The waiver program, run by the Department of Health and Human Services, allows physicians who aren’t U.S. citizens to stay in the country while transitioning from the visa they used during their training to temporary worker status. In exchange, the doctors agree to work in underserved areas for at least three years.

“It will be the patients that suffer the most because in about three months, there’s going to be hundreds of places that are not going to have a physician that should have,” said a psychiatrist caught in the delay.

The doctor — whom Â鶹ŮÓÅ Health News agreed not to identify because they fear government reprisal — was among hundreds who applied this year for a J-1 visa waiver through the HHS Exchange Visitor Program.

If they receive one, the psychiatrist — who attended medical school in their home country in Europe before coming to the U.S. for their residency and fellowship — would work with vulnerable and disadvantaged patients in New York.

In recent years, the HHS program reviewed waiver applications in one to three weeks, according to two immigration attorneys.

But it currently has a backlog of hundreds of applications, which still need to be reviewed by the State Department and approved by U.S. Citizenship and Immigration Services, according to four attorneys interviewed by Â鶹ŮÓÅ Health News.

They said the foreign physicians will likely have to return to their home countries if their applications don’t advance to USCIS by July 30.

For them to reenter the U.S., their employers would have to pay a new $100,000 fee associated with the H-1B work visa. It’s a cost that many hospitals and clinics in rural and underserved areas say they can’t afford. “That’s the cliff that this train is headed for,” said Charles Wintersteen, a Chicago-based attorney who specializes in health workforce-related immigration.

HHS spokesperson Emily Hilliard didn’t answer questions about the number of pending applications or explain what caused the delays. But she said the Exchange Visitor Program has reviewed all fiscal year 2025 clinical J-1 waiver applications, as well as some from fiscal 2026.

The department is “implementing key process improvements to prevent future delays” and “working diligently” to evaluate remaining applications ahead of the July 30 deadline, she said.

The psychiatrist in limbo said employers hiring J-1 waiver physicians have to show they were unable to fill positions with American workers. If the doctors they planned to hire can’t arrive on time — or at all — patients will have to wait even longer for those vacancies to be filled, they said.

Wintersteen said postgraduate medical education positions are largely funded through Medicare and that “the taxpayers who pay for that training will not get the benefit of it.”

Physicians and immigration attorneys said HHS hasn’t explained the delays or let them know what to expect from their applications.

“Why would HHS want to take a program that is working — a program that places hundreds of U.S. trained international physicians in highly underserved parts of the country every year — and slow-walk it into non-existence,” Jennifer Minear, a Virginia-based health workforce immigration lawyer, said in an email. “How does that serve the public health? It is baffling.”

Waylaid Waivers

The U.S. healthcare system depends on foreign-born professionals to fill its ranks of doctors, nurses, technicians, and other health providers, particularly in chronically understaffed facilities in rural and low-income urban communities.

Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to .

Once noncitizens complete postgraduate education in the U.S., which typically ends on June 30, they must return to their home country and wait two years before applying for an H-1B work visa. Or, they can seek , which lets them remain in the U.S. on H-1B status in exchange for working for three years in a provider shortage area.

The attorneys said they’re seeing delays only in the Exchange Visitor Program, not in the other federal or state J-1 waiver programs.

The HHS clinical care program received 750 waiver applications last year, Minear and Wintersteen said, and is reserved for doctors working in pediatrics, psychiatry, family and internal medicine, or obstetrics and gynecology.

The program typically needs to forward recommendations to the State Department by mid-March, from John Whyte, CEO of the American Medical Association.

Minear said HHS stopped processing applications in late September or early October before it started forwarding them again a few months ago.

“But the pace is dramatically slower” than usual, she said.

Minear said the State Department usually takes two or three months to review HHS recommendations and must send them to USCIS before July 30 for most of the doctors to stay in the country.

If they don’t make that deadline, Wintersteen said, doctors will have to leave the country unless they obtain another kind of visa, get a J-1 waiver through another program, or extend their current visa by taking board exams or doing additional training.

The psychiatrist, who is supposed to start work on July 1, said they applied for a waiver in order to stay in the U.S with their partner, and because it would let them help the most vulnerable mental health patients. They said their future clients would likely include trafficking survivors, homeless people, and prison or jail inmates. “That’s the population I want to work with,” they said.

Waiver Delay Meets H-1B Dilemma

President Donald Trump issued a that railed against the tech industry’s use of H-1B work visas. The order created the $100,000 fee that applies to workers in all fields — not only tech — living outside the U.S. The payment doesn’t apply to those already in the country.

As of Feb. 15, employers had paid the fee for 85 workers, from USCIS. It’s unclear if any of those payments were for physicians or other medical providers.

The psychiatrist said officials at the hospital that plans to hire them said they can’t afford to pay to bring them back to the U.S. if they must go home.

“A lot of hospitals who hire J-1 waiver physicians are in underserved areas, and so they treat Medicare and Medicaid patients,” they said. “By definition, for the most part, they’re not rich hospitals.”

Barry Walker, an attorney in Tupelo, Mississippi, focused on health workforce-related immigration, said employers have already spent money on recruiters and attorneys like him to help with the waiver process.

Adding the H-1B fee is “just a deal killer, especially for the small, rural hospitals,” he said.

Attorneys said most employers will sponsor physicians in need of an H-1B visa only if they’re in lucrative specialties, such as cardiology or orthopedics, in which they can recover the cost of the fee.

They said healthcare facilities are much less likely to pay the fee to hire foreign nurses, lab technicians, and other healthcare professionals who are more likely than physicians to complete their training outside the U.S.

Employers , but attorneys said they haven’t heard of a hospital or clinic being granted one.

