Six months after a West Virginia man died following a protracted battle with his health insurer over doctor-recommended cancer care, the state’s Republican governor signed a bill intended to curb the harm of insurance denials.

West Virginia’s Public Employees Insurance Agency enrolls nearly 215,000 people — state workers, as well as their spouses and dependents. The new law, which will take effect June 10, will allow plan members who have been approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without the need for another approval from the state-based health plan.

“This legislation is rooted in a simple principle: if a treatment has already been approved, patients should be able to pursue a medically appropriate alternative without being forced to start the process over again — especially when it does not cost more,” Gov. Patrick Morrisey said in a statement after signing the bill into law on March 31.

“This is about common sense, compassion, and trusting patients and their doctors to make the best decisions for their care,” he said.

Delegate Laura Kimble, the Republican from Harrison County who introduced the legislation, told Â鶹ŮÓÅ Health News the measure offers “a rational solution” for patients facing “the most irrational and chaotic time of their lives.”

From Arizona to Rhode Island, at least half of all state legislatures have taken up bills this year related to prior authorization, a process that requires patients or their medical team to seek approval from an insurer before proceeding with care. These state efforts come as patients across the country await relief from prior authorization hurdles, as promised by dozens of major health insurers in a pledge announced by the Trump administration last year.

The West Virginia law was inspired by Eric Tennant, a coal-mining safety instructor from Bridgeport who died on Sept. 17 at age 58. In early 2025, the Public Employees Insurance Agency of a $50,000 noninvasive cancer treatment, called histotripsy, that would have used ultrasound waves to target, and potentially shrink, the largest tumor in his liver. His family didn’t expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life. The insurer said the procedure wasn’t medically necessary and that it was considered “experimental and investigational.”

Becky Tennant, Eric’s widow, told members of a West Virginia House committee in late February that she submitted medical records, expert opinions, and data as part of several attempts to appeal the denial. She also reached out to “almost every one of our state representatives,” asking for help.

Nothing worked, she told lawmakers, until Â鶹ŮÓÅ Health News and NBC News got involved and posed questions to the Public Employees Insurance Agency about Eric’s case. Only then did the insurer reverse its decision and approve histotripsy, Tennant said.

“But by then, the delay had already done its damage,” she said.

Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure. “The insurance company’s decision did not simply delay care. It closed doors,” his wife said.

Had the new law been in effect, Kimble said, Tennant could have undergone histotripsy without preapproval, because it was a less expensive alternative to chemotherapy, which his insurer had already authorized. The bill was passed unanimously by the state legislature in March.

U.S. health insurers argue that most prior authorization requests are quickly, if not instantly, approved. AHIP, the health insurance industry trade group, says prior authorization acts as an important guardrail in preventing potential harm to patients and reducing unnecessary health care costs. But denials and delays tend to affect patients who need expensive, time-sensitive care, .

The practice has come under intense scrutiny in recent years, particularly after the in New York City in late 2024. Americans rank prior authorization as their biggest burden when it comes to getting health care, according to a by Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Samantha Knapp, a spokesperson for the West Virginia Department of Administration, would not answer questions about the law’s financial impact on the state. “We prefer to avoid any speculation at this time regarding potential impact or actions,” Knapp said.

In a fiscal note attached to the bill, Jason Haught, the Public Employees Insurance Agency’s chief financial officer, said the law would cost the agency an estimated $13 million annually and “cause member disruption.”

West Virginia isn’t an outlier in targeting prior authorization. By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books, according to a by the National Association of Insurance Commissioners.

Many states have set up “gold carding” programs, which allow physicians with a track record of approvals to bypass prior authorization requirements. Some states establish a maximum number of days insurance companies are allowed to respond to requests, while others prohibit insurance companies from issuing retrospective denials after a service has already been preauthorized. There are also a crop of new state laws seeking to regulate the use of artificial intelligence in prior authorization decision-making.

Meanwhile, prior authorization bills introduced this year across the country, including in Kentucky, Missouri, and New Jersey, have been supported by politicians from both parties.

“Republicans in conservative states see health care as a vulnerability for the midterm elections, and so, unsurprisingly, you’ll see some action on this,” said Robert Hartwig, a clinical associate professor of risk management, insurance, and finance at the University of South Carolina. “They realize that they’re not really going to get much action at the federal level given the degree of gridlock we’ve already seen.”

Last summer, the Trump administration announced a pledge signed by dozens of health insurers vowing to reform prior authorization. The insurers promised to reduce the scope of claims that require preapproval, decrease wait times, and communicate with patients in clear language when denying a request.

Consumers, patient advocates, and medical providers that companies will follow through on their promises.

Becky Tennant is skeptical, too. That’s why she advocated for the West Virginia bill.

“Families should not have to beg, appeal, or go public just to access time-sensitive care,” she told lawmakers. Tennant, who sees the bill’s passage as bittersweet, said she thought her husband would have been proud.

During Eric’s final hospital stay, Tennant recalled, right before he was discharged to home hospice care, she asked him whether he wanted her to keep fighting to change the state agency’s prior authorization process.

“‘Well, you need to at least try to change it,’” she recalled her husband saying. “‘Because it’s not fair.’”

“I told him I would keep trying,” she said, “at least for a while. And so I am keeping that promise to him.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

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Estaba pensando en retrasar el estudio, contó, porque este año la prima mensual del seguro de Obamacare se le triplicó a $2.460, lo que es igual a cerca de un tercio de sus ingresos.

Con un deducible de $2.700, habría tenido que pagar de su propio bolsillo la mayor parte del examen diagnóstico, un golpe económico que aseguró no poder asumir.

Galvin vive en North Kingstown, Rhode Island, y se retiró recientemente como director de una empresa de equipos médicos. “La colonoscopía me iba a costar cerca de $3.000. Así que decidí postergarla”, explicó.

También Nancy, la esposa de Galvin, está retrasando una costosa tomografía computarizada por unos años, hasta que pueda aplicar a Medicare y que el programa federal de salud cubra el costo. Medicare ofrece cobertura para todos los estadounidenses de 65 años en adelante.

Las personas con planes de la Ley de Cuidado de Salud a Bajo Precio (ACA) que están cerca de la edad de jubilación fueron de las más afectadas por los aumentos de precios luego de la suspensión de los subsidios federales mejorados, a finales de diciembre.

Quienes tenían ingresos superiores al 400% del nivel federal de pobreza para una familia de dos miembros— habían estado recibiendo ayuda para pagar los planes desde que la administración Biden amplió los subsidios durante la pandemia de covid-19. Los adultos de 50 a 64 años representaban alrededor de en ACA.

Ahora, sin esa ayuda financiera, algunas personas en este grupo de edad dicen que están pensando si no les conviene retrasar la atención médica hasta que califiquen para Medicare.

Según defensores de pacientes, médicos y expertos en políticas de salud, esta decisión no solo puede poner en riesgo la salud, sino también generar mayores costos para el sistema. Al postergar la atención médica hasta alcanzar la elegibilidad para Medicare, muchas afecciones se pueden agravar, lo que termina trasladando el gasto a los contribuyentes.

“Habrá mucha demanda acumulada y necesidades no atendidas”, dijo , consultora de políticas de salud que trabajó en las administraciones de Barack Obama y Joe Biden. “Medicare va a tener que gastar mucho dinero cubriendo y manejando esos tratamientos”.

