices needed to expand dramatically, sounded optimistic about the future of critical care. “We’re going to find better diagnostic tools, better preventive strategies, and better therapies,” he said.

For now, though, the ICU experience remains disorienting and sometimes traumatic. When Butcher asked 117 patients in his post-ICU clinic those next-time questions, many wanted to place limits on further medical interventions.

About a third would want to lower the level of aggressive care. Of those, about a quarter would want “do not resuscitate” and “do not intubate” orders, and almost 7% said they never wanted to return to an ICU.

Masterson is working hard to further his recovery. “I haven’t been out and about much,” he said. “I’ve been kind of homebound.” He hopes to get strong enough to resume running — he used to log 3 to 4 miles several times a week.

The future for patients contending with post-ICU syndrome often depends on their physical, mental, and cognitive health before their admission. Masterson’s previous fitness and cognitively demanding work bode well for his further progress, Butcher said.

His family remains alternatively hopeful and worried. “Down the road, what’s it going to be like?” Dedes, his brother-in-law, wondered. “We just take it day by day.”

The New Old Age is produced through a partnership with .

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OAKLAND, Calif. — Rosa María Carranza leaned forward to hold a 3-year-old’s back as the girl climbed a rock in the forested hills of northeast Oakland.

Dressed in hiking gear and beaded necklaces, Carranza, 67, maneuvered between trees and children on a sunny morning in December. “Hold on to that branch,” she said in Spanish. “You can do it, my love!”

Carranza, a child development professional who grew up swinging through trees and swimming in rivers in El Salvador, said she feels at home in the forest at the outdoor preschool she co-founded. She has worked with children and teens as a caregiver and educator for more than three decades, long enough to know when to lean in and when to step back to let her students find their own footing.

When she transitioned to working part-time last year, Carranza counted on getting Medicare and Social Security checks — benefits given to American workers and lawfully present immigrants when they retire, work history and age or disability requirements. She’s contributed tens of thousands of dollars into Medicare and Social Security over 24 years, according to her Social Security Administration earnings record, reviewed by El Tímpano and Ñî¹óåú´«Ã½Ò•îl Health News. But Carranza and an estimated immigrants will soon be cut out of Medicare.

The GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump, barred certain categories of lawfully present immigrants — including temporary protected status holders, refugees, asylum-seekers, survivors of domestic violence, trafficking victims, and people with work visas — from Medicare.

Those already in the program, like Carranza, will be disenrolled by Jan. 4 — a move by Republican lawmakers to rein in Medicare spending, as they and Trump have argued that taxpayer dollars should not be used to pay for the health care of immigrants in the U.S. without authorization.

“The Democrats want Illegal Aliens, many of them VIOLENT CRIMINALS, to receive FREE Healthcare,” Trump two months after he signed the bill into law. “We cannot let this happen!”

However, the categories of immigrants now losing coverage do have legal status. Neither the White House nor the Department of Health and Human Services responded to a question about whether it was fair to disenroll legal residents from Medicare.

Immigrants without legal status were already ineligible for Medicare or most other federally funded public benefits.

Carranza is worried that she could also lose legal permission to live in the United States if the Trump administration ends temporary protected status for Salvadorans, as it sought to do during .

If that happened, Carranza would lose legal residency, risking time in an immigration detention center or deportation.

“This is like a horror movie, a complete nightmare,” Carranza said. “This is not how I imagined getting old.”

‘Under Constant Attack’

Carranza left El Salvador in 1991 during a brutal civil war, leaving behind three young children, to earn money to send home to her family. She overstayed her visa until 2001, when she qualified for temporary protected status, after two earthquakes struck El Salvador, and displacing 1.3 million.

Temporary protected status, or TPS, was passed by Congress and signed into law by Republican President George H.W. Bush in 1990.

It allows people such as Carranza, from select nations undergoing armed conflict, civil war, and climate disasters, to live and work in the United States if being in their home country poses a risk.