Fighting on Two Fronts

Physicians, hospital leaders, lawmakers, and immigration experts are trying to draw attention to the J-1 waiver delays at HHS while hoping to overturn or limit the new H-1B fee.

The Trump administration hasn’t acted on letters from , , and that requested an exception to the $100,000 fee for physicians or all healthcare workers.

In March, a bipartisan group of lawmakers that would create a healthcare exemption. It has not yet had a hearing.

At least three lawsuits — from the , a , and a that includes a company that recruits foreign nurses and a union that represents medical graduates — are seeking to end the fee entirely.

As for the J-1 waiver delays, the American Medical Association CEO asked the Exchange Visitor Program to use “emergency batch processing” for physicians with contracts to start work this summer.

Efrén Manjarrez, president of the Society of Hospital Medicine, which represents doctors who work in inpatient units, also called for emergency measures.

“Every day this backlog persists is a day that hospitalized patients in these communities face greater risk,” to the program.

Meanwhile, Canadian hospitals have been recruiting foreign physicians completing their training in the U.S, the psychiatrist said. They said one of their friends accepted an offer, withdrawing their HHS waiver application to head north.

The psychiatrist said if they must leave the U.S., they’ll be separated from their partner and out of a job for months as they work to get licensed in their home country.

Even if their employer were able to afford the H-1B fee, they’re not sure they’d want to return.

“This entire process has been so incredibly painful and just soul-crushing,” they said. “I would rather go to a country that would appreciate my motivation to work with patients.”

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If you or someone you know is seeking help for addiction recovery, contact the free and confidential treatment referral hotline, 1-800-662-HELP, or visit findtreatment.gov.

A day after Hurricane Helene ripped through western North Carolina in late September 2024, Toni Brewer had no power or water. The storm had strewn fallen trees across most roads, wiped out phone and internet communications, and put some neighborhoods near her Asheville home underwater.

Brewer cleared out the food in her refrigerator, grabbed some clothes, and drove more than an hour southwest with her partner to Franklin, to stay with relatives.

When she arrived, she opened the center console of her car, where she kept medication, and discovered another crisis. She had only three days’ worth of Suboxone, a brand of buprenorphine, a prescription drug that eases opioid cravings. Without it, she risked relapsing into a life she described as miserable.

She recalled what it felt like to have those cravings and panicked.

“It’s terrifying just to have that feeling again of, ‘I need this, and I’ll do whatever it takes to get this,’” said Brewer, who had been in recovery from opioid addiction for 18 months at the time. She needed a new prescription but knew communication lines at her doctor’s office were down.

Now, a group of doctors is using the example of Hurricane Helene to urge federal lawmakers to help improve access to substance use medications in severe weather emergencies. Four physicians working in addiction medicine that outlines strategies for getting medication to people in recovery during natural disasters.

As climate change  in the U.S., the group of doctors urged state and federal governments to act soon or risk allowing more disasters to aggravate overdoses, relapses, and deaths caused by opioid use disorder, an ongoing epidemic that has  people in the U.S. since 1999.

that after Superstorm Sandy in 2012, 70% of New Yorkers who relied on recovery medications couldn’t get enough of them. In the two years following Hurricane Maria’s devastation in Puerto Rico in 2017, , another study found. The Tubbs and Camp fires in Northern California in patients’ access to opioid addiction medications, found a study published in 2022.

A combination of factors aggravates the opioid crisis in the U.S., the AJPH editorial authors noted. Mental health stressors, treatment disruptions, drug market volatility, and economic decline all create conditions in which climate-related disasters heighten the risk of overdose deaths.

“We make it so challenging for them to access treatment medications in the first place,” said , the climate health director at Rowan University’s Cooper Medical School and a co-author of the editorial. “When people are displaced or unable to get to their usual clinics or pharmacies, those challenges just become insurmountable.”

Their push comes as President Donald Trump has had a markedly different approach to substance use policy in the past year than in his first term. Trump in 2017 declared the nation’s opioid crisis a national public health emergency and, in 2018, signed a law, known as the , to expand access to treatments.

But his administration has also reduced federal resources for mental health and substance use services, cutting staffers last year at the Substance Abuse and Mental Health Services Administration and ending numerous grants to advance research on prevention efforts.

Disasters Threaten Treatment

SAMHSA works with states to ensure that access to opioid use disorder medication isn’t disrupted, Health and Human Services spokesperson Emily Hilliard said. States can approve emergency measures to allow people more flexibility to obtain their treatments, she added, .

, another co-author of the editorial, saw these access issues play out in the wake of Hurricane Helene.

Stearns, the chief medical officer at High Country Community Health in North Carolina’s Blue Ridge Mountains, said the first calls to her clinics were for buprenorphine. She said people who needed the medication traveled over mountains and crossed rivers to get to her clinics.

“The things that my patients did to be able to access their bupe,” Stearns said, “it was astonishing.”

The that the federal government work with pharmacies to allow patients to take home more medication during emergencies. They suggest keeping a registry of patients with recovery medication prescriptions who can get treatment when evacuating across state lines.

And they propose factoring the need for such medications into disaster response plans, whether that means stocking rescue vehicles with buprenorphine, adding backup generators to opioid treatment clinics, or training volunteer responders.

People with substance use disorders already must often navigate strict, complex regulations to get the medications. For example, methadone can be obtained only through an in-person visit to federally controlled opioid treatment centers, many of which closed for days or weeks after Hurricane Helene.

Buprenorphine is controlled by the Drug Enforcement Administration’s , which restricts supply when pharmacies order more than allowed under specified thresholds. The system is meant to catch potential overuse of recovery medication in a region.

, a clinical director of substance use disorder initiatives at the Mountain Area Health Education Center in western North Carolina, said that system delayed medications numerous times in the aftermath of Helene. No exceptions were allowed, .

