It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day his cattle wouldn’t come first. For the past 3½ years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital.

Pieper lives outside Hay Springs, which has 599 residents, according to a sign at the edge of town. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.

That February morning was one of his last dialysis sessions there before the hospital shuttered the service at the end of March.

“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he learned the center was closing, eliminating the only option near his home.

He needs dialysis to survive after cancer treatment damaged his kidneys.

Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from their blood — a job their failing kidneys could no longer do. Treatment lasts about four hours.

The closure is just one example of the long decline of health care services in rural America, where people have higher rates of many chronic conditions but less access to care than elsewhere.

The Trump administration promised to address this problem, when it launched the $50 billion federal Rural Health Transformation Program in September. It may not be enough to stop the trend.

“[President Donald] Trump says he is going to help the rural health care,” Pieper said. Dialysis “is one thing that we really need here.”

Some patients have moved to live closer to care, including several nursing home residents. Their new facilities may be farther from their families.

Others are making long drives to dialysis centers. Pieper eventually found treatment in Scottsbluff, which, with about 14,000 residents, is the biggest city in the rural Panhandle region of western Nebraska. The hour-and-a-half drive will triple his time on the road to more than nine hours each week.

Jim Wright and his wife reduced their drive time — but are spending more money — by renting a small home near Rapid City, South Dakota, and living there on weekdays so he can get dialysis. Wright said he understands that rural hospitals face financial challenges.

“But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’” getting treatment, he said. “It’s a case that if you don’t, you die.”

An Influx of Money That’s Out of Reach

Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, wrestled with the decision to end dialysis services. He and several patients said that the closure was announced as the $219 million the state will receive in first-year funding from the Rural Health Transformation Program.

But the five-year program is aimed at exploring new, creative ways to improve rural health, not to help existing services stay afloat. States can use only up to 15% of their funding to pay providers for patient care.

At least 11 states — Nebraska is not among them — have mentioned using funding for rural dialysis programs, according to a Â鶹ŮÓÅ Health News review of applications. Their ideas include starting a mobile dialysis unit and helping people get treatment at home or in long-term care facilities.

Reiners said Chadron Hospital lost $1 million a year on its dialysis service due to low reimbursement rates that didn’t cover operational costs.

The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to get increased reimbursement rates for their Medicare patients. While most of the affected patients were on Medicare, the critical access program doesn’t cover outpatient dialysis, Reiners said.

Reiners said the hospital worked for more than a year to find solutions, such as reaching out to four private companies to potentially take over the center. But he said they all passed after realizing they would lose money.

Nephrologist Mark Unruh said the dialysis closure in Chadron reflects a wider trend of staffing and funding challenges.

“You do end up in situations where you have people who are displaced like this, and it’s just sad,” said Unruh, chair of the Internal Medicine Department at the University of New Mexico.

People in rural America face significant disparities in kidney health and treatment, published in 2024 in the American Journal of Nephrology. They’re and face after diagnosis, according to data from the National Institutes of Health.

that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

Another idea, Unruh said, is boosting the rate of kidney transplantation for rural patients. He’s looking at whether it’s helpful to “fast-track” tests patients need to get approved for a transplant by scheduling all of them over a couple of days to limit travel time.

Unruh said the U.S. health system also needs to recruit more staff who can train patients and their caregivers to administer dialysis at home.

Exploring the Option of Home Dialysis

Rural dialysis patients are more likely than urban ones to get home dialysis, according to . In 2023, the rate was nearly 18% for rural patients and about 14% for urban ones.

One type of home dialysis requires surgery to get a catheter placed in the abdomen and . The other kind requires . The nearest facility to Chadron that offers training for the first option is in Scottsbluff. The nearest that offers training for the latter kind is three hours away in Cheyenne, Wyoming.

Pieper said doctors told him he’s not a candidate for home dialysis or a transplant. The Panhandle has a nonprofit, rural transit system, but its schedule won’t work for Pieper. He said that leaves him with no choice but to get treatment in Scottsbluff, a 200-mile round trip.

It takes Linda Simonson even longer — more than four hours round trip — to drive her husband, Alan, from their ranch to his treatment in Scottsbluff.

Linda sat in the waiting room with a yellow legal pad during one of Alan’s final treatments in Chadron. The paper was scrawled with phone numbers of politicians to call and driving distances to dialysis centers in the region. She said facilities closer to their ranch either don’t have room for new patients or lack good spots along the route to take a driving break in bad weather.

“It’s just unreal,” she said.

She said even if Alan took a bus, she’d have to ride along to support him during the trip and his treatment.

Jim and Carol Wright, the couple staying near Rapid City on weekdays, said they can’t afford to rent a second home forever. Their weekly commute is already taking a physical and emotional toll. They said they’ll eventually have to move to a bigger city, giving up the house they love in the scenic Nebraska National Forest.

Carol said she feels for the dialysis staffers in Chadron, who are wonderful.

“It just doesn’t seem right to sacrifice one unit that’s so vital,” she said while standing next to a pile of moving boxes stacked inside their rental.

The Wrights wrote letters to politicians and hospital leaders to share their concerns and ideas for keeping the unit open, including using the federal rural health funding.

Simonson said she spoke with aides for the governor and her state representatives but none of the leaders called her back.

“It feels like they don’t know that we exist at this end of the state,” she said.

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 .

USE OUR CONTENT

This story can be republished for free (details).

“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

Â鶹ŮÓÅ Health News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

Long Wait Times for Help

Republicans argue the Medicaid changes, which will take effect Jan. 1, 2027, in most states, will encourage enrollees to find jobs. Research on other Medicaid work requirement programs has found little evidence they increase employment.

The Congressional Budget Office would cause more people to lose health coverage by 2034 than any other part of the GOP budget law. It said last year more than 5 million people could be affected.

Many states don’t have the staff to process Medicaid applications or renewals quickly, said consumer advocates and researchers.

The Centers for Medicare & Medicaid Services tracks whether states can handle the most common type of benefit application within a 45-day window.

In December, about 30% of all Medicaid and Children’s Health Insurance Program, or CHIP, applications in Washington, D.C., and Georgia to process. More than a quarter took that long in Wyoming. In Maine, 1 in 5 applications missed that deadline.

CMS began publicly sharing state Medicaid call center data in 2023, revealing a taxed system, researchers and consumer advocates said.

In Hawaii, people waited on the phone for more than three hours in December. They waited for nearly an hour in Oklahoma, and more than an hour in Nevada.

In 2023, state Medicaid agencies began making sure enrollees who were protected from being dropped from the program during the covid pandemic still qualified for coverage. That Medicaid unwinding process didn’t go well in many states, and lost their benefits.

Health policy researchers and consumer advocates say rolling out the new Medicaid rules will be a bigger challenge. The Medicaid work rules will require extensive IT system changes and training for workers verifying eligibility on a tight timeline.

“It is a much larger scale of administrative complexity,” said Sophia Tripoli, senior director of policy at Families USA, a health care consumer advocacy organization.

After months of trying to get someone on the phone, Crouch said, she finally got answers to questions about her Medicaid benefits after writing to the office of U.S. Rep. Sarah McBride (D-Del.). McBride’s office contacted the state’s Medicaid agency, which eventually called with an update, Crouch said.

Crouch didn’t qualify for Medicaid after all. She said that had never come up in two years of interactions with the state.

“It makes absolutely no sense” that the state never realized she shouldn’t have been on the program, Crouch said.

Delaware’s Medicaid agency didn’t respond to requests for comment on Crouch’s situation.

States Short-Staffed for Medicaid

Some states told Â鶹ŮÓÅ Health News in late March that they’ll need more staff to roll out the work rules effectively.

Idaho said it has 40 eligibility worker vacancies. New York estimated it will need 80 new employees to handle the additional administrative work, at a cost of $6.2 million. Pennsylvania said it has nearly 400 open positions in county human services offices in the state. Indiana’s Medicaid agency has 94 open positions. Maine wants to hire 90 additional staffers, and Massachusetts wants to hire 70 more.

As of early March, Montana had filled 39 of 59 positions state officials projected it would need. The state still plans to roll out the rules early, starting July 1, despite its long struggle with system backlogs that applicants said have delayed benefits.

Missouri’s social services agency has been cutting staff and has 1,000 fewer front-line workers than it did roughly a decade ago — with more than double the number of enrollees in Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, according to comments Jessica Bax, the agency director, made in November.

“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”

States could have a hard time finding people interested in taking those jobs, which require months-long training, can be emotionally challenging, and generally offer low pay, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“They get yelled at a lot,” said Brooks, who formerly ran New Hampshire’s Medicaid and CHIP customer service program. “People are frustrated. They’re crying. They’re concerned. They’re losing access to health care, and so sometimes it’s not an easy job to take if it’s hard to help someone.”

States are paying government contractors millions of dollars to help them comply with the new federal law.

Maximus, a government services contractor, provides eligibility support, such as running call centers, in 17 states that expanded Medicaid and interacts with nearly 3 in 5 people enrolled in the program nationally, according to the company.

During a February earnings call, company leadership said Maximus can charge based on the number of transactions it completes for enrollees, independent of how many people are enrolled in a state’s Medicaid program.

Maximus has “no one-size-fits-all approach” to the services it offers or the way it charges for those services, spokesperson Marci Goldstein told Â鶹ŮÓÅ Health News.

The company, which reported bringing in $1.76 billion in 2025 from the part of its business that includes Medicaid work, expects that revenue to continue to grow, even as people fall off the Medicaid rolls, “because of the additional transactions that will need to take place,” David Mutryn, Maximus’ chief financial officer and treasurer, said during the earnings call.

Losing Medicaid health coverage isn’t just an inconvenience, since many people enrolled in the program probably don’t make enough money to pay for health care on their own and may not qualify for financial help for Affordable Care Act coverage, said Elizabeth Edwards, a senior attorney with the National Health Law Program.

People could be unable to afford medications or get essential care, which could lead to “devastating” health impacts, she said.

“The human stakes of this are people’s lives,” she said.

Â鶹ŮÓÅ Health News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

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 .

USE OUR CONTENT

This story can be republished for free (details).

The legislation would prohibit state and local governments from requiring crisis pregnancy centers to perform abortions, provide referrals for abortion services, or inform patients about such services or contraception options. It also would allow crisis pregnancy centers to sue the violating government entity.

Wyoming lawmakers of the Center Autonomy and Rights of Expression Act, or , on March 4. Other versions have advanced in and this year. One was in 2025. The CARE Act is “model legislation” created by the , an anti-abortion, conservative Christian legal advocacy group.

A similar proposal, the , was introduced in Congress last year but hasn’t moved out of the House Energy and Commerce Committee.

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 .

USE OUR CONTENT

This story can be republished for free (details).

It’s been a tough week for Health and Human Services Secretary Robert F. Kennedy Jr. In addition to Kennedy having surgery to repair a torn rotator cuff, personnel issues continue to plague the department: The nominee to become surgeon general, an ally of Kennedy’s, may lack the votes for Senate confirmation. The controversial head of the Food and Drug Administration’s vaccine center will be resigning next month. And a new survey finds Americans have less trust in HHS leaders now than they did during the pandemic.

Meanwhile, the Trump administration continues its crackdown over claims of rampant health care fraud. In addition to targeting the Medicaid programs in states led by Democratic governors, the Centers for Medicare & Medicaid Services is also taking aim at previously sacrosanct Medicare Advantage plans.

This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.

