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

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

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

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

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

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

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

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

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

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

The Word on the Street

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rural health facilities also face challenges in implementing AI.

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

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

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

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

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

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

Will States Share AI Results?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other mergers have been proposed in , , and Minnesota.

Asheville’s Dominant Hospital

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Birth of a Monopoly

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Julie Rovner Ñî¹óåú´«Ã½Ò•îl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of Ñî¹óåú´«Ã½Ò•îl Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Democratic primary voters in Michigan chose former Detroit public health director Abdul El-Sayed as their Senate nominee this week. El-Sayed is one of several high-profile candidates around the country who have been pushing “Medicare for All,” again elevating the issue, at a time when millions of Americans are losing their health coverage because of high costs.

Meanwhile, the Senate this week confirmed Erica Schwartz to lead the Centers for Disease Control and Prevention, which has been without a permanent leader for almost a year. But it remains unclear whether her support for childhood vaccinations will run afoul of her boss, Health and Human Services Secretary Robert F. Kennedy Jr.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Alice Miranda Ollstein of Politico, and Amanda Seitz of Ñî¹óåú´«Ã½Ò•îl Health News.

Panelists

Joanne Kenen Johns Hopkins University and Politico

Alice Miranda Ollstein Politico

Amanda Seitz Ñî¹óåú´«Ã½Ò•îl Health News Read Amanda's stories.

Among the takeaways from this week’s episode:

• El-Sayed’s primary victory in Michigan means a vocal supporter of Medicare for All will be on the ballot this fall. Progressives again are rallying behind universal healthcare as costs spike and more people lose their coverage — although there are few details so far to explain how they would implement such a policy.
• New polling shows more people are experiencing “job lock” because of limited options to obtain healthcare coverage outside employer-sponsored insurance. Meanwhile, more hospitals are reporting a sharp rise in the number of uninsured and in the costs to cover them.
• A federal judge recently declined to halt the implementation of Medicaid work requirements while considering a case brought by several states challenging the policy’s burden on sick people. And early reports out of Nebraska, the first state to implement the work requirements, show eligible people are losing coverage for administrative reasons.
• Kennedy sat down for an interview with CNN, during which he could not articulate specific plans to address disease outbreaks — as multiple outbreaks are ongoing. And a Senate committee voted along party lines Thursday to hold former public health official Anthony Fauci in contempt of Congress over his appearance before the committee last week.

Also this week, as part of the “How Would You Fix It?” series, Rovner interviews Sen. Andy Kim (D-N.J.), who has a new bill that would provide universal health coverage for all children.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: The New York Times’ “,” by Sheryl Gay Stolberg.  

Alice Miranda Ollstein: NOTUS’ “,” by Margaret Manto.  

Joanne Kenen: The New York Times Magazine’s “,” by Helen Ouyang.  

Amanda Seitz: The Wall Street Journal’s “,” by Katherine Long.  

Also mentioned in this week’s podcast:

• The Bulwark’s “,” by Jonathan Cohn.
• The New York Times’ “,” by Reed Abelson.
• Politico’s “” by Alice Miranda Ollstein and Josh Gerstein.
• Underlying Conditions’ “,” by Céline Gounder.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News” on , , , , , or wherever you listen to podcasts.

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

Kim, who serves on the Senate Health, Education, Labor and Pensions Committee, said it is “a real dereliction of our duty that we have not found a way to be able to ensure that every child is able to go see a doctor when they need to without breaking the bank.”

Under the senator’s proposal, children would be automatically enrolled at birth in the public program, which he . Parents would have the option to opt their kids out, though they could reenroll them at any time until age 26, Kim told Rovner.

“You want to make sure that all of these kids are able to get the care that they need as their bodies are and their brains are developing and that you don’t see the kind of withdrawal of or restriction of care that could have real consequences down the road,” he said.

Kim said offering comprehensive, universal coverage to American children would help them avoid chronic conditions in adulthood, in addition to providing broader societal benefits, such as a healthier workforce.

