Vince Lahey of Carefree, Arizona, embraces chatbots. From Big Tech products to “shady” ones, they offer “someone that I could share more secrets with than my therapist.”

He especially likes the apps for feedback and support, even though sometimes they berate him or lead him to fight with his ex-wife. “I feel more inclined to share more,” Lahey said. “I don’t care about their perception of me.”

There are a lot of people like Lahey.

Demand for mental health care has grown. Self-reported poor mental health days rose by 25% since the 1990s, analyzing survey data. According to the Centers for Disease Control and Prevention, suicide rates in 2022 that hadn’t been seen in nearly 80 years.

There are many patients who find a nonhuman therapist, powered by artificial intelligence, highly appealing — more appealing than a human with a reclining couch and stern manner. with begging for a therapist who’s “not on the clock,” who’s less judgmental, or who’s just less expensive.

Most people who need care don’t get it, said Tom Insel, former head of the National Institute of Mental Health, citing his former agency’s research. Of those who do, 40% receive “minimally acceptable care.”

“There’s a massive need for high-quality therapy,” he said. “We’re in a world in which the status quo is really crappy, to use a scientific term.”

Insel said engineers from OpenAI told him last fall that about 5% to 10% of the company’s then-roughly 800 million-strong user base rely on ChatGPT for mental health support.

Polling suggests these AI chatbots may be even more popular among young adults. A Â鶹ŮÓÅ poll found about 3 in 10 respondents ages 18 to 29 for mental or emotional health advice in the past year. Uninsured adults were about twice as likely as insured adults to report using AI tools. And nearly 60% of adult respondents who used a chatbot for mental health didn’t follow up with a flesh-and-blood professional.

The App Will Put You on the Couch

A burgeoning industry of apps offers AI therapists with human-like, often unrealistically attractive avatars serving as a sounding board for those experiencing anxiety, depression, and other conditions.

Â鶹ŮÓÅ Health News identified some 45 AI therapy apps in Apple’s App Store in March. While many charge steep prices for their services — one listed an annual plan for $690 — they’re still generally cheaper than talk therapy, which can cost hundreds of dollars an hour without insurance coverage.

On the App Store, “therapy” is often used as a marketing term, with small print noting the apps cannot diagnose or treat disease. One app, branded as OhSofia! AI Therapy Chat, had downloads in the six figures, said OhSofia! founder Anton Ilin in December.

“People are looking for therapy,” Ilin said. On one hand, the product’s name ; on the other, it warns in that it “does not provide medical advice, diagnosis, treatment, or crisis intervention and is not a substitute for professional healthcare services.” Executives don’t think that’s confusing, since there are disclaimers in the app.

The apps promise big results without backup. its users “immediate help during panic attacks.” it was “proven effective by researchers” and that it offers 2.3 times faster relief for anxiety and stress. (It doesn’t say what it’s faster than.)

There are few legislative or regulatory guardrails around how developers refer to their products — or even whether the products are safe or effective, said Vaile Wright, senior director of the office of health care innovation at the American Psychological Association. Even federal patient privacy protections don’t apply, she said.

“Therapy is not a legally protected term,” Wright said. “So, basically, anybody can say that they give therapy.”

Many of the apps “overrepresent themselves,” said John Torous, a psychiatrist and clinical informaticist at Beth Israel Deaconess Medical Center. “Deceiving people that they have received treatment when they really have not has many negative consequences,” including delaying actual care, he said.

States such as Nevada, Illinois, and California are trying to sort out the regulatory disarray, enacting laws forbidding apps from describing their chatbots as AI therapists.

“It’s a profession. People go to school. They get licensed to do it,” said Jovan Jackson, a Nevada legislator, who co-authored an enacted bill banning apps from referring to themselves as mental health professionals.

Underlying the hype, outside researchers and company representatives themselves have told the FDA and Congress that there’s little evidence supporting the efficacy of these products. What studies there are — and some companion-focused chatbots are “consistently poor” at managing crises.

“When it comes to chatbots, we don’t have any good evidence it works,” said Charlotte Blease, a professor at Sweden’s Uppsala University who specializes in trial design for digital health products.

The lack of “good quality” clinical trials stems from the FDA’s failure to provide recommendations about how to test the products, she said. “FDA is offering no rigorous advice on what the standards should be.”

Department of Health and Human Services spokesperson Emily Hilliard said, in response, that “patient safety is the FDA’s highest priority” and that AI-based products are subject to agency regulations requiring the demonstration of “reasonable assurance of safety and effectiveness before they can be marketed in the U.S.”

The Silver-Tongued Apps

Preston Roche, a psychiatry resident who’s , gets lots of questions about whether AI is a good therapist. After trying ChatGPT himself, he said he was “impressed” initially that it was able to use techniques to help him put negative thoughts “on trial.”

But Roche said after seeing posts on social media discussing people developing psychosis or being encouraged to make harmful decisions, he became disillusioned. The bots, he concluded, are sycophantic.

“When I look globally at the responsibilities of a therapist, it just completely fell on its face,” he said.

This sycophancy — the tendency of apps based on large language models to empathize, flatter, or delude their human conversation partner — is inherent to the app design, experts in digital health say.

“The models were developed to answer a question or prompt that you ask and to give you what you’re looking for,” said Insel, the former NIMH director, “and they’re really good at basically affirming what you feel and providing psychological support, like a good friend.”

That’s not what a good therapist does, though. “The point of psychotherapy is mostly to make you address the things that you have been avoiding,” he said.

While polling suggests many users are satisfied with what they’re getting out of ChatGPT and other apps, there have been about the service or encouragement to self-harm.