Panelists

Among the takeaways from this week’s episode:

• Americans feel more confident in career scientists at federal health agencies than in the agencies’ leaders, according to a new survey from the Annenberg Public Policy Center at the University of Pennsylvania. Yet the survey also sheds more light on the erosion of trust in public health officials and scientific research.
• The FDA’s vaccine chief, Vinay Prasad, is leaving — again. Prasad was a critic of the agency before he joined it, and his tenure has been shaped by the same attitude, affecting career officials’ morale and the agency’s interactions with outside companies.
• The Trump administration has extended its fraud crackdown campaign into Medicare Advantage plans. The privately run alternative to traditional Medicare coverage has been a GOP darling from the get-go. Yet President Donald Trump is nudging the party away from its pro-business stance on private insurance, arguing the government should give money to patients rather than insurers — a justification for policies undermining the Affordable Care Act.
• And Wyoming became the latest state to enact a six-week abortion ban, a move that’s being challenged in court. The development points to the fact that while federal policymaking on abortion has largely stalled, the issue is still very much in play in the states as abortion opponents keep pushing back on access to the procedure.

Also this week, Rovner interviews Andy Schneider of Georgetown University about the Trump administration’s crackdown on what it alleges is rampant Medicaid fraud in Democratic-led states.

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

Julie Rovner: The Marshall Project’s “,” by Shannon Heffernan, Jesse Bogan, and Anna Flagg.

Anna Edney: The Wall Street Journal’s “,” by Christopher Weaver, Tom McGinty, and Anna Wilde Mathews.

Shefali Luthra: The New York Times’ “,” by Apoorva Mandavilli.

Joanne Kenen: The Idaho Capital Sun’s “,” by Laura Guido.

Also mentioned in this week’s podcast:

• The Annenberg Public Policy Center’s “.”
• Â鶹ŮÓÅ Health News’ “Six Federal Scientists Run Out by Trump Talk About the Work Left Undone,” by Rachana Pradhan and Katheryn Houghton.
• Bloomberg Law’s “,” by Sandhya Raman.
• The 19th’s “,” by Shefali Luthra.
• The Georgetown University McCourt School of Public Policy Center for Children and Families’ “,” by Andy Schneider.

Clarification:ÌýThis page was updated at 5:10 p.m. ET on March 12, 2026, to clarify that Vinay Prasad, the FDA’s vaccine chief, will be leaving his job in April. In an email after publication, William Maloney, an HHS spokesperson, said Prasad is “leaving of his own accord.”

[Editor’s note:ÌýThis transcriptÌýwas generatedÌýusing both transcription software and a human’s light touch. It hasÌýbeen editedÌýfor style and clarity.]Ìý

Julie Rovner:ÌýHello fromÌýÂ鶹ŮÓÅÌýHealthÌýNews and WAMUÌýpublic radioÌýin Washington, D.C. Welcome toÌýWhat theÌýHealth?ÌýI’mÌýJulie Rovner,Ìýchief Washington correspondent forÌýÂ鶹ŮÓÅ HealthÌýNews, andÌýI’mÌýjoined byÌýsome ofÌýthe best and smartest reporters covering Washington. We are taping this week on Thursday, March 12, at 10Ìýa.m.ÌýAs always, news happens fast and things might have changed by the time you hear this. So,Ìýhere we go.Ìý

TodayÌýweÌýare joinedÌývia videoconference by Shefali LuthraÌýof the 19th.Ìý

Shefali Luthra:ÌýHello.Ìý

Rovner:ÌýAnnaÌýEdney ofÌýBloomberg News.Ìý

Anna Edney:ÌýHi,Ìýeverybody.Ìý

Rovner:ÌýAndÌýJoanneÌýKenenÌýat the Johns Hopkins Bloomberg School of Public Health andÌýPoliticoÌýMagazine.Ìý

Joanne Kenen:ÌýHi,Ìýeverybody.Ìý

Rovner:ÌýLater in this episode,Ìýwe’llÌýhave my interview with Andy Schneider of Georgetown University, who will try to explain how the federal government’s fraud crackdown on blue-state Medicaid programsÌýis somethingÌýcompletely different from any fraud-fighting effortÌýwe’veÌýseen before. But first,Ìýthis week’s newsÌý—ÌýandÌýsome ofÌýlastÌýweek’s.Ìý

Let’sÌýstart at the Department of Health and Human Services, where I thinkÌýit’sÌýsafe to say Secretary Robert F Kennedy Jr.Ìýis not havingÌýa great week. TheÌýsecretaryÌýreportedly hadÌýto have his rotator cuff surgically repaired on Tuesday.ÌýIt’sÌýnot clear if he injured it during one of his famous video workouts. But it is clear, at least according toÌýÌýfrom the University of Pennsylvania’s Annenberg Center, that the American public is not buying whatÌýhe’sÌýselling when it comes to policy. According to the survey, public trust in HHS agencies, which already took a dive during the pandemic, has fallen even more since Kennedy took over the department. Although, interestingly, public trust in career HHS officials is higher than it is for their political leaders. And trust in outside professional health organizations, places like the American Heart Association and the American Academy of Pediatrics, is higher than for any of the government entities.Ìý

Perhaps related to that is another piece of HHSÌýnews fromÌýthis week.ÌýThe FDAÌý[Food and Drug Administration]Ìýapproved a label change for the drug leucovorin, which Secretary Kennedy last fall very aggressively touted as a potential treatment for autism. But the drugÌýwasn’tÌýapprovedÌýto treat autism. Rather, the label changes to treat a rare genetic condition. Kennedy bragged about leucovorin, by the way, atÌýthe same press conference that PresidentÌý[Donald]ÌýTrump urged pregnant women not to take Tylenol, which has notÌýbeen shownÌýto contribute to the rise in autism.ÌýMaybe it’sÌýfair to say the public is paying attention to theÌýnewsÌýand that helps explain the results of this Annenberg Center survey?Ìý

Luthra:ÌýMaybe.ÌýI was just thinking, we do know that Tylenol prescriptions for people who are pregnant did go down,Ìýright? There’s research that shows,Ìýafter that press conference,Ìýbehaviors did change. AndÌýsoÌýto your point,Ìýit’sÌýclear there isÌýa lot ofÌýconfusion, and confusionÌýmaybe breedsÌýmistrust. But IÌýdon’tÌýknow that we can necessarily say that American voters and the public at large are very obviously informed asÌýmuchÌýas they areÌýperhaps disenchantedÌýby things that seem as if theyÌýwere toldÌýwould restore trust and make things clearer and in fact have not done so.Ìý

Rovner:ÌýThat’sÌýaÌýfair assessment.ÌýAnna.Ìý

Edney:ÌýYeah, I thinkÌýthere’s a lot of overpromising and underdelivering, and that can kind of create this issue where this administrationÌý—Ìýand RFK Jr.Ìýhas been doing this as wellÌý—Ìýkind of is making these decisions from the top, rather than having these normal conversations with the career scientists and things like that, where the public can kind of follow along on why the scientific decisions are being made if they so choose to,Ìýor at leastÌýhave an idea that there was a discussion out there. AndÌýthat’sÌýnot happening. SoÌýthat’sÌýnot somethingÌýthat’sÌýcreatingÌýa lot ofÌýtrust.ÌýI think peopleÌýare seeing that as unscientific and chaotic.Ìý

Rovner:ÌýI wasÌýparticularly interested in one of the findings in the survey,Ìýis that Dr.ÌýFauci, Dr.ÌýTony Fauci, who wasÌýsort ofÌýtheÌýbête noireÌýof the pandemic, has a higher approval rating than either RFK Jr.ÌýorÌýsome ofÌýhis top deputies.ÌýJoanne, I see you nodding.Ìý

Kenen:ÌýYeahÌýthat was soÌýstri—ÌýI mean,Ìýit’sÌýstill not high. It was,ÌýI believe itÌýwasÌý—ÌýI’mÌýlooking for my noteÌý—Ìýbut IÌýthinkÌýwas 54%,Ìýwhich is not great. But itÌýwas better thanÌýDr.Ìý[Mehmet]ÌýOzÌý[head of the Centers for Medicare & Medicaid Services]. It was better than Kennedy. ItÌýwas better than a bunch of people.ÌýSo,Ìýbut it also shows thatÌýhalfÌýthe country stillÌýdoesn’tÌýtrust him.ÌýIt wasÌýa really interestingÌýsurvey, but the gaps in trust in credible science are still significant. What was interesting is the declining trust in our government officials in healthÌýcare, butÌýthere’sÌýstill,Ìýnationally, the U.S.Ìýpopulation,Ìýthere’sÌýstillÌýa lot ofÌýskepticism of science and public health. Maybe not as bad as it was, but stillÌýpretty bad.Ìý

Luthra:ÌýAnd Julie, you alluded to these famous push-up and workout videos. And part of whatÌýyou’reÌýgetting atÌý—Ìýright?Ìý—Ìýis that the communications that we seeÌýare targetedÌýtoward a not necessarilyÌývery largeÌýaudience.ÌýIt is these people who are hyper-online,Ìýin particular internetÌýspaces and communities, and that’sÌýsomewhat divorcedÌýfrom most people and how they live their lives.ÌýAnd when you focusÌýyour message and you’re campaigning on this very particular slice, it’s justÌýa lotÌýeasier to lose sight of where people are and what they want from their government and what they willÌýactually appreciate.Ìý

Rovner:ÌýIt’sÌýtrue.ÌýThe onlineÌýAmerica is very separate from the rest of America, which is aÌýwhole lot bigger.ÌýWell—Ìý

Kenen:ÌýAndÌýthere’sÌýalso the young people whoÌýprobablyÌýaren’tÌýin these surveys who,Ìýteenagers,ÌýwhoÌýare gettingÌýa lot ofÌýinformation on TikTok about supplements and raw milk.ÌýAnd the young men and the teenage boys and the supplementsÌýis a big deal, andÌýthat’sÌýonline. AndÌýalsoÌýwe have beenÌýseeingÌýfor a while, but I thinkÌýit’sÌýprobably creepingÌýup,Ìýthe recommendations about psychedelics.ÌýSoÌýthere’sÌýall this stuff out there thatÌýisn’tÌýgoing toÌýbe pickedÌýup by that poll. But yes, it was an interesting poll.Ìý

Rovner:ÌýAll right. Well, meanwhile over at the Food and Drug Administration, in-againÌýout-again in-againÌývaccine chief Vinay Prasad isÌýapparently outÌýagain, orÌýwill be as of later this spring. I feel like Prasad’s very rockyÌýtenure has beenÌýkind of aÌýmicrocosm for the difficulties this administration has had working withÌýcareerÌýscientists at FDA and elsewhere, at HHS.ÌýAnna, what made him so controversial?Ìý

Edney:ÌýWell, I think, Prasad was an FDA critic before he came to the agency. And soÌýessentially,Ìýwhen he was out in public, particularly during covid, but there were even criticisms he had before that.ÌýHe was criticizing these career scientists at the agency. AndÌýsoÌýhe got there, and the way he appeared toÌýoperateÌýwas that he knewÌýbestÌýand heÌýdidn’tÌýneed to talk to any of these people that had been there,ÌýsomeÌýfor decades, and that was getting him inÌýa lot ofÌýtrouble. But he wasÌýbeing defendedÌýand protected by FDAÌýCommissioner Martin Makary, and he really supported Prasad, and he called him a genius and wanted him to stay on.ÌýSoÌýthe first time Prasad left, he convinced him to come back. And now this time, I think, thingsÌýmaybe justÌýwentÌýa bridge too far when there was sort of this behind-the-scenes but very public fight with a company trying to make a rare-disease drug. And this is something that,Ìýparticularly,ÌýseveralÌýsenators really, really hate, is when the FDA is getting in the way of a rare-disease drug getting to market, because they don’t think that that’s something the agency should be trying to do unless the drug isÌýmaybe whollyÌýunsafe. But they thinkÌýanyoneÌýshould be able to try it. AndÌýsoÌýwhen this exploded and FDA officials were and HHS officials were behind the scenes, but very publicly, calling this company a liar, it was just a bridge too far.Ìý