ACA ha sido una fuente clave de cobertura médica para personas de 50 a 64 años. El acceso a los planes del Obamacare ayudó a reducir a la mitad la tasa de personas sin seguro en este sector, un grupo de defensa que representa a adultos mayores.

Esto permitió que algunas personas se jubilaran antes manteniendo cobertura. También ha servido como red de seguridad para los dueños de pequeños negocios y para quienes tienen empleos que no ofrecen seguro médico.

El otoño pasado se produjo el cierre del gobierno más largo de la historia, en medio de un intento fallido de los demócratas por extender los subsidios mejorados. Los republicanos que se opusieron a la medida argumentaron que la ayuda beneficiaba a las aseguradoras e incentivaba el fraude y la oferta de cobertura innecesaria.

El tema seguirá siendo relevante en la política, especialmente ante las elecciones de medio término de este año, incluso entre los estadounidenses mayores, que votan de manera regular, dijo el estratega republicano , quien dirige Atlas Strategy Group.

“¿El costo de la atención médica va a ser un tema? Sin duda”, dijo. “¿Los precios de la atención médica influirán? Sí”.

Incluso antes de que expiraran los subsidios, los costos de la atención médica, los hogares de adultos mayores y los medicamentos recetados eran algunas de las principales preocupaciones de salud entre las personas mayores de 50 años, según .

Los adultos de mediana edad con planes del Obamacare sienten con más fuerza el impacto de la eliminación de estos subsidios, porque primas hasta tres veces mayores que a las de 20, ya que estas últimas, por lo general, usan menos servicios médicos.

Y muchos adultos de mediana edad ya estaban inscriptos en los planes de menor costo disponibles, lo que los deja sin opciones más baratas, señaló , analista de políticas en Â鶹ŮÓÅ, una organización sin fines de lucro de información en salud que incluye Â鶹ŮÓÅ Health News.

“Esto es muy grave para las personas mayores inscriptas en el mercado de seguros”, dijo.

Quienes ganan apenas unos dólares por encima del 400% del nivel federal de pobreza ahora quedan fuera de los subsidios, y en algunos estados las primas promedio para este grupo .

 Muchas personas están viendo aumentos anuales de miles de dólares, con primas que pueden representar hasta una cuarta parte de sus ingresos.

, médico de atención primaria e investigador de políticas de salud en la Universidad de Michigan, contó que con frecuencia sus pacientes mayores le hablan de sus esfuerzos para afrontar el pago de su atención médica. Algunos, de poco más de 60 años, probablemente abandonen la cobertura de ACA debido al aumento, dijo.

“Es una apuesta arriesgada”, opinó.

Marci Heinbaugh podría verse obligada a asumir ese riesgo. La trabajadora social de 63 años, que vive en una zona rural de Illinois, contó que su prima mensual superó el doble de su valor, pasando de unos $1.100 a $2.333, por un plan con gasto máximo de bolsillo de $10.150.

Sabía que tendría que pagar más, dijo, pero no imaginaba un aumento de esa magnitud. Después de unos meses, ya no está segura de poder mantener el plan durante el resto del año y dijo que incluso podría quedarse sin seguro. “Me da pánico siquiera pensarlo”, confesó Heinbaugh.

Las personas quieren comprar su propio seguro en el mercado y muchos adultos de mediana edad podrían pagarlo con un poco de ayuda financiera federal, dijo , vicepresidente senior de políticas públicas en AARP. Quienes abandonan la cobertura o retrasan la atención hasta cumplir 65 años pueden estar ahorrando dinero ahora, pero eso podría resultar más costoso para ellos —y para los contribuyentes— más adelante.

“Existe una probabilidad significativa de que los supuestos ahorros por reducir los subsidios a medida que las personas se acercan a la jubilación terminen convirtiéndose en mayores costos para Medicare”, señaló Weil.

Los afiliados a Medicare no están protegidos de los aumentos de costos. Por ejemplo, en enero, las primas estándar de la subieron de $185 al mes a casi $203.

Hasta que Galvin pueda inscribirse en Medicare, prevé gastar los $30.000 de su cuenta de jubilación para cubrir los pagos de primas y el deducible de su plan del mercado.

reveló que 1 de cada 5 adultos mayores de 50 años no tiene ahorros para la jubilación y que a 3 de cada 5 les preocupa no tener suficientes fondos para mantenerse.

La expiración de estos subsidios del Obamacare ejerce una presión financiera adicional sobre los estadounidenses a medida que se acercan a la jubilación, dijeron investigadores de políticas de salud.

“Están obligando a las personas a tomar decisiones imposibles”, dijo , directora de defensa federal en salud de la organización sin fines de lucro Justice in Aging.

¿Tienes dificultades para pagar tu seguro médico? ¿Has decidido prescindir de la cobertura? Haz clic aquí para contactar a Â鶹ŮÓÅ Health News y compartir tu historia.

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He was already thinking about delaying it — then his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income, he said. And with a $2,700 deductible, he’d be on the hook for most of the diagnostic exam, a financial hit he said he couldn’t stomach.

“It was going to cost close to $3,000,” said Galvin, who lives in North Kingstown, Rhode Island, and recently retired as director of a durable medical equipment company. “I put it off.”

Galvin said his wife, Nancy, is delaying a costly CT scan for a few years until she too qualifies for Medicare, so it can foot the bill. The federal health program offers coverage for all Americans 65 and older.

People on Affordable Care Act plans nearing retirement age experienced some of the largest price increases following the expiration of enhanced federal subsidies at the end of December. Those with incomes above 400% of the federal poverty level — — had been getting help paying for the plans since the Biden administration expanded the subsidies during the covid-19 pandemic. Adults ages 50 through 64 of those ACA enrollees.

Now, without that federal financial help, some in this age group say they’re wrestling with whether to delay care until they qualify for Medicare. Not only does that put their physical health at risk, said patient advocates, doctors, and health policy researchers, but it potentially just shifts the costs — and could lead to taxpayers’ footing even bigger bills to fix health issues that worsen amid the delays.

“There’s going to be a lot of pent-up demand and unmet need,” said , a health policy consultant who worked in the Obama and Biden administrations. “Medicare is going to have to spend a whole heck of a lot of money covering and dealing with their treatment.”

The Affordable Care Act has been a key source of health care coverage for people 50 through 64. Access to Obamacare plans helped cut the uninsured rate for this age group by half, , a lobbying group that represents older adults. That allowed some people to retire early while keeping coverage. It also has provided a safety net for small-business owners and those with jobs that don’t offer health insurance.

Last fall, the longest-ever government shutdown occurred amid an unsuccessful effort by Democrats to extend the enhanced subsidies. Republicans opposing the extension had said the assistance went to insurers, incentivizing fraud and wasteful coverage.

Waiting for Medicare

John Galvin, 64North Kingstown, Rhode Island

John Galvin knows he needs a colonoscopy. But he’s waiting until he turns 65 in December to schedule it, so that Medicare will pick up the tab. His monthly Obamacare premium payment jumped this year — from $800 to more than $2,400 — so he’s burning through a $30,000 retirement account to cover the additional costs. And that’s for a plan with a $2,700 deductible, which means he’d be on the hook for most of the pricey diagnostic exam. “It was going to cost close to $3,000,” Galvin says. “I put it off.”