And or have been filed against OpenAI after ChatGPT users died by suicide or became hospitalized. In most of those cases, the plaintiffs allege they began using the apps for one purpose — like schoolwork — before confiding in them. These cases are being .

Google and the startup Character.ai — which has been funded by Google and has created “avatars” that adopt specific personas, like athletes, celebrities, study buddies, or therapists — are settling other wrongful-death lawsuits, .

OpenAI’s CEO, Sam Altman, has said up to may talk about suicide on ChatGPT.

“We have seen a problem where people that are in fragile psychiatric situations using a model like 4o can get into a worse one,” Altman said in a public question-and-answer session reported by , referring to a particular model of ChatGPT introduced in 2024. “I don’t think this is the last time we’ll face challenges like this with a model.”

An OpenAI spokesperson did not respond to requests for comment.

The company has said it on safeguards, such as referring users to 988, the national suicide hotline. However, the lawsuits against OpenAI argue existing safeguards aren’t good enough, and some research shows the problems are . OpenAI its own data suggesting the opposite.

OpenAI is , offering, early in one case, a variety of defenses ranging from denying that its product caused self-harm to alleging that the defendant misused the product by inducing it to discuss suicide. It has also said it’s working to .

Smaller apps also rely on OpenAI or other AI models to power their products, executives told Â鶹ŮÓÅ Health News. In interviews, startup founders and other experts said they worry that if a company simply imports those models into its own service, it might duplicate whatever safety flaws exist in the original product.

Data Risks

Â鶹ŮÓÅ Health News’ review of the App Store found listed age protections are minimal: Fifteen of the nearly four dozen apps say they could be downloaded by 4-year-old users; an additional 11 say they could be downloaded by those 12 and up.

Privacy standards are opaque. On the App Store, several apps are described as neither tracking personally identifiable data nor sharing it with advertisers — but on their company websites, privacy policies contained contrary descriptions, discussing the use of such data and their disclosure of information to advertisers, like AdMob.

In response to a request for comment, Apple spokesperson Adam Dema to the company’s App Store policies, which bar apps from using health data for advertising and require them to display information about how they use data in general. Dema did not respond to a request for further comment about how Apple enforces these policies.

Researchers and policy advocates said that sharing psychiatric data with social media firms means patients could be profiled. They could be targeted by dodgy treatment firms or charged different prices for goods based on their health.

Â鶹ŮÓÅ Health News contacted several app makers about these discrepancies; two that responded said their privacy policies had been put together in error and pledged to change them to reflect their stances against advertising. (A third, the team at OhSofia!, said simply that they don’t do advertising, though their app’s notes users “may opt out of marketing communications.”)

One executive told Â鶹ŮÓÅ Health News there’s business pressure to maintain access to the data.

“My general feeling is a subscription model is much, much better than any sort of advertising,” said Tim Rubin, the founder of Wellness AI, adding that he’d change the description in his app’s privacy policy.

One investor advised him not to swear off advertising, he said. “They’re like, essentially, that’s the most valuable thing about having an app like this, that data.”

“I think we’re still at the beginning of what’s going to be a revolution in how people seek psychological support and, even in some cases, therapy,” Insel said. “And my concern is that there’s just no framework for any of this.”

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El gobierno federal no lleva un registro de cuántos niños han ingresado a este sistema como consecuencia de operativos de control migratorio, lo que dificulta saber con qué frecuencia ocurre.

En Oregon, hasta febrero, dos niños habían sido ubicados en hogares temporales luego de ser separados de sus padres en casos de detención migratoria, según Jake Sunderland, vocero del Departamento de Servicios Humanos del estado.

“Antes del otoño de 2025, esto nunca había ocurrido”, aseguró.

Hasta mediados de febrero, casi por el Servicio de Inmigración y Control de Aduanas (ICE, por sus siglas en inglés).

El récord de 73.000 personas detenidas en enero representó un comparado con el año anterior. Según una , hasta agosto de 2025, padres de 11.000 niños con ciudadanía estadounidense habían sido detenidos desde el inicio del mandato de Trump.

El medio NOTUS que por lo menos 32 niños de padres detenidos o deportados habían sido colocados en hogares temporales en siete estados.

Sandy Santana, director ejecutivo de Children’s Rights, una organización de defensa legal, dijo que sospechan que el número real es mucho mayor.

“Ese número nos parece realmente muy bajo”, dijo.

La separación de sus padres es profundamente traumática para los niños y suele provocar , incluido el trastorno de estrés postraumático. El estrés prolongado e intenso también puede causar infecciones más frecuentes en los niños y problemas en el desarrollo. Ese “estrés tóxico” también se asocia con daños en áreas del cerebro responsables del aprendizaje y la memoria, , una organización sin fines de lucro dedicada a la información en salud que incluye a Â鶹ŮÓÅ Health News.

Durante el primer mandato de Trump, . y modificaron algunas leyes para permitir que tutores recibieran derechos parentales temporales en casos relacionados con migración. Ahora, tras el regreso de Trump al poder el año pasado, el aumento en los controles migratorios está impulsando una nueva ola de respuestas estatales.

En Nueva Jersey, legisladores están considerando un proyecto para modificar estatal que permite que los padres designen tutores temporales para casos de muerte o incapacidad. La nueva versión agregaría como otra razón válida la separación por control migratorio federal.

El año pasado, Nevada y California aprobaron leyes para proteger a las familias separadas por acciones de control migratorio. La ley de California, llamada Ley del Plan de Preparación Familiar (), permite que los padres designen tutores y compartan derechos de custodia, en lugar de que sus derechos se suspendan mientras están detenidos. Si son liberados y pueden reunirse con sus hijos, recuperan sus derechos parentales completos.