Rovner:ÌýWell, and he,Ìýthis was,Ìýthis incredibly unusualÌýÌýin which he tried to not be quoted by name, but kind of hard when the head of the agency, or the head of theÌýcenter at FDA is basically trashing a company,Ìýtrying to do it on background. Was that kind of the last straw?Ìý

Edney:ÌýYeah, I think so. AndÌýsort of anÌýasideÌýonÌýthat.ÌýI’mÌýcurious how that phone callÌýevenÌýwasÌýallowedÌýto be set up and called.ÌýBecause,Ìýit’sÌýnot like he did it on his own. ThereÌýwere,Ìýthere was an infrastructure around him that helped him set that up.ÌýSoÌýI’mÌýcurious about why that even went down, butÌýI think thatÌýwasÌýdefinitely whatÌýpushed him out the door. You know, this company wanted to get this drug approved. The FDA had said,ÌýNo, not unless you do this extremely difficult trial, which the company said would require drilling holes in people’s heads,Ìýfor what they were trying to get approved, and that it would be a placebo, essentially, for some of those patients, even when you get a hole drilled in your head, and this could be a 10-hour sham surgery, is what the company said. And thenÌýPrasad comesÌýout andÌýsays:ÌýNo,Ìýthey’reÌýlying.ÌýThatÌýdefinitely couldÌýbe a half-hour.ÌýNo big deal.ÌýAndÌýI just think that thereÌýwereÌýsenators frustrated with this, the White HouseÌýnot wanting toÌýsee another thing blowÌýup over rare-disease drugs, because that has, thereÌýhaveÌýbeenÌýa lot ofÌýissues at FDA under his tenure, of just drugs not being able to get to market. OrÌýhaving issues with vaccines that have been years in development not being able toÌýget even reviewed, and then thatÌýbeing reversed.ÌýSoÌýit wasÌýjust,Ìýthat wasÌýkind of theÌýlast straw.Ìý

Rovner:ÌýAndÌýofÌýcourseÌýPresident Trump himself has been a big proponent of this whole Right to Try effort,Ìýthat it should be easier for people with, particularly with terminal diseases to be able to try drugs that may or may not help.ÌýJoanne, you want to add something.Ìý

Kenen:ÌýAlsoÌýwasn’tÌýhe still,ÌýPrasad, still living in California and running upÌýreally hugeÌýtravel bills and—Ìý

Rovner:ÌýYes.Ìý

Kenen:Ìý—not being at the FDA very much, at a time when everybody else hasÌýbeen forcedÌýto come back to work?ÌýSo,Ìýbut I do confess that I keep looking at my phone to check ifÌýhe’sÌýstill out orÌýis heÌýalready back again.Ìý

Rovner:ÌýRight.Ìý

Kenen:ÌýI’mÌýreally notÌýtotally convinced that this is the end of Prasad, butÌýyeah.Ìý

Rovner:ÌýYeah,ÌýI was not kidding when I saidÌýon-againÌýoff-again on-againÌýoff-again. All right. Well, moving over to the National Institutes of Health, which also has a directorÌýthat’sÌýdoing more than one job in more than one place. I know there’s so much news that it’s hard to keep track of it all, but I do think it’s important to continue to follow things that look toÌýbe settled, like funding for the NIH,Ìýwhich CongressÌýactually increasedÌýin the spending bill that passed at the end of January. To that end, a shout-out to our podcast panelistÌýSandhya Raman, formerly of CQ,Ìýnow at Bloomberg, forÌýÌýgrant funding that still pays for most of the nation’s basic biomedical research is still being held up. This is months after itÌýwas orderedÌýresumed by courts and appropriated by Congress.Ìý

Shout-out as well to myÌýÂ鶹ŮÓÅ HealthÌýNews colleaguesÌýRachana PradhanÌýand KatherynÌýHoughton forÌýtheir projectÌýon the people and research projects that have been disrupted by all the cuts at NIH,Ìýas well as new bureaucratic hurdles put in place. I feel like if there weren’t so much else going on, what’s happening atÌýbasically theÌýeconomic and health engine of NIH would be getting much,Ìýmuch,ÌýmuchÌýmore attention, particularly because of the continuing brain drain with researchers moving to other countries and students choosing different careers rather than becoming researchers. I wonder if this sortÌýof drip,Ìýdrip, drip at NIH is going to turn into a very long-term holeÌýthat’sÌýgoing to beÌývery difficultÌýto fill.ÌýAÌýlot ofÌýthese things have years-Ìýif not decades-long runways.ÌýThese great scientific achievements start somewhere, and it looks likeÌýthey’reÌýjustÌýsort of pullingÌýout the whole starting part.Ìý

Kenen:ÌýIt’sÌýalready affecting the pipeline. In graduate schools,ÌýmanyÌýschools fund their PhD candidates, andÌýit’sÌýNIH money, or partly NIH money.ÌýIt’sÌýdifferentÌý—ÌýI’mÌýnot an expert in every single school’sÌýsupportÌýsystemsÌýfor PhD candidates, but I do know that the pipeline hasÌýbeen shrunkenÌýinÌýsomeÌýfields atÌýsomeÌýschools, andÌýthat’sÌýbeenÌýreportedÌýonÌýwidely. AndÌýthere’sÌýbeenÌýa lot ofÌýcoverage about years andÌýyears of research. YouÌýcan’tÌýjust restart a multiyear,Ìýcomplicated clinical trial or research project. Once you stop it,Ìýyou’reÌýlosing everything to date, right? YouÌýcan’tÌýjustÌýsort of say,ÌýOh,ÌýI’llÌýput it on hold for a couple of years and resume it.ÌýYouÌýcan’tÌýdo that.ÌýSoÌýwe’ve already reachedÌýsome kind ofÌýaÌýcriticalÌýpoint.ÌýIt’sÌýjust a matter of how much worse it gets, or whether the ship begins to stabilize in any way going forward. But there’s already damage.Ìý

Rovner:ÌýI say,Ìýare you guys as surprised as I am, though, that this isn’tÌý—Ìýthe NIH has been this sort of bipartisan jewel that everybody has supported over the decades that I’ve been covering it, and now it’sÌýbasically beingÌýdismantled in front of our eyes, and nobody’s saying very much aboutÌýit.Ìý

Kenen:ÌýIt’sÌýalso an engine of economic growth.ÌýYou see different ROIÌý[return on investment]Ìýnumbers when you look at NIH, but I think the lowest number you hear isÌýtwo and a half dollars of benefit for every dollar we invest. AndÌýI’veÌýseenÌýreportsÌýup to $7.ÌýIÌýdon’tÌýknow what the magic number is, but this is an engine of economic growth in the United States. This is basic biomedical research that the private sector or the academic sector cannot do.ÌýItÌýhas toÌýcome from the government.ÌýAnd IÌýdon’tÌýthink any of us have really gotten our heads aroundÌý— why harm the NIHÌýwhen it isÌýbipartisan,Ìýit is economically successful,Ìýand it has humanitarian value.ÌýIt’sÌýthe basis.ÌýThe drug companies develop the drug and bring it to the market. But that basic, basic,ÌýearlierÌýwhat’sÌýcalled bench science,Ìýthat’sÌýfunded by theÌýNIH.Ìý

Rovner:ÌýI know.ÌýIt’sÌýa mystery. Well, adding to RFK Jr.’s bad week are the growing divisions within his base,ÌýtheÌýMake AmericaÌýHealthyÌýAgainÌýmovement. While the White House, seeing that the public doesn’t really supportÌýMAHA’sÌýanti-vaccine positions,Ìýis trying to get HHS to tone it down, there was a major MAHAÌýmeetup just blocks from the White House this week, with sessions urging a complete end to the childhood vaccine schedule and the removal of all vaccines from the market, quote, until they can be provenÌý“safe and effective.”ÌýBy the way,ÌýmostÌýofÌýthem haveÌýbeen already. Meanwhile,Ìýlots ofÌýMAHAÌýfollowers are still angry that the White House is supporting the continuing production of glyphosate, the weed killer sold commercially as Roundup. Democrats,Ìý, are trying to exploit the divisions in the MAHA movement, which leads to the question:ÌýWillÌýMAHAÌýbe a net plus or a net minus for this fall’s midterm elections?ÌýOn the one hand,ÌýI think TrumpÌýappointed Kennedy because he was hoping thatÌýthe MAHA movement would beÌýa boost to turnout.ÌýOn the other hand, MAHAÌýseemsÌýpretty splitÌýright now.Ìý

Edney:ÌýWell, I thinkÌýthat’sÌýthe million-dollar question,ÌýisÌýwhich wayÌýthey’reÌýgoing to swing if they swing at all. And it’s hard to say right now, becauseÌýI think theyÌýare angry at certain aspects of things this administration is doing,Ìýthe two things you mentioned,ÌýonÌýRoundup and on vaccines, kind of telling RFK to kind of talk a little bit less about those. But will they be able to then vote for Democrats instead? IÌýthink,Ìýit’sÌýonly March,ÌýsoÌýit’sÌýso difficult to sayÌýwhat will happen between now and then.ÌýI think there’s still things that the health secretary could do on food thatÌýhe’sÌýtalked about, that could draw attention away from that anger, that might makeÌýmanyÌýof them happy.ÌýI think thereÌýwereÌýsomeÌýthings heÌýkind of startedÌýdoing early in his termÌýthatÌýhasn’tÌýbeen talkedÌýabout as much.ÌýAnd also, I think there’s still the prospect of CaseyÌýMeans becomingÌýsurgeonÌýgeneralÌý—Ìýor notÌý—Ìýout there, and that’sÌýkind of aÌýbig piece of this.ÌýIf she is to get into the administration, and that is sort of up in theÌýairÌýright now, then that couldÌýkind of giveÌýthem something else to focus on, because she is a large part of this playbook of the MAHA movement.Ìý

Rovner:ÌýThat’sÌýright.ÌýAnd we are waiting to see sort of if she can get the votes even to get out of committee, much less get to the floor, seeÌýwhether we’re going to have, asÌýsomeÌýare saying, the firstÌýsurgeonÌýgeneral who does not have an active license to practice medicine. Shefali, you wantedÌýto add something.Ìý

Luthra:ÌýNo, I just thinkÌýwe’veÌýtalked about this before on the podcast, that the food stuff is much more popular than the vaccine stuff. The vaccine components ofÌýMAHAÌýremain very unpopular.ÌýIt’sÌýdifficult to really see or say sort of what the White House can do on food in a sustained, focused way,Ìýwithout goingÌýoff-script, that is also popular. But I think to Anna’s point,Ìýit’sÌýjust so hard to say to what extent thisÌýultimately mattersÌýin November, because there are just so many concerns right now. PeopleÌýcan’tÌýafford their health insurance, and gas prices are going up. AndÌýI just think weÌýhave toÌýwait and see to what extent people are voting based on food policy.Ìý

Rovner:ÌýYeah, well, we will see. AllÌýright,Ìýwe’reÌýgoing to take a quick break. We will be right back.Ìý

OK, turning to another Trump administration priority, fighting fraud. This week, the administration accused anotherÌýDemocratic-led state, New York, of not policing Medicaid fraud forcefully enough. This comes after the Centers for MedicareÌý&ÌýMedicaid Services said it will withhold hundreds of millions of dollars from Minnesota, which our guest,ÌýAndy Schneider,Ìýwill talk about at more length. Minnesota, by the way, lastÌýweek sued the federal government over its Medicaid efforts. So that fight will continue for a while. ButÌýit’sÌýnot just blue states, andÌýit’sÌýnot just Medicaid. In something IÌýdidn’tÌýhave on my bingo card, this administration is also going after fraud in the Medicare AdvantageÌýprogram, which has long been a Republican darling.Ìý