The agency did not respond to questions about the system.

Individual pharmacies also control who gets medication and who doesn’t. When people try to get medication for opioid use disorder far from home, it can raise alarms.

“We realized there were some pharmacies that would just be like, ‘I don’t know this person. I will only give you three days’ worth, and I’m sure they’ll be back in Asheville soon,’” Fagan said. “They didn’t want to fill a month’s worth. And in our mind, we’re sitting in the disaster, and we’re like, ‘They’re not coming back in a month.’”

Risk of Relapse

When Brewer made it to Franklin, she immediately logged in to the Mountain Area Health Education Center patient portal, dubious about whether she would be able to have her three-month Suboxone prescription refilled.

She didn’t know that her doctors had left the area, too, to get a stable internet connection. They were trying to call and email patients to fill prescriptions.

Trying to be thorough, Brewer messaged several doctors. Two responded, and one filled her prescription.

But when she went to a local Walgreens, it was out of Suboxone. So Brewer took another trip, this time to Clayton, Georgia, where she was finally able to pick up a month’s worth.

The medication that would have been mostly covered by North Carolina Medicaid if she’d stayed in-state was about $130, a high price for Brewer, who had temporarily lost her job when her workplace, a sober living facility, lost power and closed because of the storm.

Despite what little income she had at the time, Brewer said, she paid for her prescription. The thought of relapsing back to her previous life when her addiction was untreated scared her, she said.

“I would wake up every day, and the only thing on my mind was finding my next fix so I could go on about my day, or even just take care of things like feed myself, or bathe, and show up for my daughter,” she said.

Brewer recalled feeling relief after getting her prescription refilled. Her panic washed away.

“Now I can worry about everything else,” she recalled thinking as she drove home to Asheville.

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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.”

Someone in America dies by suicide every 11 minutes. It’s that common. But not normal.

Humans have evolved over centuries to survive. So when people try to kill themselves, something has gone wrong. Typically, the assumption is that something happened in the person’s mind — a mental illness.

But in recent decades, there’s been a growing movement to ask a different question: What went wrong in the world around that person?

For Chris Pawelski, it was a torrent of factors. His dad — one of his best friends, whom he worked with daily for decades — was diagnosed with renal cancer and died six months later. Pawelski was left as the primary caregiver for his mom, who had dementia.

His family’s in New York’s Orange County — where he first worked as a 5-year-old, collecting onions that fell out of crates — was hemorrhaging money. Pawelski said he was growing roughly $200,000 worth of crops some years but took home only about $20,000, unable to negotiate higher prices with wholesale buyers that dominated the market.

Debt to suppliers and equipment vendors piled up, and the burden strained his marriage. He had little time for friends, working sunup to sundown seven days a week, desperately trying to preserve his family’s legacy.

“It’s all stuff collapsing down upon you,” he said. “It’s weeks, months, years of dealing with all sorts of pressures that you can’t alleviate.”

Pawelski started wondering what it would be like to get hit by a truck on the busy road in front of his house. “You think you’re already on your way out, so why wait?” he said.

Millions of Americans have , and tens of thousands . Suicide repeatedly ranks among the — making the U.S. an .

Prevention efforts have typically focused on connecting individuals in crisis with treatment — despite therapy and medication being , the healthcare system , and a consensus that suicide is caused by a , including but not limited to mental illness.

Now, many people working to prevent suicide, including some who have tried to harm themselves or lost a loved one to it, are calling for a broader approach. Some were galvanized by the covid pandemic, when rates of — not because everyone’s brain chemistry suddenly changed but because the world changed. That led many to believe that, while treatments and crisis care are vital, the goal of suicide prevention needs to expand beyond stopping people from dying to also giving them reasons to live.

“It’s not rocket science,” said , a psychologist and internationally recognized suicide prevention researcher who lost her brother to suicide. If “you have happier, healthier people, they live longer, happier lives.”

That means suicide prevention shouldn’t be limited to answering hotlines or treating patients in psychiatric wards, she said. It should also involve running food banks to ensure families don’t go hungry or hosting weekly book clubs for homebound seniors to make friends. It can take the form of school programs that build resilience in children or housing policies that prevent evictions.

shows these — even if they don’t have the words “mental health” or “suicide” in the title — can reduce the number of people who kill themselves. They often lower rates of crime, addiction, and poverty, too.

The U.S. has lagged other countries in adopting this approach, Spencer-Thomas said, perhaps because it’s easier — and more politically palatable — to tell someone to go to therapy than it is to enact sweeping policy changes, such as an .

“As long as we have that convenient narrative that it’s just a bunch of broken people needing medicine and treatment, then we’re never accountable for fixing the broken things in our communities,” Spencer-Thomas said.

The Trump Administration’s Approach

Overhauling suicide prevention efforts to focus on broad social and economic policies might seem overwhelming and unrealistic — especially right now. This approach requires large upfront investments that lack across-the-board support, either because of budgeting realities or ideological bents.

President Donald Trump and his appointees have said little about suicide directly, but many of their policies do the opposite of what shows .

The administration has championed and the that are projected to leave and in coming years. It has injected uncertainty into the economy through , , and . It has for school-based mental health initiatives, gutted federal programs that focus on at-risk blue collar workers, and . (Suicides are the in America.)

“All of these changes are creating a firestorm,” said , the chief advocacy officer for the National Alliance on Mental Illness. They can cause “extreme stress and anxiety” in people’s lives, she added, and “when people feel desperate, that’s when crises can emerge.”

Federal health officials insist that suicide prevention remains a priority.