Existen importantes obstáculos legales para la reunificación familiar una vez que un niño entra bajo custodia estatal, explicó Juan Guzman, director del tribunal de menores y tutela en Alliance for Children’s Rights, una organización de defensa legal en Los Ángeles.

Si el niño es colocado en cuidado temporal y ni el padre ni la madre pueden participar en los procesos judiciales requeridos porque están detenidos o han sido deportados, es menos probable que puedan volver a reunirse con su hijo, afirmó Guzman.

Se estima que que son ciudadanos estadounidenses viven con un padre u otro familiar que no tiene estatus migratorio legal, según investigaciones de Brookings Institution, un centro de estudios en Washington, D.C. Dentro de ese grupo, 2,6 millones de niños tienen a ambos padres sin estatus legal.

Santana dijo que es probable que el número de casos de separación familiar aumente a medida que el gobierno de Trump avance con su campaña migratoria. Por lo tanto, más niños corren el riesgo de terminar en el sistema de cuidado temporal.

Las exigen que la agencia se esfuerce en facilitar la participación de los padres detenidos en los procedimientos de los tribunales de familia, de bienestar infantil o de tutela, pero Santana indicó que no está claro que el ICE esté cumpliendo con estas normas.

Los funcionarios de ICE no respondieron a las solicitudes de comentarios para este artículo.

Antes de que cambiara la ley de California, la única razón por la que un padre podía compartir derechos de custodia con otro tutor era si tenía una enfermedad terminal, contó Guzman.

Ahora, si los padres preparan un plan con anticipación y designan a alguien de confianza que pueda hacerse cargo de sus hijos si llegara a ser necesario, la agencia estatal de bienestar infantil puede iniciar el proceso para entregar a los niños a esa persona sin tener que abrir un caso formal de cuidado temporal, agregó.

Si bien el año pasado los legisladores de Nevada ampliaron una ley de tutela existente para incluir la aplicación de las leyes de inmigración, la medida exige a los padres dar el paso adicional de presentar documentación notariada ante la oficina del Secretario de Estado, señaló Cristian González-Pérez, abogado de Make the Road Nevada, una organización sin fines de lucro que brinda recursos a las comunidades inmigrantes.

González-Pérez señaló que algunos inmigrantes dudan en completar formularios gubernamentales por temor a que el ICE pueda acceder a esa información y los persiga. Él les asegura a los miembros de la comunidad que los formularios estatales son confidenciales y solo pueden ser consultados por hospitales y tribunales.

El gobierno de Trump ha tomado para acceder a información sensible a través de los Centros de Servicios de Medicare y Medicaid, el Servicio de Impuestos Internos (IRS), el Programa de Asistencia Nutricional Suplementaria (SNAP), el Departamento de Vivienda y Desarrollo Urbano y otras entidades.

González-Pérez y Guzmán consideran que muchos padres inmigrantes no conocen sus derechos. Designar un tutor temporal y crear un plan familiar es una forma de no sentirse impotentes, afirmó González-Pérez.

“La gente no quiere hablar de esa cuestión”, reflexionó Guzman. “Que un padre tenga que hablar con un niño sobre la posibilidad de separarse da miedo. No es algo que nadie quiera hacer”, concluyó.

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The federal government doesn’t track how many children have entered foster care because of immigration enforcement actions, leaving it unclear how often it happens. In Oregon, as of February two children had been placed in foster care after being separated from their parents in immigration detention cases, according to Jake Sunderland, a spokesperson for the Oregon Department of Human Services.

“Before fall 2025, this simply had never happened before,” Sunderland said.

As of mid-February, nearly by Immigration and Customs Enforcement. The record 73,000 people in detention in January represented an compared with one year before. According to , parents of 11,000 children who are U.S. citizens were detained from the beginning of Trump’s term through August.

The news outlet NOTUS that at least 32 children of detained or deported parents had been placed in foster care in seven states.

Sandy Santana, executive director of Children’s Rights, a legal advocacy organization, said he thinks the actual number is much higher.

“That, to us, seems really, really low,” he said.

Separation from a parent is deeply traumatic for children and can lead to , including post-traumatic stress disorder. Prolonged, intense stress can lead to more-frequent infections in children and developmental issues. That “toxic stress” is also associated with responsible for learning and memory, according to Â鶹ŮÓÅ.

, and amended existing laws during Trump’s first term to allow guardians to be granted temporary parental rights for immigration enforcement reasons. Now the enforcement surge that began after Trump returned to office last year has prompted a new wave of state responses.

In New Jersey, lawmakers are considering to amend a state law that allows parents to nominate standby, or temporary, guardians in the cases of death, incapacity, or debilitation. The bill would add separation due to federal immigration enforcement as another allowable reason.

Nevada and California passed laws last year to protect families separated by immigration enforcement actions. California’s law, called the , allows parents to nominate guardians and share custodial rights, instead of having them suspended, while they’re detained. They regain their full parental rights if they are released and are able to reunite with their children.

There are significant legal barriers to reunification once a child is placed in state custody, said Juan Guzman, director of children’s court and guardianship at the Alliance for Children’s Rights, a legal advocacy organization in Los Angeles.

If a parent’s child is placed in foster care and the parent cannot participate in required court proceedings because they are in detention or have been deported, it’s less likely they will be able to reunite with their child, Guzman said.

are U.S. citizens who live with a parent or family member who does not have legal immigration status, according to research from the Brookings Institution, a Washington, D.C.-based think tank. Within that group, 2.6 million children have two parents lacking legal status.

