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

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

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

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

Landlords With Influence

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

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

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

Absence of Oversight

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

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

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

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

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

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

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

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

Low Staffing at a Chain

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

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

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

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

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

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

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

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

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

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

A $110 Million Verdict

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

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

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

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

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

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

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

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

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

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

‘Wet From Head to Toe’

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

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

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

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

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

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

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

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

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

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

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

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

A 67% Profit

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

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

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

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

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

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

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• Read Wells’ “Urgent Care Clinics Move To Fill Abortion Care Gaps in Rural Areas.”

Â鶹ŮÓÅ Health News Montana correspondent Katheryn Houghton discussed doula Medicaid reimbursements on Montana Public Radio on April 9.

• Read Houghton’s “This Northern Cheyenne Doula Was About To Start Getting Paid — Then Medicaid Cuts Hit.”

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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

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

There are a lot of people like Lahey.

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

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

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

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

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

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

The App Will Put You on the Couch

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Silver-Tongued Apps

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

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

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

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

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

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

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

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

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

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

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

An OpenAI spokesperson did not respond to requests for comment.

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

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

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

Data Risks

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

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

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

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

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

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

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

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

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

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But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.

Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.

Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.

As in Indiana, Republican Idaho lawmakers approved a three-month requirement, and the state’s governor signed the bill into law on April 10.

The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.

“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.

The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.

Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.

Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.

When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.

Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.

“I think very few,” Roob replied. “It’ll never be none.”

After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.

Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.

Republicans have said imposing these limits protects the Medicaid program’s longevity.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”

Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.

Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.

Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.

“If the point is to get people engaged, the one month would do it,” Mueller said.

Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”

An analysis by the Center on Budget and Policy Priorities predicted that work rules will and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”

Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.

In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”

Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.

Chappell, a Republican, said his initiative would encourage a “working mindset.”

Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”

Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.

She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.

“I work very hard,” Meyer said.

In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.

of adults ages 19 to 64 on Medicaid already work, according to Â鶹ŮÓÅ. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, Â鶹ŮÓÅ has found.

Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.

For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.

Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.

But this short-term hardship exemption would be off the table in Missouri.

Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.

This <a target="_blank" href="/insurance/federal-medicaid-work-rules-one-three-months-indiana-missouri/">article</a&gt; first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

HAY SPRINGS, Neb.— The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning.

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 .

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.

The best way to address this is to focus on prevention, Unruh said. He pointed to a 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.

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That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans.

“Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said.

Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a found that many returning marketplace enrollees reported higher costs this year.

In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage.

Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans.

As of this year, that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan.

Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints.

But because states have passed laws exempting from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans.

Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions.

Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be than unsubsidized marketplace plans, plan managers say.

As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins.

“We’re trying to present another option,” he said.

Sowing Choices

In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to for subsidized enrollees who retained their marketplace plan, according to Â鶹ŮÓÅ.

Last year, was one of four states that passed laws permitting farm bureau health plans. The others were , , and .

Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage . Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them.

In Missouri, the farm bureau offers with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network.

Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said.

It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years.

“People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said , general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.”

Staying Rooted in Coverage

Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said.

“We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said.

And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said , principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network.

Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said.

“We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said.

Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions.

Meanwhile, policy experts share Howard’s concerns.

Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said , vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans.

Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said.

Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans.

“I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said , co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact Â鶹ŮÓÅ Health News and share your story.

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“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.

This <a target="_blank" href="/medicaid/medicaid-cuts-work-requirements-state-staff-shortages/">article</a&gt; first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

LISTEN: AI scribes are changing medical care. Here’s what to know if the technology shows up at your next doctor’s appointment.

Family physician Eric Boose has been using an artificial intelligence tool to get back to what he calls “old-fashioned medicine” — talking with patients face-to-face, without having to type into a computer at the same time. 

“I can really just sit there and engage and just focus on them and listen,” said Boose, who . 

Roughly two years ago, he started using an AI notetaker app during patient visits. The tool listens while he talks with patients and then automatically generates a visit summary based on the conversation. The summary is usually ready within seconds after the appointment ends. 

“It’s taking care of all that tedious work of charting and taking notes during the visit,” he said. “It’s just freeing up a lot more time to get that done, and I can get home to my family earlier.” 

Nearly a third of physician practices are using AI scribes and others are working to add the tool, in an effort to cut down on administrative work. 