He added that he hopes his idea could gain traction should Democrats claim a majority in Congress in the midterm elections, as well as foster an important discussion about healthcare in the 2028 presidential race.

An abbreviated version of this interview aired Aug. 6 during Episode 458 of What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News: “The Return of ‘Medicare for All.’”

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

Angelica helped Barahona, 41, schedule an appointment to complete her paperwork in person at Kern Family’s offices before she submitted it to Kern County officials for approval. When Barahona had a conflict with her office-cleaning job, Angelica rescheduled the appointment. Barahona finished the process a little later than she’d planned but early enough to avoid an interruption in her coverage.

“It was easy. The fact that Angelica spoke Spanish when we were on the phone made it better,” Barahona, whom Ñî¹óåú´«Ã½Ò•îl Health News met through Kern Family Health Care, said via a translator. “It felt like I was talking to a real person.”

She definitely wasn’t.

“Angelica” is the name assigned to an AI program deployed last year by Kern Family Health Care, the largest provider of Medi-Cal services in Kern County. An estimated 52% of residents there rely on the safety net program for health coverage, among the highest enrollment rates in the state.

Kern Family has spent about $370,000 on the software , a San Francisco startup, to facilitate rapid and repeated outreach to members when it’s time to renew their coverage — a process that is about to become more complex under new Medicaid eligibility rules established under Republicans’ One Big Beautiful Bill Act, signed into law last year by President Donald Trump. Mandatory work requirement documentation will take effect nationally beginning in 2027, and under the GOP’s new rules, most Medicaid patients will now have to renew their enrollment twice a year, rather than once a year.

Kern Family and other similar health plans have an interest in keeping people enrolled, since they’re paid through managed care contracts with Medi-Cal. They can also save money by using AI software to do what Kern says would otherwise require it to hire 40 full-time workers. Angelica does it at a fraction of the cost and without increasing payroll — or requiring Kern Family to navigate workers’ rights issues or government-mandated workplace protections.

Although Kern Family officials say no workers have lost jobs, the health plan, which is not unionized, estimated it would have had to spend $2.4 million in staffing costs to match the program’s more than 800,000 calls to its 387,000 members since Kern Family began using Angelica late last year.

As the federal government ended pandemic-era protections and states resumed screening people for Medicaid eligibility, health plans such as Kern Family began looking to technology to keep eligible people enrolled. Kern Family officials say that Angelica helps people, in their preferred language, set up appointments with the plan’s staffers, who make sure that applications are filled out correctly and delivered to county health officials for verification and processing.

Careforce CEO Huzaifa Sial said Kern Family is one of a few health insurers using his company’s software to help boost its Medi-Cal enrollment, and the company is also working with the Central California Alliance for Health in much the same way. “Most people don’t know what they need, and if they do, they have a hard time getting there,” Sial said. “That’s the hidden execution problem that nobody sees.”

The rise of AI in the healthcare industry has prompted worries about who’s overseeing these tools and whether people are being improperly or . Unions have raised concerns about workplace surveillance and the . Polling shows over AI-driven job losses and growing income inequality, while health policy researchers have also about algorithmic biases, transparency, data privacy, and safety risks.

Mark Duggan, a Stanford University economics professor who has studied the Medicaid system for 30 years, said one long-standing fear is that insurers could use such software to cherry-pick patients for coverage.

“When you have a new technology like this, you need to police it,” Duggan said.

Complying With Regulations

California health plan regulators say they are tracking AI use closely, and the state attorney general’s office has to healthcare entities about their obligation to follow consumer protection rules.

Anthony Cava, a spokesperson for the state’s Department of Health Care Services, said Medi-Cal health plans have flexibility in how they handle member renewals, including with the use of AI tools. But plans are responsible for ensuring that technology complies with state and federal regulations, including patient privacy and data security, he said.

Last year, the agency, foreseeing the huge volume of reenrollments that were going to be required in the state, began allowing managed care plans to contact members about renewals. State rules still prohibit Medi-Cal health plans from soliciting new enrollees, and only county health officials determine eligibility.