Carranza missed her youngest daughter’s graduation from kindergarten and first medal-winning performance in track. She worked overnight shifts babysitting newborns and later substitute-taught in public schools in the San Francisco Bay Area to pay for her children’s schooling in El Salvador, and for her own classes at City College of San Francisco, where she earned a degree in child development.

And she cared for dozens of 3-, 4-, and 5-year-olds who gazed in awe as they uncovered little treasures buried in the redwood forest of the Oakland park where she co-founded Escuelita del Bosque, a Spanish immersion preschool that teaches children outdoors.

The trade-off was supposed to be a peaceful retirement. But Congress narrowed Medicare eligibility to citizens, lawful permanent residents, Cuban and Haitian nationals, and people covered under the Compacts of Free Association, agreements between the United States and Pacific island nations.

The move followed Trump’s efforts to bar some lawfully present immigrants from Medicaid, marketplace insurance subsidies, and social support services, such as food assistance, housing subsidies, and medical visits in federally funded health centers. Altogether, 1.4 million lawfully present immigrants were projected to lose health insurance, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A spokesperson for House Speaker Mike Johnson, Taylor Haulsee, did not respond to requests for comment.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said Republicans wanted to enact tax cuts and eliminate health insurance for immigrants because it wouldn’t upset their base.

“They don’t want to turn the United States into a welfare magnet,” he said. “And they resent the government for making them pay for a welfare state.”

While data on lawfully present immigrants is not available, immigrants without legal status and $25.7 billion into Social Security in 2022, according to the Institute on Taxation and Economic Policy. The Congressional Budget Office estimated that the Medicare restrictions alone would reduce federal spending by 2034.

Health experts say eliminating coverage for immigrants with legal status .

“This is actually the first time that Congress has taken away Medicare from any group,” said Drishti Pillai, director of immigrant health policy at KFF. “This change is impacting immigrants who have lawful presence in the U.S., and many of whom have already worked and paid into the system for decades.”

As older adults like Carranza lose their Medicare coverage, clinicians anticipate that they will delay their care, leading to an increase in severely ill patients, especially in hospital emergency rooms.

Seniors can become sick suddenly and quickly, and they are more vulnerable to cardiovascular diseases such as heart disease and high blood pressure, especially if they put off routine care, said Theresa Cheng, an emergency physician at Zuckerberg San Francisco General Hospital and assistant clinical professor of emergency medicine at the University of California-San Francisco.

“It’s quite easy for them to fall off the cliff,” Cheng said.

Carranza hikes and considers herself healthy, but she acknowledges that she is aging and starting to struggle to keep up with the kids in the forest.

Late last year she was diagnosed with high blood pressure, and in January she woke up with a tight chest and went to urgent care because it had spiked to dangerous levels. A few weeks later, she tripped on a curb while walking and fell to the ground. She woke up the next day with a swollen foot. A doctor at the local hospital told her she had arthritis.

These were scary moments, she said, but she was grateful to have to pay only $10 for the urgent care visit and $5 to see her primary care doctor. However, that will change when she loses Medicare by early next year.

The stress of knowing she will lose health insurance coverage, and potentially her legal status, all while masked federal agents are detaining immigrants like her across the country, has taken a toll on her mental health, she said. She is searching for a therapist and acupuncture services to treat her insomnia and anxiety — and the feeling that she is “under constant attack.”

Nowhere To Turn

In California, home to the largest number of , Carranza could have enrolled in state-sponsored insurance, but this year the state for adults 19 and older who are a TPS holder, in the U.S. without authorization, or an asylum-seeker. Other states with Democratic governors such as have also scaled back their health programs for immigrants amid budget pressures.

In January, California Gov. Gavin Newsom proposed a state budget that would not backfill federal health care cuts to about 200,000 lawfully present immigrants, noting the $1.1 billion annual price tag and state budget shortfalls.

“Given these fiscal pressures, the administration cannot backfill for this change in federal policy,” California Department of Finance spokesperson H.D. Palmer said.

