Within months, the state enacted a that required hospitals to proactively screen patients and give financial aid to those who qualify for it. Oregon’s new rules, which took effect in July 2024, required hospitals to skip applications for nearly all patients 鈥� a rarity among hospitals nationwide.

“They will be told up front, Hey, we got you,” said Democratic Oregon state Sen. Lisa Reynolds, who introduced the legislation. “You are here at a very scary time in your life because of illness or injury, and we got your back.”

The law worked.

Oregon Health & Science University’s hospital, one of the largest in the state, saw 64% of its patients automatically qualify for financial assistance in the early months of the new law, up from 12% previously.

In their first full fiscal year under the law, spending by Oregon hospitals on financial assistance more than doubled, on average, according to federal financial reports from about two-thirds of the state’s hospitals. That’s compared with their last full year before the change.

For patients, the switch meant direct relief from high healthcare costs, advocates said.

“They don’t have to have the late nights being like, how am I going to afford my mortgage? How am I going to afford these medical bills?” said Adam Zarrin, a director of state government affairs for the advocacy group Blood Cancer United.

Hospitals in the state have pushed back on the requirements, saying they , and they face added financial strain from the Trump administration’s domestic policy agenda. Millions of people are health insurance in coming years under cuts to Medicaid pushed through by Republicans in Congress.

Oregon’s early success is the first big test of a new approach that more states are turning to, known as . Hospitals skip the applications and screen patients automatically to determine if they qualify for aid.

North Carolina this year to include patients with income up to triple the poverty line. and are requiring hospitals to automatically grant financial aid by July 2027.

A Promising Tool To Prevent Medical Debt

As many as 100 million adults in the U.S. have healthcare debt, according to a 吃瓜不打烊 analysis. That financial burden can alter people’s lives, forcing them to skip prescriptions and follow-up care to avoid further bills.

Hospitals are a of that debt, and they have faced growing scrutiny over and billing practices.

Policymakers have focused specifically on nonprofit hospitals, which account for the sector. Nonprofit hospitals , in exchange for providing benefits to their communities 鈥� a vaguely defined standard under federal law. Many hospitals meet this requirement by providing free or discounted care to low-income patients.

That financial assistance, however, can be difficult to get. Applications can be onerous and confusing. Congress and state officials have spent years testing policies to and , with mixed results.

Research finds , as does the degree to which hospitals property, sales, or income taxes.

“Hospitals have been on the winning side of this deal for a long time,” said Reynolds, the Oregon lawmaker. “They enjoy millions and millions and millions of dollars in tax breaks, and that money is supposed to be then spent on poor people who can’t afford their care or even their copayments. It has not penciled out.”

Reynolds pressed for Oregon’s screening requirement, she said, to hold hospitals “accountable for what they should have been doing all along.”

Early evidence suggests the law is doing what Reynolds hoped. Oregon hospitals’ spending on free and discounted care increased to 2.7% of all operating expenses, on average, from 1.4%, among the roughly two-thirds of hospitals with available federal data.

That brings hospitals in Oregon closer to the national average for nonprofit hospitals, which from 2021 to 2024 was about 2.4%, according to an analysis by Johns Hopkins University researcher Hossein Zare, who studies the industry.

More Help for the Insured

Among those in Oregon who started to get more help: patients with health insurance.

OHSU’s spending on help for insured patients reached about $39 million in the first year under the law, federal data shows, about five times as much as in previous years.

Lawrence Furnstahl, then OHSU’s chief financial officer, said in a public meeting in January 2025 that, before the law, insured patients often didn’t apply for help and instead paid their share of the bills. The new automatic screening often wiped out or reduced what they owed 鈥� including for large deductibles that patients have to meet out-of-pocket before insurance will kick in.

Patients who pay hospital bills often still carry medical debt, surveys show, because many use from family, friends, or banks to afford their care.

A from the Commonwealth Fund found that 1 in 3 adults with private insurance have medical debt.

“It defies the purpose of health insurance coverage, which is to enable people to get healthcare when they need it and protect them from serious costs,” said Sara Collins, an economist and senior scholar with the Commonwealth Fund.