If your practitioner suggests using an AI scribe at your next appointment, here are three things to keep in mind:

1. Clinicians should ask for your permission. 

At the start of an appointment, your doctor might ask something like, “Are you OK if I use an AI scribe to help me take notes during this appointment?” A common practice is to accept verbal, not written, consent from patients before turning the tool on. However, the legal requirements for getting permission to record a patient conversation vary by state. 

Boose said you can ask to pause the AI scribe at any point, especially to discuss something sensitive. And if you decline altogether, your practitioner will likely return to taking manual notes on a computer. 

2. AI scribes make mistakes too, so check their work. 

Like other AI tools, medical scribes can “hallucinate,” or spontaneously add errors into a record. AI scribes can also omit important information or miss context clues within a conversation. 

Clinicians are supposed to review and edit the AI-generated visit summaries before adding them to a patient’s record. As a patient, it’s a good practice to carefully review your visit summary and contact your health provider if you notice errors. 

3. Yes, the AI company could use your data, with limitations. 

Companies and health systems that offer AI scribe tools have access to medical data and are subject to federal standards about how they use and store patient data, under the Health Insurance Portability and Accountability Act, more commonly known as HIPAA. 

They may use data from your appointment to help improve their software without informing you, said Darius Tahir, who reports on health technology for Â鶹ŮÓÅ Health News. “ If information is ‘de-identified,’ which can mean stripping it of identifiers [and] making sure it’s not personally traceable back to people, then it is more free to be used in more ways,” he said. “There are way fewer regulatory requirements.” 

If you want to know how your data is being used, ask either your practitioner or medical system for more information. But you might not get a clear answer, Tahir said. 

People and Policy 

The U.S. health care system will likely continue to integrate AI technology into patient care. The Trump administration strongly supports the development and use of AI, especially in health care. In early 2025, President Donald Trump issued  reducing existing regulations on AI to help the U.S. “retain global leadership of artificial intelligence.” In December, the U.S. Department of Health and Human Services released an  stating that the department supports “integrating AI to modernize care and public health infrastructure to improve health at the individual and population levels.” 

Emily Siner at Nashville Public Radio contributed to this report. 

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and Â鶹ŮÓÅ Health News.

This <a target="_blank" href="/health-industry/healthq-ai-scribes-notetaker-doctor-visit-data-privacy/">article</a&gt; first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a Â鶹ŮÓÅ Health News investigation showed.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax-and-spending law. The changes will add red tape and restrictions. They are coming at a steep price ― both in the cost to taxpayers and coverage losses ― according to state documents obtained by Â鶹ŮÓÅ Health News and interviews.

The documents showÌýgovernment agenciesÌýwill spend millionsÌýto saveÌýconsiderablyÌýmoreÌýbyÌýremovingÌýpeople fromÌýhealth benefits.ÌýWhile statesÌýsignÌýeligibility system contracts with companiesÌýandÌýwork with them to manageÌýupdates, the federal governmentÌýfootsÌýmost of the bill.

The law’s Medicaid policies will causeÌýÌýtoÌýbecome uninsuredÌýby 2034, according to the nonpartisan Congressional Budget Office.ÌýRoughlyÌýÌýwill loseÌýaccess toÌýmonthly cashÌýassistanceÌýforÌýfood, including those with children.Ìý

In five statesÌýalone,ÌýÌýfor state officialsÌýand reviewed by Â鶹ŮÓÅ Health NewsÌýshow that changesÌýwill cost at least $45.6ÌýmillionÌýcombined.Ìý

The lawÌýrequires most statesÌýtoÌýtieÌýMedicaid coverageÌýfor some adultsÌýtoÌýhavingÌýaÌýjob,ÌýandÌýimposes other restrictions that will make it harder forÌýpeopleÌýwith low incomesÌýto stay enrolled.ÌýSNAP restrictions began to take effect in 2025. Major Medicaid provisionsÌýbeginÌýlater this year.Ìý

DocumentsÌýprepared by consulting company DeloitteÌýestimateÌýthat a pair ofÌýcomputer systemÌýchangesÌýforÌýMedicaid work requirementsÌýin WisconsinÌýwillÌýÌý. Two other changesÌýrelatedÌýto the state’s SNAP program will cost an additional $4.2Ìýmillion, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company thatÌýoperatesÌýthe state’sÌýeligibility system.Ìý