Emily Duran, CEO of Kern Health Services (which administers Kern Family), said that the plan worked closely with the Kern County Department of Human Services to obtain some data, allowing Kern Family to know when a member’s Medi-Cal eligibility will expire.

The health plan, in turn, lets the county know anytime it receives updated demographic or contact information for its Medi-Cal members. And the county has stationed workers inside Kern Family Health Care’s main facility in Bakersfield to answer enrollment questions for people who walk in to finish their paperwork.

“They have a leadership group that is very innovative and forward-thinking,” Vanessa Frando, the chief deputy director of Kern County Human Services, said of Kern Family. The agency also works closely with other Medi-Cal providers in the county, Frando said.

Duran said the health plan was initially concerned about how Angelica would be received.

“We had to set the tone to really be open to the idea, because you hear ‘AI’ and you’re like, ‘Oh, yeah, Jeff Bezos laid off 100,000 people because of that,’” Duran said. “But we are already stretched thin. We need this functionality to be much more effective and augment our efforts.”

Duran said Kern Family’s leadership and staff bought in after seeing a demonstration.

Today, it would take 40 Kern Family employees, each working 40 hours a week, to match Angelica’s calls to remind people to reenroll and talk them through what is involved, according to Jackie Byrd, a spokesperson for the health plan. The AI program’s settings are constantly adjusted to match the capacity of Kern Family’s full-time staff.

Full Conversations With AI

Barahona said she received a Medi-Cal packet in the mail but didn’t think about it until Angelica called days later. That exchange highlights one of local and state health officials’ biggest concerns — that people who’ve grown accustomed to automatic renewals aren’t aware of the reenrollment requirements.

Angelica speaks more than 30 languages and can answer lengthy questions. In samples of actual conversations provided to a reporter, Angelica sounded lifelike at first, although more than once cross-talk with a patient caused the program to pause suddenly. Barahona said it took her a minute before she realized she wasn’t speaking with a human, but she ended up having a full conversation with Angelica.

Duran said Kern Family was able to redirect full-time staff to focus on the more complex parts of the Medi-Cal process, such as making sure the patients’ information is complete and up to date. The Angelica software also operates at all hours, making it easier for patients to call back at their convenience. Another version, David, is used internally to help staffers navigate the technology.

“This will always be, in my opinion, an AI-human combination,” said Careforce’s Sial. Working with AI solutions for more than a decade at UnitedHealthcare and Optum, Sial said, he saw an opportunity to improve the enrollment process by helping people organize their paperwork.

Kern Family’s Medi-Cal renewal rate in April was 94.9%, delighting the plan’s officials, who feared a significant drop-off from patients who’d gotten used to being automatically renewed over the past several years. By comparison, Duran said that about 80% of enrollments had automatically renewed under federal pandemic-era rules, but that figure was cut in half as those protections began to expire.

Kern Family officials say there could be other uses for Careforce’s software in the future; Angelica, like other generative-AI large language models, can learn and adapt to new situations and requests.

Cesar Delgado, Kern Family’s chief information officer, said Angelica is already being used to make general greeting calls to new members and can discuss plan benefits and answer basic questions. But Kern Family officials say the program’s primary purpose, for now, is limited to contacting patients whose Medi-Cal eligibility is coming up for review.

Duggan, the Stanford professor, said Angelica could help Kern Family minimize the number of Medi-Cal enrollees who lose coverage as federal requirements take effect.

“The best-case scenario is helping people to stay on when they don’t realize that things are changing,” Duggan said. “It’s not an easy program to navigate.”

This article was produced in collaboration with , an independent, California-based nonprofit investigative news publication that reports on inequality, climate change and other issues.

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

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

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

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

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

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

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

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

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

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

‘No Easy Answers’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘One Important Tool’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Xavier Becerra, Running for Governor in California

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

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

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

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

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

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

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

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

Amy Acton, Running for Governor in Ohio

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But behind the house, the 44-year-old’s backyard garden showcases her goals for the future, one that involves a long, healthy life with her kids: collard greens, bell peppers, onions, tomatoes, red and white potatoes, kale.