But some Democratic lawmakers and consumer advocates say the state should step in. State Assembly member Mia Bonta, who chairs the Assembly’s health committee, said she is working on a legislative budget solution to bring immigrants who will lose health coverage, including older adults, into Medi-Cal, the state’s version of Medicaid.

The East Bay Democrat is especially concerned for people like Carranza, “who have lived here for decades and contributed into this economy, who have given into our cultural fabric and into our communities and who built families and lives and who are now wanting to be able to retire with dignity and live with dignity and have the health care that they need.”

A Sign of the Future

Last April, Carranza got a glimpse of what losing her health coverage and retirement benefits could look like, after the Social Security Administration sent her a letter informing her that she no longer qualified for retirement benefits because she was not lawfully present in the U.S. — even though she was. Then Medicare stopped payments to her health plan, which disenrolled her as a result.

As a TPS holder with a work permit, she knew a mistake had been made. Yet, without her check, Carranza didn’t have money to pay her rent for a month. She worked off her rent by babysitting her landlords’ children. Last May, the office of U.S. Rep. Lateefah Simon, an Oakland Democrat, helped Carranza recover her retirement benefits, but it took months for her to get her health insurance back.

The experience left her reeling.

“It’s like getting slapped on the face after more than 30 years working for the system here,” Carranza said. “And in return, this is what we have now.”

She lies awake at night imagining the future: here, where she’s spent half her life, without health insurance and possibly Social Security benefits; or in El Salvador, where two of her three children remain. Her daughter, a green-card holder who lives in Texas, hopes to become a citizen so she can petition for permanent residency for Carranza, but the process can take years. Then there’s the possibility she fears most: indefinite detention or deportation.

On a recent morning in her basement studio in Oakland, Carranza pulled a box from the back of her closet. In it was a thick stack of identification cards that included old driver’s licenses, her Social Security card, and dozens of work IDs issued by the federal government.

“My life is in that box,” she said.

This article was produced in collaboration with , a civic media organization serving and covering the Bay Area’s Latino and Mayan immigrant communities.

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While taking her history and vital signs, Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148/86, above normal despite her taking two medications intended to lower it. “Clearly that was too high,” he said recently.

Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet, and a lack of regular exercise. She had also told Supiano that she typically drank a couple of glasses of wine each evening.

After Supiano discussed ways to lower her risk, the woman and her husband joined a gym. She stopped taking the anti-inflammatory and cut back on salt and alcohol, bringing her systolic blood pressure readings into the 130-to-140 range — still hypertension, according to  issued by the American Heart Association and the American College of Cardiology later that year, but more acceptable. (Systolic is the top number in the blood pressure ratio and the more clinically important number.)

By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. “I was not as aggressive as I should have been,” Supiano recalled. He added a third drug for high blood pressure to the woman’s regimen, and her readings fell to 120 or lower.

The shifting guidelines for blood pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, “How low can you go?”

For more than 25 years, a reading of 140/90 or below was considered normal, according to the AHA/ACC guidelines. But the 2017 update introduced major changes, backed by results from the , which enrolled adults over 50 who were at high cardiovascular risk.

The SPRINT trial found that intensive treatment aimed at bringing the systolic number below 120 reduced the risk of heart attacks, strokes, other cardiovascular illnesses, and overall mortality so substantially that the investigators .

It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.

°Õ³ó±ðÌý, issued last year, encourage still tighter control. They call for patients at cardiovascular risk to strive for systolic readings below 120, and they also call that target “reasonable” even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.

Blood pressure normally rises with age because “with stiffening of the arteries, the heart has to pump harder,” said Erica Spatz, the director of the preventive cardiovascular health program at the Yale School of Medicine. From 2021 to 2023, about  had hypertension, according to the operative definition at the time.

But recent revisions could “define a lot more people as having high blood pressure,” said Rita Redberg, a cardiologist at the University of California-San Francisco.

To Supiano, recent  and  that show cognitive benefit for the lower readings “have tipped the scales” for older adults. “What’s good for the heart is good for the brain,” he said, calling those findings “a lever to get people to pay more attention to their blood pressure. They may not want to live longer, but they want to hold on to their cognition longer.”

Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization’s board), have endorsed the latest guidelines.

“I used to be lenient in many of my older patients,” said John Dodson, a cardiologist and researcher at NYU Langone Health. “If I overtreated high blood pressure, bad things were going to happen.”

Blood pressure that drops too low — hypotension — can cause dizziness and fainting or injuries from falls.

Now, Dodson said, “I’m treating my older patients more aggressively.” Studies have shown that treating high blood pressure . And while older adults in the SPRINT trial had more fall injuries, the rate wasn’t higher  than in those undergoing standard treatment. Among those over 75, it was  for both groups.

Another significant change: The new guidelines recommend at-home monitoring.

“Blood pressure is tricky,” Spatz pointed out. “It varies throughout the day, depending on whether a person is just waking up or just ate or it’s hot outside.” Systolic readings can bounce around by 30 points or more in a single day.

And they’re almost always higher in a doctor’s office. “I don’t want to put much stock in one reading,” Spatz said.

“Maybe the patient has white-coat syndrome,” she added, referring to anxiety about doctors and testing, “or they had a fight with the parking attendant” on the way in.

She asks patients to record their blood pressure twice a day for a week or two before their appointments. Some doctors prescribe a 24-hour home monitor.

Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.

Price is not likely to present an obstacle. Most patients need two or three drugs to lower blood pressure, but as generics they’re “dirt cheap, about $5 a month,” and rarely interact with the other drugs that are often prescribed for older people, Supiano said. A blood pressure monitor for home use , or more for those that digitally transmit data.

Although some side effects are serious — a fall can be life-altering — most complications “thankfully are transient and reversible and rather mild,” he said.

Yet the guidelines have skeptics, too. Redberg, for example, counsels older patients about diet, exercise, and weight loss but does not urge them to start medication to reduce a 135 systolic reading to below 120.

They already seem overanxious about their blood pressure, she said, adding, “I encourage them to go out and enjoy themselves.”

“Take a class! Go to a museum!” she said. “You can’t do that if you’re at home taking your blood pressure five times a day.”

While trials and guidelines address benefits for the population as a whole — even small reductions in dementia would have an enormous impact — they are not useful for predicting individual outcomes. The , used to gauge whether someone would see cardiovascular benefit from hypertension treatment, has not been validated for people over 79 and does not factor in cognitive benefits, Supiano noted.

For people with other serious illnesses — cancer patients or frail nursing home residents with dementia, for instance — controlling blood pressure may be far down the list of concerns.

Time is also a factor in weighing risks versus benefits. A meta-analysis of older patients by Sei Lee, a geriatrician at UCSF, and colleagues found that for 200 patients in intensive treatment for hypertension, it would .

Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. “You’d have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher.”

Supiano’s 78-year-old patient did hit that target and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and eventually received an Alzheimer’s diagnosis.

Given what researchers are reporting about the cognitive benefits of treating high blood pressure, “maybe it gave her another couple of good years,” he mused. “Maybe it delayed the progression.” Or maybe, he added, he should have started intensive treatment earlier.

The New Old Age is produced through a partnership with .

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

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

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

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

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

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

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

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

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

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

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

Beware: More Underwriting

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

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

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

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

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

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

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called , a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found. 

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

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

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

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about members, more than half the people eligible for Medicare. 

CMS is set to announce a final rate decision by early next month. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online. 

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

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

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

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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“The person said he was an officer of the Department of Criminal Investigations looking into drug trafficking and money laundering,” the woman recalled. He seemed to know a lot about her: the states where she and her late husband had lived; his name and occupation; and her current address in Washington County, Rhode Island.

On her phone, he showed her a convincing badge and a photo ID with his name (“‘Frank’ something”), plus an article describing the supposed investigation. The woman, a 76-year-old retiree, denied any involvement.

“You can hire a very expensive criminal defense attorney, or you can cooperate with me,” Frank told her.