Last week, CMS banned the Medicare Advantage planÌýoperatedÌýbyÌýElevanceÌýHealth, which hasÌýnearly 2Ìýmillion Medicare patients currently enrolled,Ìýfrom adding any new enrollees starting March 31,Ìýfor what the agency described as, quote,Ìý“substantial and persistent noncompliance with Medicare Advantage risk adjustment data.”ÌýAnd on Tuesday, theÌýcongressional Joint Economic Committee reported that overpayments to those Medicare AdvantageÌýplans raised premiums by an estimated $200 per Medicare enrollee annuallyÌý—ÌýandÌýthat’sÌýall Medicare enrollees, not just those in the private Medicare Advantage plans. Is this the end of the honeymoon for Medicare Advantage? Joanne, you were there with me when Republicans were pushing this.Ìý

Kenen:ÌýI’veÌýbeen surprised, as you have,ÌýJulie, becauseÌýbasically MedicareÌýAdvantage has been theÌýdarling, and itÌýis popular with people.ÌýIt’s grown and grown and grown,Ìýnot because the government forced people in. It has good marketing andÌýsomeÌýbenefits for the younger, healthier post-65 population, gyms and things like that.ÌýButÌý—Ìýand vision and dental, whichÌýare a big deal. ButÌýwe’veÌýalso seen a backlash, inÌýsomeÌýways, because there’s the prior authorization issues in Medicare Advantage have gottenÌýa lot ofÌýattentionÌýthe last couple of years. But not just am I surprised byÌýsortÌýofÌýtheÌýswingÌýthatÌýwe’reÌýhearingÌýaboutÌýgenerally.ÌýI’mÌýsurprised by Dr.ÌýOz, because when he ran for Senate a coupleÌýyearsÌýago in Pennsylvania, andÌýmuchÌýof his public persona has been really, really,Ìýreally gung-ho, pro Medicare Advantage.Ìý

And yet,Ìýsome ofÌýyou were at or,Ìýlike me, watched the live stream ofÌý—Ìýhe didÌýa very interesting, thoughtful, and,ÌýI’ve mentioned this at least one time before, hourlong conversation withÌýa lot ofÌýQ&A at the Aspen Institute here in D.C.Ìýa couple of months ago. And one of the questions was someone said:ÌýDr.ÌýOz,Ìýyou’veÌýjust turned 65.ÌýAre you doing Medicare Advantage, orÌýareÌýyou doing traditional Medicare?ÌýAnd the expected answer for me was, well, I knew thatÌýhe’sÌýon government insurance now.ÌýSoÌýhe, youÌýhave to,Ìýat 65 youÌýhave toÌýgo into Medicare Advanta—ÌýMedicare A,ÌýwhetherÌýyouÌý—Ìýthat’s automatic.ÌýThat’sÌýthe hospital part. But you have the choice. But ifÌýyou’reÌýstill working and getting insurance or governmentÌý—Ìýhe’sÌýon a government plan. HeÌýdoesn’tÌýhave to do that. ButÌýhe actually, andÌýhe pointed that out, but the next sentence really surprised me, because he said:ÌýIÌýdon’tÌýknow. My wife and I are still talking about that.ÌýAnd I thought that wasÌýA)ÌýaÌývery honest answer. HeÌýdidn’tÌýhave to evenÌýsay. But it was also,Ìýit just was interesting to me that after all thatÌýRah-rahÌýMedicare AdvantageÌýwe were hearing about, his own personal choiceÌýwas,ÌýNotÌýsure if that one’s right for me.ÌýSoÌý—Ìý

Rovner:ÌýI was going to say,ÌýI feel like the Republicans are sort of twisting right now between Medicare Advantage, which they’ve always pushedÌý—Ìýthey want to privatize Medicare because they don’t like government health insuranceÌý—Ìýand then there’sÌýthe current populistÌýpush against big insurance companies, because, of course, all those Medicare AdvantageÌýplans belong to those big insurance companies that Republicans are suddenly saying are too big and getting too much money.ÌýSoÌýthey’reÌýsort of caughtÌýbetweenÌýtrying to have it both ways.ÌýI’llÌýbe interested to see how they come down. One of the things that did strike me, though, even before Dr.ÌýOzÌýsort of startedÌýhis little crusade against Medicare Advantage, was,ÌýI think itÌýwas at Kennedy’s confirmation hearing that Sen.ÌýBill Cassidy was suddenly questioning Medicare Advantage. That was, I think, the first Republican I saw to like,ÌýOh.ÌýThat made me raise my eyebrows.ÌýAnd I think since then, I’veÌýkind of seenÌýwhy.Ìý

Kenen:ÌýTheÌýpopulist talkÌýagainstÌýinsurance companies,Ìýnot giving money to insurance companies,Ìýis part of the RepublicanÌý—Ìýand,Ìýspecifically, President Trump’sÌý—Ìýdesire to not extend the ACA,Ìýthe Affordable Care Act,Ìýenhanced subsidies. That was the basic:ÌýWell,Ìýwe’reÌýnot going to do this,ÌýbecauseÌýwe’reÌýjust throwing money at these insurance companies. And weÌýdon’tÌýwant to do that. We want to empowerÌýthe patients.ÌýThat wasÌýthe,ÌýI’mÌýnot, and the missing piece of that argument is:ÌýYes, the ACA subsidies go to insurance companies. However, all of us are benefiting inÌýsomeÌýway or other from government policies thatÌýbenefitÌýinsurance companies.ÌýThe tax breaks our employers get. The tax breaks we get for our insurance.ÌýAnd then the biggie, of course, is Medicare Advantage.Ìý

We are paying Medicare Advantage more than we are paying traditional Medicare.ÌýSoÌýMedicare Advantage isÌýprivateÌýinsuranceÌýcompanies, and the government hasÌýbeen justÌýsending themÌýlotsÌýandÌýlots ofÌýmoney for years.ÌýSoÌýI’m not sure it’sÌý—Ìýthis Medicare Advantage thing is just bubbling up, and we’re notÌýreally sureÌýhow this plays out. ButÌýI think thatÌýthe rhetoricÌýagainst insurance companiesÌýisÌýthe rhetoricÌýagainst the ACA.Ìý

Rovner:ÌýOh, it is.Ìý

Kenen:ÌýRather thatÌýhasn’tÌýyetÌýbeen connectedÌýto the Medicare Advantage. I thinkÌýthey’re,Ìýyes, we all knowÌýthey’reÌýconnected. But I think the political debate, it’sÌýnot MedicareÌýAdvantageÌýis bad because insurance companies are bad.ÌýIt’s theÌýACA is bad because it enriches insurance companies.ÌýThere’sÌýa different ideological parade going down the road.Ìý

Rovner:ÌýI was going to say,Ìýit’sÌýimportant to remember at the beginning of Medicare Advantage, which was a Republican proposal back in 2003,Ìýthey purposely overpaid it. They gave it more money because they know that when they give them more money, the insurance companiesÌýare requiredÌýtoÌýreturnÌýsome ofÌýthat money to beneficiaries in the form of these extra benefits.ÌýThat’sÌýwhy there are gym memberships and dental and vision and hearing coverage in these Medicare Advantage plans. It does make them popular, so people sign up. And that wasÌýsort of Republicans’Ìýintent at the beginning. It was toÌýsort of notÌýso much push people into it but entice people into it.Ìý

Kenen:ÌýAndÌýthen—Ìý

Rovner:ÌýAnd then maybe cut it back later.Ìý

Kenen:ÌýNo, butÌýit’s exceededÌýexpectations.Ìý

Rovner:ÌýAbsolutely.Ìý

Kenen:ÌýThe number of people going into Medicare Advantage has beenÌýreally high, higher than people expected.ÌýAndÌýit’sÌýalso hard to get out, depending on what state you live in.ÌýIt’sÌýnot impossible, butÌýit’sÌýcostly and difficult, except forÌýa few,ÌýI thinkÌýit’sÌýseven or eightÌýstatesÌýmake itÌýpretty easy. But also remember that the earlier version of what we now call Medicare Advantage wasÌý—ÌýwhichÌýwas theÌý’90s, right Julie?Ìý—ÌýI think the Medicare Part C,Ìýand that failed.ÌýSoÌý—Ìý

Rovner:ÌýWell after,Ìýthat failed because they cut it when they wereÌý—Ìý

Kenen:ÌýRight.ÌýRight.Ìý

Rovner:ÌýThey cut all the funding when they were balancing the budgetÌý—Ìý

Kenen:ÌýRight.ÌýÌý

Rovner:Ìý—ÌýinÌý1997.Ìý

Kenen:ÌýBut thatÌýgave themÌýtheÌýexcu—Ìýright.Ìý

Rovner:ÌýThey made itÌýfail.Ìý

Kenen:ÌýThatÌýgave them an excuse to give them more money later that, when they revived it, renamed it,Ìýand launched itÌýinÌý2003 legislation,Ìýthat initial push to give them a ton of money, because they could say,ÌýWell, we didn’t give them enough money, and that’s why theyÌýfa—.ÌýThereÌýareÌýall sorts of politicalÌýthings going on thatÌýweren’tÌýstrictly money. ButÌýyeah,Ìýit was part of the narrative ofÌýWhy weÌýhave toÌýgive them more money,ÌýisÌýThey need it.Ìý

Rovner:ÌýYeah.ÌýAnyway,Ìýwe’llÌýalso watch that space. Well, finally, this week, there’s news on the reproductive health front, because there’s always news on the reproductive health front. Shefali,ÌýWyoming has become the latest state to enact a so-called heartbeat ban, barring abortions when cardiac activity canÌýbe detected.ÌýThat’sÌýoften around six weeks, which is beforeÌýmanyÌýpeople are even aware of being pregnant. I thought the Wyoming Supreme Court said just this past January that its constitution prevents abortion bans.ÌýSoÌýwhat’sÌýup here?Ìý

Luthra:ÌýThey did, in fact, say that, and so we are seeing this law taken to court.ÌýIt wasÌýactually addedÌýin a court filing to a preexisting case challenging other abortion restrictions in the state.ÌýI’mÌýsureÌýthat’sÌýgoing to play out for quiteÌýsomeÌýtime. ButÌýwhat’sÌýinteresting about the WyomingÌýConstitutionÌý—Ìýright?Ìý—Ìýis that it protects the right to make health care decisions,Ìýin an effort toÌýsortÌýofÌýfight against the ACA. That was thisÌýconservative approach that now has come to reallyÌýbenefitÌýabortion rights supporters as well. But what I thinkÌýthis underscoresÌýis that even as we are seeingÌýfairly littleÌýabortion policy in Washington, at least in a meaningful way,Ìýa lotÌýis still happening on the state level. That really is where the bulk of action is, whether you see that in Wyoming,Ìýin Missouri, whereÌýthey’reÌýtrying to undo the abortion rights protections there, and just—Ìý

Rovner:ÌýThe ones that passed by voters.Ìý

Luthra:ÌýExactly. AndÌýsoÌýwhat we’re really thinking about is anti-abortion activists are not really that confident in theÌýpresident’s desire, interest, ability, what have you, to get their agenda items done. And for now, they are really focusing on the states, and that is where their interest, I think, will only remain, at least until the primary for the next presidential race begins in earnest.Ìý

Rovner:ÌýWell,ÌýShefali,ÌýI also want to ask you aboutÌýÌýthis week on just how many things ripple out economically from abortion restrictions. NowÌýit’sÌýhaving an impact on rent prices?ÌýPlease explain.Ìý