, director of the Centers for Disease Control and Prevention’s injury center, said the agency is focused on creating systems that can support people “no matter what may be happening” in the world around them. “There’s always going to be turmoil in people’s lives,” she added.

Arwady and , who leads suicide prevention work at the Substance Abuse and Mental Health Services Administration, said several of the Trump administration’s priorities align with an upstream approach.

For example, they said, its could help address the , since exercise is proven . Similarly, people who are homeless have , and the administration has been . Federal officials have also encouraged , and research shows members of faith communities are .

However, the Trump administration has made at and and has for , leading to questions about whether or how this work will continue.

A History of Medical and Crisis Care

Suicide prevention reached the national stage in the late 1990s, said , who worked at the CDC for 15 years before joining the , a nonprofit focused on teen and young-adult mental health.

As suicide rates grew among young people, a group of government officials, clinicians, and advocates gathered in Reno, Nevada, in 1998 to discuss the pressing issue. Over the next few years, the surgeon general and the federal government published its .

These documents acknowledged the role of society and economics in suicide risk but focused heavily on identifying people in crisis and increasing access to medical treatment.

Those are critical steps to suicide prevention, many mental health researchers and clinicians say. They’re also politically favorable. For elected officials, who have a few years to demonstrate their achievements before the next campaign, it’s easier to count the number of people receiving therapy than the number of people who never developed suicidal thoughts because long-term economic and social investments helped them maintain steady jobs and strong friendships.

The push for individual treatment also comes from a pervasive misconception that suicide is always the result of an underlying mental illness, said , who is the senior director of population health at Mental Health America and contributed to a .

Although how many people who die by suicide — with estimates from to — the takeaway is that mental illness is not the sole cause, Reinert said. That means treating it can’t be the sole response.

Plus, mental illnesses can be by life circumstances. Treating depressive symptoms without looking at factors such as childhood trauma, the loss of a loved one, or being laid off from a job is an incomplete approach, many mental health researchers and clinicians say.

The covid pandemic, especially, made people in the field recognize “we really need to address all of these conditions that are creating stress, anxiety, and crises,” Stone said.

In July 2022, the federal government — a shorter number for the national suicide crisis line, meant to provide an alternative to 911 for mental health emergencies.

, who led federal work on 988, said the infusion of money and attention on the hotline helped states build better crisis response systems, from centers that answer calls to mobile crisis units.

But that’s not enough to solve America’s suicide problem, she said. “You’ll never be able to build a system based on crisis alone.”

Help for the Farm and the Farmer

Pawelski, the onion farmer in New York, hit his breaking point in 2020.

He had a decent crop that year, but Canadian exporters were into American markets, making it difficult for him to sell his product.

“I was having to beg people” to buy, he said. And when he managed to sell, prices were comparable to prices in the 1980s.

By the end of the season, he had incurred losses of a few hundred thousand dollars.

He said he and his wife decided, “We couldn’t afford to grow onions again.”

The idea that his family’s onion farm would end with him was “soul-crushing,” Pawelski said. He lost weight rapidly and thought about ending his life.

He and his wife called for help. Founded at Cornell University in 1986, the free program connects farmers with two consultants: a financial analyst specializing in farm planning and a social worker focused on emotional concerns and family dynamics.

The financial specialist helped Pawelski develop a new business plan. Instead of farming onions for wholesale, he could grow greens, tomatoes, peppers, and eggplants at a small scale to sell directly to consumers. He could upgrade an old truck with a cooler and deliver produce to people’s doors. He would supplement that income with teaching, speaking engagements, and other work that took advantage of his master’s degree in communications.

The social worker helped him accept that new reality — equally crucial, Pawelski said. “If you’re pissed off” about the change, “no matter what kind of proposal or idea they have, it’s not going to go anywhere.”

The adjustment took months. Pawelski also saw a therapist during that time.

Then one day a neighbor noted that Pawelski seemed much happier. That “caught me off guard,” Pawelski recalled. He didn’t realize his inner transformation was so apparent.

Today, Pawelski’s business has stabilized, and he and his wife are paying down debt. Pawelski advocates for programs to help farmers’ mental health and address their .

That can mean crisis hotlines and access to affordable therapy, Pawelski said. But what he really wants are policy changes that help farmers get fair prices for their produce, debt relief, and the installation of broadband internet in rural areas so farm families and employees can be connected.

“We need to think broader and longer-term than a helpline,” he said. That’s “a band-aid on a gunshot wound.”

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It was “just like a mosquito bite, nothing major, and I just scratched it,” said Toska, a political science professor.

Then she began to itch everywhere. She couldn’t see anything in the dark, so her husband shined his phone light on her.

She was covered in hives.

Because she also felt pressure in her chest, the family quickly went to an urgent care clinic. A doctor there recognized she was experiencing , a life-threatening, fast-moving allergic reaction.

The doctor rushed her to a room without checking her in, saw her blood pressure was low, and administered two epinephrine injections and IV fluids, Toska said. The itching stopped, and the tightness in her chest went away.

But the doctor said she needed to be monitored in an emergency room for at least two hours in case the reaction flared up again. Toska said the doctor insisted she take an ambulance to a nearby hospital, Atrium Health Lake Norman.

Minutes later, she found herself lying on a stretcher in the ER.

A doctor she described as “lovely” came in and spoke to her for no more than five minutes, Toska said. A nurse administered medicine through the IV line inserted at the urgent care clinic.

Toska was exhausted, but her mind was on her daughters. “I had two little kids who were scared, so I was playing with them and trying to distract them.”

After about an hour and a half, the doctor returned briefly, then the family went home, she said.

“That’s it,” Toska said. “Nothing happened at the ER.”

Then the bill came.