鈥楢 Very Different World’

For hospitals, the new requirements come as healthcare costs are climbing and federal support for the safety net is shrinking. Nationally, an estimated will be uninsured in 2034 as a result of President Donald Trump’s signature tax-and-domestic-spending law and the expiration of enhanced Obamacare subsidies that Republican lawmakers allowed to lapse at the end of last year.

Hospitals supported Oregon’s new presumptive eligibility law, said Sean Kolmer, an executive vice president for the Hospital Association of Oregon. But they’re feeling more financial pressure, with the organization expecting the state’s uninsured rate to 10% or higher in coming years, he said, up from about 3% .

“That’s a very different world,” he said.

OHSU saw costs rise rapidly. “It is a good thing, but it is an expensive thing,” Furnstahl said in a public meeting as he gave an update on the first months under the law.

In the first year under the new law, OHSU spent about $64 million on free and discounted care 鈥� of what it spent on operations that year.

The true cost of more up-front screening is hard to quantify, medical debt experts said. It must also take into account how many people would have never paid their bills anyway and how much hospitals save by not chasing payments.

Lawmakers said hospitals pressed them for relief, and in April, Oregon to ease the state’s screening requirement.

The original law required hospitals to screen everyone on Medicaid or who was uninsured and anyone who owed $500 or more. Lawmakers raised the monetary screening threshold for a single visit . The Medicaid or uninsured requirement remains.

Reynolds, who spearheaded the original law, was unsympathetic to hospitals’ cost concerns. But she agreed to the rollback because she wanted hospitals to have some relief as they fine-tuned their screening process. Oregon hospitals reported that their screening data was less accurate for patients with higher incomes, leading some people who didn’t qualify for help to receive financial assistance.

OHSU studied economic data for Oregon’s residents and reported that about 57% likely had incomes that qualified them for its financial assistance, slightly under the 64% of patients who were receiving help.

Hospitals’ warning of increasing financial stress was a motivator for Democratic Rep. Rob Nosse, who chairs the healthcare committee in the Oregon House of Representatives.

“I don’t want any suburban or rural hospitals to close on my watch,” Nosse said.

People who are no longer automatically eligible can still apply for help with bills less than $1,500, he said.

“I’ve got to make it more expensive for someone to get healthcare so that the hospitals can stay in business,” he added. “What a country.”

This article is part of “,” an investigative series from and 吃瓜不打烊 about how hospitals can protect their patients from the life-altering harms of medical debt.

This article first appeared on 吃瓜不打烊 and is republished here under a .

Aimee Carlock needed surgery in August 2025 to treat severe pain and bleeding from her uterus. But first, she needed to come up with $5,500.

Texas Health Resources, one of the state’s largest nonprofit hospital systems, told her it wouldn’t schedule the procedure unless she paid up front, Carlock said. The self-employed house cleaner didn’t have the money.

“I panicked because I live paycheck to paycheck,” she said. “I have no extra money whatsoever.”

Carlock borrowed cash from her best friend and parents. Her father offered money he inherited when Carlock’s grandfather died a few years ago.

Only after the surgery did Carlock, 35, learn she qualified for hospital financial aid. Her care should have been free, but the system doesn’t give full refunds. The $5,500 was gone.

Carlock’s poor health has kept her out of work most of this year. She took out loans for groceries and utilities and applied for food stamps. It will take years, she said, to chip away at what she owes.

“I’m just trying to pick myself back up,” Carlock said. “But it’s really hard.”

Hospitals have a tool to automatically screen people like Carlock for financial aid and grant them relief — a process known as . But if, when, and how hospitals deploy this tool is largely up to them; there are few state or federal requirements.

A found that in Texas nearly half of nonprofit hospitals say they will bill patients before screening them for financial aid. And most hospitals will not offer refunds to patients who pay and are eventually found to qualify for free care.

Many patients are unaware that hospitals offer financial help, often known as charity care. Others are stymied by onerous applications that require people to turn over financial information, such as bank statements, car notes, pay stubs, retirement accounts, and even divorce records.

“It’s like going through a tax audit,” said Stanford University health economist Neale Mahoney, who studies medical debt. “The current system is broken.”