Like Lowery, many in the small towns of Lumberton and nearby Pembroke are citizens of the Lumbee Tribe who have dealt with heart conditions. The mother of four struggled with obesity and had to take insulin pills and shots daily. By when her first grandchild was born, in 2024, Lowery imagined her own life ending the way her biological father’s did: Daily insulin shots for diabetes. Kidney dialysis treatments at home. Dead of a heart attack at 63. She wanted her grandkids to remember her.

“If I don’t get this weight off me, if I don’t change my eating habits, it’s going to take me over,” she recalled thinking.

So, she expanded her garden. She cut fatty foods and sugary drinks out of her diet, stopped eating fried and fast food, and started moving more. She lost 120 pounds in two years and weaned herself off the daily insulin pills.

The Lumbee Tribe of North Carolina late last year became the 575th tribe to secure federal recognition as a sovereign nation, a milestone that leaders and citizens celebrated in tears. The designation provides federal funding for an array of services, including for healthcare. , chairman of the tribe and a state representative, “the biggest benefit” would be access to the Indian Health Service — its clinics and hospitals, as well as funding that it could provide for the tribe to .

But Lumbee researchers and healthcare providers say that money won’t be enough. For decades, IHS has been , with the agency’s budget workgroup estimating that of what it needs this year. And that was before the Trump administration’s cuts to other federal agencies further pinched IHS. Slashes to the Centers for Disease Control and Prevention last year initially included laying off nearly , and President Donald Trump’s proposed 2027 budget cuts more than $150 million for a in Native American tribes.

The nearest IHS facility is more than a two-hour drive to another state for most of the 55,000 Lumbee citizens in Robeson County. The county is one of the and has some of the .

The Congressional Budget Office in 2022 estimated that the tribe could increase IHS spending by .

The tribe will have to rely on other revenue sources that are now allowed through recognition, such as a casino, to reverse the health disparities their people have faced for decades, Lumbee researchers said.

“None of us can depend on IHS alone, because we just don’t have the resources within that system,” said , a physician, a researcher at the Johns Hopkins Center for Indigenous Health, and a member of the Oglala Lakota tribe. “But it’s a great starting point.”

The IHS did not respond to questions about plans for the tribe’s health system. John Lowery did not respond to requests for an interview or a list of questions, but he said on a June podcast that he expected healthcare to be the .

‘Not Just Statistics’

Eighteen years ago, , a doctor in Lumberton and a citizen of the tribe, was working at a nearby medical center. There, she said, she was taught that patients with certain last names “are often referred directly to cardiac catheterization,” a procedure to diagnose heart conditions.

Blackburn said she realized that common Lumbee surnames carried an expectation of disease.

“Nearly two decades later, I can tell you that reality has not changed,” she told assembled tribal leadership and citizens at a public hearing.

Robeson County’s rates of heart disease, diabetes, and continue to rank among the highest in the state, Blackburn noted. In 2025, were Medicaid enrollees, the highest percentage of all counties in the state.

“But these are not just statistics to me,” she said. “These are my patients. These are our families.”

For Angie Lowery, breaking free from those statistics meant taking her health into her own hands.

She hopes a healthy diet is the answer to breaking her family’s cycle and living long enough to form relationships with her grandkids. And she brought the rest of the family with her. Her teenage daughter lost about 35 pounds. Two of her other children are now “health fanatics,” Lowery said.

Her granddaughter will be 2 in November. One Sunday morning in March, Lowery served up macaroni, cauliflower, and chickpeas for her as they spent the day together.

Lowery had supported building a casino, believing it would provide better education, infrastructure, and healthcare for her family.

“That vote, I’m thinking of my children’s future,” she said.

Casino Dreams in Limbo

Tribal citizens are deeply divided over how to reverse decades of economic decline that have led to poor living conditions, unaffordable health services, and chronic disease.