— Sam Whitehead

The issue will continue to have political relevance, especially in this year’s midterm elections, including among older Americans who reliably show up to the polls, said Republican strategist , who runs the Atlas Strategy Group.

“Is affordability going to be an issue? Absolutely,” he said. “Are health care prices going to factor into that? Yes.”

Even before the subsidies expired, the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50, a found.

Middle-aged adults with Obamacare plans acutely feel the pinch of the expired subsidies, because to charge adults in their 60s up to three times as much for premiums as those in their 20s, who generally use fewer medical services.

And many middle-aged adults were already enrolled in the lowest-cost plans available, which leaves them without cheaper options to fall back on, said , a policy analyst with Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“This is very dire for the older marketplace enrollees,” he said.

Someone making a few dollars over 400% of the federal poverty level earns too much to get a subsidy now, and in some states average premium payments were due to for this group. Many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes.

, a primary care physician and health policy researcher at the University of Michigan, said he has regular conversations with older patients who are trying to figure out how to afford their medical care. Some in their early 60s are likely to drop ACA coverage because of rising premiums, he said.

“That’s a gamble,” he added.

Marci Heinbaugh may take that bet. The 63-year-old social services worker, who lives in rural Illinois, said her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum.

She knew she’d be paying more, she said, but wasn’t anticipating that kind of increase. A few months in, she’s not sure if she’ll stick with the plan for the rest of the year. She said she may go uninsured.

“I’m petrified to even think about that,” Heinbaugh said.

People want to buy their own insurance on the marketplace, and many middle-aged adults could afford it with just a little federal financial help, said , senior vice president of public policy at AARP. Those who drop coverage or delay care until they reach age 65 might save money now, but that could be more costly for them — and taxpayers — later.

“There’s significant possibility that the purported savings associated with reducing subsidies as people approach retirement end up turning into higher utilization costs for Medicare,” Weil said.

And Medicare enrollees aren’t insulated from rising costs. In January, for example, standard Medicare from $185 per month to almost $203.

Until Galvin joins Medicare, he said, he expects to burn through a $30,000 retirement account to cover his marketplace plan’s premium payments and deductible.

A found that 1 in 5 adults over 50 had no retirement savings and 3 in 5 were worried they wouldn’t have enough retirement savings to support themselves.

The expiration of these Obamacare subsidies puts additional financial pressure on Americans as they approach retirement, health policy researchers said.

“It’s forcing people to make impossible choices,” said , director of federal health advocacy for the national nonprofit Justice in Aging.

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Lingering pain from a car crash two months ago, on top of an already hardscrabble life, has Angulo worried about her pregnancy. So, she was relieved when a mobile street medicine van from St. John’s Community Health pulled up near her encampment last month.

“Thank God that we have them,” she said.

, which operates 28 clinics, mostly in L.A. County, is part of the nation’s network of nonprofit community clinics that care for the poorest Americans. Around 80% of its 144,000 patients, including Angulo, have Medi-Cal, California’s version of the Medicaid program for people with low incomes or disabilities.

But federal cuts to Medicaid spending under the Republican-passed One Big Beautiful Bill Act, compounded by in Sacramento, could cost St. John’s up to one-third of its $240 million annual revenue, requiring cuts to services that might include street medicine, said Jim Mangia, the president and CEO.

Smaller, more cash-strapped clinics in L.A. County could face harsher consequences, including closure, if the lost funding is not replaced.

That’s why Mangia, along with a coalition of community clinics, health care workers, and advocates, is pushing for a five-year, in the nation’s most populous county to help backfill the projected loss of federal and state dollars. St. John’s has contributed at least $2 million to the campaign so far.

Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said there aren’t a lot of options to save the health care system from disaster.

“Our backs are up against the wall,” she said. “This has the potential to be a game changer. It will be an absolutely significant offset to the losses.”

The L.A. County Board of Supervisors last month for inclusion on the June 2 primary ballot, over the objection of some cities within the county. Their leaders argued the tax would put a strain on consumers and business owners. Most of an in annual revenue generated would be used to protect safety-net health care at community clinics, hospitals, and schools.

Scrambling To Stay Afloat

Nationally, the GOP budget law is expected to cut federal Medicaid spending by over 10 years, and it could lead to an increase of in the number of people left uninsured. The L.A. ballot proposal is among many local and state initiatives nationwide, as clinics, hospitals, health care workers, advocates, and legislators scramble for new money to help offset the spending cuts.

In Michigan, where the federal law is projected to cost the state , Democratic Gov. Gretchen Whitmer’s office has proposed on tobacco, vape products, online gambling, sports betting, and digital advertising, which it projects would raise hundreds of millions of dollars annually.

In Rhode Island, a group of state legislators hopes to ease some of the pain caused by the federal cuts with a that includes a tax on digital ads and a 3% surcharge on taxable incomes above roughly $640,000.

“The goal is not to replace the revenue; it’s to mitigate the damage,” said Democratic state Rep. Brandon Potter, one of the legislators involved.

In Washington, Democratic state Rep. Shaun Scott recently introduced legislation to address the loss of federal dollars with on large companies, applied to employee salaries exceeding $125,000 a year.

In California, the GOP law will slash the to Medi-Cal by an a year, or 25%. Enrollment in Medi-Cal could by 2028 as a result of the federal and state spending cuts, according to an analysis by the UCLA Center for Health Policy Research and the University of California-Berkeley Labor Center.

In July, California will slash Medi-Cal payments that community clinics receive for certain services provided to patients with “unsatisfactory” immigration status by about . Those patients include permanent residents in the country for less than five years, refugees, asylees, and other lawfully present people.

Bracing for a ‘New Reality’?

Advocates and health care experts say finding new revenue is the only way to avoid a crisis in California’s health care system.

“Are we going to let the gaps created by federal policies and state budget cuts leave millions of people uninsured?” said Laurel Lucia, deputy executive director of programs at the UC Berkeley Labor Center. “I think a lot of that question comes down to revenues.”

Some medical professionals say that new revenue is needed in the short term but that the country needs to address its notoriously expensive health care system.

“This new reality is that we have to do our work with less money going into the future,” said Hector Flores, of the Los Angeles County Medical Association. “So, this is an opportunity for us to look at how we can do things better.”

In the meantime, efforts to raise taxes for health care abound.

Voters in Santa Clara County, home to Silicon Valley, last November approved a five-year 0.625% to offset federal Medicaid cuts. A will be on the June ballot in Contra Costa County.

The best-known initiative, and a hotly contested one, is a union-sponsored ballot proposal in California for a on the state’s . Democratic Gov. Gavin Newsom strongly opposes it; Sen. Bernie Sanders (I-Vt.) stumped for it in California recently and has a national version in Congress.

Proponents of the temporary wealth tax say it would raise , which would mostly be used to backfill lost federal and state dollars in Medi-Cal and other safety-net programs. Proponents are trying to collect nearly 875,000 signatures needed to get it on the November ballot.

“We are on the precipice of a collapse of our health care system. So the most fortunate among us pay a modest tax that will hold us over and allow us to figure out a long-term solution,” said Suzanne Jimenez, chief of staff for Service Employees International Union-United Healthcare Workers West, the measure’s chief sponsor. “They would still be incredibly wealthy after that.”