The Medical Service

Toska said the ER doctor reviewed her vitals and discussed her allergic reaction and what to watch for when she got home. She also received a dose of famotidine, a drug often used to treat an upset stomach that is also administered for allergic reactions.

The Bill

The in-network hospital system charged Toska’s insurer, Blue Cross Blue Shield of North Carolina, $6,746.50 for the ER visit, including $20.60 for the famotidine and $6,445.60 in “critical care” charges. Toska, who had not met her insurance deductible, was responsible for a $150 copay and $3,100.24 of the charges.

The Billing Problem: Critical Care

“Paying $3,100.24 for literally sitting in the ER entertaining my kids for an hour and a half feels kind of incredible,” Toska said.

Medical providers in the United States use a uniform coding system to bill for procedures and services. Most of Toska’s ER charges stemmed from Atrium Health’s use of two billing codes for “critical care” — one for 30 to 74 minutes of care, at $5,617.85 (code 99291), and another for an additional 30 minutes (code 99292), at $827.75.

According to the coding system, critical care is when a doctor “directly” provides at least 30 minutes of care to a patient with “a probability of imminent or life-threatening deterioration.”

According to the ER’s visit notes, which Toska shared with Â鶹ŮÓÅ Health News, Toska told the doctor there she was feeling “significantly better” when she arrived, and the doctor reported providing 90 minutes of personal critical care.

Anaphylactic shock is treated under code 99291, according to the . Though Toska’s symptoms may have indicated she was no longer in shock, treatment guidelines require at least two hours of monitoring, said Arjun Venkatesh, the chair of emergency medicine at the Yale School of Medicine.

With anaphylaxis, “some people are going to progress and require admission to the ICU, and some won’t,” Venkatesh said.

Toska was under critical care because of what could have happened, not what did happen, Venkatesh said. Hospitals use the same billing codes for the ER visit, whether a patient’s condition deteriorates or not.

“The billing rules are not built around this,” Venkatesh said.

Laura Eberhard, a spokesperson for Blue Cross Blue Shield of North Carolina, said Toska’s claims “were submitted by the provider using critical care codes, which represent a higher level of severity and reimbursement, and were processed in-network under the terms of the member’s plan.” She did not answer questions about whether Blue Cross Blue Shield negotiated the charges.

A spokesperson for Atrium Health did not answer questions from Â鶹ŮÓÅ Health News about Toska’s visit.

The Resolution

Toska said she called Blue Cross Blue Shield of North Carolina, trying to get a better explanation for why the bill for so little hands-on care was so high.

“The doctor determines the severity of the situation, and that’s the code we have,” the insurance representative said, according to Toska’s recollection. “This is critical care, and that’s what it costs.”

After Toska contacted the hospital, Atrium Health’s Audit and Appeals Department replied in a letter that the critical care designation was “based on the presenting problem that brought you to the emergency room, the treatment provided, and the nursing staff that took care of you.”

“It also includes the room, supplies, and equipment utilized during the visit,” the letter continued. “The charge is not based on time spent in the facility or with clinicians.”

Asking why the ER visit cost so much was more a matter of principle than necessity, she said, though she thought back a few years to a time when it would have been much harder for her to pay.

“The system is so broken,” Toska said.

The Takeaway

“Her experience is, sadly, very typical,” said Barak Richman, a professor of business law and co-director of the Health Law and Policy program at George Washington University. “Once you are brought onto the train of health care delivery, you have no control over where the stops are.”

Emergency rooms — for many the for medical care — are notorious for high costs, he said, adding that insurance companies should always try to negotiate critical care codes.

Toska was fortunate to dodge another problem common in emergencies: The bill for taking an ambulance to the ER was about $275, she said, notable since ambulance rides frequently result in bigger bills that may not be covered by insurance.

Patients can dispute charges with their insurance and the hospital. Like Toska, they should come to the phone with an itemized bill, medical records, and any other relevant documents, such as explanation-of-benefits statements.

Regardless of whether that’s a fight they can win, some who see one ER bill , especially if it might put them in .

In early March, Toska had a second allergic reaction. “OK,” she recalled thinking, “Do I go get the EpiPen? Do I go to the ER and get another massive bill?”

She decided against the trip and took Benadryl instead.

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“They’re the folks that work at restaurants. They’re the teacher’s aides,” said Starr, a registered nurse who became Open Door’s chief executive more than six years ago. Those patients, he said, are “really the heart and soul of rural America.”

He said if his remote health centers don’t get a share of the billions of dollars Congress earmarked to transform health care in rural America, patients may soon lose services. About 50% of Open Door’s 60,000 patients are on Medicaid, the joint state and federal insurance program that, together with the related Children’s Health Insurance Program, covers with low incomes or disabilities.

When Congress approved the One Big Beautiful Bill Act last summer, it cut nearly $1 trillion from Medicaid over the next decade. Now, Starr hopes the $50 billion Rural Health Transformation Program, which was part of the same bill, will help keep his patients covered.

Yet, small community health care providers, such as Open Door, may find they are sharing the billions with an army of corporate giants before it reaches their patients.

Months after federal leaders announced that all 50 states won first-year awards, ranging from $147 million for New Jersey to $281 million for Texas, state plans reveal that a heavy dose of prescribed spending will go to companies that can increase the use of electronic health records, strengthen cybersecurity, and improve state and health system technology platforms.

And at least four large-scale coalitions of companies are now pitching multipronged services to the states. Many of the companies already work with regional health systems and states through Medicaid contracting or mobile and telehealth operations.

How those services will help improve the health care of rural Americans at places such as Open Door remains an open question.