Luthra:ÌýI thoughtÌýthis was so interesting. It was thisÌýNBERÌý[National Bureau of Economic Research]Ìýpaper that came out this week, and they looked at comparably trending rental markets in states with abortion bans and those without them. And what they saw was that after theÌýDobbsÌýdecision, rental prices declinedÌýrelativeÌýto places without bans, compared to those in those that had them.ÌýAnd this isÌýreally interesting.ÌýIt justÌýsort of continues.ÌýRental prices went down,Ìýand alsoÌývacancies went up.ÌýAnd what the researchers say is this isÌýa very, very dramaticÌýand clear relationship, and it illustrates that people, when they have a choice, are considering abortion rights in terms of where they want to live. And anecdotally, we know that,ÌýbecauseÌýwe’veÌýseen residents make choices about where they will practice.ÌýWe’veÌýseen doctors decide where they will live. We have seen people move. Companies offer relocation benefits if people want them. And this is more data that illustrates thatÌýactually thatÌýaffects the economy of communities, and it really underscores that where we live just simply will look different based on thingsÌýlike abortion rights and abortion policy and other of these things thatÌýare treatedÌýas social but really do affect people’s economic behaviors.Ìý

Rovner:ÌýAnd as we pointed out before,Ìýit’sÌýnot just about quote-unquoteÌý“abortion,”Ìýbecause when doctors choose not to live in a certain place,Ìýit’sÌýother types of healthÌýcare.ÌýIt’sÌýallÌýhealthÌýcare. And we know that doctors tend to marry or partner with other doctors. So sometimes if an OB GYNÌýdoesn’tÌýwant to move to a certain place, then that OB-GYN’sÌýpartner, who may beÌýsomeÌýcompletely other type ofÌýdoctor,Ìýisn’tÌýgoing to move there either.ÌýSoÌýwe are starting to seeÌýsome ofÌýthese geographical shifts going on.Ìý

Luthra:ÌýAnd one pointÌýactually thatÌýthe researcher made that I thought was so interesting was that abortion policy, it can be emblematic, in and of itself, a reason people choose not to live somewhere, but people may also be making these decisions because of what it represents. Do I look at an abortion policy and say,ÌýOh, this reflects social values or gender beliefs?ÌýOr does it also suggestÌýmaybe moreÌýanti-LGBTQ+Ìýlaws?ÌýAnd all of that can create a picture that is broader than simply abortion orÌýnot, andÌýdetermineÌýwhere and how people want to live their lives.Ìý

Rovner:ÌýIt’sÌýa really interestingÌýstory.ÌýWe willÌýlinkÌýto it.ÌýAll right, that is this week’s news. NowÌýI’llÌýplay my interview with Andy Schneider of Georgetown University, and then we will be back to do our extra credits.Ìý

Rovner:ÌýI am pleased to welcome to the podcast Andy Schneider, a research professor of the practice at the Georgetown University McCourt School of Public Policy. And he spentÌýmanyÌýyears on Capitol Hill helping write and shape Medicaid law as a top aide to California DemocraticÌýcongressmanÌýHenry WaxmanÌý—ÌýandÌýmanyÌýhours explaining it to me.ÌýI have asked him here to help untangle the Medicaid fraud fight now taking place between the federal government and,Ìýat least so far, mostlyÌýDemocratic-led states. Andy, thanks for being here.Ìý

Andy Schneider:ÌýThanks for having me,ÌýJulie.Ìý

Rovner:ÌýSo,Ìýit’sÌýnot like fraud in MedicaidÌý—Ìýand other health programs,Ìýfor that matterÌý—Ìýis anything new.ÌýWho are the major perpetrators of health care fraud?ÌýIt’sÌýnot usually theÌýpatients, is it?Ìý

Schneider:ÌýNo,Ìýit’sÌýusuallyÌýsomeÌýbad-actor providers or bad-actor businesspeople.Ìý

Rovner:ÌýSo how are fraud-fighting efforts at both the federal and state level, since Medicaid fundingÌýis shared, supposed to work?ÌýHow does the federal government and the state governmentÌýsort of tryÌýand make fraud as minimal as possible? SinceÌýpresumably they’reÌýnever going to getÌýrid of it.Ìý

Schneider:ÌýUnfortunately, IÌýdon’tÌýthinkÌýyou’reÌýever going to get rid of it in Medicaid or Medicare or private insurance or in otherÌýwalks of life. There are bad actors out there.ÌýThey’reÌýgoing to try to takeÌýadvantage.ÌýSoÌýyou need your defenses up.ÌýSoÌýthe short of this is,ÌýMedicaidÌýis administeredÌýon a day-to-day basis by the states. The federal governmentÌýpays forÌýa majority ofÌýit and oversees how the states run their programs. In that context, the state Medicaid agency and the stateÌýfraudÌýcontrolÌýunit have aÌýprimary role inÌýidentifyingÌýwhere there might be fraud, investigating,Ìýand then,ÌýinÌýappropriate cases,Ìýprosecuting. The federal government also has a role, however. Depending on the scope of the fraud, it could involve the FBI. It could involve the Office of Inspector General at the Department of Health and Human Services.ÌýSoÌýthere’sÌýboth federal and state presence, but the primary responsibilities were theÌýstates’.Ìý

Rovner:ÌýWe know that Minnesota has been experiencing a Medicaid fraud problem,Ìýbecause both the state and the federal government have been working on it for more than a year now. What is the Trump administration doing in Minnesota?ÌýAnd why isÌýthisÌýdifferent from what the federal government has traditionally done whenÌýit’sÌýtrying to ensure that states are appropriately trying to minimize fraud?Ìý

Schneider:ÌýWell, usually theÌýviceÌýpresident of the United States does not get up at a White House press conference and announce he and the Centers for MedicareÌý&ÌýMedicaidÌýServices areÌýwithholding $260 million in federal funds,ÌýcalledÌýaÌýdeferral. That is highly, highly unusual. And normallyÌýtheÌýhead of the CentersÌýfor MedicareÌý&ÌýMedicaid Services does notÌýgo and makeÌývideos in the state before something like thisÌýis announced.ÌýSoÌýI would say that this isÌýway outÌýof the ordinary, andÌýI think itÌýhas to do withÌýsomeÌýanimus in the administration towardsÌýGov.Ìý[Tim]ÌýWalz and his administration.Ìý

Rovner:ÌýRight.ÌýGov.ÌýWalz, for those whoÌýdon’tÌýremember, was theÌývice presidentialÌýcandidate in 2024 running against President Trump, who did win, in fact. But there have been two different efforts to withhold Medicaid money for Minnesota, right?Ìý

Schneider:ÌýYeah. NowÌýyou’reÌýintoÌýthe MedicaidÌýweeds, but since you asked the question,ÌýI’llÌýtake you there. So in January, theÌýadministra—Ìýthe Center for MedicareÌý&ÌýMedicaid ServicesÌý—Ìýwe’ll call them CMS hereÌý—Ìýthey announced they were going to withhold aboutÌý$2 billionÌýa year going forward, not looking backÌýbut going forward,Ìýin matching funds that the federal government would otherwise pay to the state of Minnesota for the services that it was providing to its over 1 million beneficiaries. In February at this White House press conference, what theÌýviceÌýpresident announced was withholding temporarilyÌý—Ìýwe’ll see how temporary it isÌý—Ìýbut withholding temporarilyÌý$260 million in federal Medicaid matching funds that applied to state spending that’s already occurred, happened in the past, happened in the quarter ending Sept.Ìý30, 2025.ÌýSoÌýboth the past expenditures and future expenditures are targets for these CMS actions.Ìý

Rovner:ÌýSoÌýwhat happens if the federal governmentÌýactually doesn’tÌýpay the state this money? I assume more than people who are committing fraud wouldÌýbeÌýimpacted.Ìý

Schneider:ÌýWell,Ìýlet’sÌýbe clear.ÌýTheÌýamounts of money here,Ìýthere’sÌýno relationship between those and howeverÌýmuchÌýfraud is going on in Minnesota. And there has been fraud against Medicaid in Minnesota.ÌýEverybody’sÌýclear about that. The state is clear about it. The feds are clear about it. ButÌý$2 billionÌýgoing forward in a year,Ìý$1 billionÌýgoing,Ìýlooking backwards,Ìý$260 million times fourÌý—Ìýthere’sÌýno relationship between those amounts, right? Should theyÌýcome to passÌý—and all of this is still in processÌý—Ìýshould those amountsÌýcome to pass, you’re looking at, depending on who’s doing the estimates, betweenÌý7Ìýand 18% of the amount of money the federal government pays,Ìýhelps the state with,Ìýeach year in Medicaid.ÌýThat’sÌýjust an enormous hole for a state to fill, and itÌýdoesn’tÌýhaveÌýmanyÌýgood options. It can cut eligibility. It can cut services. It can cut reimbursement rates. Filling in that hole with state revenues,Ìýthat’sÌýgoing to be a real stretch.Ìý

Rovner:ÌýSoÌýit’sÌýnot just Minnesota. Now the administration says it is seeing concerning things going on in New York and has launched a probeÌýthere. Is there anyÌýindicationÌýthat this administration is going after states thatÌýare not runÌýby Democrats?Ìý

Schneider:ÌýSoÌýthe only letters thatÌýwe’veÌýseen from the administration have been to California, New York,Ìýand Maine. There may be other letters out there. We only access the publicÌýrecord.ÌýSoÌýsoÌýfar, based on what we know,Ìýit’sÌýjustÌýbeenÌýDemocraticallyÌýrunÌýstates.Ìý

Rovner:ÌýAs long asÌýI’veÌýbeen covering this, which is now a long time, fraud-fighting has beenÌýpretty bipartisan.ÌýIt’sÌýbeen something that Congress has worked on, Democrats and Republicans in Congress, Democrats and Republicans in theÌýstates.ÌýWhat’sÌýthe danger of politicizing fraud-fighting,Ìýwhich is whatÌýcertainly seems to beÌýgoing on right now?Ìý

Schneider:ÌýYeah,Ìýthat’sÌýa terrific point.ÌýSoÌýitÌýalways hasÌýbeenÌýbipartisan, becauseÌýmoney is green.ÌýIt’sÌýnot red.ÌýIt’sÌýnot blue.ÌýIt’sÌýgreen. And trying to keep bad actors from ripping it off from Medicaid or MedicareÌýhas always been a bipartisan undertaking. The reason that’s important, particularly in a program like Medicaid, where the federal government and the stateÌýhave toÌýtalk to one another when they are flagging potential fraud, when they’re investigating it, when they’re prosecuting it, you don’t want the agencies tripping all over one another. You want themÌýsharingÌýinformationÌýas necessary,Ìýetc.ÌýWhen that gets politicized,Ìýit’sÌývery badÌýfor the results and for the effective operation of the program.Ìý

Rovner:ÌýWellÌýwe will keep watching this space, andÌýwe’llÌýhave you back to explain it more. Andy Schneider, thankÌýyou very much.Ìý

Schneider:ÌýJulieÌýRovner, thank you very much.Ìý

Rovner:ÌýOK,Ìýwe’reÌýback.ÌýNowÌýit’sÌýtime for ourÌýextra-creditÌýsegment.ÌýThat’sÌýwhere we each recognize the story we read thisÌýweekÌýwe think you should read,Ìýtoo.ÌýDon’tÌýworry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us offÌýthis week?Ìý