An estimated 100 million adults in the U.S. have healthcare debt, according to a 吃瓜不打烊 analysis. That includes amounts people owe to hospitals and doctors, as well as loved ones, credit card companies, and banks. This debt can be life-altering, forcing people to take on additional jobs, push off retirement, or cut back on essentials like groceries and medical care.

Tradeoffs analyzed the financial assistance policies of all 166 nonprofit general hospitals and children’s hospitals in Texas, which has than .

The analysis is believed to be the first detailed look at presumptive eligibility policies of nonprofit hospitals, which . They get these tax breaks in exchange for , such as financial assistance. and in have questioned whether nonprofits do enough to earn those tax breaks.

Since 2020, a , including Texas, have debated or adopted requirements for hospitals to use presumptive eligibility in financial assistance to protect patients from avoidable debt.

“This is clearly an industry that is not policing itself very well,” said Tom Oliverson, a physician and Texas lawmaker who has proposed legislation to require hospitals to screen patients before sending a bill.

Automatic screening is a good option to help some patients, said Anna Stelter, vice president of policy at the Texas Hospital Association. But often, she said, there are other payment options, such as insurance, which hospitals need to pursue first. “Charity care is the relief of last resort,” she said.

Most Texas Hospitals Can Automatically Give Help

To identify nonprofit hospitals in Texas, Tradeoffs consulted state and federal records and a list of hospital policies maintained by , a group that helps patients apply for financial assistance. To verify policies were up to date, Tradeoffs scoured websites, often clicking through multiple links to find policies. When policies were missing, Tradeoffs reached out directly to hospitals and filed public records requests with the state, which requires hospitals to submit policies annually.

Tradeoffs’ analysis found that nearly every Texas nonprofit hospital can screen and proactively reduce bills when patients are found eligible for help.

Nationally, around 90% of nonprofit hospitals reported the same in 2022, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. That’s up from 72% six years earlier.

Hospitals’ use of automatic financial aid , in part, to the Affordable Care Act, which added protections for patients. The law created for hospitals that aggressively go after payment without trying to identify whether patients need help. Presumptive eligibility is .

Covenant Health, a five-hospital system based in Lubbock, was the only system in Texas to say it does not automatically grant financial aid, though its policy allows it.

Covenant doesn’t use the option “due to the regulatory requirements and administrative complexities,” said Ainsley Nelson, the system’s spokesperson. “Our focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.”

Bill First or Screen First?

About 8% of hospitals in Tradeoffs’ analysis have policies that require screening patients for charity care before sending a bill.

Far more, 41%, say they screen patients before turning unpaid bills over to debt collectors or taking , such as garnishing wages, placing a lien on property, or denying further care without payment.

Southeastern Texas hospitals owned by , for example, will automatically wipe out bills only “after all other eligibility and payment sources have been exhausted,” according to its Texas financial assistance policy.

CommonSpirit declined an interview request.

Research shows the sooner patients get financial aid, the better it is for their health.

found that people were more likely to be diagnosed and treated for conditions like depression and diabetes and make follow-up appointments when they received financial aid within weeks of receiving care. of people who had medical debts wiped out after months or years found no health benefit from the relief.

The signal is clear, said Ray Kluender, an associate professor at Harvard University, who worked on both studies. “The timing of when financial assistance is provided by a hospital is just extraordinarily important.”

Some hospitals told Tradeoffs that what they do isn’t always written in policy. For example, spokespeople for and say their systems screen some patients before sending bills — though their policies include no requirement to do so.

When hospitals do wipe out patient costs after sending bills, about 40% say they will not inform patients their balance has been cleared. Just 8% require notification, and the rest say nothing about it in their policies.

“Patients will not be notified to inform them of this decision,” reads CommonSpirit’s policy.

Stelter, with the Texas Hospital Association, said many hospitals have limited staff in their billing departments and would likely prioritize helping patients apply over notifying those who already got help.

“It’s cruel to not notify someone,” said Erin Fuse Brown, a Brown University professor who studies medical debt. “Not to give them the closure to say you can spend that money elsewhere. You can buy your groceries this month. You can fill your prescription because you don’t have to budget for this.”