States Stare Down Reporting Deadlines

Federal regulators were “really interested in seeing digital health investments” when they crafted the five-year rural health program rules last year, said Maya Sandalow, an associate director at the Bipartisan Policy Center, a think tank based in Washington, D.C. She co-authored a recent report on how the 50 states plan to invest in technology, including modernizing health care infrastructure and expanding virtual care options such as telehealth and remote patient monitoring.

“The rural health fund isn’t really designed to directly replace or offset the lost Medicaid funding,” Sandalow said, noting that the federal staffers in charge of the program — money that could help rural hospitals and clinics pay for patient care — at 15% of the total funding awarded to a state.

Federal regulators also established tight reporting deadlines, forcing states to move quickly.

States must file progress reports and obligate all first-year funding , according to the Centers for Medicare & Medicaid Services, the federal agency overseeing the program. States could see their awards decreased or terminated at any time if they fail to follow federal requirements, according to the .

As of early April, CMS had not approved or had only partially approved some state budgets, including those of Wyoming, Colorado, and Vermont, according to state officials. CMS spokesperson Catherine Howden, who declined to say which states still needed revised budgets approved, said the agency does not provide “state-by-state updates.”

In Alaska, the budget is approved but the state has not announced when it will release full grant proposals and awards, said Tricia Franklin, program coordinator for Alaska’s rural health transformation.

“Early summer was the target,” Franklin said. But the response from vendors and applicants has been “much greater than expected, so it may take us a little longer.”

Working with consulting companies is an established way for states to “quickly and effectively” meet federal deadlines and roll out grant money, said , national director for population health at the Milbank Memorial Fund, a nonprofit focused on state health policy work.

Upgrading Technology, Modernizing Rural Health

Science Applications International Corp., a Fortune 500 government contractor, pulled together the . SAIC does a variety of technology work such as cybersecurity and engineering support. The alliance also includes Walgreens and Mission Mobile Medical, which turns RVs into primary care clinics. A data analytics company, a telemedicine and software company, and a company that helps place medical graduates in health systems are also part of the coalition.

The SAIC alliance offers “an ecosystem” of companies that can coordinate the work states have promised, said , SAIC’s Rural Health Transformation Program lead and a former chief information officer for the Virginia Department of Health. Each of the companies has representatives focused on the rural program, he said.

A lack of digital infrastructure — such as electronic health records at different clinics and hospitals that can talk to one another — has been a consistent barrier for rural medical care teams, said the Bipartisan Policy Center’s Sandalow.

“The funding hasn’t always been there in order for rural areas to create the infrastructure that’s needed to fully adopt remote patient monitoring, telehealth, artificial intelligence in ways that will really be supportive,” Sandalow said. “It takes things like updating infrastructure, changing workflows.”

Sandalow’s found that Maine and Utah are investing in cybersecurity; Indiana, Missouri, and New Mexico plan to modernize their electronic health records; Oklahoma plans to buy hardware and software, subsidize subscriptions, and give technical support to rural providers; and states such as Arizona and South Carolina will use funds to create telehealth hubs or buy remote patient monitoring equipment.

Federal regulators, when creating the rural program’s spending rules, also said no more than 5% of a state’s total funding awarded could be used to replace electronic medical records systems that already meet federal standards. Sandalow said that means states will focus on enhancements and upgrades to their current systems.

Gainwell Technologies, which operates the systems for dozens of state Medicaid programs, is spearheading . Rushil Desai, a Gainwell senior vice president, said states’ detailed spending plans are “changing in real time.”

Maine’s Medicaid plan contracts with Gainwell, and the state’s initial application listed four contracts worth more than $16 million over five years for the company. The state confirmed it has received federal approval for only its first year of spending, which includes a to implement changes to the state’s Medicaid claims system.

James Lomastro, a senior-care advocate in rural Massachusetts with the nonprofit , said he worries that large vendors and health systems will get the state’s transformation dollars.

Clinics, home care agencies, and nursing homes that “actually provide day-to-day support in the community are mostly on the margins” of state discussions about how to spend the money, he said. A spokesperson for Massachusetts’ Executive Office of Health and Human Services, Olivia James, said state officials would “ensure that everyone has a seat at the table” with training, financial incentives, and direct investments.

Arizona’s rural fund budget, which is $167 million for the first year, allocates for medical diagnostic equipment and technology upgrades, including to electronic health records, specifically for rural health care facilities.

But it also for county public health departments, said Pima County Public Health Director Theresa Cullen. The approved budget includes up to $4 million for grants to support community health workers.

“In these rural communities, you need to be present,” Cullen said.

Alina Czekai, director of the CMS rural health transformation office, said her team plans to visit all 50 states. She spoke at the National Rural Health Association’s policy conference in Washington, D.C., in February and told the audience that her team wants “the money to go to rural communities, rural providers, rural patients.” The association’s members include rural hospitals and clinics, which are expected to suffer big losses under the Medicaid cuts.

In California, Open Door’s Starr said he provided input on his state’s initial application, which won $234 million in first-year funding, but he is not clear on what the next steps will be for getting money from the program.

For his patients, Starr said, money is needed for technology upgrades. After all, he said, updated electronic health systems could operate seamlessly and store the documentation needed to keep a patient enrolled in Medicaid.

Updated technology could be exactly what Open Door and other area clinics need to “help keep people covered,” Starr said.

Â鶹ŮÓÅ Health News senior correspondent Phil Galewitz and rural health care correspondent Arielle Zionts contributed to this report.

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The patient lived alone, and “really struggles with social isolation,” Guzman said. After a serious fall and subsequent surgery, the woman was using a wheelchair. She confided that she would like to attend services at a church down the road but had no way to get there and did not want to seem “a bother.”

“We called the pastor to see if there was someone who could pick her up” on Sundays, Guzman said. And there was.