Edney:ÌýSure.ÌýMine is inÌýThe Wall Street Journal.ÌýIt’sÌý[“”].ÌýThis is a look at the booming business of providing therapy to children with autism. AndÌýthat’sÌýparticularlyÌýbeen big in the MedicaidÌýprogram. And IÌýdon’tÌýwant to give away too much, because thereÌýareÌýjust so many jaw-dropping detailsÌýinÌýthis.ÌýSoÌýI guess the reportersÌýwere able toÌýkind of goÌýthrough the data and billing records in a way that showedÌýsome ofÌýthese companies and what they were doing and how they were becoming millionaires, people who had never done anything in autism before.ÌýSoÌýif you enjoy a sort of jaw-dropping read, I think you shouldÌýtake a lookÌýat it.Ìý

Rovner:ÌýYeah, jaw-dropping isÌýdefinitely theÌýright description.ÌýJoanne.Ìý

Kenen:ÌýSoÌýIÌýsort of rummagedÌýaround the internet to the less widely read sources, and I came across thisÌýgreat storyÌýfrom the IdahoÌýCapitalÌýSun by Laura Guido. It has a long headline.ÌýReminder that 988 is the mental health crisis line and suicide help. The headline is:Ìý“”ÌýThe story is that a 15-year-old boy named JaceÌýWoods calledÌýtwo years agoÌý—Ìýso this stillÌýhasn’tÌýbeen fixedÌýafter two yearsÌý—Ìýand they cutÌýhimÌýoff. TheyÌýsort of gentlyÌýcutÌýhimÌýoff. But theyÌýcan’tÌýtalk to these kids who have,Ìýwho are in crisis,Ìýwithout parental consent. They do a quick assessment. If they think someone’s life isÌýimmediatelyÌýinÌýdangerÌýright then and there, they can stay on. But a kidÌýwho’sÌýwhat they call suicidal ideation, seriously depressed and at risk, and knowsÌýhe’sÌýat risk orÌýshe’sÌýat risk, and made this phoneÌýcall,ÌýtheyÌýdon’tÌýtalk to them unless they thinkÌýit’sÌýimminent.ÌýSoÌýit also affects,Ìýthese parental,Ìýit affects sexual health and STDs and abortion andÌýwholeÌýlot of otherÌýthings.Ìý

Rovner:ÌýThat’sÌýwhat it was for.Ìý

Kenen:ÌýThat was theÌýinitialÌýreason, but it got bigger.ÌýSoÌýa kid who calls in a crisis can get no help at all. And even in those emergency situations where they can stay on the line and try to get emergency help if they doÌýthinkÌýaÌýkid’sÌýin imminent danger,Ìýthey’reÌýnot allowed to make a follow-up call to make sureÌýthey’reÌýOK.ÌýSoÌýthis kid has been trying for two years.ÌýThere’sÌýa state lawmaker.ÌýThey’reÌýrefining a law. They sayÌýit’s,Ìýthey’reÌýrefining a bill.ÌýThey sayÌýit’sÌýgoing to go through. But really this,Ìýtalk about unintended consequences. We have a national mental health crisis, particularly acute for teens. This is not solving any problems.Ìý

Rovner:ÌýIt is not.ÌýShefali.Ìý

Luthra:ÌýMy story is inÌýThe New York Times. It is byÌýApoorvaÌýMandavilli. The headline isÌý“.”ÌýAndÌýit’sÌýjustÌýa good storyÌýabout what is happening with the Ryan White AIDSÌýDrugÌýAssistanceÌýPrograms, which people use to get their HIV medications paid for or for free. They get insurance support. And these areÌýreally important.ÌýFunding has beenÌýpretty flatÌýfor quiteÌýsomeÌýtime because they’re funded by Congress.ÌýAnd what the story gets into is that with growing financial pressure on these programs, there is more-expensive drugs, there are more-expensive insurance premiums, more people might be losing Medicaid. States are having to makeÌývery difficultÌýchoices, and they are cutting benefits. They are changing who is eligible, becauseÌýit’sÌýgetting more expensive and there is more need and there is no support coming. And I wasn’t really on top of this and did not know what was going on, and I just thought it was interesting andÌýa very usefulÌýlook atÌýsome ofÌýthe consequences of the policy choices that are makingÌýall ofÌýthese health programs more expensive and health care,Ìýin general, harder to afford.Ìý

Rovner:ÌýMy extra credit this week is fromÌýThe Marshall Project.ÌýIt’sÌýcalledÌý“.”ÌýIt’sÌýby ShannonÌýHeffernanÌýand JesseÌýBoganÌýand Anna Flagg. It answers the question that I’ve been wondering about since the whole immigration crackdown began, which is:ÌýWhat happens to the people whoÌýare snatchedÌýoff the streets or out of their cars or homes,Ìýflown to a distant state, and then someone says:ÌýOops, sorry. You can go.ÌýHow do you get home from Texas or Louisiana to Minnesota or Massachusetts? AuthoritiesÌýdon’tÌýgive you plane or even bus ticketsÌýto get back to where youÌýwere pickedÌýup, even thoughÌýthat’sÌýwhereÌýmost ofÌýthoseÌýbeing releasedÌýareÌýrequiredÌýto go to report back to immigration authorities. It turns outÌýthere’sÌýa small network of charities that is helping. But as the story detailsÌýpretty vividly, the harm to these familiesÌýdoesn’tÌýend when their detentionÌýdoes./Ìý

OK.ÌýThat’sÌýthis week’s show. As always, thanks to our editor,ÌýEmmarie Huetteman,Ìýand our producer-engineer.ÌýFrancis Ying. AÌýreminder:ÌýWhat theÌýHealth?Ìýis now available on WAMU platforms, the NPR app,Ìýand wherever you get your podcasts, as well as, of course,Ìýkffhealthnews.org.ÌýAlso, as always, you can emailÌýusÌýyour comments or questions.ÌýWe’reÌýat whatthehealth@kff.org.ÌýOr you can still find me onÌýX,Ìý, or onÌýBluesky,Ìý. Where areÌýyou guysÌýhanging these days?ÌýShefali?Ìý

Luthra:ÌýI am at Bluesky,Ìý.Ìý

Rovner:ÌýAnna.Ìý

Edney:ÌýÌýandÌý,Ìý@annaedney.Ìý

Rovner:ÌýJoanne.Ìý

Kenen:ÌýAÌýlittle bit ofÌýÌýand more onÌý,Ìý@joannekenen.Ìý

Rovner:ÌýWeÌýwillÌýbe back in your feed next week. Until then, be healthy.Ìý

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Â鶹ŮÓÅ Health News” on , , , , , or wherever you listen to podcasts.

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 .

USE OUR CONTENT

This story can be republished for free (details).

But plans to spend those nine-digit awards aren’t all warmly received.

At least one group of Republican state lawmakers appears to have scuttled an initiative preapproved by federal officials. And at least one hospital association persuaded its state health leaders to alter who greenlights spending. Other critics are taking a more cautious approach.

That’s because the Centers for Medicare & Medicaid Services, which manages the five-year Rural Health Transformation Program, says states could lose money if they make major changes to the plans approved in their applications. Changes could also delay states’ ability to get projects rolling in time to show the agency that they’re meeting progress deadlines.

“During the application period, states were advised to only propose initiatives and state policy actions that the state deemed feasible,” said CMS spokesperson Catherine Howden, who noted that the agency will work with states case by case.

The recent pushback reflects “tension” over state plans — which were approved by the federal government — from state lawmakers and health leaders who want more input amid tight deadlines, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics.

Cochran-McClain said many states must pass a bill to allow federal dollars to be spent and added that because the program rolled out so quickly “there’s important work that still needs to be done in some states between the legislatures and the governors.”

State lawmakers want to have a say, she said, in “how the funding is being allocated — how the implementation will go.”

Congressional Republicans created the program as a last-minute sweetener to include in their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is expected to slash Medicaid spending by nearly $1 trillion over a decade.

CMS officials announced first-year funding — ranging from $147 million for New Jersey to $281 million for Texas — on Dec. 29, after scoring applications. Federal officials will begin evaluating progress in late summer and announce 2027 allocations at the end of October.

A chorus of critics say the program won’t make up for harm caused by Medicaid cuts.

The program is “a complete sham,” Sen. Ron Wyden (D-Ore.) said at a rural policy conference in February.

Medicaid, a joint federal-state program for low-income and disabled Americans, serves nearly , and many rural hospitals depend on it to stay afloat.

But the rural health program tilts toward seeding innovative projects and technologies, not shoring up rural hospital finances. States can use only up to 15% of their funding to pay providers for patient care.

That hasn’t stopped some federal officials and lawmakers from framing the program as a rural hospital rescue.

For example, the White House , “President Trump secured $50 billion in funding for rural hospitals.”

Now that applications have been approved, some state Republican lawmakers — who are more likely to represent rural voters than Democrats are — and hospital associations are upset that the political rhetoric doesn’t match what they see.

They’re also lobbing criticisms at specific aspects of their states’ plans, including the proposed projects, what’s not included, and the spending approval process.

In Wyoming, lawmakers didn’t just criticize an initiative from their state’s application. They moved to kill it.

State Rep. John Bear, a Republican, said he and other lawmakers declined to fund “BearCare,” a proposed state-sponsored health insurance plan that patients could use only after medical emergencies. But they did approve other aspects of the rural health program.

The Wyoming Department of Health won’t “proceed with BearCare without express legislative authority to do so,” said spokesperson Lindsay Mills.

While Wyoming lawmakers removed an initiative from their state’s rural health plan, a group in Ohio wants to add something.

Ohio Rep. Kellie Deeter and other Republican lawmakers to use the maximum allowed funding for provider payments — 15% — to support 13 independent, rural hospitals.

“We understand that the rural transformation fund is not designed to be given directly to prop up hospitals,” Deeter said. “We just want to capitalize on the mechanism of the fund that can be utilized for that purpose.”

Those hospitals “operate with very, very narrow margins, and it’s just difficult and, frankly, unsustainable,” she added.

Ken Gordon, a press secretary responding for the governor’s office and the state health department, said, “It’s still very early in this process, and many details are being worked out.”

State lawmakers around the country are also trying to ensure the federal program’s dollars benefit rural areas.

In North Dakota, Rep. Bill Tveit, a Republican who lives in a town with about 2,000 residents, that would have required the state to reserve its funding for programs located more than 35 miles from urban areas and small cities.

During a hearing, lawmakers appeared sympathetic to Tveit’s concerns but quickly shot down his idea.

State Sen. Brad Bekkedahl said the North Dakota health department already committed to prioritizing funding for the most pressing rural health needs. He also said he’s concerned any significant changes could cause the state to lose funding because CMS already reviewed and approved the plan.

Meanwhile, Republican lawmakers in Michigan and North Carolina have criticized their states’ definitions of “partially rural” or “rural,” saying that counties that include urban population centers could take money from lower-density counties, according to and .

Lawmakers aren’t the only ones speaking out.

The Colorado Hospital Association to state lawmakers denouncing how the state created its plan and two of its proposed initiatives.

“Not only were Colorado’s rural hospitals’ recommendations disregarded,” president and CEO Jeff Tieman wrote, but the plan includes ideas “they actively oppose and believe will harm the communities they serve.”

The department responded to one of the association’s concerns by adding rural health leaders to the .

Meanwhile, and Nebraska, some health groups are upset that their states’ plans lack specific funding streams for rural hospitals.

Lauren LaPine-Ray, who oversees rural health policy at the Michigan Health & Hospital Association, predicted the state’s rural hospitals will compete with other organizations, such as academic centers and health clinics, for funding. She said about 65% of the group’s rural members have never applied for a state grant before.

“The rural hospitals, the ones that really need the funding the most, will not be well equipped to apply for and pull down these dollars,” LaPine-Ray said.

Jed Hansen, executive director of the Nebraska Rural Health Association, said the federal funding won’t go to “rural hospitals, rural clinics, and rural providers in a meaningful way.”

“Rural Health Transformation will not save a single hospital in our state,” he said. “I don’t think it will save a hospital nationally.”