Santana said he expects the number of family separation cases to grow as the Trump administration continues its immigration enforcement campaign, putting more children at risk of being placed in foster care.

the agency to make efforts to facilitate detained parents’ participation in family court, child welfare, or guardianship proceedings, but Santana said it’s uncertain whether ICE is complying with those rules.

ICE officials did not respond to requests for comment for this report.

Before the change in California’s law, the only way a parent could share custodial rights with another guardian was if the parent was terminally ill, Guzman said.

If parents create a preparedness plan and identify an individual to assume guardianship of their children, the state child welfare agency can begin the process of placing the children with that individual without opening a formal foster care case, he added.

While Nevada lawmakers expanded an existing guardianship law last year to include immigration enforcement, the measure requires the parents to take the additional step of filing notarized paperwork with the secretary of state’s office, said Cristian Gonzalez-Perez, an attorney at Make the Road Nevada, a nonprofit that provides resources to immigrant communities.

Gonzalez-Perez said some immigrants are still hesitant to fill out government forms, out of fear that ICE might access their information and target them. He reassures community members that the state forms are secure and can be accessed only by hospitals and courts.

The Trump administration has taken through the Centers for Medicare & Medicaid Services, the IRS, the Supplemental Nutrition Assistance Program, the Department of Housing and Urban Development, and other entities.

Gonzalez-Perez and Guzman said that not enough immigrant parents know their rights. Nominating a temporary guardian and creating a plan for their families is one way they can prevent feelings of helplessness, Gonzalez-Perez said.

“Folks don’t want to talk about it, right?” Guzman said. “The parent having to speak to a child about the possibility of separation, it’s scary. It’s not something anybody wants to do.”

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

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

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

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

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

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

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

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

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

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

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

A Lifeline of Care

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

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

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

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

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

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

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

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

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

A New Lease on Life?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Not all Montana health leaders are worried.

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

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

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

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Oz, who heads the U.S. Centers for Medicare & Medicaid Services, there was approximately $3.5 billion of fraud in the hospice and home health care industry in Los Angeles County alone. “This administration under President [Donald] Trump is not going to tolerate taxpayer dollars being stolen because people aren’t paying attention anymore. We’re focused on this,” . He claimed the fraud was largely orchestrated by the “Russian, Armenian mafia” and said that most of the money spent on home and community-based services across California “might be fraudulent.”

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Those preliminary numbers from the open enrollment period that ended in January are less than a third of what state officials had projected. Nevada is the third state so far to launch a public option plan, along with Colorado and Washington state. The idea is to offer lower-cost plans to consumers to expand health care access.

But researchers said plans like these are unlikely to fill the gaps left by sweeping federal changes, including the expiration of enhanced subsidies for plans bought on Affordable Care Act marketplaces.

The public option gained attention in the late 2000s when Congress considered but ultimately rejected creating a health plan funded and run by the government that would compete with private carriers in the market. The programs in Washington state, Colorado, and Nevada don’t go that far — they aren’t government-run but are private-public partnerships that compete with private insurance.

In recent years, states have considered creating public option plans to make health coverage more affordable and to reduce the number of uninsured people. Washington was the first state to launch a program, in 2021, and Colorado followed in 2023.

Washington and Colorado’s programs , including a lack of participation from clinicians, hospitals, and other care providers, as well as insurers’ rate reduction benchmarks or lower premiums compared with other plans offered on the market.

Nevada law requires that the carriers of the public option plans — Battle Born State Plans, named after a state motto — lower premium costs compared with a benchmark “silver” plan in the marketplace by 15% over the next four years.

But that amount might not make much difference to consumers with rising premium payments from the loss of the ACA’s enhanced tax credits, said Keith Mueller, director of the Rural Policy Research Institute.

“That’s not a lot of money,” Mueller said.

Three of the eight insurers on the state’s exchange, Nevada Health Link, offered the state plans during the open enrollment period.

Insurance companies plan to meet the lower premium cost requirement in Nevada by , which prompted opposition from insurance brokers in the state. In response, Nevada marketplace officials told state lawmakers in January that they will give a flat-fee reimbursement to brokers.

The public option has faced opposition among state leaders. In 2024, a state judge dismissed a lawsuit, brought by a Nevada state senator and a group that advocates for lower taxes, that challenged the public option law as unconstitutional. They have appealed to the state Supreme Court.

Federal Policy Impacts

Recent federal changes create more obstacles.

Nevada is consistently among the states with the of people who do not have health insurance coverage. Last year, in the state received the enhanced ACA tax credits, averaging $465 in savings per month, according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

But the enhanced tax credits expired at the end of the year, and it that lawmakers will bring them back. Nationwide ACA enrollment has decreased by so far this year, down from record-high enrollment of 24 million last year.

About 4 million people are expected to lose health coverage from the expiration of the tax credits, according to the . An additional 3 million are because of other policy changes affecting the marketplace.

, an associate research professor at the Center on Health Insurance Reforms at Georgetown University, said the changes to the ACA in the Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will make it more difficult for people to keep their coverage. These changes include more frequent enrollment paperwork to verify income and other personal information, a shortened enrollment window, and an end to automatic reenrollment.

In Nevada, the changes would amount to an losing coverage, according to Â鶹ŮÓÅ.

“All of that makes getting coverage on Nevada Health Link harder and more expensive than it would be otherwise,” Giovannelli said.

State officials projected ahead of open enrollment that about 35,000 people would purchase the public option plans. Of the 104,000 people who had purchased a plan on the state marketplace as of mid-January, 10,762 had enrolled in one of the public option plans, according to Nevada Health Link.

Katie Charleson, communications officer for the state health exchange, said the original enrollment estimate was based on market conditions before the recent increases in customers’ premium costs. She said that the public option plans gave people facing higher costs more choices.