OptumÌý—ÌýwhichÌýoperatesÌýthe platform Vermont residents useÌýfor Medicaid and marketplaceÌýhealthÌýplans under the Affordable Care ActÌý—ÌýÌýÌýÌýÌýtoÌýevaluate andÌýincorporateÌýnewÌýhealthÌýcoverage restrictions.Ìý

Initial changes in Kentucky, which has had a contract with Deloitte since 2012,ÌýÌýÌýÌýÌý. And in Illinois,ÌýÌýwill cost at least $12 million.

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And CEO Brad Meyer fears times will soon get worse for the clinic and its 21,000 patients. That’s because Nebraska is set to become the first state to require certain Medicaid enrollees to work or lose their coverage under new rules in President Donald Trump’s One Big Beautiful Bill Act.

“This will have a huge financial impact on us,” Meyer said. On May 1, seven months before the law requires, the state will begin imposing work requirements on eligible adult Medicaid enrollees.

Most of Bluestem’s patients are covered by the government program for people with low incomes or disabilities. Meyer estimates up to 15% of them may be kicked off Medicaid, which could cost his center about $600,000 a year. That could mean cutting services or staff.

Nationwide, about 17,000 federally funded community health centers like Bluestem . They’re bracing for fallout from the law Trump signed last year, which could cost the nonprofit health centers $32 billion collectively over five years, according to the Commonwealth Fund, a health research foundation.

Health centers receive annual federal grants but depend on Medicaid reimbursements for patient care as their largest source of revenue. The government insurance program covered about half of their roughly 33 million patients in 2024.

Commonwealth estimates that 5.6 million patients of health centers will lose Medicaid coverage over the next decade as most states enact work requirements — a provision of Trump’s law that requires nondisabled enrollees to work, volunteer, or perform another approved activity for at least 80 hours a month.

Most are expected to lose coverage not because they don’t work but because of paperwork errors, like failing to document their hours or verify that they qualify for an exemption.

Health center officials say there’s no easy way to make up for the lost revenue other than cutting staff or services, which would affect all their patients. The cuts will coincide with an expected increase in patients, as people who lose coverage turn to the clinics for low-cost care.

By law, health centers are required to treat all patients regardless of their ability to pay.

A Double Whammy

Overall, about 10 million fewer Americans will have insurance by 2034, the Congressional Budget Office estimates, both because of Trump’s law and congressional Republicans’ decision to scale back premium subsidies for Affordable Care Act health plans.

“We are incredibly worried,” said Jeffrey McKee, CEO of Community Health Centers of Burlington in Vermont. His clinics treat about 35,000 patients a year, nearly a third covered by Medicaid.

He predicts a surge in uninsured patients will cost another $3 million in lost revenue. That revenue crash could imperil street medicine programs and home care for patients 65 and older, he said.

In 2024, community health centers because of rising costs and the expiration of covid pandemic-era relief funds, according to a Â鶹ŮÓÅ analysis.

Centers with high rates of uninsured patients typically struggle more financially, while some centers are sustained through private donations.

People without insurance — who made up about 18% of all health center patients in 2024 — pay on a sliding scale. Those amounts are a fraction of what insurers pay.

The new Medicaid work requirements apply to Washington, D.C., and 40 states that expanded Medicaid eligibility under the ACA, and to adults with incomes up to 138% of the federal poverty level — $22,025 for a single person this year.

Republicans say the work requirements will nudge people into the workforce and help preserve Medicaid for children and people who are pregnant or have disabilities. Studies by Â鶹ŮÓÅ and others show most enrollees already work, go to school, or have a health condition that prevents them from working.

Nebraska Is First Up

The Trump administration approved Nebraska’s early launch of its work requirement program, which could affect about . State Medicaid officials say they plan to use state and national databases to check whether people are already working or meeting an exemption so that most won’t have to do anything to keep coverage. But thousands will need to prove they satisfy the requirements.

At Bluestem in Lincoln, Meyer worries many of his Medicaid patients won’t take the steps needed to keep coverage.

Angelisa Corum, 57, said she loves the care she has gotten from her regular doctor at Bluestem Health over the past dozen years, particularly in dealing with breast cancer. “I am cancer-free, and they helped me get through that,” she said.