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 .

USE OUR CONTENT

This story can be republished for free (details).

But when Quinn chipped a tooth and it became infected, she could not find a dentist near her home who would accept her government health coverage and was taking new patients.

She went to an emergency room, receiving painkillers and antibiotics, but she remained in agonizing pain weeks later and paid a dentist $200 to extract the tooth.

Years later, it still hurts to chew on that side, she said, but Quinn — a 34-year-old who has four children and, with her husband, earns about $30,000 a year — still can’t find a dentist nearby.

“You should be able to get dental care,” she said, “because at the end of the day dental care is health care.”

The federal government has long required states to offer dental coverage for children enrolled in Medicaid, the joint state-federal health program for people who are low-income or disabled. Paying for adults’ dental care, though, is optional for states.

In recent years, several states have opted to expand the coverage offered by their Medicaid programs, seeking to boost access in recognition of its importance to overall health. So far, increasing adult dental care is a work in progress: In a sampling of six of those states by Â鶹ŮÓÅ Health News, fewer than 1 in 4 adults on Medicaid see a dentist at least once a year.

But under congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last year, the federal government is expected to reduce Medicaid spending by more than $900 billion over the next decade. The range from about $184 million for Wyoming to about $150 billion for California.

State Medicaid programs typically expand or reduce benefits depending on their finances, and such massive federal cuts could force some to shrink or eliminate what they offer, including dental benefits.

“We will lose all the gains we have made,” said Shillpa Naavaal, a dental policy researcher at Virginia Commonwealth University in Richmond.

Tennessee’s Medicaid program, for instance, spent nearly $64 million on its dental coverage in 2024 and saw a 20% decrease in dental-related ER visits, said Amy Lawrence, the program’s spokesperson.

But under the new law, Tennessee is projected to lose about $7 billion in federal funding over the next decade.

As of last year, 38 states and the District of Columbia offered enhanced dental benefits for adult Medicaid beneficiaries, according to the American Dental Association. Most of the others offer limited or emergency-only care. Alabama is the only state that offers no dental coverage for adult beneficiaries.

Since 2021, 18 states have enhanced their coverage to include checkups, X-rays, fillings, crowns, and dentures, while loosening annual dollar caps for benefits.

Use of dental benefits in states with the enhanced benefits is greater than in states with only limited or emergency coverage, though still low overall, according to with the latest data as of December. No more than a third of adult Medicaid recipients saw a dentist in 2022 in any state.

To review more recent progress, Â鶹ŮÓÅ Health News asked one-third of the states that have expanded their benefits in the past five years for their most recent data on the percentage of adults on Medicaid who visit a dentist at least once a year:

• Maryland — 22% (in 2024)
• Oklahoma — 16% (in 2025)
• Maine — 13% (in 2025)
• New Hampshire — 19% (in 2025)
• Tennessee — 16% (in 2024)
• Virginia — 21% (in 2025)

In comparison, about 50% to 60% of adults with private dental coverage see a dentist at least once a year, according to the ADA.

Nationwide, 41% of dentists reported participating in Medicaid in 2024, a share that has remained stable over the past decade despite the dental benefit expansions in many states, the ADA says. Many participating dentists, though, limit the number of Medicaid enrollees they treat, and some will not accept new patients on Medicaid.

Reimbursement rates have not kept up with costs, deterring dentists from accepting Medicaid, said Marko Vujicic, chief economist and vice president at the ADA Health Policy Institute.

Because of a lack of dentists who take Medicaid in southwestern Virginia, the Appalachian Highlands Community Dental Center in Abingdon sees patients who travel more than two hours for care — and must turn many away, said Elaine Smith, its executive director.

The center’s seven residents treated about 5,000 patients last year, most of them on Medicaid. About 3,000 people are on its waitlist, waiting up to a year to be seen.

“It’s sad because they have the means now to see a dentist, but they still don’t have a dental home,” Smith said.

Low-income adults face other barriers to dental care, including a lack of transportation, child care, or time off work, she said.

The inability to see a dentist has consequences broader than tooth pain. Poor dental health can contribute to a host of other significant health problems, such as heart disease . It can also make it harder to do things like apply for jobs and generally lead a healthy life.

Robin Mullins, 49, who has been off and on Medicaid since 2013, said a lack of regular dental visits contributed to her losing her bottom teeth. Unable to find a dentist near her home in rural Clintwood, Virginia, she drives almost 90 minutes to Smith’s clinic — that is, when she can afford to get time away from driving for DoorDash or find help watching her daughter, who has special needs.

She gets by with partial dentures but misses her natural teeth, she said. “It’s absolutely horrible, as you can’t chew your food properly.”

In New Hampshire, though, the challenges have more to do with low demand than a low supply of dentists, said Tom Raffio, chief executive of Northeast Delta Dental, which manages the state’s Medicaid dental program. The company has added new dentists to its list of participating providers, along with two mobile dental units that traverse the state, he said.

Raffio said Northeast Delta Dental also has publicized the state benefits using radio advertising and social media, among other efforts.

Until 2023, New Hampshire Medicaid covered only dental emergencies.

“Culturally, it’s going to take a while,” he said, “as people just are used to not going to the dentist, or going to the ER when have dental pain.”

Brooks Woodward, dental director at Baltimore-based Chase Brexton Health Care, called Maryland’s rate of roughly 1 in 5 adults on Medicaid seeing a dentist in 2024 “pretty good” considering the benefits had been enhanced only since 2023.

Woodward said many adults on Medicaid believe that you go to a dentist only when you’re in pain. “They’ve always just not gone to the dentist, and that’s just the way they had it in their life,” he said.

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 .

USE OUR CONTENT

This story can be republished for free (details).

The state could tackle rural health issues long into the future by investing its awards from the Rural Health Transformation Program, the director of Wyoming’s health department, Stefan Johansson, told state lawmakers.

But it’s unclear whether the maneuver will pass muster with the federal government.

If approved, Wyoming’s Rural Health Transformation Perpetuity fund could provide $28.5 million for the state to spend every year, presented to lawmakers.

CMS officials announced first-year funding on Dec. 29 after scoring states’ applications. States had until Jan. 30 to submit revised budgets and other documents that align with their grant awards. CMS has until March 1 to review and approve the updated material.

Wyoming — the least populous state, with about 588,000 residents — will receive $205 million in the program’s first year, $5 million more than it asked for.

States must spend each year’s grants by the end of the following fiscal year, . If they don’t, unused money will be . The final deadline for all spending is Oct. 1, 2032, with leftover funds being returned to the federal government.

Given those rules, “how do you square that with squirreling money away in an account?” state Rep. Ken Pendergraft, a Republican, asked during a hearing on Wyoming’s plan.

Johansson said that depositing the federal grants into the perpetuity fund counts as expending them.

He said that CMS called in December to specifically ask questions about the fund and that he believes the agency has formally approved it. But “the devil’s always in the details,” he said, as the state works with CMS during the budget review period.

Emails obtained by Â鶹ŮÓÅ Health News through public records requests show CMS told officials in some states in early November that the grant money can’t “fund an endowment, capital fund, or other vehicle resembling an investment fund with the purpose of generating income.”

Wyoming officials that the perpetuity fund won’t be making or keeping any profit.

“All program income from these investments will directly fund” rural health programs, they wrote.

CMS spokesperson Catherine Howden did not directly comment on whether Wyoming’s perpetuity idea is allowed. Instead, she said states must follow regulations related to the program and federal grants.

The Trump administration gave states a mandate to spend their money by fall 2032, but on projects that will continue to help rural patients even after the federal program ends.

The perpetuity fund would ensure just that, said Patrick Hardigan, dean of the College of Health Sciences at the University of Wyoming.

“Rather than spend out now,” Hardigan said, “we would have this available to help fund us over a longer time period.”

The state health department has already presented lawmakers with to create the perpetuity fund and approve other parts of its rural health plan.

The legislation says Wyoming would put 80% of this year’s award — $164 million — and 69.5% of the funding it receives over the next four years into the fund. The state treasurer’s office would invest the fund in equities, including stocks. The health department plans to spend 4% of the fund’s money — in line with its expected return — each year, .

About 41% of the annual fund distribution would be spent on incentive payments for qualifying small hospitals, the bill says. The assistance could include one-time grants, medical debt relief for patients, and ongoing payments to offset fixed costs. This funding could amount to 2.5% to 10% of these hospitals’ annual operating expenses, in Wyoming’s application.

Bennett said it’s unclear whether all those types of payments are allowed under the federal rules.

“I think that states will try to do a lot of creative things like this, and CMS will approve or not on a case-by-case basis,” he said.

The bill says around 27% of annual spending would go to incentive payments to encourage coordination or consolidation among rural ambulance services. The funding could be ongoing or grants that help pay for ambulances, communications equipment, and regional dispatch services.

But these incentives would come with . Hospitals and ambulance services could receive payments only if they reduce “unprofitable, duplicative or nonessential” services and participate in “cost-containment arrangements,” such as regional collaborations and shared services.

About 22% of the annual spending would provide scholarships to help Wyomingites afford nursing, behavioral health, emergency medical services, and physician education. In exchange, recipients would have to work in the state for five years.

The remaining spending, around 11%, would be for scholarships to help doctors in training afford medical school, residency programs, and fellowships if they agree to work in an “underserved” Wyoming county for five years. The state health department would prioritize scholarships for people pursuing family medicine, obstetrics, or other high-demand specialties.

Johansson told Wyoming lawmakers that CMS could claw back money if a future state legislature decides to spend the fund in ways not allowed under the federal rural health program. He said this “check and balance” could last for decades.

“I can’t predict the future,” Johansson said, but “I think they have the authority to go look at the appropriate use of those funds through their audit parameters.”

Other states proposed funds in their applications, but Wyoming’s appears unique, according to a Â鶹ŮÓÅ Health News review of state applications.

For example, Kentucky wants to create a rural health endowment to continue its work once the federal program ends. But it would be backed by charitable donations, not seed money and investments from the federal funding.

Several states mention putting some of their federal award money into what they call rural health “catalyst funds.” But these funds, sometimes augmented with private contributions, would be invested in rural health technology.

Bennett said he’s never heard of a state investing any other federal health grant the way Wyoming wants to.

He said that in setting aside significant portions of its Rural Health Transformation Program awards, Wyoming would have much less money for rural health care in the short term in exchange for an ongoing revenue stream that could last decades.

“Everything has trade-offs,” Bennett said.

The Wyoming House Appropriations Committee unanimously approved the bill on Feb. 12, sending the legislation to the House floor.

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 .

USE OUR CONTENT

This story can be republished for free (details).

La mujer de 59 años, que vive en Harrisburg, Carolina del Norte, cerró el año pasado su escuela de artes circenses sin fines de lucro porque ya no veía lo suficientemente bien como para estar al día con todo el papeleo administrativo. Luego trabajó un tiempo haciendo masas en una pizzería. Ahora clasifica materiales reciclables, como latas y botellas, en un lugar de conciertos local. Es su principal fuente de ingresos, pero el trabajo no es durante todo el año.

“Este lugar me conoce, y este lugar me quiere”, dijo Kelley sobre su empleador. “Aquí no tengo que explicar por qué no puedo leer”.

Kelley vive en una casa rodante y sobrevive con menos de $10.000 al año. Dice que eso es posible, en parte, gracias a su cobertura de salud de Medicaid, que le cubre medicamentos para la artritis y la ansiedad, y le permite ir al doctor para controlar su hipertensión.

Pero le preocupa perder esa cobertura el año que viene, cuando entren en vigencia nuevas reglas que exigirán a millones de personas como ella trabajar, hacer voluntariado, ir a la escuela o realizar otras actividades que califiquen durante al menos 80 horas al mes.