“We expect enrollment in Battle Born State Plans to grow over time as awareness increases and as Nevadans continue seeking quality coverage options that help reduce costs,” Charleson said.

According to Â鶹ŮÓÅ, nationally the enhanced subsidies an average of $705 annually in 2024, and enrollees would save an estimated $1,016 in premium payments on average in 2026 if the subsidies were still in place. Without the subsidies, people enrolled in the ACA marketplace could be seeing their premium costs more than double.

Insights From Washington and Colorado

Washington and Colorado are not planning to alter their programs due to the expiration of the tax credits, according to government officials in those states.

Other states that had recently considered creating public options have backtracked. Minnesota officials a public option in 2024, citing funding concerns. Proposals to create public options in Maine and New Mexico also sputtered.

Washington initially saw meager enrollment in its Cascade Select public option plans; only 1% of state marketplace enrollees chose a public option plan in 2021. But that changed after lawmakers with at least one public option plan by 2023. Last year the state reported that 94,000 customers enrolled, accounting for 30% of all customers on the state marketplace. The public option plans were the lowest-premium silver plans in 31 of Washington’s 39 counties in 2024.

found that since Colorado implemented its public option, called the Colorado Option, coverage through the ACA marketplace has become more affordable for enrollees who received subsidies but more expensive for enrollees who did not.

Colorado requires all insurers offering coverage through its marketplace to include a public option that follows state guidelines. The state set premium reduction targets of 5% a year for three years beginning in 2023. Starting this year, premium costs are medical inflation.

Though the insurers offering the public option did not meet the premium reduction targets, enrollment in the Colorado Option has increased every year it has been available. Last year, the state saw record enrollment in its marketplace, with purchasing a public option plan.

Giovannelli said states are continuing to try to make health insurance more affordable and accessible, even if federal changes reduce the impact of those efforts.

“States are reacting and trying to continue to do right by their residents,” Giovannelli said, “but you can’t plug all those gaps.”

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

Â鶹ŮÓÅ Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts contributed to this report.

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Hsu, a board-certified general surgeon, was one of six out-of-state doctors who joined the Atlanta Goals Aesthetics & Plastic Surgery center during the pandemic. The surgeons received temporary licenses to practice in Georgia, which in response to the sudden need for more medical personnel to address the covid-19 outbreak — even though the center specialized in elective cosmetic surgeries, such as Brazilian butt lifts, or BBLs, and liposuction, paid for in cash or on credit.

The Atlanta center in March 2021 as an expansion of New York-based Goals Aesthetics & Plastic Surgery, which markets “precision body contouring” for about a dozen surgery clinics in eight states, promising patients a “.”

But the Atlanta center’s early days were marred by allegations of substandard patient care. Court records show that at least 20 women filed medical malpractice lawsuits against the facility, or its owner and surgeons. Hsu was named as a defendant in seven suits filed against the Atlanta center, more than any other physician there. An eighth patient sued Hsu alleging negligence in an operation he performed at a Goals office in New York.

Hsu did not respond to requests for comment. Goals declined to comment. Both have denied any negligence.

Cosmetic surgery chains across the country are attracting patients by promising “minimally invasive” operations to reshape their bodies or get rid of stubborn fat — even helping arrange outside financing for people who can’t pay up front. Hundreds of thousands of patients are undergoing such procedures each year, and plastic surgeons can make more than $500,000 each year in in American medicine.

An investigation by Â鶹ŮÓÅ Health News found that lawsuits filed by injured patients have trailed the industry’s growth, in some cases alleging that surgeons lacked adequate training, had histories of malpractice lawsuits, or had faced disciplinary action by state medical licensing boards — yet crossed into another state and kept practicing.

In the Atlanta lawsuits, Goals has denied any negligence and won dismissal of several of them because patients had signed papers agreeing to outside arbitration — which requires them to resolve disputes privately and outside the court system.

Yet Goals argued in a separate contract dispute that several of its Atlanta surgeons, including Hsu, were indeed prone to problems — either because they lacked adequate training or had troubled pasts, including investigations by state medical licensing boards into misconduct, court records show. One of Hsu’s Atlanta patients said in a separate lawsuit that she suffered in pain for over a year because a piece of a scalpel was left inside her body after a BBL and liposuction.

In a June 2023 court filing in that contract dispute, Goals blamed the problems on a medical staffing firm — Barton Associates, a firm in Massachusetts — it said failed to do adequate background checks on the doctors it supplied. Barton denied the allegations and said it met all terms of the contract.

No public database exists to help patients learn the full practice histories of physicians, including cosmetic surgeons. And patients are largely left on their own to decipher which certificates hanging on a surgeon’s wall, or ballyhooed in web advertising, signify appropriate training and which do not. Disputes among medical specialty groups over whose members are to perform cosmetic operations — and deliver the best results — add to the confusion.

No government agency tracks injuries or other complication rates at clinics offering cosmetic surgery or any other type of operations. And in many jurisdictions, including Georgia, gaining access to court records — a possible red flag for spotting problems — is laborious and costly.

Charleetra Hornes, 52, who lives in the Atlanta suburbs and is suing the Goals center for medical malpractice, said she knew nothing of its alleged early troubles and chose the company because its advertising promised “” for recovery and that she would remain awake during the operation.

She said she paid $6,650 for a “double BBL,” in which fat is suctioned from the stomach, purified, and injected into the buttocks and hips to create what Goals calls a “”

Goals went ahead with her surgery on July 2, 2022, even though she had tested positive for covid that day, according to the suit. Hornes alleged that two days before the surgery Goals assigned her to surgeon Thomas Shannon, who has worked for Goals in Georgia and Texas.