Four months after Trump signed the Lumbee Fairness Act — “I love the Lumbee Tribe” — tribal leaders gathered at a business meeting to take the first steps toward building a casino and establishing gaming as a new revenue source. Hundreds of federally recognized tribes across 29 states have used gaming as a source of revenue, in fiscal 2024, according to the latest report from the National Indian Gaming Commission.

The approach has been popular among tribal nations looking for more dollars to build up healthcare. The Choctaw Nation of Oklahoma in 1999 to build its own hospital, using roughly $25 million in gaming money, and the Eastern Band of Cherokee Indians in western North Carolina funded its own hospital in 2015 mostly with $82 million in gaming funds.

But the Lumbee Tribe’s effort to establish a casino collapsed in June.

rejected a Lumbee constitutional amendment that would have allowed tribal leaders to create infrastructure needed for a gaming business. John Lowery said that he doesn’t plan on bringing back the initiative now that it was rejected “by the majority of Lumbee voters.” His term as chairman ends in two years.

Other funding sources to provide health services for the tribe could include gas stations or hotels, he said in a call with citizens before the vote.

Lumbee and other Native health researchers said they believe a twofold system — using IHS money and additional revenue — is necessary. Funds from gaming could compensate for what IHS can’t support.

Casinos’ impact on tribal health has been debated in research for decades. that the money from gaming helps tribes build more facilities, hire more doctors, and improve social services, but unhealthy substance use and smoking increase.

“There’s going to be negative impacts,” , a social work professor at the University of North Carolina and citizen of the Lumbee Tribe, said at a June panel discussion on gaming.

, 62, a Lumbee citizen and a researcher studying Native health at UNC, said the community has felt ripple effects from systemic racism, having not been acknowledged as a tribal nation for so long, and the economic downturn following the loss of Robeson County’s manufacturing and tobacco jobs.

That history plays a part in the health statistics in Robeson today, Bell said. But with federal recognition, he said, the Lumbee people have achieved a victory they’ve fought for since 1888.

“I think about the resilience of the Lumbee people and how they’ve gone through this 100-plus-year fight for federal recognition,” Bell said. “I sort of see that as a continuation of this resilience, and how now we have this opportunity with federal recognition to bring in resources to help address those issues.”

Resolution and Uncertainty

Jada Brooks, a Lumbee citizen and UNC researcher who studies Indigenous health and lives in Robeson County, is conducting a study about heart health among Lumbee women. The initiative includes classes in which Lumbee women ages 18 to 50 signed up to discuss their health. That’s where she met Angie Lowery, who talked about her lifestyle changes with the group.

“I was just floored by, like, just the extent to which she went,” Brooks said.

She and other Lumbee researchers said federal recognition allows Lumbee citizens to be set apart in census data, paving a way to get clear information on heart health, cancer rates, diabetes diagnoses, and mental health risks.

“There’s challenges in even understanding the nuances of these complex health disparities, because a lot of data isn’t out there,” said Ryan Dial, a public health researcher at UNC and a member of the Lumbee Tribe.

But access and confidence may be the biggest barriers Lumbee people will have to overcome, Brooks said.

“I think what really matters is people feeling like they can trust the healthcare system.”

Brooks said she worried that a casino would encourage bad health habits, such as smoking and drinking.

“Let’s not create more problems for ourselves than we already have,” she said. She voted against the casino.

Like others in the tribe, Angie Lowery believes in her people’s power to help themselves, regardless of whether government steps in to help.

“Just because we’re federally recognized don’t mean that the doors are going to open up and money’s going to fall through the door like dirt,” she said.

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

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

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

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

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

Pros and Cons

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

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

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

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

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

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

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

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

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

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

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

A Toss-Up Race

National political observers say the Iowa governor’s race

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

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

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

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

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

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

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

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

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

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

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

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

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

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

None responded to requests for comment for this article.

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

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

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

Now, the same pain had returned — on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an , which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed . There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are .

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance — But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs — except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient , which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to Ñî¹óåú´«Ã½Ò•îl Health News, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations — or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off — sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

Bill of the Month is a crowdsourced investigation by Ñî¹óåú´«Ã½Ò•îl Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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