She said the care was the same when she was covered by her husband’s commercial insurance through his employer and when she was on Medicaid while he wasn’t working.

The work requirements are just one part of the Republican law passed last year that could hurt the health centers. It also requires more frequent eligibility checks for adults enrolled under Medicaid expansion, which advocates say could also lead people to lose coverage. Many states now require eligibility checks only once a year.

The law also reduces overall federal Medicaid funding to states, which may prompt them to cut reimbursements to centers and other health providers.

The National Association of Community Health Centers, the largest advocacy group for the clinics, has tried to walk a tightrope, warning about impending cuts from the law while still working with the Trump administration. The group praised Congress for increasing base grant funding for health centers in the federal budget approved in January.

Kyu Rhee, CEO of the national association, said the clinics enjoy strong bipartisan support in Washington despite the Medicaid cuts.

He has met with Trump administration officials to discuss how health centers can play a role in keeping people from losing coverage due to work requirements. He said they can help meet other priorities of the administration’s, like improving American diets, expanding primary care, and focusing on chronic diseases — though it’s unclear how any of that would result in more funding.

To further show the reach of health centers, the association recently funded a study that found 52 million people visited the clinics over a three-year-period. “It makes a statement we serve a lot more Americans than those from just a single year,” Rhee said.

Health center officials are hopeful they will get some of the funding from the $50 billion Rural Health Transformation Program included in the GOP-passed law. States will begin spending the first tranche of that money this spring.

Rhee said he is encouraged that states will have technology to help tap into databases to verify many enrollees’ work status or health conditions to meet “medical frailty” rules that could help them avoid being disenrolled.

Others are less optimistic.

“Health centers are bracing for a major financial impact,” said Sara Rosenbaum, a health law and policy professor at George Washington University and Medicaid expert who co-authored the Commonwealth Fund study. “The way they cope is the same way health systems usually cope as they go through mass layoffs, site closures, and service reductions.”

Amanda Pears Kelly, CEO of Advocates for Community Health, a trade group representing 52 health centers, said health centers are also worried about rising costs, especially for prescription drugs. The impending financial challenges will make it more difficult to hire staff both in rural areas where doctors and nurses are scarce and in more populated areas, where competition for workers is more acute, she told Â鶹ŮÓÅ Health News.

“The challenge is health centers are being hit from every direction,” Pears Kelly said.

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

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

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

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

Landlords With Influence

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

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

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

Absence of Oversight

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

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

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

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

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

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

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

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

Low Staffing at a Chain

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

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

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

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

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

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

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

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

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

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

A $110 Million Verdict

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

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

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

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

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

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

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

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

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

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

‘Wet From Head to Toe’

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

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

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

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

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

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

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

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

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

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

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

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

A 67% Profit

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

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

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

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

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

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

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• Read Wells’ “Urgent Care Clinics Move To Fill Abortion Care Gaps in Rural Areas.”

Â鶹ŮÓÅ Health News Montana correspondent Katheryn Houghton discussed doula Medicaid reimbursements on Montana Public Radio on April 9.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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

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

There are a lot of people like Lahey.

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

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

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

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

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

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

The App Will Put You on the Couch

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Silver-Tongued Apps

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

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

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

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

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

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

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

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

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

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

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

An OpenAI spokesperson did not respond to requests for comment.

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

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

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

Data Risks

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

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

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

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

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

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

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

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

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

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But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.

Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.

Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.

As in Indiana, Republican Idaho lawmakers approved a three-month requirement, and the state’s governor signed the bill into law on April 10.

The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.

“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.

The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.

Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.

Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.

When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.

Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.

“I think very few,” Roob replied. “It’ll never be none.”

After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.

Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.

Republicans have said imposing these limits protects the Medicaid program’s longevity.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”

Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.

Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.

Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.

“If the point is to get people engaged, the one month would do it,” Mueller said.

Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”

An analysis by the Center on Budget and Policy Priorities predicted that work rules will and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”

Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.

In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”

Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.

Chappell, a Republican, said his initiative would encourage a “working mindset.”

Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”

Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.

She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.

“I work very hard,” Meyer said.

In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.

of adults ages 19 to 64 on Medicaid already work, according to Â鶹ŮÓÅ. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, Â鶹ŮÓÅ has found.

Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.

For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.

Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.

But this short-term hardship exemption would be off the table in Missouri.

Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.

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HAY SPRINGS, Neb.— The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning.

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 .

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.

The best way to address this is to focus on prevention, Unruh said. He pointed to a 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.

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That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans.

“Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said.

Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a found that many returning marketplace enrollees reported higher costs this year.

In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage.

Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans.

As of this year, that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan.

Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints.

But because states have passed laws exempting from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans.

Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions.

Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be than unsubsidized marketplace plans, plan managers say.

As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins.

“We’re trying to present another option,” he said.

Sowing Choices

In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to for subsidized enrollees who retained their marketplace plan, according to Â鶹ŮÓÅ.

Last year, was one of four states that passed laws permitting farm bureau health plans. The others were , , and .

Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage . Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them.

In Missouri, the farm bureau offers with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network.

Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said.

It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years.

“People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said , general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.”

Staying Rooted in Coverage

Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said.

“We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said.

And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said , principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network.

Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said.

“We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said.

Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions.

Meanwhile, policy experts share Howard’s concerns.

Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said , vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans.

Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said.

Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans.

“I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said , co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact Â鶹ŮÓÅ Health News and share your story.

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“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.

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LISTEN: AI scribes are changing medical care. Here’s what to know if the technology shows up at your next doctor’s appointment.

Family physician Eric Boose has been using an artificial intelligence tool to get back to what he calls “old-fashioned medicine” — talking with patients face-to-face, without having to type into a computer at the same time. 

“I can really just sit there and engage and just focus on them and listen,” said Boose, who . 

Roughly two years ago, he started using an AI notetaker app during patient visits. The tool listens while he talks with patients and then automatically generates a visit summary based on the conversation. The summary is usually ready within seconds after the appointment ends. 

“It’s taking care of all that tedious work of charting and taking notes during the visit,” he said. “It’s just freeing up a lot more time to get that done, and I can get home to my family earlier.” 

Nearly a third of physician practices are using AI scribes and others are working to add the tool, in an effort to cut down on administrative work. 

If your practitioner suggests using an AI scribe at your next appointment, here are three things to keep in mind:

1. Clinicians should ask for your permission. 

At the start of an appointment, your doctor might ask something like, “Are you OK if I use an AI scribe to help me take notes during this appointment?” A common practice is to accept verbal, not written, consent from patients before turning the tool on. However, the legal requirements for getting permission to record a patient conversation vary by state. 

Boose said you can ask to pause the AI scribe at any point, especially to discuss something sensitive. And if you decline altogether, your practitioner will likely return to taking manual notes on a computer. 

2. AI scribes make mistakes too, so check their work. 

Like other AI tools, medical scribes can “hallucinate,” or spontaneously add errors into a record. AI scribes can also omit important information or miss context clues within a conversation. 

Clinicians are supposed to review and edit the AI-generated visit summaries before adding them to a patient’s record. As a patient, it’s a good practice to carefully review your visit summary and contact your health provider if you notice errors. 

3. Yes, the AI company could use your data, with limitations. 

Companies and health systems that offer AI scribe tools have access to medical data and are subject to federal standards about how they use and store patient data, under the Health Insurance Portability and Accountability Act, more commonly known as HIPAA. 

They may use data from your appointment to help improve their software without informing you, said Darius Tahir, who reports on health technology for Â鶹ŮÓÅ Health News. “ If information is ‘de-identified,’ which can mean stripping it of identifiers [and] making sure it’s not personally traceable back to people, then it is more free to be used in more ways,” he said. “There are way fewer regulatory requirements.” 

If you want to know how your data is being used, ask either your practitioner or medical system for more information. But you might not get a clear answer, Tahir said. 

People and Policy 

The U.S. health care system will likely continue to integrate AI technology into patient care. The Trump administration strongly supports the development and use of AI, especially in health care. In early 2025, President Donald Trump issued  reducing existing regulations on AI to help the U.S. “retain global leadership of artificial intelligence.” In December, the U.S. Department of Health and Human Services released an  stating that the department supports “integrating AI to modernize care and public health infrastructure to improve health at the individual and population levels.” 

Emily Siner at Nashville Public Radio contributed to this report. 

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and Â鶹ŮÓÅ Health News.