People with medical debt are three to four times as likely to delay future physical and mental healthcare as people without medical debt, a .

Hospitals Want To Help Patients — And Get Paid

Texas has for decades required nonprofit hospitals to meet one of a few they give patients — one of which is spending at least 4% of their annual patient revenue on charity care.

Research has found such spending targets have had mixed results. Some hospitals helped more patients, and others spending or , including training doctors and subsidizing money-losing but essential services.

The Texas Hospital Association in the state offers presumptive eligibility, but Stelter said screening tools can be unreliable.

Before they grant aid, hospitals want to know if a patient might be among the narrow population of adults who or if a grant might cover their bills — a determination that can require additional time and information.

Stelter also said that providing aid before sending bills could let insurers off the hook. Patients with insurance typically must spend some money before insurers pitch in, known as a deductible. Insurers can hold down consumers’ monthly premiums by raising deductibles, which have climbed to an average of for job-based coverage and for people on marketplace plans.

If they know hospitals will pick up the tab, “what incentive does an insurer have to lower a deductible?” Stelter said.

Hospitals nationwide are expected to come under since Congress reduced subsidies for many people buying health insurance through the Affordable Care Act, and are expected to push millions of low-income Americans .

That policy shift leaves hospitals to pick up more of the safety net, which they can’t afford, said Jill Horwitz, a Northwestern University health policy professor.

“It would be wonderful if nonprofit hospitals could solve the problem of Americans being uninsured or underinsured by paying for the free care,” Horwitz said. “But nonprofit hospitals do not have the money to solve what is ultimately a major federal problem.”

‘You Had To Pay It’

Becca Wahl said she knew nothing about financial assistance when she landed in Memorial Hermann Katy Hospital last October with a concussion after fainting in a Walmart.

“I just thought you had a bill and you had to pay it,” said the 33-year-old uninsured yoga instructor.

So when Wahl saw the $38,000 tab for her emergency room visit, she panicked. The bill was more than she makes in a year.

“I thought, ‘I’m doomed,’” Wahl said. “I just went out to get a birthday card and fell over. And now I have $38,000 of debt.”

Shortly afterward, the hospital called and revised her bill, offering its price for patients who pay cash, she said. That left Wahl with $11,000 in debt and a $1,000-a-month payment plan — better than $38,000, but still out of reach.

Desperate, Wahl went online and found Dollar For, which helps patients apply for financial aid. One week after Dollar For submitted Wahl’s application, Memorial Hermann wiped out her bill.

Memorial Hermann’s policy says its hospitals should screen patients for financial assistance before sending a bill.

Wahl agreed to waive her patient privacy rights so Memorial Hermann could talk about her case. But the hospital declined an interview request. A spokesperson told Tradeoffs that Memorial Hermann is “dedicated to ensuring that every patient has access to clear information about the expected costs of services, and available coverage options and our financial assistance program.”

Wahl is just glad that she doesn’t have to put her life on hold while she pays off that debt.

“The amount of stress that was lifted off of my shoulders by finding out that this medical debt was forgiven was huge,” she said.

Few Hospitals Give Refunds

Some patients who pay down their bills before hospitals wipe them out never get their money back, Tradeoffs found.

Roughly 2 in 3 nonprofit hospitals in Texas have policies that say patients won’t receive full refunds.

CommonSpirit’s policy has no requirement to refund patients who get automatic financial aid. Felicity Simmons, a system spokesperson, said in an email clarifying its policy that “refunds are case specific.”

A few hospitals say they will return amounts that exceed what the — a federal requirement for all facilities. That is the case at Texas Health, where Carlock paid $5,500 up front for her uterine surgery, before the hospital wrote off the rest of her bill.

Carlock’s $5,500 stayed with the hospital.

Carlock agreed to give Texas Health permission to speak with Tradeoffs about her bill. Texas Health didn’t respond.

Stelter with the Texas Hospital Association said hospitals follow for refunding patients. Those regulations require hospitals to fully refund some patients who submit an application. The rules don’t apply to those who got help through presumptive eligibility, experts on the regulation told Tradeoffs.