“Now, when you think about it, it doesn’t make any sense,” the woman acknowledged recently. But persuaded by the badge and ID, she agreed to cooperate. Otherwise, “I thought they were going to come and arrest me.”

Frank called each morning to learn where she was going, what she was doing. His team would be watching, he warned. The woman, feeling “petrified,” started looking around as she drove to garden club meetings. Was somebody following her?

It was all a scam.

Because victims’ sense of shame often leaves them reluctant to report such crimes, the extent of elder financial exploitation is hard to calculate. The Federal Trade Commission of $2.4 billion in 2024, largely driven by investment and and impersonations, with total losses much higher.

Americans age 60 and older lose more than $28 billion annually to financial exploitation, .

As those numbers rise, because the population is aging and predators are growing increasingly resourceful, banks and investment firms are becoming the first line of defense.

Frank’s initial target: her account at Fidelity Investments. He instructed her to shift about $250,000 into her checking account, telling the financial adviser at her local office that she and her family intended to buy real estate.

That scheme fizzled when the adviser said Fidelity could not approve the transaction without more information on the property.

So Frank sent her to her local branch of Washington Trust Company to take $70,000 in cash from a home-equity line of credit. “We don’t give out that much in cash,” the teller said, quietly messaging the branch manager, who had known the woman and her husband for years.

The manager ushered the woman into her office to talk, and the scam stopped there, with a call to the local police. The woman’s assets remained intact, but the experience proved so mortifying that she has not told even her family how close she came to losing much of her life savings. The New York Times is withholding her name to spare her embarrassment.

“I felt so stupid,” she said. “I felt like a fool.”

Financial predators targeting older adults represent “a heightened focus for us now,” said Mary Noons, president and chief operating officer of Washington Trust.

A regional community bank, Washington Trust cranked up its efforts last fall to advise older customers and their families about finances, including the dangers of elder fraud and exploitation. It published and distributed a booklet called “Age With Wisdom” and brought in an expert on dementia to speak with staff members.

And it became one of the 1,500 financial institutions to date to use BankSafe, a free AARP video program that trains front-line employees to spot the indicating possible elder exploitation and to intervene. Everyone at the branch where the 76-year-old banked had taken the training.

“Some older customers visit their bank far more frequently than they see their health care providers,” Noons pointed out.

Until recent years, financial institutions placed “more of an emphasis on the autonomy of the client,” said Pamela Teaster, director of the Virginia Tech Center for Gerontology and an elder abuse researcher. Their approach was, “an adult has the capacity to make poor choices, and we’re going to let them make them,” she added.

But changes in government and industry policies and practices have encouraged greater vigilance. Congress passed in 2018, protecting banks and financial firms from liability if they reported suspected exploitation to authorities.

That year, the Financial Industry Regulatory Authority began requiring member firms to ask for a when investors open or update accounts. (The account holder isn’t obliged to provide one, however.) And since 2022, it has on older investors’ transactions if they suspect exploitation is involved.

About half of states have enacted laws that permit financial institutions to deny suspicious transactions or impose holds for specified periods to allow investigations, said Jilenne Gunther, the director of BankSafe.

“It adds friction,” she explained. “With space and time, the criminal gets worried and might move on. And the potential mark has time to stop and think.”

Teaster’s analysis of during a six-month pilot in 82 financial institutions, found that participants were much more likely to report suspected cases and save customers money than a control group was.

Not all of older adults’ losses result from predators, however. They can, on their own, get caught up in investment fads, take on too much debt, or make otherwise unwise decisions, even without criminals pulling the strings or relatives looting their accounts.

Managing finances presents complex cognitive challenges, said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine. “It requires a lot of brain,” he said, including: “Memory, remembering that a bill is due. Executive function, the ability to manage your time. Abstraction, hypothesizing about your future.”

He added, “Financial errors are not infrequently the or a neurocognitive disorder.”

A by the Federal Reserve Bank of New York, for instance, found an increased probability of delinquent payments and deteriorating credit ratings in the five years before a dementia diagnosis. Those errors can reduce seniors’ access to credit and raise their interest rates on loans at the very point when caregiving expenses are likely to soar.