The next day, Guzman visited a woman with heart failure who required constant oxygen. She lives in “less than ideal housing,” with no kitchen and only a plug-in heater for warmth.

“We were trying to figure out if she qualifies for HUD housing or assisted living,” Guzman said, referring to the federal Department of Housing and Urban Development. “We spent a lot of time talking about the options and came up with a game plan.”

Wednesday’s schedule included a 20-mile drive to Hood River to see an 81-year-old woman whose partner of nearly 40 years was contending with a serious cancer. Guzman, who speaks to her in Spanish, found her distraught at the possibility of losing him.

Guzman had arranged for the woman to begin seeing a therapist to help her through the crisis — no minor achievement. But on this visit, “I just handed her tissues and tried to give words of comfort,” she said. “Honestly, sometimes just sitting and listening” is the best response.

A community healthcare worker, the , is a “trusted member” of a local community or someone who has “an unusually close understanding” of it, enabling the worker to serve as intermediary between patients and the healthcare system.

These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics , which the National Association of Community Health Workers says is probably an underestimate.

That partly reflects the difficulty of counting workers who go by a variety of names — community health educators, outreach specialists, promotores de salud — and operate under different state regulations, sometimes with no licensure or certification required.

What they have in common is that “they talk like the people they work with,” said Sam Cotton, who directs the curriculum for several such programs at the University of Louisville in Kentucky.

With shortages of healthcare professionals and an aging population, “there’s a lot of momentum for this,” she said.

In Oregon, for example, five rural clinics employ community health workers, who become state-certified after completing 90 hours of online training, through a program called Connected Care for Older Adults. A sixth clinic employing a community health worker operates in neighboring Washington.

Their frail patients are struggling. “They can’t drive, so they can’t get to a grocery store and shop,” said Elizabeth Eckstrom, chief of geriatrics at Oregon Health & Science University, who helped oversee the program’s start in 2022. “They’re not taking their medications, either for cognitive reasons or because they can’t get to a pharmacy.”

Few have completed an advance directive, specifying the care they want — or don’t want — if they suffer a health crisis.

Connected Care’s community health workers tackle many of those not-exactly-medical problems — from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to work with each patient, usually during home visits.

They help coordinate follow-up appointments. They administer cognitive and mental health screenings and watch for the use of too many medications, entering their observations into the patients’ electronic health records.

“It’s like being the eyes and ears for the doctors, to see what’s happening outside the 20 minutes they get to spend with patients,” said Guzman, whose work has ranged from ordering a bath mat to reporting suspected financial abuse.

In a  (average age: 77), a subsample found substantial decreases in emergency department visits and hospitalizations among those served by community health workers.

More extensive research, not yet published, supports that finding, Eckstrom said.

“ED visits cost thousands, and hospitalizations are tens of thousands,” she pointed out. The cost per patient for the 90-day program is $1,500. Its workers earn $25 an hour, a fairly typical wage, and receive full employee benefits.

Manali Patel, an oncologist at Stanford University, found for older patients with advanced cancer in a clinical trial at the Department of Veterans Affairs’ Palo Alto Health Care System.

“Lots of people were passing away” in the intensive care unit, she recalled. “If we’d asked, they probably would have wanted to be at home.” Oncologists, she added, are “notoriously bad at engaging in and documenting those conversations.”

But when a lay health worker made regular phone calls to help patients understand their options, discuss their preferences with their care team, and file advance directives, the results — published in JAMA Oncology in 2018 — were “very dramatic,” Patel said.

More than 90% of the participating veterans had their goals documented in their records compared with fewer than 20% of the control group. The lay worker’s patients had significantly fewer emergency room visits and hospitalizations and were more likely to enroll in hospice care.

Patel and her co-authors have gone on to document the benefits of lay health workers, the term they used, in undertaking other tasks in other settings.

In oncology clinics in Arizona and California, for instance, two bilingual lay health workers to cancer patients over age 75 to assess symptoms like pain, nausea, breathlessness, and depression.

Alerting healthcare teams to these patients’ problems substantially reduced their emergency department use and hospitalizations, and the cost savings averaged $12,000 a patient.

“This low-tech, human-administered intervention reaped huge dividends,” said an  in JAMA.

“Community health workers should be part of every healthcare team,” Eckstrom said. “They support the patient in ways the medical system just can’t, no matter how hard we try.”

One obstacle to expanding their use, however, is unstable funding.

In 2024, Medicare began covering some community health worker services, but not all. (The costs of driving 30 miles to remote homes, for example, are not reimbursed.) Medicaid coverage is piecemeal, reimbursing for some services in some states and not others.

“A lot of community health worker roles rely on short-term grants,” said Neena Schultz, a director of the National Association of Community Health Workers. “Sustainability is something we talk about every day.”

The organization and other supporters are pressing for more state and federal funding. The new federal , which is distributing $10 billion a year, will include funding for community health worker programs, but cuts to state Medicaid budgets could more than offset those gains.

The grants funding Connected Care for Older Adults continue, though. Guzman, employed by the nonprofit clinic One Community Health, keeps making her rounds.

One recent victory: A newly widowed patient in his 60s, struggling financially without his wife’s income, lost his housing and was sleeping in his truck. Through another patient, Guzman learned of an unused recreational vehicle whose owner was willing to donate it.

The widower now lives comfortably in a mobile home park.

When you’re in a patient’s home, “there’s a sense of ease,” Guzman said. “They feel safer talking about things. They don’t feel rushed. You develop a relationship, and they feel they have someone to advocate for them.”

The New Old Age is produced through a partnership with .

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The plan was to begin handing out boxes of groceries at 11, but the truck delivering the food blew a tire en route. No one complained.