Though staff gave her pills to manage the discomfort, Hornes said, she suffered “excruciating pain” during the procedure, according to the suit.

That night, she spiked a fever that sent her to the emergency room. She spent two weeks in the hospital recovering from injuries, including a “severe burn on her side,” according to the suit.

“I’ve been disfigured and burned up, and it’s not fair,” she said in an interview.

In June 2024, Hornes sued Shannon, the Goals center, and Barton Associates, alleging malpractice. On Sept. 2, a Georgia judge dismissed Shannon from the case, ruling that Hornes failed to serve him with the complaint in Texas before the statute of limitations ran out. He did not respond to requests for comment. 

In a separate order issued on the same day, the judge also dismissed the other defendants, citing the statute of limitations issue and that Hornes had previously signed an arbitration agreement. Some cosmetic surgery chains and other medical practices ask patients to sign such agreements. 

Hornes wishes she had learned more about the Atlanta surgery center, instead of accepting what she calls its “flashy” come-ons. “I wish I would have taken it more seriously,” she said in an interview, “because it was life-altering.”

Useful Tools

Â鶹ŮÓÅ Health News identified more than 200 lawsuits filed against multistate cosmetic surgery companies, mostly over the past seven years, including cases involving a dozen deaths, using databases of court records.

Lawsuits by themselves don’t prove wrongdoing. Many cases are settled under confidential terms that keep critical details under wraps. Yet medical authorities and most physician licensing boards regard malpractice cases and settlements as a useful possible patterns of substandard health care that may harm patients.

Court files show that surgeons who were sued numerous times for malpractice — and in some cases disciplined by state medical boards for misconduct — have managed to get hired by cosmetic surgery chains.

Goals, owned by physician Sergey Voskin, has contracted with eight surgeons with three or more malpractice cases filed against them, including in the Atlanta area, court records allege. Gerald Hickson, founding director of the Vanderbilt Center for Patient and Professional Advocacy and an expert on medical malpractice issues, called that number of suits a “warning” of possible problems, despite their outcome.

Earlier this year, a Pennsylvania woman identified in court filings as “P.C.” sued Goals, Voskin, and surgeon Peter Driscoll, alleging Driscoll came on board despite an “extensive history of malpractice allegations, licensing suspensions and discipline” in and , according to medical board records cited in the suit. Companies hiring doctors have ready access to the nonpublic , which details disciplinary problems in a doctor’s past. But it’s not clear from court records whether anybody made these standard background checks. Goals did not respond to a request for comment.

The suit also accuses Goals of consumer fraud for touting its surgeons as “double if not triple board certified plastic surgeons.” According to the complaint, Driscoll was board-certified by the American Board of Otolaryngology, a specialty that focuses on treatment and surgery of head and neck areas. Driscoll is in the specialty, according to the American Board of Medical Specialties website.

The woman alleges that Driscoll sexually harassed her and made “unwanted and unwelcome sexual contact” during a BBL procedure in June 2022 at a Goals office in New Jersey. 

According to the suit, staff members overheard Driscoll watching pornography in an office bathroom multiple times, but Goals did not terminate him at the time. New Jersey’s State Board of Medical Examiners in February 2023 related to the incident, and the woman’s lawsuit is pending in federal court in New Jersey. Goals and Voskin have denied the allegations in the suit and filed a motion to dismiss or compel arbitration of the case. Driscoll, who has not filed a response with the court, could not be reached for comment.

Performance Issues Not ‘Disqualifying’

Other cosmetic surgery chains have faced multiple malpractice actions targeting surgeons or other health care providers who staff their clinics, court records show.

The surgeon roster at Mia Aesthetics, a Miami-based chain that operates 13 cosmetic surgery offices nationwide, lists four doctors with three or more malpractice actions since 2020, court records show.

Nearly a dozen injured patients have filed lawsuits criticizing the credentials of doctors and nurse practitioners affiliated with Belle Medical, including the family of a 70-year-old Utah woman with five children who died in the car two days after liposuction as her husband rushed her from home to a hospital, according to court records.

Her husband alleges he called Belle Medical’s office the day after the procedure to say his wife was having difficulty breathing and heart palpitations and couldn’t walk more than a short distance, which the lawsuit argued were “textbook symptoms of pulmonary embolism, or blood clot in the lung.” According to the suit, nobody at Belle Medical advised the family to seek immediate medical care. An autopsy found she died from “bilateral pulmonary emboli,” according to the suit.

Backed by Peterson Partners, a Utah private equity and investment firm, Belle Medical operates in Utah, Idaho, and Oklahoma, offering liposuction and other cosmetic surgery. Neither Belle Medical nor Peterson Partners responded to requests for comment. In court filings, Belle Medical has argued that its medical providers are independent contractors who are solely responsible for any procedures they perform.

Private equity-backed Sono Bello, the largest of the cosmetic surgery chains with more than 100 locations nationwide, has defended more than a dozen lawsuits alleging the company contracted with inadequately trained doctors or practitioners previously disciplined by medical licensing boards. In May 2023, Ohio’s medical board revoked the license of a Sono Bello contract surgeon after three of her patients died, two of them following procedures at a Sono Bello office in the Cleveland area, according to medical board records.

Robert Centeno, Sono Bello’s medical director for the East region, told Â鶹ŮÓÅ Health News that many surgeons have past performance issues, which he called “not, in fact, disqualifying.”

“The vast majority of our colleagues are extremely professional and committed to their profession,” he said in an interview. “And while there may be a momentary lapse or issue with their practice, most of our surgeons take those sanctions, take that counseling, that advice, and improve their practices and go on to be very, very productive members of the medical community.”