States Seek Standards

By July 2027, six states will require hospitals to use presumptive eligibility for certain patients: , , , , , and

Oregon has arguably one of the most aggressive approaches. Starting in July 2024, hospitals had to screen anyone who owes more than $500 and every patient who is on Medicaid or uninsured — . Lawmakers in 2026 amid and the law’s impact on hospital finances.

Hospitals in Oregon more than doubled the amount of charity care they provided, on average, during their first full year under the law, Tradeoffs found. That’s based on an analysis of available Medicare data from roughly two-thirds of hospitals. At OHSU Hospital in Portland, one of the state’s largest, the percentage of patients receiving financial aid jumped from 12% before the law .

In Texas, state representative Oliverson, a Republican, hopes his state will go even further than Oregon. He proposed legislation in 2025 that would require nonprofit hospitals to screen patients and provide aid before sending bills. Those that don’t would face penalties.

The legislation failed, but Oliverson said he plans to reintroduce it in 2027. The lawmaker said nonprofits are falling short of their obligations.

“If you’re sending bills to people that you know when you finally get around to screening them for charity they’re not going to be obligated to pay,” he said, “that should be grounds for losing your tax-exempt status.”

Oliverson said hospitals that already care for a higher share of low-income patients would be exempt from his proposed requirements. But he’s adamant that most nonprofit hospitals should be doing more to protect patients from unnecessary debt.

“If you’re advertising that you’re willing to accept uninsured patients and that you have a charity program,” Oliverson said, “you got to deliver on that.”

This story is part of , an investigative series from and 吃瓜不打烊 about how hospitals can protect their patients from the life-altering harms of medical debt. Read our full .

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

This article first appeared on 吃瓜不打烊 and is republished here under a .

One way patients can avoid medical debt is through hospital financial assistance, also known as charity care. Most of the nation’s hospitals offer free or discounted medical care to patients with very high medical debt or low incomes.

Getting financial assistance, however, can be challenging. Many that hospitals offer financial help, surveys show, and leave others stymied.

Hospitals often demand that applicants turn over bank statements, pay stubs, tax returns, divorce filings, or other materials, and submit their applications in person, by mail, or by fax.

“They don’t make it easy,” said Neale Mahoney, a Stanford University economist who studies medical debt.

Such hurdles leave many patients with unpaid bills they should never have had to pay in the first place. In a single year, hospitals and health systems billed patients for at least , one analysis found.

As healthcare costs climb and more people lose their coverage, states and hospitals are testing an emerging approach to fix this problem: automatically screening patients to see if they qualify for assistance and proactively wiping out debt when they do. This is known as “presumptive eligibility.”

Under this approach, patients may have the cost of their care wiped out before they see any bills 鈥� but not always. Hospitals differ on when, how, and for whom they use auto-enrollment, potentially impinging on patients’ finances.

Here’s what you need to know about how auto-enrollment works.

What is hospital financial assistance?

In many states, hospitals for whom they provide financial aid. Eligibility is typically based on income for the patient’s entire household. The closer patients are to poverty, the less they have to pay. Patients with middle incomes and insurance are sometimes eligible for discounts, especially if their bills would gobble up a big chunk of what they earn.

require hospitals to wipe out bills for low-income patients, though income cutoffs vary. Georgia, for example, mandates free care for anyone with income slightly above the federal threshold for poverty. In several states 鈥� including Oregon, North Carolina, and Maryland 鈥� patients can earn double that amount and still get free care.

But in most states, many patients must complete applications to receive assistance.

Several states in recent years have and designed to make it easier for people to get help. , however, suggests gaps persist.

How many hospitals use auto-enrollment?

Nearly all nonprofit hospitals say they screen and automatically reduce bills for certain patients.

Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or ding their credit over bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016.

In the first year under the new rules, about 70% of tax-exempt hospitals nationwide said they screened patients and proactively reduced bills, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. As of 2022, that figure was nearly 90%.

The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.

In six states, policymakers require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.

Who is eligible to be automatically enrolled in financial assistance?

In most states, hospitals decide which patients can skip the application.

Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like , which will write off bills for anyone in a religious order who took a vow of poverty.

Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, state only that they may screen patients “with a sufficient unpaid balance.”

Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.

In Oregon, starting in 2024, hospitals had to screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. In 2025, roughly 80% of Oregon patients who got financial help with bills never filled out an application, based on data shared publicly by the first 26 hospitals to do so. The state’s legislature this year raised the screening threshold to include patients who owe at least $1,500 for a single visit.

Without an application, how do hospitals figure out who gets help?

Hospitals have several ways to find patients eligible for financial assistance.

Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.

For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine whether they qualify for free care.

Hospitals may also consider how likely patients are to pay bills, regardless of how much they earn. This is called “propensity to pay.” California and Oregon prohibit its use, concerned that hospitals may try to collect more often from people who dutifully pay their bills even though their incomes qualify them for financial assistance.

When do hospitals screen patients for financial aid?

It depends.

Illinois, North Carolina, and Oregon require hospitals to screen certain patients before they send any bills. California hospitals will have to do the same starting in 2027.

Some hospitals voluntarily screen patients before sending bills; others try to collect money from patients first. As long as they screen patients before suing them for very overdue bills, hospitals can stay within the letter of the federal law that pushed many of them to embrace presumptive eligibility.

For example, the is to screen patients only “after all other eligibility and payment sources have been exhausted.”

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment 鈥� like Medicaid or county safety net programs 鈥� before they give out financial assistance.

“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”

Hospitals’ publicly posted policies may also be fuzzy about when they will screen for patients likely eligible for help. For example, in Fort Worth, Texas, says its goal is to determine a patient’s eligibility “as soon as sufficient information is available.”

Who pays the bills when patients get free care?

In one sense, we all do. Taxpayers cover some or all of the cost of financial assistance, though the amount varies by hospital.

About half the nation’s hospitals are nonprofit and legally get a pass on paying most taxes. KFF estimates that nonprofit hospitals in 2020 that they would otherwise have paid as income, sales, or property taxes.

Government-owned and for-profit hospitals have their own sets of tax benefits to help offset costs for low-income patients. Government hospitals often , and for-profit hospitals generally receive smaller government subsidies, like for caring for high numbers of uninsured and Medicaid patients.

Whether taxpayer dollars fully cover hospitals’ costs for financial assistance depends on the amount of government support they receive 鈥� information often not publicly available. It also hinges on how many patients need help, how many meet hospitals’ criteria for assistance, and how many get through an application. Research shows hospitals spend on financial assistance, from less than 1% of yearly expenses to more than 7%.

Philanthropy and hospitals’ income cover costs not absorbed by tax dollars.

This article is part of “,” an investigative series from and 吃瓜不打烊 about how hospitals can protect their patients from the life-altering harms of medical debt.

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

This article first appeared on 吃瓜不打烊 and is republished here under a .

Can’t see the audio player? Visit kffhealthnews.org to listen.

When Josh Fleig, Louisiana’s chief innovation officer, learned his state had set aside $20 million a year, for five years, to invest in startup rural health companies, his reaction was not surprising: “Wow!”

In rural America, where people are often reported to be sicker with poor access to healthcare, the cash influx is a relief. In the economic development space where Fleig operates, it’s an opportunity.

“Look, that’s a lot of money for what we do,” said Fleig, whose state-funded economic development office invests in corporate launches, ranging from software startups to shipbuilders.

Louisiana and a handful of other states set aside money from their share of the $50 billion federal Rural Health Transformation Program to quickly invest in new technologies, mirroring private industry moves. Lawmakers added the rural health program to offset more than $900 billion in reduced Medicaid spending expected over 10 years from Republicans’ sweeping 2025 tax and spending law.

But rather than filling the budget hole, the rural program’s assignment is to find new approaches for revitalizing rural communities where doctors are in short supply and hospitals have been downsizing and closing for decades. The federal government doled out the first-year rural health program awards to states this year, with pots ranging from $147 million in New Jersey to $281 million in Texas.

Modernizing technology infrastructure is a key pillar of the federal rural health program, and the catalyst money epitomizes the administration’s strategy to move fast and experiment with untested technology 鈥� much like the “move fast and break things” mantra during the heyday of Silicon Valley.