Perry Hall was among those waiting. His wife, Lilly Hall, volunteers with the distribution team. Perry has been dealing with a form of cancer called multiple myeloma. The Halls get by on around $1,500 a month from his Social Security benefits, plus assistance from the federal , or SNAP. But because of her age, Lilly, 59, recently became subject to new SNAP work requirements and at risk of losing her benefits.

As part of the federal One Big Beautiful Bill Act, all “able-bodied adults” 64 or younger who don’t have dependents and don’t work, volunteer, or participate in job training at least 80 hours a month are now restricted to three months of benefits every three years from SNAP, formerly known as food stamps. Previously, the federal requirement applied to those 54 or younger. The new rule, which went into effect in November, also applies to parents of children 14 or older. And it removed exemptions for veterans, people experiencing homelessness, and young adults who’ve aged out of foster care.

Proponents of work requirements argue that they incentivize people who are “work-ready” to seek and keep jobs, reducing dependence on government assistance and upholding the “.”

Rhonda Rogombé serves as health and safety net policy analyst for the . She and her colleagues have studied the effects of SNAP work rules and found that requiring recipients to work does not lower an area’s unemployment rate.

Previous work requirements were suspended nationwide during the covid pandemic and reinstated in fall 2023. The researchers found that the average number of people employed in Mingo County each month actually went down after the requirement was reimposed.

A 2018 federal research project that examined several data sources, including SNAP data from nine states, found that work requirements “have no impact on labor force participation and the number of hours worked.”

There are a number of possible explanations, Rogombé said, “but when people are hungry, they’re not able to support themselves. When people are hungry, it’s harder to focus at work. It’s harder to engage in work activity, and we think that that’s part of it.”

Jobs are scarce in this southern West Virginia county. Lilly Hall found work at a Delbarton restaurant. But it’s unpaid until a waitress position opens — enough to preserve her benefits, but far from ideal.

On that mild Wednesday in late March, House of Hope provided chicken, eggs, bread, potatoes, fresh fruit and vegetables, and milk.

Among those in line were older residents and “some young people that have lost their way and they can’t get work and they just need help,” said Timothy Treleven, who operates the pantry with his wife, Christine, and Gail Lendearo.

House of Hope’s scheduled distribution day is the last Saturday of each month — supplemented by occasional weekday Facing Hunger visits — as money from monthly checks begins to run out and cupboards go bare.

On a typical Saturday, pantry staff and volunteers hand out up to 400 boxes of food.

“It’s an honor to do this,” Lendearo said. “It’s a blessing.”

Perry Hall’s cancer is now in remission, but for a while his treatment required that he and Lilly travel back and forth, 4½ hours each way, to Morgantown. The couple’s van couldn’t make the trip, so they paid a friend for rides.

Mingo’s population is just under 22,000, down from around 27,000 in 2010. It once flourished, fueled by coal. Williamson, the county seat, was home to an opera house and businesses operated by immigrants from Italy, Russia, and Syria. The region is still referred to as “the coalfields,” but little is mined here these days. .

Rogombé and her colleagues found that Mingo County residents face significant barriers to securing what few jobs are available. These include unreported physical and mental impairments, housing insecurity, and a lack of high school diplomas and identification documents.

Filing the paperwork to receive benefits or to confirm compliance is difficult for many residents. The West Virginia Center on Budget and Policy’s research found that about 1 in 4 lack reliable internet access.

Additional changes lie ahead for the SNAP program. Currently, the federal government and the states share administrative costs equally, but in October states will assume 75% of those costs. And beginning in October 2027, they’ll be required to pay additional costs based on .

Kentucky, like West Virginia, is among the poorer states that will be most affected by the new requirements and costs. The Kentucky Center for Economic Policy estimates that with the expanded work requirements.

Jessica Klein, a researcher with the center, worries about the consequences. “We know SNAP has an impact on health, and not just because it decreases food insecurity,” she said. It worsens blood pressure rates, obesity, medication adherence, and more.

With the additional financial burden placed on states, “I think what we’ll see is some states changing rules that impact participation in order to have a smaller, more affordable program,” Klein said. “My fear is that some states will choose not to operate SNAP at all.”

In Mingo County, folks are stepping up. At least eight food pantries offer groceries to those in need.

Janet Gibson runs the Blessing Barn pantry in the Ben Creek community. “I can go from one end of the creek to the other” and tell you everyone’s name and a little something about them, she said. She takes pride in feeding her people.

Gibson said it can be hard to find even volunteer opportunities in the county, largely because of transportation challenges. A look at a local map can be misleading: A couple of dozen miles into a holler or up a ridge could take an hour or more.

“Whether you’re working full-time or not, you’re still spinning out gas to get to work,” Gibson said, “and gas ain’t cheap now.”

A single mother of three, Trista Shankle of Paducah, Kentucky, isn’t subject to the new SNAP requirements, but she worries about the fragility of the social safety net. She overcame challenges, is earning a master’s degree in social work, and works for an organization that connects community college students with benefits. Her family receives SNAP, Medicaid, housing support, and assistance from the USDA’s . If any one of those is cut, she said, she may have to drop out of school.

Shankle is certain she wouldn’t have advanced to where she is today without the benefits she and her family have received: “They bring a sense of calm and comfort. I know that my kids aren’t going to go hungry.”

The first week in April, Lilly Hall reported for work at Black Bear Trails Restaurant. She’s grateful for the opportunity. And when a waitress slot opens, “I’ll snag that position so quick it’ll make your head flip.”

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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.

This <a target="_blank" href="/rural-health/dialysis-unit-closes-rural-transformation-health-fund-nebraska/">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;">

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This <a target="_blank" href="/courts/immigrants-ice-arrests-family-separation-children-foster-care/">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;">