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State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a Â鶹ŮÓÅ Health News investigation showed.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax-and-spending law. The changes will add red tape and restrictions. They are coming at a steep price ― both in the cost to taxpayers and coverage losses ― according to state documents obtained by Â鶹ŮÓÅ Health News and interviews.

The documents showÌýgovernment agenciesÌýwill spend millionsÌýto saveÌýconsiderablyÌýmoreÌýbyÌýremovingÌýpeople fromÌýhealth benefits.ÌýWhile statesÌýsignÌýeligibility system contracts with companiesÌýandÌýwork with them to manageÌýupdates, the federal governmentÌýfootsÌýmost of the bill.

The law’s Medicaid policies will causeÌýÌýtoÌýbecome uninsuredÌýby 2034, according to the nonpartisan Congressional Budget Office.ÌýRoughlyÌýÌýwill loseÌýaccess toÌýmonthly cashÌýassistanceÌýforÌýfood, including those with children.Ìý

In five statesÌýalone,ÌýÌýfor state officialsÌýand reviewed by Â鶹ŮÓÅ Health NewsÌýshow that changesÌýwill cost at least $45.6ÌýmillionÌýcombined.Ìý

The lawÌýrequires most statesÌýtoÌýtieÌýMedicaid coverageÌýfor some adultsÌýtoÌýhavingÌýaÌýjob,ÌýandÌýimposes other restrictions that will make it harder forÌýpeopleÌýwith low incomesÌýto stay enrolled.ÌýSNAP restrictions began to take effect in 2025. Major Medicaid provisionsÌýbeginÌýlater this year.Ìý

DocumentsÌýprepared by consulting company DeloitteÌýestimateÌýthat a pair ofÌýcomputer systemÌýchangesÌýforÌýMedicaid work requirementsÌýin WisconsinÌýwillÌýÌý. Two other changesÌýrelatedÌýto the state’s SNAP program will cost an additional $4.2Ìýmillion, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company thatÌýoperatesÌýthe state’sÌýeligibility system.Ìý

OptumÌý—ÌýwhichÌýoperatesÌýthe platform Vermont residents useÌýfor Medicaid and marketplaceÌýhealthÌýplans under the Affordable Care ActÌý—ÌýÌýÌýÌýÌýtoÌýevaluate andÌýincorporateÌýnewÌýhealthÌýcoverage restrictions.Ìý

Initial changes in Kentucky, which has had a contract with Deloitte since 2012,ÌýÌýÌýÌýÌý. And in Illinois,ÌýÌýwill cost at least $12 million.

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And CEO Brad Meyer fears times will soon get worse for the clinic and its 21,000 patients. That’s because Nebraska is set to become the first state to require certain Medicaid enrollees to work or lose their coverage under new rules in President Donald Trump’s One Big Beautiful Bill Act.

“This will have a huge financial impact on us,” Meyer said. On May 1, seven months before the law requires, the state will begin imposing work requirements on eligible adult Medicaid enrollees.

Most of Bluestem’s patients are covered by the government program for people with low incomes or disabilities. Meyer estimates up to 15% of them may be kicked off Medicaid, which could cost his center about $600,000 a year. That could mean cutting services or staff.

Nationwide, about 17,000 federally funded community health centers like Bluestem . They’re bracing for fallout from the law Trump signed last year, which could cost the nonprofit health centers $32 billion collectively over five years, according to the Commonwealth Fund, a health research foundation.

Health centers receive annual federal grants but depend on Medicaid reimbursements for patient care as their largest source of revenue. The government insurance program covered about half of their roughly 33 million patients in 2024.

Commonwealth estimates that 5.6 million patients of health centers will lose Medicaid coverage over the next decade as most states enact work requirements — a provision of Trump’s law that requires nondisabled enrollees to work, volunteer, or perform another approved activity for at least 80 hours a month.

Most are expected to lose coverage not because they don’t work but because of paperwork errors, like failing to document their hours or verify that they qualify for an exemption.

Health center officials say there’s no easy way to make up for the lost revenue other than cutting staff or services, which would affect all their patients. The cuts will coincide with an expected increase in patients, as people who lose coverage turn to the clinics for low-cost care.

By law, health centers are required to treat all patients regardless of their ability to pay.