Lachs has called on fellow doctors to recognize what he calls , a syndrome that can affect even older people with normal cognition, especially if they contend with medical illnesses, sensory deficits, or social isolation.

And he remains skeptical about the financial industry’s claims of heightened attention to its oldest customers. “I still see concerning financial transactions executed that should have received far greater scrutiny,” he said.

Training more front-line staff members and increasing emphasis on establishing trusted contacts for older customers would help, Gunther said, because “once the money leaves the account, it’s near impossible to ever retrieve it.” More states could enact laws allowing financial institutions to deny suspicious transactions or impose holds.

Several related bills with bipartisan support are working their way through Congress. The would require the FBI to coordinate efforts to protect seniors. A would at least provide the consolation of excusing scam victims from paying taxes on money they no longer have.

However, new weapons like artificial-intelligence voice cloning — in which the supposed grandson four states away who urgently needs $5,000 in gift cards actually sounds like the victim’s grandson — keep advocates and bankers awake at night.

In the Washington Trust branch where the Rhode Island woman didn’t lose her money, employees just days earlier had stopped a scam similar to the one that had targeted her.

But more recently, nobody spotted any danger signs when an older woman withdrew $9,000 for a kitchen renovation, until it went to a scammer instead of a contractor.

The New Old Age is produced through a partnership with .

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“I was kind of a mess,” recalled Abrams, 69. Trying to cope, “I was eating myself into oblivion.” As her weight hit 270 pounds and her blood pressure, cholesterol, and blood glucose levels climbed, “I knew I was in trouble health-wise.”

What came to mind? “Oh, oh, oh, Ozempic!” — the from television commercials that promoted the GLP-1 medication for diabetes. The ads also pointed out that patients who took it lost weight.

Abrams remembered the commercials as “joyful” and sometimes found herself humming the jingle. They depicted Ozempic-takers cooking omelets, repairing bikes, playing pickleball — “doing everyday activities, but with verve,” she said. “These people were enjoying the hell out of life.”

So, just as such ads often urge, even though she had never been diagnosed with diabetes, she asked her doctor if Ozempic was right for her.

Small wonder Abrams recalled those ads. Novo Nordisk, which manufactures Ozempic, spent an estimated $180 million in direct-to-consumer advertising in 2022 and $189 million in 2023, according to MediaRadar, which monitors advertising.

By last year, the sum — including radio and TV commercials, billboards, and print and digital ads — had reached an estimated $201 million, and total spending on direct-to-consumer advertising of prescription drugs topped $9 billion, by MediaRadar’s calculations.

Novo Nordisk declined to address those numbers.

Should it be legal to market drugs directly to potential patients? This controversy, which has simmered for decades, has begun receiving renewed attention from both the Trump administration and legislators.

The question has particular relevance for older adults, who contend with more medical problems than younger people and are more apt to take prescription drugs. “Part of aging is developing health conditions and becoming a target of drug advertising,” said Steven Woloshin, who studies health communication and decision-making at the Dartmouth Institute.

The debate over direct-to-consumer ads dates to 1997, when the FDA loosened restrictions and allowed prescription drug ads on television as long as they included a rapid-fire summary of major risks and provided a source for further information.

“That really opened the door,” said Abby Alpert, a health economist at the Wharton School of the University of Pennsylvania.

The introduction of Medicare Part D, in 2006, brought “a huge expansion in prescription drug coverage and, as a result, a big increase in pharmaceutical advertising,” Alpert added. A study she co-wrote in 2023 found that pharmaceutical ads in areas with a high proportion of residents 65 and older.

and have shown that ads influence prescription rates. Patients are more apt to make appointments and request drugs, either by brand name or by category, and doctors often comply. may ensue.

But does that benefit consumers? Most developed countries take a hard pass. Only New Zealand and, despite the decadelong , the United States allow direct-to-consumer prescription drug advertising.