“Ahora mismo tengo miedo”, dijo.

Antes de que se promulgaran los cambios para acceder a esta cobertura, legisladores republicanos sugirieron que hombres jóvenes y desempleados estaban abusando del programa gubernamental de salud que ofrece cobertura médica a millones de personas con bajos ingresos o con alguna discapacidad.

Medicaid no está pensado para “hombres de 29 años sentados en el sofá jugando videojuegos”, dijo Mike Johnson, presidente de la Cámara de Representantes, .

Pero en realidad, los adultos de entre 50 y 64 años, especialmente las mujeres, son quienes probablemente por las nuevas reglas, según explicó Jennifer Tolbert, subdirectora del Programa sobre Medicaid y Personas sin Seguro de Â鶹ŮÓÅ, una organización sin fines de lucro de información sobre salud de la cual Â鶹ŮÓÅ Health News forma parte.

Para Kelley y otras personas, los requisitos laborales crearán obstáculos para mantener su cobertura, explicó Tolbert. Muchos podrían perder Medicaid, poniendo en riesgo su salud física y financiera.

A partir de enero de 2027, unos 20 millones de estadounidenses de bajos ingresos en 42 estados y el Distrito de Columbia tendrán que cumplir con los requisitos de actividad para obtener o conservar esta cobertura.

Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming no ampliaron sus programas de Medicaid para cubrir a más adultos de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), por lo que no tendrán que implementar las reglas de trabajo.

La no partidista Oficina de Presupuesto del Congreso, prevé que las reglas de trabajo resulten en al menos 5 millones de personas menos bajo Medicaid en la próxima década.

, estas reglas son el principal factor de pérdida de cobertura dentro de la ley presupuestaria republicana, la cual recorta cerca de $1.000 millones para compensar reducciones de impuestos que benefician principalmente a personas con mayores ingresos y para aumentar la seguridad fronteriza.

“Estamos hablando de ahorrar dinero a costa de vidas humanas”, dijo Jane Tavares, investigadora en gerontología de la Universidad de Massachusetts en Boston. “El requisito de trabajo es solo una herramienta para lograr eso”.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos, dijo que exigir a los “adultos sin discapacidades” que trabajen garantiza la “sostenibilidad a largo plazo” de Medicaid, mientras protege a las personas más vulnerables.

Las personas con discapacidades, quienes cuidan a familiares, personas embarazadas o en posparto, veteranos con discapacidades totales y otras personas que enfrentan dificultades médicas o personales están exentas de la regla de trabajo, indicó Nixon a Â鶹ŮÓÅ Health News.

La expansión de Medicaid ha sido un salvavidas para adultos de mediana edad que, de otro modo, no tendrían seguro médico, . Medicaid cubre a 1 de cada 5 estadounidenses de entre 50 y 64 años, dándoles acceso a atención médica hasta que califican para Medicare a los 65 años.

Entre las mujeres beneficiarias de Medicaid, las que tienen entre 50 y 64 años enfrentan más desafíos para conservar su cobertura que las más jóvenes, y suelen tener una mayor necesidad de servicios de salud, explicó Tolbert.

Estas mujeres de mediana edad tienen menos probabilidades de trabajar el número requerido de horas porque muchas son cuidadoras familiares o tienen problemas de salud que limitan su capacidad para trabajar, agregó.

Tavares y otros investigadores hallaron que de la población total de Medicaid que se considera “apta para trabajar” no trabaja. Este grupo está compuesto en su mayoría por mujeres muy pobres que han salido de la fuerza laboral para convertirse en cuidadoras. Entre ellas, 1 de cada 4 tiene 50 años o más.

“No son adultos jóvenes saludables simplemente perdiendo el tiempo”, escribieron los investigadores.

Además, dificultar el acceso a la cobertura de Medicaid “podría en realidad dificultar que estas personas trabajen”, ya que sus problemas de salud no recibirían tratamiento, advirtió Tolbert. De todas formas, si este grupo pierde la cobertura, sus condiciones crónicas igual necesitarán atención, señaló.

Muchos adultos empiezan a tener problemas de salud antes de ser elegibles para Medicare.

Si las personas mayores no tienen recursos para tratar sus problemas de salud antes de los 65 años, llegarán más enfermas a Medicare, lo que podría generar mayores costos para ese programa, apuntaron expertos en políticas de salud.

Muchas personas de entre 50 y principios de los 60 años ya no trabajan porque son cuidadoras de tiempo completo de hijos o familiares mayores, explicaron defensores, quienes se refieren a este grupo como “la generación sándwich”.

La ley presupuestaria republicana permite que algunos cuidadores queden exentos de las reglas de trabajo de Medicaid, pero las excepciones son “muy limitadas”, dijo Nicole Jorwic, directora de programas del grupo Caring Across Generations.

Le preocupa que personas que deberían calificar para una exención queden fuera por errores o complicaciones.

“Vamos a ver a más cuidadores familiares enfermándose, dejando de atender su propia salud y a más familias enfrentando crisis”, dijo Jorwic.

Paula Wallace, de 63 años, residente de Chidester, Arkansas, dijo que trabajó la mayor parte de su vida adulta y ahora dedica sus días a cuidar a su esposo, quien tiene cirrosis avanzada.

Después de años sin seguro, recientemente obtuvo cobertura gracias a la expansión de Medicaid en su estado, lo que significa que tendrá que cumplir con los nuevos requisitos laborales para conservarla. Pero le cuesta imaginar cómo podrá hacerlo.

“Como soy su única cuidadora, no puedo salir a trabajar fuera de casa”, dijo.

Su esposo recibe beneficios del Seguro por Incapacidad del Seguro Social, explicó, y la ley dice que ella debería quedar exenta de los requisitos de trabajo como cuidadora de tiempo completo de una persona con discapacidad.

Pero las autoridades federales aún no han emitido instrucciones específicas sobre cómo definir esa exención. Y la experiencia de Arkansas y Georgia —los únicos estados que han implementado programas de trabajo en Medicaid— muestra que muchas personas beneficiarias tienen dificultades para navegar sistemas de beneficios complejos.

“Estoy muy preocupada”, dijo Wallace.

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 .

USE OUR CONTENT

This story can be republished for free (details).

The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told Â鶹ŮÓÅ Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you're going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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 .

USE OUR CONTENT

This story can be republished for free (details).

In Alaska and Michigan, legislators are nonetheless advancing bills to keep medical debt off consumer credit reports.

The attorneys general of California and Colorado said they would stand behind credit reporting laws enacted in those states in recent years, even as Colorado faces a lawsuit from debt collectors contesting such laws.

Indiana and Ohio lawmakers have dropped proposals to remove medical debt from credit reports but are pushing legislation that would extend other protections to patients who cannot pay their medical bills.

“ of Alaska voters don’t think credit reports should include medical debt,” said state Rep. , a Democrat there. “I’m not going to wait on the courts on the medical debt issue.”

An estimated 100 million Americans are saddled with health care debt. And a growing number of red and blue states have enacted laws to protect patients.

But federal policy on such debt boomeranged this year when President Donald Trump’s administration chose not to defend federal regulations that would have removed medical debt from all Americans’ credit scores. And in October, Trump’s Consumer Financial Protection Bureau do not have the authority to regulate consumer credit reports.

“It’s sort of a head-spinning, 180-degree reversal,” said , an attorney with the National Consumer Law Center, which advocates for people with low incomes. She called the Consumer Financial Protection Bureau, now led by Project 2025 architect , the “evil twin” of its predecessor under President Joe Biden.

The bureau did not respond to requests for comment.

Eight days after the new federal guidance, debt collectors filed a lawsuit contesting Colorado’s 2023 medical debt credit reporting law, the first to require removal of some or all medical debt from credit reports.

Scott Purcell, CEO of , which is a debt collection trade group and a plaintiff in the Colorado suit, said removing the debt makes it harder to gauge creditworthiness, which he said would lead creditors to assume everyone is a riskier bet.

His also argues the Colorado law violates the First Amendment by suppressing “truthful commercial speech.”

Colorado Attorney General Phil Weiser, a Democrat, called the lawsuit outrageous in a statement to Â鶹ŮÓÅ Health News. His office, he said, “will strongly oppose all efforts to strip away critical medical debt protections.”

In California, Attorney General Rob Bonta, too, is standing firm on his state’s law regardless of how federal officials now interpret state rights. The Democrat told constituents in a : “Let me be clear: This remains the law in California.”

In other states still contemplating credit reporting laws, legislators are adjusting their strategy to account for the lawsuit and the Trump administration’s moves, by either ditching the plan to remove medical debt from credit reports or modifying such legislation.

Wu said her organization saw the federal change coming and had already urged state lawmakers to make pending legislation on credit reporting more lawsuit-proof by looking upstream and downstream of the credit reporting agencies. For example, Wu said, states can tell landlords, employers, or other credit report perusers that they cannot use a person’s medical debt history in their decision-making. And states can require health providers to include, in their contracts with debt collectors, limits on what they can tell credit reporting agencies about the bills they’re collecting.

“You’ll often hear providers say, ‘Oh, well, we don’t want to hurt our patients’ credit,’” she said. “Tell the debt collectors, ‘Don’t report this.’”

Alaska’s legislation has both elements: It bars landlords from making decisions about potential renters based on their medical debt history, and it bars providers and collectors from telling credit reporting agencies about patient debt.

Elsewhere, state lawmakers have opted out of trying to pass credit reporting provisions in proposed legislation. Indiana state Sen. , a Democrat, that tries to, among other things, cap interest rates, limit wage garnishment, and keep people from losing their homes over unpaid bills from medically necessary procedures. But he and his colleagues made a tactical decision to leave out credit reporting, after unsuccessfully including it in a similar bill last year.

“It’s out of legislative pragmatism,” Qaddoura said. “We want to be sure that you don’t get a piece of legislation killed with many benefits to tens of thousands of families just because one provision can’t go in.”

In Ohio, Democratic state Rep. made a similar calculation. She has been working on to ban wage garnishment over medical debt, cap interest rates for such debt at 3%, and scratch it from credit reports. She said she and other lawmakers recently removed the credit reporting portion.

“It’s better to pass something than nothing at all,” Grim said. “It still bans wage garnishment, which is a very aggressive, more-common-than-you-think practice. And it caps the interest rate.”

A recent investigation by Â鶹ŮÓÅ Health News found that, in Colorado alone, thousands of people each year have their wages garnished to pay back medical bills, and some people taken to court for medical debts never actually owed the money.

Legislative efforts to protect people from the effects of medical debt are often bipartisan, but that doesn’t mean they pass easily. Even before the Consumer Financial Protection Bureau reversed its stance on credit reports, several measures hit obstacles in conservative states this year, and legislation failed in Wyoming and South Dakota that aimed to take medical debt off credit reports.

Americans are largely protected from having their credit scores dinged by small medical debts. In 2023, the three big credit bureaus — TransUnion, Equifax, and Experian — to remove medical debts under $500 from their credit reports, and the Consumer Data Industry Association, a trade group for the companies, confirmed they are still doing so.

Even so, lawmakers in several states said they are deciding whether and how to get ahead of the federal guidance with legislation that tackles additional, larger medical debt on credit reports.

“We know that this will need to get beefed up,” said , a Democratic state senator in Michigan, of . She isn’t sure what that will look like, though consumer advocates including Libby Benton hope to see the measure follow Wu’s strategy.

“These aren’t debts that people choose to take on. People might choose to buy a huge pickup truck and that’s a bad financial decision,” said Benton, director of the Michigan Poverty Law Program. “People don’t choose to have emergency heart bypass surgery.”

Yet both can end up on a credit report.

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 .

USE OUR CONTENT

This story can be republished for free (details).