Billionaires Push Back

The plan has stirred considerable controversy, not just in the Golden State but nationwide, and has generated strong and others.

Critics argue the measure could prompt billionaires to leave California, putting a damper on innovation, jobs, and tax receipts. And, some warn, the measure could end up in a legal quagmire, as those deemed liable to pony up challenge it on multiple fronts.

“If this passed, you would expect it to be tied up in court for some time,” said Jared Walczak, a visiting fellow at the California Tax Foundation. “It is fairly plausible that no revenue could come in for a number of years, if there’s ever any revenue at all.”

The prospect of such complications has led some health care advocates to focus instead on local initiatives that could start generating revenue more quickly, such as the proposed sales tax in L.A. County.

That one has critics too, including leaders of multiple cities within the county who to reject a proposal they argued would add to the affordability worries of consumers and put a strain on businesses.

Kathryn Barger, a Republican and the only L.A. County supervisor to oppose putting the measure on the June ballot, said in a statement that the proposed tax would make the county “less affordable for families and less appealing for consumers to shop and businesses to operate.”

But supporters say safety-net health care is already feeling the impact of diminished funding. Last month, for example, L.A. County’s Department of Public Health announced it was due to $50 million in federal, state, and local funding cuts.

Medi-Cal enrollees are worried, too. “We get a lot of calls from panicked patients afraid they’re going to lose their Medi-Cal. Dozens of calls a day, hundreds of calls a week,” said St. John’s Mangia.

“We tell them that we’re working on a solution and hopefully we’ll have that solution come June.”

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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“La persona dijo que era un oficial del Departamento de Investigaciones Criminales que trabajaba en un caso de tráfico de drogas y lavado de dinero”, recordó la mujer. Parecía saber mucho sobre ella: los estados donde ella y su difunto esposo habían vivido, el nombre y la ocupación de él y su dirección actual en el condado de Washington, en Rhode Island.

En el teléfono, él le mostró una placa convincente y una identificación con su nombre (“Frank algo”), además de un artículo que describía la supuesta investigación. La mujer, una jubilada de 76 años, negó cualquier participación.

“Puede contratar a un abogado penal muy caro o bien cooperar conmigo”, le dijo Frank.

“Ahora, cuando uno lo piensa, no tiene ningún sentido”, reconoció recientemente la mujer. Pero convencida por la placa y la identificación, aceptó cooperar. De lo contrario, “pensé que iban a venir a arrestarme”.

Frank llamaba cada mañana para saber a dónde iba y qué estaba haciendo. Su equipo estaría vigilando, le advirtió. La mujer, sintiéndose “aterrada”, empezó a mirar a su alrededor mientras asistía a las reuniones del club de jardinería. ¿La estaría siguiendo alguien?

Todo era una estafa.

La falta de denuncias, muchas veces motivada por la vergüenza, dificulta estimar la magnitud de la explotación financiera de las personas mayores. La Comisión Federal de Comercio (FTC, por sus siglas en inglés) estimó  fueron de $2.400 millones en 2024, principalmente debido a  e inversión, así como a robos de identidad. Las pérdidas totales, sin embargo, son mucho mayores.

Los estadounidenses mayores de 60 años pierden más de $28.000 millones cada año por explotación financiera,  (American Association of Retired Persons) en 2023.

A medida que estas cifras aumentan, debido al envejecimiento de la población y a que los estafadores se vuelven cada vez más ingeniosos, los bancos y las firmas de inversión se están convirtiendo en la primera línea de defensa.

El objetivo inicial de Frank era la cuenta de la mujer en Fidelity Investments. Le indicó que transfiriera alrededor de $250.000 a su cuenta corriente y que le dijera al asesor financiero de la oficina local que ella y su familia planeaban comprar propiedades.

Ese plan fracasó cuando el asesor dijo que Fidelity no podía aprobar la transacción sin más información sobre la propiedad.

Entonces Frank la envió a su sucursal local de Washington Trust Company para retirar $70.000 en efectivo de una línea de crédito sobre el valor acumulado de su vivienda. “No entregamos tanto efectivo”, dijo la cajera, mientras mandaba discretamente un mensaje al gerente de la sucursal, quien conocía a la mujer y a su esposo desde hacía años.

El gerente llevó a la mujer a su oficina para conversar y allí se detuvo la estafa, con una llamada a la policía local. Los bienes de la mujer permanecieron intactos, pero la experiencia fue tan humillante que ella ni siquiera le ha contado a su familia lo cerca que estuvo de perder gran parte de los ahorros de toda su vida. The New York Times (donde originalmente se publica esta columna) decidió no utilizar su nombre para evitarle más vergüenza.

“Me sentí tan tonta”, dijo. “Me sentí como una ingenua”.

Los estafadores financieros que atacan a los adultos mayores representan “una prioridad mayor para nosotros ahora”, dijo Mary Noons, presidenta y directora de operaciones de Washington Trust.

Como banco comunitario regional, Washington Trust intensificó sus esfuerzos el otoño pasado para asesorar a los clientes mayores y a sus familias sobre temas financieros, incluidos los peligros del fraude y de la explotación de la gente mayor. También publicaron y distribuyeron un folleto titulado “Envejecer con sabiduría” y llevaron a un experto en demencia para capacitar a su personal.

El Washington Trust se convirtió en una de las 1.500 instituciones financieras que, hasta la fecha, han utilizado Bank Safe, un programa gratuito de videos de AARP que capacita a los empleados que atienden directamente al público para detectar  que indiquen la posible explotación de personas mayores y así intervenir a tiempo. Todos los empleados de la sucursal donde la mujer de 76 años tenía su cuenta habían recibido esa capacitación.

“Algunos clientes mayores visitan su banco con mucha más frecuencia de la que ven a sus proveedores de atención médica”, señaló la señora Noons.

Hasta hace pocos años, las instituciones financieras ponían “más énfasis en la autonomía del cliente”, dijo Pamela Teaster, directora del Centro de Gerontología de Virginia Tech e investigadora especializada en abuso a personas mayores. Su enfoque era: “un adulto tiene la capacidad de tomar malas decisiones y vamos a permitir que las tome”, agregó.

Pero cambios en políticas y prácticas del gobierno y de la industria han impulsado una mayor vigilancia. El Congreso aprobó la ley en 2018, que protege a bancos y firmas financieras de responsabilidad legal si reportan a las autoridades sospechas de explotación.

Ese mismo año, la Autoridad Reguladora de la Industria Financiera (FINRA) comenzó a exigir que las firmas miembro pidan un cuando los inversionistas abren o actualizan una cuenta (aunque el titular de la cuenta no está obligado a proporcionarla). Desde 2022, se permite que las entidades de clientes mayores si sospechan que los están tratando de estafar.

Aproximadamente la mitad de los estados han promulgado leyes que permiten a las instituciones financieras rechazar transacciones sospechosas o suspenderlas por un plazo definido para que puedan investigarse, dijo Jilenne Gunther, directora de Bank Safe.

“Esto les pone un freno”, explicó. “Con un poco de tiempo de por medio, el delincuente se pone nervioso y puede que vaya a buscar a otra persona. Y la posible víctima tiene tiempo para detenerse y pensar”.