Public health advocates argue that such ads encourage the use and overuse of expensive new medications, even when existing, cheaper drugs work as effectively. (Drug companies don’t bother advertising once patents expire and generic drugs become available.)

In a 2023 study in JAMA Network Open, for instance, researchers analyzed the “” of the drugs most advertised on television, based on the assessments of independent European and Canadian organizations that negotiate prices for approved drugs.

Nearly three-quarters of the top-advertised medications didn’t perform markedly better than older ones, the analysis found.

“Often, really good drugs sell themselves,” said Aaron Kesselheim, senior author of the study and director of the Program on Regulation, Therapeutics, and Law at Harvard University.

“Drugs without added therapeutic value need to be pushed, and that’s what direct-to-consumer advertising does,” he said.

Opponents of a ban on such advertising say it benefits consumers. “It provides information and education to patients, makes them aware of available treatments and leads them to seek care,” Alpert said. That is “especially important for underdiagnosed conditions,” like depression.

Moreover, she wrote in a recent , direct-to-consumer ads lead to increased use not only of brand-name drugs but also of non-advertised substitutes, including generics.

The Trump administration entered this debate last September, with calling for a return to the pre-1997 policy severely restricting direct-to-consumer drug advertising.

That position has repeatedly been urged by Health and Human Services Secretary Robert F. Kennedy Jr., who has charged that “pharmaceutical ads hooked this country on prescription drugs.”

At the same time, the FDA said it was issuing about deceptive drug ads and sending “thousands” of warnings to pharmaceutical companies to remove misleading ads. Marty Makary, the FDA commissioner, in an essay in The New York Times.

“There’s a lot of chatter,” Woloshin said of those actions. “I don’t know that we’ll see anything concrete.”

This month, however, the that the agency had found its TV spot for a new oral version of Wegovy false and misleading. Novo Nordisk said in an email that it was “in the process of responding to the FDA” to address the concerns.

Meanwhile, Democratic and independent senators who rarely align with the Trump administration also have introduced legislation to ban or limit direct-to-consumer pharmaceutical ads.

Last February, independent Sen. Angus King of Maine and two other sponsors prohibiting direct-to-consumer ads for the first three years after a drug gains FDA approval.

King said in an email that the act would better inform consumers “by making sure newly approved drugs aren’t allowed to immediately flood the market with ads before we fully understand their impact on the general public.”

Then, in June, he and independent Sen. Bernie Sanders of Vermont proposed entirely. That might prove difficult, Woloshin said, given the Supreme Court’s Citizens United ruling .

Moreover, direct-to-consumer ads represent only part of the industry’s promotional efforts. Pharmaceutical firms actually spend than to consumers.

Although television still accounts for most consumer spending, because it’s expensive, Kesselheim pointed to “the mostly unregulated expansion of direct-to-consumer ads onto the web” as a particular concern. Drug sales themselves are bypassing doctors’ practices by moving online.

Woloshin said that “disease awareness campaigns” — for everything from shingles to restless legs — don’t mention any particular drug but are “often marketing dressed up as education.”

He advocates more effective educational campaigns, he said, “to help consumers become more savvy and skeptical and able to recognize reliable versus unreliable information.”

For example, Woloshin and Lisa Schwartz, a late colleague, designed and tested a simple “,” similar to the nutritional labeling on packaged foods, that summarizes and quantifies the benefits and harms of medications.

For now, consumers have to try to educate themselves about the drugs they see ballyhooed on TV.

Abrams read a lot about Ozempic. Her doctor agreed that trying it made sense.

Abrams was referred to an endocrinologist, who decided that her blood glucose was high enough to warrant treatment. Three years later and 90 pounds lighter, she feels able to scramble after her 2-year-old grandson, enjoys Zumba classes, and no longer needs blood pressure or cholesterol drugs.

So Abrams is unsure, she said, how to feel about a possible ban on direct-to-consumer drug ads.

“If I hadn’t asked my new doctor about it, would she have suggested Ozempic?” Abrams wondered. “Or would I still weigh 270 pounds?”

The New Old Age is produced through a partnership with .

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