A Double Whammy

Overall, about 10 million fewer Americans will have insurance by 2034, the Congressional Budget Office estimates, both because of Trump’s law and congressional Republicans’ decision to scale back premium subsidies for Affordable Care Act health plans.

“We are incredibly worried,” said Jeffrey McKee, CEO of Community Health Centers of Burlington in Vermont. His clinics treat about 35,000 patients a year, nearly a third covered by Medicaid.

He predicts a surge in uninsured patients will cost another $3 million in lost revenue. That revenue crash could imperil street medicine programs and home care for patients 65 and older, he said.

In 2024, community health centers because of rising costs and the expiration of covid pandemic-era relief funds, according to a Â鶹ŮÓÅ analysis.

Centers with high rates of uninsured patients typically struggle more financially, while some centers are sustained through private donations.

People without insurance — who made up about 18% of all health center patients in 2024 — pay on a sliding scale. Those amounts are a fraction of what insurers pay.

The new Medicaid work requirements apply to Washington, D.C., and 40 states that expanded Medicaid eligibility under the ACA, and to adults with incomes up to 138% of the federal poverty level — $22,025 for a single person this year.

Republicans say the work requirements will nudge people into the workforce and help preserve Medicaid for children and people who are pregnant or have disabilities. Studies by Â鶹ŮÓÅ and others show most enrollees already work, go to school, or have a health condition that prevents them from working.

Nebraska Is First Up

The Trump administration approved Nebraska’s early launch of its work requirement program, which could affect about . State Medicaid officials say they plan to use state and national databases to check whether people are already working or meeting an exemption so that most won’t have to do anything to keep coverage. But thousands will need to prove they satisfy the requirements.

At Bluestem in Lincoln, Meyer worries many of his Medicaid patients won’t take the steps needed to keep coverage.

Angelisa Corum, 57, said she loves the care she has gotten from her regular doctor at Bluestem Health over the past dozen years, particularly in dealing with breast cancer. “I am cancer-free, and they helped me get through that,” she said.

She said the care was the same when she was covered by her husband’s commercial insurance through his employer and when she was on Medicaid while he wasn’t working.

The work requirements are just one part of the Republican law passed last year that could hurt the health centers. It also requires more frequent eligibility checks for adults enrolled under Medicaid expansion, which advocates say could also lead people to lose coverage. Many states now require eligibility checks only once a year.

The law also reduces overall federal Medicaid funding to states, which may prompt them to cut reimbursements to centers and other health providers.

The National Association of Community Health Centers, the largest advocacy group for the clinics, has tried to walk a tightrope, warning about impending cuts from the law while still working with the Trump administration. The group praised Congress for increasing base grant funding for health centers in the federal budget approved in January.

Kyu Rhee, CEO of the national association, said the clinics enjoy strong bipartisan support in Washington despite the Medicaid cuts.

He has met with Trump administration officials to discuss how health centers can play a role in keeping people from losing coverage due to work requirements. He said they can help meet other priorities of the administration’s, like improving American diets, expanding primary care, and focusing on chronic diseases — though it’s unclear how any of that would result in more funding.

To further show the reach of health centers, the association recently funded a study that found 52 million people visited the clinics over a three-year-period. “It makes a statement we serve a lot more Americans than those from just a single year,” Rhee said.

Health center officials are hopeful they will get some of the funding from the $50 billion Rural Health Transformation Program included in the GOP-passed law. States will begin spending the first tranche of that money this spring.

Rhee said he is encouraged that states will have technology to help tap into databases to verify many enrollees’ work status or health conditions to meet “medical frailty” rules that could help them avoid being disenrolled.

Others are less optimistic.

“Health centers are bracing for a major financial impact,” said Sara Rosenbaum, a health law and policy professor at George Washington University and Medicaid expert who co-authored the Commonwealth Fund study. “The way they cope is the same way health systems usually cope as they go through mass layoffs, site closures, and service reductions.”

Amanda Pears Kelly, CEO of Advocates for Community Health, a trade group representing 52 health centers, said health centers are also worried about rising costs, especially for prescription drugs. The impending financial challenges will make it more difficult to hire staff both in rural areas where doctors and nurses are scarce and in more populated areas, where competition for workers is more acute, she told Â鶹ŮÓÅ Health News.

“The challenge is health centers are being hit from every direction,” Pears Kelly said.

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