El análisis de la doctora Teaster sobre , durante un programa piloto de seis meses en 82 instituciones financieras, encontró que era más probable que quienes participaban del programa reportaran casos sospechosos y protegieran el dinero de los clientes que un grupo de control.

No todas las pérdidas de los adultos mayores se deben a estafadores. También pueden, por sí solos, dejarse llevar por modas de inversión, asumir demasiadas deudas o tomar decisiones poco prudentes, incluso sin que haya delincuentes manipulándolos ni familiares vaciándoles las cuentas.

Administrar las finanzas implica desafíos cognitivos complejos, dijo el doctor Mark Lachs, codirector de geriatría y medicina paliativa en Weill Cornell Medicine. “Es una tarea que pone a trabajar muchas funciones del cerebro”, explicó: “Memoria para recordar que hay una factura que vence. Función ejecutiva, capacidad de organizar el tiempo. Abstracción, poder proyectarse hacia el futuro”.

Agregó: “No pocas veces los errores financieros son la primera señal de una o de un trastorno neurocognitivo”.

±«²ÔÌý del Banco de la Reserva Federal de Nueva York, por ejemplo, encontró una mayor probabilidad de pagos atrasados y de deterioro en las calificaciones crediticias en los cinco años previos a un diagnóstico de demencia.

Esos errores pueden reducir el acceso al crédito de las personas mayores y aumentar las tasas de interés de sus préstamos justo en el momento en que los gastos de cuidado tienden a aumentar.

El doctor Lachs ha recomendado a otros médicos que reconozcan lo que él llama , un síndrome que puede afectar incluso a personas mayores con cognición normal, especialmente si enfrentan enfermedades, déficits sensoriales o aislamiento social.

Y sigue siendo escéptico respecto a que  la industria financiera preste mayor atención a sus clientes de más edad. “Todavía veo que se ejecutan transacciones financieras preocupantes sin el nivel de revisión que deberían haber recibido”, dijo.

Capacitar a más empleados de tratan directamente con los clientes y poner mayor énfasis en establecer contactos de confianza para personas mayores ayudaría, opinó la señora Gunther, porque “una vez que el dinero sale de la cuenta, es casi imposible recuperarlo”. Más estados podrían aprobar leyes que les permitan a las instituciones financieras rechazar o frenar por un plazo las transacciones sospechosas.

En el Congreso avanzan varios proyectos de ley relacionados al tema, con apoyo bipartidista. La requeriría que el FBI asumiera la coordinación de los esfuerzos para proteger a las personas mayores. Un proyecto de ley que al menos ofrecería el consuelo de eximir a las víctimas de estafas de pagar impuestos sobre un dinero que ya no tienen.

Sin embargo, nuevas herramientas como la clonación de voz con inteligencia artificial —en la que el supuesto nieto que llama desesperado desde otro estado pidiendo con urgencia $5.000 en tarjetas de regalo suena igual que el nieto real de la víctima— les quitan el sueño a defensores y banqueros.

En la sucursal de Washington Trust donde la mujer de Rhode Island pudo salvar su dinero, días antes los empleados habían detenido una estafa similar.

Pero, más recientemente, nadie detectó señales de peligro cuando otra mujer mayor retiró $9.000 para una remodelación de cocina, hasta que el dinero terminó en manos de un estafador en lugar de un contratista.

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

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

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

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

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

It was all a scam.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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That’s the case in New Orleans, where an investigation by Verite News found high lead levels in about half of the playgrounds on city property and found in most homes that tested their drinking water in a voluntary program.

No level of lead exposure is safe, according to federal environmental officials, but undertaking a comprehensive cleanup can be financially prohibitive. New Orleans is facing a $220 million budget deficit that has led to city employee furloughs and layoffs.

Congress allocated $15 billion over five years to lead pipe replacement under the Bipartisan Infrastructure Law, a Biden-era measure set to expire at the end of this year. In 2024, the Environmental Protection Agency also tightened the standards for lead-contaminated soil for the first time in 30 years and mandated that water systems by late 2037.

But passed by Congress and signed by President Donald Trump in January redirected $125 million of that lead remediation money to wildfire prevention. And since October, the EPA has partially rolled back protections against soil contamination, raising the federal hazard level in urban areas and the threshold for removing contaminated soil.

Tom Neltner, the national director of the nonprofit advocacy group Unleaded Kids, said it was the first time an administration had loosened the limits on lead in soil.

“ We’ve seen the Trump administration say positive things about its commitment to lead but then take actions that undermine that,” Neltner said.

But, he added, progress is still being made in some communities.

EPA press secretary Brigit Hirsch said the changes made under the Trump administration have reduced confusion and uncertainty that could hamper cleanup efforts.

“The Trump EPA’s record on protecting Americans — especially American children — from lead is unmatched,” Hirsch said in an emailed statement. “In just the last year, the Trump EPA backed up its commitment to reducing lead exposure in children with BILLIONS of dollars and historic action.”

She cited a of $3 billion available to pay for water pipe replacement. That money is from the passed during the Biden administration.

Verite News spoke with people in Michigan, Indiana, and Rhode Island to learn how they addressed their lead pollution, with the aim of finding options that could be applied in New Orleans and other cities.

“ We don’t need to do research on lead anymore,” said Tulane University professor Felicia Rabito, an epidemiologist who researches the toxic metal and its sources. “What we need are policies to get the lead out of the environment.”

Benton Harbor, Michigan: Lead Pipes Begone

Benton Harbor, a predominantly Black beach town of about 9,000 people on the southeastern shore of Lake Michigan, spent three years out of compliance with federal drinking water standards. The concentration of lead in the water remained dangerously high until residents and organizations petitioned the EPA in 2021, drawing responses from state and federal officials.

“Nobody should be drinking lead in their water for this long,” said Elin Betanzo, an engineer who provided the petitioning residents with technical support.

That year, federal officials issued an for the Michigan city to bring its water supply into compliance, and the state required Benton Harbor to replace all its lead pipes within 18 months. Gov. Gretchen Whitmer, a Democrat, committed to securing funding in the state budget for the $35 million effort, which included bottled water distribution and paying outstanding water bills for low-income residents. The state, alongside the city, allocated money from its general fund, secured regional water loans, and cobbled together grants from several federal programs to cover the total.

By the end of 2023, city officials had completed the project. Now it’s one of 21 municipalities in Michigan that have replaced all their lead pipes. Benton Harbor had more than 4,500 pipes to replace.

The Trump administration has said it would defend the Biden-era mandate for lead pipe replacement by 2037 against a lawsuit challenging it.

Betanzo recommended that utilities in other cities reduce barriers to line replacement to increase efficiency, as Benton Harbor’s water system did.

City officials saved time after assuming most pipes would be lead. They decided to go street by street, digging up, inspecting, and replacing nearly every pipe. If the pipe wasn’t lead, it wasn’t replaced, but nearly all were, Betanzo said.

Concentrating the mass replacement in one zone at a time made the contracts more cost-effective, Betanzo added. Contractors bid on zones in the city, and multiple contractors worked in different neighborhoods simultaneously. For transparency, progress was published on a public database.

The city also passed a law requiring lead lines be replaced, including those on customers’ side of the water meter. All residents had to allow the contractors onto their property or face disconnection. The residents didn’t pay for the line replacements.