Asked about malpractice lawsuits filed against the company, Centeno said that Sono Bello has “performed over 300,000 procedures to date,” which he described as “more procedures for more patients completed safely than anyone else in the industry. It would be natural and understandable to know that at some point during that process, that a patient has actually sued us,” Centeno said.

‘Unable To Perform’

In early 2020, as the pandemic slowed business in New York City, Goals sought to expand to Atlanta — a hot market for its BBLs. In a , Goals promised patients “amazing contours” and boasted of having “some of the most experienced, and aesthetically forward surgeons in the industry.” BBLs and liposuction make up 95% of its business, marketed to mostly Black and Hispanic women, Goals owner Voskin testified in a deposition filed this year in the Driscoll case. Many Atlanta patients suing the company paid roughly $6,000 to $8,000 for their surgeries, court records show.

Goals initially staffed the Atlanta center through Barton Associates. Many hospitals and medical offices rely on such firms to find temporary doctors and other staff. Under the deal, Barton charged Goals $1,400 for each procedure and paid about $600 of that to the surgeon, according to Goals’ court filings.

In 2023, Barton sued Goals in a Massachusetts court, alleging it was owed $487,000 in fees. Goals admitted that it “temporarily ceased payment” to Barton. But it fired back with a counterclaim accusing Barton of failing to check the qualifications and backgrounds of surgeons as required by the agreement.

Goals named five surgeons Barton sent to the center, including Hsu, and pointed to the spate of malpractice cases in Atlanta to bolster its argument.

Goals said it “became immediately apparent” that another surgeon was “fundamentally unable to perform his duties.” The surgeon was “abrasive, vulgar and could not conduct himself in accordance with reasonable professional standards that were expected in a medical workplace,” according to Goals’ counterclaim.

A second surgeon Barton presented as “highly skilled” turned out to have “an extensive history of complaints about his professional conduct” in two other states, according to the counterclaim.

Barton and Goals settled the case and counterclaim in April 2024 under confidential terms. Barton did not respond to requests for comment. Barton denied Goals’ allegations in earlier court filings and said that it “complied fully” with the terms of its contract with the surgery company.

In its counterclaim, Goals argued that shortly after Hsu joined the staff in 2021, it learned he had “multiple issues” in California and “was about to lose his medical license as a result,” according to a court filing.

Goals provided “significant legal and other assistance” to keep that from happening and Hsu “required substantial training in order to do acceptable work on patients,” the company argued in court filings.

Seven women filed malpractice suits in 2023 alleging they sustained injuries from BBLs and liposuction Hsu performed at the Atlanta office between mid-February 2021 and the end of June 2021, court records show. Barton, the staffing firm, also is a defendant in these cases and has denied wrongdoing. Hsu has denied wrongdoing in the cases and sought to enforce arbitration agreements. 

Hsu’s emergency Georgia medical license, approved in January 2021, expired in April 2022, state records show. Hsu is licensed in and , where he has also worked for Goals.

Two suits accuse Hsu of leaving a piece of metal inside the bodies of women, a calamity patient safety experts believe

In one Atlanta case, a patient who alleged she had experienced constant pain since her surgery at Goals in 2021 said she discovered why more than a year later when a chest X-ray ordered after a car crash showed a piece of scalpel blade in her upper abdomen, according to her court filings. The action against Hsu and Barton Associates was settled early this year, court records show.

In the second case, a New Jersey woman who had a BBL at Goals’ Harlem office in New York City in February 2022 alleged she overheard Hsu say in the operating room that he had “left something inside of her,” which turned out to be a metal liposuction cannula tip that had broken off in her stomach. A judge dismissed her lawsuit due to an arbitration clause. She filed a notice of appeal, but the case was settled in August.

The California medical board’s investigation of Hsu ended in October 2023 with . The state accused him of “repeated negligent acts” in treating six patients dating to 2016, including three people who died. None involved cosmetic surgery like his work at Goals.

The board revoked his license but stayed the action and imposed a four-year probation, tacking on a $24,000 penalty to cover costs of the investigation. The order also required Hsu to find a practitioner to help oversee his practice and prohibits him from serving on any on-call panel for general surgery. In settling the case, Hsu did not admit any wrongdoing.

Goals has featured Hsu in a , and that he is a “highly skilled surgical specialist,” who provides “top-notch surgical care.”

Fellowship Training

How much training cosmetic surgery chains demand of surgeons varies, judging by physician service contracts obtained by Â鶹ŮÓÅ Health News through court filings. Some contracts simply require that the doctor hold a valid state medical license, while others specify that a doctor to perform cosmetic surgery and have not been disciplined by licensing boards or been hit with major malpractice awards.

Sono Bello takes a different route. The company sponsors a six- to eight-week training course for surgeons, which it calls a “fellowship,” and .

Sono Bello accepts applicants from more than half a dozen surgical specialties and focuses its training on liposuction and a type of .ÌýÌý

Court records show that Sono Bello has defended at least a dozen lawsuits from patients who argued some surgeons lacked sufficient training or had other problems, or alleged they were misled by some advertising that described surgeons who completed the fellowship as “board certified plastic surgeons.”

Sono Bello’s credentialing process came under attack in a 2023 malpractice lawsuit filed by Shirley Webb, a 79-year-old Nevada woman who spent months in hospitals and rehabilitation care recovering from sepsis after a tummy tuck and liposuction performed by surgeon Charles Kim in Las Vegas in December 2022.ÌýÌý

Kim, a colorectal surgeon, took the Sono Bello fellowship from July 2022 to October 2022, court records show. In a deposition, Kim, who is board-certified in general surgery, stated that Sono Bello knew he had been disciplined by Nevada’s state medical licensing board for alleged malpractice in which a patient he operated on died. Kim paid a $4,000 fine and received a letter of reprimand in settling the medical board case without admitting wrongdoing.