“ The health benefits of lead service line replacement are greatest the sooner you get it done,” Betanzo noted, referencing a she co-authored. “If you do it wrong, you can absolutely increase exposure to lead through a lead service line replacement.”

Completion of full pipe replacement is rare in the U.S., because of the cost, poor service line tracking, the time it takes, and the prioritization of other issues. In New Orleans, the process could require up to $1 billion of investment over 10 years, according to the city’s Sewerage and Water Board.

Indianapolis: Safe Dirt for Kids

It’s not just lead pipes that are problematic. In 2024, a in the academic journal GeoHealth estimated that nearly a quarter of homes in the U.S. have unsafe levels of lead in the soil on their properties.

To that end, Indianapolis has taken some actions that other cities can learn from, said Gabriel Filippelli, a professor at the Indiana University-Indianapolis School of Science who led the study and has researched the risk of lead exposure through soil for years.

The Indy Parks & Recreation department partnered with Filippelli’s team to test a dozen parks relatively close to the contaminated site of a shuttered lead smelter.

Out of all the parks tested, Filippelli’s team found only one hot spot, beneath an old bench from which lead-based paint had flaked off into the surrounding soil.

The parks department followed Filippelli’s suggestion to replace the bench and add concrete and a thick layer of mulch and plants on the ground, so kids wouldn’t be able to play directly in the contaminated dirt.

“It was a relatively low-cost intervention,” he said, estimating it cost a few thousand dollars. The ground wasn’t excavated, and new dirt wasn’t brought in. “If you deal with it by dilution and by capping, remove the source, you’re solving the problem for today and probably many, many years to come.”

The contaminated dirt may need to be removed in some cases and replaced with clean soil, such as after severe, widespread pollution from industrial sources. But Filippelli said such extensive remediation can be impractical and too expensive for cities to undertake on their own.

Where full remediation is cost-prohibitive, Filippelli said, there are more creative solutions, like landscaping, covering the area with new dirt, or mulching. These methods won’t eliminate the lead entirely, but they will significantly reduce exposure risk.

“You can eliminate the hazard at a fraction of the cost,” he said.

Cities could also look to New York City’s , which places uncontaminated soil left over from construction projects in neighborhood-level banks for volunteers to distribute, he said.

Rhode Island: Stopping Lead at the Source

New England, home to some of the nation’s oldest homes, has led the U.S. in mitigating one of the largest ongoing sources of lead contamination: paint.

In 2023, the state legislature in Rhode Island, where most of the homes were built before lead paint was banned in 1978, passed strengthening the state’s ability to enforce tenant protections.

Prior to 2023, the state had long required most landlords to have their property inspected to ensure it met “lead safe” guidelines, said DeeAnn Guo, a community organizer for the . Although no level of lead is considered safe, replacing windows and doors that have lead paint, painting over all interior and exterior walls, and mitigating contaminated soil significantly reduce the risk of exposure.

But for years “there was no incentive to do it,” Guo said, “aside from it being the right thing to do.”

Now, landlords can be fined if they don’t have an active lead certificate on file for homes built before 1978, and the property has to be inspected every two years to remain in compliance. Before the new law, less than 15% of rentals were certified. In late 2025, that had increased to 40%, Guo said.

The state has also seen a steady decline in the in children’s blood.

Guo said it helps that the state has federal funding from the Department of Housing and Urban Development to subsidize its If a homeowner or landlord owns an old house, they can apply for the state to send an inspector. If lead is found, the state will then send a certified contractor to address the problem at little to no cost to the property owner.

Rhode Island prioritizes low-income households and homes with pregnant women or children under 6 years old, because of the heightened health risk. It can also help pay to remediate homes if a child living there has elevated levels of lead in their blood.

States and communities looking to start a successful lead paint abatement program using HUD money should combine strong enforcement, public education, and offers of subsidies, Guo said. It also helps to include community members in the planning process, she said.

Under the Trump administration, however, it might become harder for more communities like New Orleans to receive money for a “lead safe” program. Last year, HUD asked Congress to eliminate new funding for its lead hazards program, stating it would be restored in 2027. But advocates for more lead protections argue that once funding is lost, it is unlikely to be approved again.

“It shows the White House’s hypocrisy, where they talk about lead as being important and then propose eliminating the funds that are essential to cleaning up affordable housing,” said Neltner, the Unleaded Kids director. “This administration talks about the importance of children and then seems to be careless about children’s brains.”

This article was produced in collaboration with . The four-month investigation was supported by a Kozik Environmental Justice Reporting grant funded by the National Press Foundation and the National Press Club Journalism Institute. It was also produced as a project for the USC Annenberg Center for Health Journalism’s National Fellowship fund and Dennis A. Hunt Fund for Health Journalism.

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La regulación de la inteligencia artificial, en especial su uso por parte de las aseguradoras de salud, se está convirtiendo en un tema que divide políticamente y altera las líneas partidarias tradicionales.

Quienes la impulsan, con Trump a la cabeza, no solo quieren insertar la IA de lleno en el gobierno, como en el experimento de Medicare que la utiliza en las autorizaciones previas (el proceso para autorizar ciertos tratamientos y medicamentos), sino que además buscan frenar a los estados que pretenden poner reglas y límites. Una firmada en diciembre busca invalidar la mayoría de los esfuerzos de los estados para regularla, al plantear que existe “una carrera con adversarios por la supremacía” en una nueva “revolución tecnológica”.

“Para ganar, las empresas estadounidenses de IA deben tener la libertad de innovar sin regulaciones engorrosas”, dice la orden de Trump. “Pero la regulación estatal excesiva frustra este imperativo”.

En todo el país, los estados se están rebelando. Al menos cuatro —Arizona, Maryland, Nebraska y Texas— aprobaron el año pasado leyes que limitan el uso de la IA en los seguros de salud. Otros dos, Illinois y California, habían aprobado leyes similares el año anterior.

Los legisladores de Rhode Island se proponen intentarlo de nuevo este año, después de que durante 2025 no lograran sancionar un proyecto que exigía a los organismos reguladores que recopilaran datos sobre el uso de las tecnologías. El año pasado, en Carolina del Norte, una iniciativa que exige que las aseguradoras no utilicen la IA como única base para decidir la cobertura generó interés entre legisladores republicanos.

DeSantis, ex candidato presidencial del Partido Republicano, ha presentado una “Carta de Derechos de la IA”, incluyen restricciones a su uso en la tramitación de reclamos de seguros y el requisito de que un organismo regulador estatal inspeccione los algoritmos.

“Tenemos la responsabilidad de garantizar que las nuevas tecnologías se desarrollen de forma moral y ética, de modo que refuercen nuestros valores estadounidenses, no que los erosionen”, dijo DeSantis durante su discurso anual sobre la situación de su estado en enero.

Lista para regular

Las encuestas muestran que los estadounidenses desconfían de la IA. En , un relevamiento  de Fox News encontró que el 63% de los votantes se describen como “muy” o “extremadamente” preocupados por la inteligencia artificial. La preocupación es mayoritaria en todo el espectro político. Casi dos tercios de los demócratas y poco más de 3 de cada 5 republicanos dijeron tener reparos sobre la IA.