Kim also testified in the medical malpractice case that Sono Bello was aware he had previously settled four medical malpractice cases, court records show. Christopher Chung, Sono Bello’s chief medical officer, said the company verified that Kim’s state medical license and other credentials “were up to date and in good standing” before it hired him. “We reviewed his surgical log, which detailed the voluminous and complex surgeries he had performed at the hospital where he was then employed, and received positive references from his employer and other surgeons,” Chung said in an emailed statement.

A medical expert hired by Webb’s legal team opined that Sono Bello’s use of the term “fellowship” is deceptive because the program is not accredited, or recognized by any subspecialty certifying board, professional society, or hospital. A medical fellowship is typically a training program that lasts at least a year. “We strongly disagree with the suggestion that our website is misleading. We accurately state that our physicians are board-certified surgeons — because they are,” Sono Bello spokesperson Mark Firmani said in response.

In her lawsuit, Webb testified that Sono Bello’s advertisements on television and online led her to believe the company employed only board-certified plastic surgeons.

Had she been told of Kim’s background in advance, “I wouldn’t have had the surgery done,” Webb testified in a 2024 deposition. 

The parties settled the suit early this year under confidential terms.

Have you had liposuction, a “Mommy Makeover,” a tummy tuck, a Brazilian butt lift, or another type of cosmetic surgery? We’d like to hear about your experience. Click here to contact our reporting team.

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Here’s why: A state-issued medical license grants a physician what a Federation of State Medical Boards called the “privilege of practicing the full breadth of medicine.”

That policy leaves the door open for any licensed doctor to perform cosmetic surgery after scant training, such as a weekend course in liposuction, and some doctors have done just that.

The federation adds that doctors “have a professional and ethical duty to put their patients’ best interests before their own and only offer treatments to patients that they are able to provide competently.”

But what credentials surgeons should hold and be permitted to advertise — the use of the term “board-certified,” in particular — remains contentious. And, for patients, figuring out which of those credentials and marketing claims to trust, and how to steer clear of doctors with troubled pasts, can be a challenge.

Here are tips for picking a cosmetic surgeon:

Do a background check.

The Federation of State Medical Boards operates an with information about a doctor’s practice history, including disciplinary actions. The federation also for each state medical board. Many states compile profiles of doctors with details about their training and practice history. Some include medical malpractice payments to patients who filed suit.

Understand board certification.

In the field of cosmetic surgery, the American Board of Medical Specialties recognizes only the , which requires a minimum of three years training in plastic surgery as well as a written and oral exam.

Board-certified members of the American Society of Plastic Surgeons decry what they see as doctors with less training infringing on their territory, by citing unrecognized certifying boards to buff their credentials, among other things. The society posts a directory of its members .

“A lot of people say they do plastic surgery,” said society president Scott Hollenbeck. “It’s confusing to patients.” The plastic surgery board “is the only one that is legitimate.”

Not so fast, say more than 400 surgeons nationwide who are certified by an alternative board called the .

The group says it accepts only doctors who have completed a residency training program in a surgical specialty, taken a one-year fellowship in cosmetic surgery, and passed a test of their competence and knowledge.

Yet the group has struggled to gain broad acceptance, it says, because of pushback from the plastic surgeons.

Jeffrey Swetnam, an Arkansas cosmetic surgeon and president of the American Board of Cosmetic Surgery, told Â鶹ŮÓÅ Health News that plastic surgeons have long sought to beat back competitors. Swetnam said that plastic surgery training focuses on a broad range of reconstructive operations, including cosmetic procedures, while members of his group focus exclusively on cosmetic operations.

“This whole deal is a money grab, a turf war over money,” he said.

In April, for example, Florida’s medical board rejected a request by cosmetic surgeons that they be permitted to advertise board certification without adding the caveat that their board is not recognized by the American Board of Medical Specialties.

In some cases, state medical licensing boards have disciplined doctors for allegedly misstating their credentials.

One was Kenneth Adams, a board-certified emergency medicine specialist, who opened Premier Liposuction in Las Vegas after taking a two-day course in liposuction and fat transfer, according to Nevada’s medical licensing board. In a civil complaint in April 2024, the board accused Adams of practicing “beyond the scope of his license.”

The complaint alleged that Adams’ advertising “misleads the public that his certification in Emergency Medicine provides the necessary training to perform liposuction surgery to inflate his credentials and induce patients to seek his services.”

Adams settled the case in November. The settlement prohibited him from performing liposuction, fined him $3,000, and issued him a letter of reprimand.

The American Board of Medical Specialties for checking a doctor’s board certification in recognized specialties, including plastic surgery.

Check for court action.

Some jurisdictions have posted dockets online, which can be searched by name to find lawsuits, though many charge for access and copies, costs that can add up fast. Gerald Hickson, a physician researcher at Vanderbilt University and expert on medical malpractice cases, said a pattern of lawsuits is a red flag. He said that most doctors don’t get sued often, regardless of their specialties.

Consider word of mouth.

It may sound old-fashioned, but some experts, including Hickson, recommend checking with friends and neighbors when picking a doctor. He added that patients need to use “common sense” when interacting with a medical practice to make sure it is right for them.

“Don’t shop for surgery like it’s a sale item,” adds cosmetic surgeon Swetnam. “Invest the time to choose a surgeon based on their training, outcomes, experience, and integrity — not just their title.”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The with bipartisan support.

An estimated 100 million adults in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under regulations issued in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed other medical debt protections in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in and , despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in , , and .

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are disproportionately burdened by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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