Las tácticas de las aseguradoras de salud para reducir costos también preocupan a la población. Una de Â鶹ŮÓÅ mostró un descontento generalizado en temas como la autorización previa.

En los últimos años, y han destacado el uso de algoritmos para rechazar rápidamente reclamos de seguros o solicitudes de autorización previa, al parecer con muy poca revisión por parte de un profesional de salud.

En enero, el Comité de Medios y Arbitrios de la Cámara de Representantes convocó a ejecutivos de Cigna, UnitedHealth Group y otras grandes aseguradoras para discutir preocupaciones sobre los altos costos de la atención médica.

Cuando se les preguntó directamente, los ejecutivos negaron o evitaron referirse al uso de la tecnología más avanzada para rechazar solicitudes de autorización o descartar reclamos.

La IA “nunca se utiliza para una denegación”, aseguró a los legisladores David Cordani, director ejecutivo de Cigna. Al igual que otras empresas del sector de seguros de salud, la compañía enfrenta demandas por sus métodos para rechazar reclamos, como destacó ProPublica. Justine Sessions, vocera de Cigna, dijo que el proceso de rechazo de reclamos de la empresa “no está impulsado por la IA”.

De hecho, las compañías insisten en presentar la IA como una herramienta de apoyo que no decide sola. Optum, parte del gigante de la salud UnitedHealth Group, anunció el 4 de febrero que implementaría autorización previa impulsada por tecnología, destacando que permitirá aprobaciones más rápidas.

“Estamos transformando el proceso de autorización previa para abordar los puntos de conflicto que genera”, dijo John Kontor, vicepresidente sénior de Optum, en un .

Aun así, Alex Bores, científico informático y miembro de la Asamblea de Nueva York, una figura clave en el debate legislativo del estado sobre la IA—que terminó en una ley integral para regular esta tecnología—, aseguró que la IA es un campo que, naturalmente, requiere regulación.

“Muchas personas consideran que las respuestas que reciben de sus aseguradoras son difíciles de entender”, dijo Bores, demócrata que compite por un escaño en el Congreso. “Agregar una tecnología que no puede explicar sus propias decisiones no ayudará a hacer las cosas más claras”.

Al menos una parte del ámbito de la salud —por ejemplo, muchos médicos— respalda a los legisladores y a quienes defienden las regulaciones.

La Asociación Médica Americana (AMA, por sus siglas en inglés) “apoya las regulaciones estatales que buscan más responsabilidad y transparencia de las aseguradoras comerciales que usan herramientas de IA y aprendizaje automático para revisar solicitudes de autorización previa”, dijo John Whyte, su director ejecutivo.

Whyte señaló que las aseguradoras ya utilizan IA y que “los médicos siguen enfrentando retrasos en la atención de los pacientes, decisiones poco claras de las aseguradoras, reglas de autorización inconsistentes y una carga administrativa abrumadora”.

Las aseguradoras responden

Con legislación aprobada o pendiente de aprobación en por lo menos nueve estados, aún no está claro el impacto real que tendrán esas leyes estatales, dijo Daniel Schwarcz, profesor de Derecho en la Universidad de Minnesota. Los estados no pueden regular los planes “autoasegurados”, que utilizan muchos empleadores; solo el gobierno federal tiene esa facultad.

Pero hay problemas más profundos, dijo Schwarcz: la mayoría de las leyes estatales que ha visto exigirían que un ser humano apruebe cualquier decisión propuesta por la IA, pero no especifican qué significa eso en la práctica.

Las leyes no ofrecen un marco claro para entender cuánta revisión es suficiente y, con el tiempo, los humanos tienden a volverse un poco descuidados y simplemente dan el visto bueno a cualquier sugerencia de una computadora, dijo.

Aun así, las aseguradoras ven esta ola de proyectos de ley como un problema.

“En términos generales, la carga regulatoria es real”, dijo Dan Jones, vicepresidente sénior de asuntos federales de la Alliance of Community Health Plans, un grupo comercial que representa a algunas aseguradoras de salud sin fines de lucro. Si las aseguradoras pasan mucho tiempo lidiando con un mosaico de leyes estatales y federales, agregó, eso significa que se dispondrá de “menos tiempo y recursos para enfocarnos en lo que se supone que debemos hacer: asegurarnos de que los pacientes tengan el acceso adecuado a la atención médica”.

Linda Ujifusa, senadora estatal demócrata en Rhode Island, dijo que las aseguradoras se opusieron el año pasado a un proyecto que presentó para restringir el uso de la IA en las denegaciones de cobertura. Fue aprobado en una cámara, pero en la otra no avanzó.

“Hay una oposición enorme” a cualquier intento de regular prácticas como la autorización previa, dijo, y también “una oposición enorme” a señalar a intermediarios —como las aseguradoras privadas o los administradores de beneficios farmacéuticos— “como parte del problema”.

En , AHIP, el principal grupo que representa a las aseguradoras, pidió “políticas equilibradas que promuevan la innovación y, al mismo tiempo, protejan a los pacientes”.

“Los planes de salud reconocen que la IA tiene el potencial de impulsar mejores resultados en la atención médica mejorando la experiencia del paciente, cerrando brechas en la atención, acelerando la innovación y reduciendo la carga administrativa y los costos para mejorar el enfoque en la atención al paciente”, dijo Chris Bond, portavoz de AHIP, a Â鶹ŮÓÅ Health News.

Y agregó que el sector necesita “un enfoque nacional coherente basado en un marco federal integral de políticas de IA”.

En busca de equilibrio

En California, Newsom ha promulgado algunas leyes que regulan la IA, incluida una que exige que las aseguradoras de salud garanticen que sus algoritmos se apliquen de manera justa y equitativa. Pero el gobernador demócrata ha vetado otras iniciativas con un enfoque más amplio, como un proyecto que imponía más requisitos sobre cómo debe funcionar la tecnología y que exigía revelar su uso a reguladores, médicos y pacientes cuando lo pidieran.

Según Chris Micheli, lobista de Sacramento, es probable que el gobernador quiera asegurarse de que el presupuesto estatal —que se mantiene fuerte gracias a las grandes ganancias de la Bolsa, especialmente de las empresas tecnológicas— no se resienta. Y para eso, dijo, hace falta equilibrio.

Newsom está tratando de “garantizar que ese flujo de dinero continúe y, al mismo tiempo, que haya algunas protecciones para los consumidores de California”, afirmó. Añadió que las aseguradoras consideran que ya están sujetas a una gran cantidad de regulaciones.

La administración Trump parece estar de acuerdo. La reciente orden ejecutiva del presidente propone demandar ante la Justicia y restringir ciertos fondos federales a cualquier estado que apruebe lo que caracteriza como una regulación estatal “excesiva”, con algunas excepciones, como las políticas destinadas a proteger a los niños.

Esa orden posiblemente sea inconstitucional, dijo Carmel Shachar, experta en políticas de salud de la Facultad de Derecho de Harvard. La autoridad para invalidar leyes estatales generalmente recae en el Congreso, explicó, y los legisladores federales consideraron en dos ocasiones, pero finalmente rechazaron, una disposición que prohibía a los estados regular la IA.

“Según nuestro conocimiento previo del federalismo y del equilibrio de poderes entre el Congreso y el Poder Ejecutivo, es muy probable que una impugnación tenga éxito”, dijo Shachar.

Algunos legisladores ven la orden de Trump con mucho escepticismo, y señalan que la administración ha eliminado controles y ha impedido que otros los establezcan, en un grado extremo.

“En este momento, no se trata de decidir si la regulación debe ser federal o estatal”, dijo Alex Bores. “La pregunta es si va a haber regulación a nivel estatal o directamente no va a haber ninguna”.

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

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

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

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

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

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

Novo Nordisk declined to address those numbers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Regulating artificial intelligence, especially its use by health insurers, is becoming a politically divisive topic, and it’s scrambling traditional partisan lines.

Boosters, led by Trump, are not only pushing its integration into government, as in Medicare’s experiment using AI in prior authorization, but also trying to stop others from building curbs and guardrails. A December seeks to preempt most state efforts to govern AI, describing “a race with adversaries for supremacy” in a new “technological revolution.”

“To win, United States AI companies must be free to innovate without cumbersome regulation,” Trump’s order said. “But excessive State regulation thwarts this imperative.”

Across the nation, states are in revolt. At least four — Arizona, Maryland, Nebraska, and Texas — enacted legislation last year reining in the use of AI in health insurance. Two others, Illinois and California, enacted bills the year before.

Legislators in Rhode Island plan to try again this year after a bill requiring regulators to collect data on technology use failed to clear both chambers last year. A bill in North Carolina requiring insurers not to use AI as the sole basis of a coverage decision attracted significant interest from Republican legislators last year.

DeSantis, a former GOP presidential candidate, has rolled out an “AI Bill of Rights,” include restrictions on its use in processing insurance claims and a requirement allowing a state regulatory body to inspect algorithms.

“We have a responsibility to ensure that new technologies develop in ways that are moral and ethical, in ways that reinforce our American values, not in ways that erode them,” DeSantis said during his State of the State address in January.

Ripe for Regulation

Polling shows Americans are skeptical of AI. A from Fox News found 63% of voters describe themselves as “very” or “extremely” concerned about artificial intelligence, including majorities across the political spectrum. Nearly two-thirds of Democrats and just over 3 in 5 Republicans said they had qualms about AI.

Health insurers’ tactics to hold down costs also trouble the public; from Â鶹ŮÓÅ found widespread discontent over issues like prior authorization. (Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.) Reporting and in recent years has highlighted the use of algorithms to rapidly deny insurance claims or prior authorization requests, apparently with little review by a doctor.

Last month, the House Ways and Means Committee hauled in executives from Cigna, UnitedHealth Group, and other major health insurers to address concerns about affordability. When pressed, the executives either denied or avoided talking about using the most advanced technology to reject authorization requests or toss out claims.

AI is “never used for a denial,” Cigna CEO David Cordani told lawmakers. Like others in the health insurance industry, the company is being sued for its methods of denying claims, as spotlighted by ProPublica. Cigna spokesperson Justine Sessions said the company’s claims-denial process “is not powered by AI.”

Indeed, companies are at pains to frame AI as a loyal servant. Optum, part of health giant UnitedHealth Group, announced Feb. 4 that it was rolling out tech-powered prior authorization, with plenty of mentions of speedier approvals.

“We’re transforming the prior authorization process to address the friction it causes,” John Kontor, a senior vice president at Optum,

Still, Alex Bores, a computer scientist and New York Assembly member prominent in the state’s legislative debate over AI, which culminated in a comprehensive bill governing the technology, said AI is a natural field to regulate.

“So many people already find the answers that they’re getting from their insurance companies to be inscrutable,” said Bores, a Democrat who is running for Congress. “Adding in a layer that cannot by its nature explain itself doesn’t seem like it’ll be helpful there.”

At least some people in medicine — doctors, for example — are cheering legislators and regulators on. The American Medical Association “supports state regulations seeking greater accountability and transparency from commercial health insurers that use AI and machine learning tools to review prior authorization requests,” said John Whyte, the organization’s CEO.

Whyte said insurers already use AI and “doctors still face delayed patient care, opaque insurer decisions, inconsistent authorization rules, and crushing administrative work.”

Insurers Push Back

With legislation approved or pending in at least nine states, it’s unclear how much of an effect the state laws will have, said University of Minnesota law professor Daniel Schwarcz. States can’t regulate “self-insured” plans, which are used by many employers; only the federal government has that power.

But there are deeper issues, Schwarcz said: Most of the state legislation he’s seen would require a human to sign off on any decision proposed by AI but doesn’t specify what that means.

The laws don’t offer a clear framework for understanding how much review is enough, and over time humans tend to become a little lazy and simply sign off on any suggestions by a computer, he said.

Still, insurers view the spate of bills as a problem. “Broadly speaking, regulatory burden is real,” said Dan Jones, senior vice president for federal affairs at the Alliance of Community Health Plans, a trade group for some nonprofit health insurers. If insurers spend more time working through a patchwork of state and federal laws, he continued, that means “less time that can be spent and invested into what we’re intended to be doing, which is focusing on making sure that patients are getting the right access to care.”

Linda Ujifusa, a Democratic state senator in Rhode Island, said insurers came out last year against the bill she sponsored to restrict AI use in coverage denials. It passed in one chamber, though not the other.

“There’s tremendous opposition” to anything that regulates tactics such as prior authorization, she said, and “tremendous opposition” to identifying intermediaries such as private insurers or pharmacy benefit managers “as a problem.”

In a , AHIP, an insurer trade group, advocated for “balanced policies that promote innovation while protecting patients.”

“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden and costs to improve the focus on patient care,” Chris Bond, an AHIP spokesperson, told Â鶹ŮÓÅ Health News. And, he continued, they need a “consistent, national approach anchored in a comprehensive federal AI policy framework.”

Seeking Balance

In California, Newsom has signed some laws regulating AI, including one requiring health insurers to ensure their algorithms are fairly and equitably applied. But the Democratic governor has vetoed others with a broader approach, such as a bill including more mandates about how the technology must work and requirements to disclose its use to regulators, clinicians, and patients upon request.

Chris Micheli, a Sacramento-based lobbyist, said the governor likely wants to ensure the state budget — consistently powered by outsize stock market gains, especially from tech companies — stays flush. That necessitates balance.

Newsom is trying to “ensure that financial spigot continues, and at the same time ensure that there are some protections for California consumers,” he said. He added insurers believe they’re subject to a welter of regulations already.

The Trump administration seems persuaded. The president’s recent executive order proposed to sue and restrict certain federal funding for any state that enacts what it characterized as “excessive” state regulation — with some exceptions, including for policies that protect children.

That order is possibly unconstitutional, said Carmel Shachar, a health policy scholar at Harvard Law School. The source of preemption authority is generally Congress, she said, and federal lawmakers twice took up, but ultimately declined to pass, a provision barring states from regulating AI.

“Based on our previous understanding of federalism and the balance of powers between Congress and the executive, a challenge here would be very likely to succeed,” Shachar said.

Some lawmakers view Trump’s order skeptically at best, noting the administration has been removing guardrails, and preventing others from erecting them, to an extreme degree.

“There isn’t really a question of, should it be federal or should it be state right now?” Bores said. “The question is, should it be state or not at all?”

Do you have an experience navigating prior authorization to get medical treatment that you’d like to share with us for our reporting? Share it with us here.

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