Instead of breaking things, though, the goal is to “move fast, fast-fail, innovate quickly, and move to sustainability,” said Aaron Bujnowski, a managing director with the healthcare industry group at the consultancy Alvarez & Marsal. “This is a transformation that is still meant to serve the people.”

Rigorous Rules and Tight Deadlines

Beyond Louisiana, Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, confirmed that Delaware, Georgia, Massachusetts, Nebraska, South Carolina, Virginia, and West Virginia are also creating rural health tech catalyst funds.

Every year, states must compete for rural funding in the five-year federal program. Federal regulators will take money away from states that do not meet the goals promised in their applications, including whether they designated money to companies for tech innovations.

CMS, which is overseeing the program, released a seven-step for states to follow when creating the tech catalyst operations. No more than 10% of each state’s award can be spent on a rural tech catalyst fund.

States’ initial annual progress reports for the rural fund were due at the end of August. CMS has declined to publicly post those reports; it plans to publish an annual report on state progress. States must show that first-year funds will be obligated 鈥� but not necessarily spent 鈥� by Oct. 30, according to the CMS guidance document.

Daniel X. O’Neil, a technology consultant who advocates for open data and open government, created a and parsed the original state applications to find dozens that mention catalyst awards and technology funds.

O’Neil said he is “looking forward to the clawbacks and the craziness of October because, you know, that’s serious stuff.”

For the rural health catalyst funds, CMS requires states to submit the list of finalists “at least 15 business days” before announcing winners, along with “sufficient information” for the agency to “assess each proposed project,” according to the guidance document.

The document outlines intellectual property and federal rights but does not provide guidance or standards for patient rights or protections. CMS spokesperson Foster stated in an email that the technology investments must comply with federal “privacy, security, interoperability, and patient safety” requirements.

Protecting Patients

Maya Sandalow, director of the health program at the Bipartisan Policy Center and one of the leading analysts watching the rural fund, said the catalyst funds are “public dollars” and has called for more transparency in the overall rural health program. The center is a nonprofit think tank in Washington, D.C.

Accurate and timely reporting must be done to ensure “the necessary guardrails are in place” to protect patients, she said, adding that the innovation needs to be “tested in a way that’s safe for the patients that they are going to be used on.”

To apply, startups must be less than 10 years old and have raised less than $50 million in early funding. Companies that win a portion of state catalyst funds must meet predetermined milestones before being paid 鈥� and federal officials will make “targeted reviews as needed,” according to the guidance document.

Louisiana officials announced the state’s tech catalyst fund with an event in rural Natchitoches, known as the filming location of the 1989 film Steel Magnolias. The fund quickly drew more than 200 companies competing for between $250,000 and $3 million in seed money.

Tiny startup Greens Health was invited to the event. The 2-year-old company analyzes Medicare claims to identify patients with chronic diseases, such as diabetes, and works with local home health nurses and senior facilities to improve care.

“We’ve been looking for a way to launch in Louisiana,” said Kehlin Swain, co-founder and chief executive of Greens Health. The company serves about 100 patients across Texas, Alabama, and Florida and hopes to get a $250,000 investment from Louisiana.

Louisiana’s Fleig said his state is “at a really interesting turning point.” The state secured $208.4 million for the first year of the rural health program and quickly created its catalyst fund using the state’s already established innovation department.

At the same time, nearly 1.1 million people live in Louisiana’s rural parishes and the state ranks as the “least healthy” in the nation, according to its own application. State rates of diabetes, obesity, and cardiovascular disease are among the highest in the nation.

Fleig believes Louisiana is an ideal place to test technology solutions. So, while Silicon Valley has “not needed much of what Louisiana has had to offer” for much of its existence, it does now, he said.

Caret Health is one of those companies. Co-founders Riya Pulicharam, who is a physician-researcher, and Kevin Zhao, an engineer, met in Silicon Valley. Together, they created a technology platform that identifies patients who need help getting to their appointments, having scans done, or picking up prescriptions. That technology flags a human, who then contacts the patient with a call or text.

Zhao said Caret had successful pilots at large health systems, but those places also had other vendors and “it was a pretty big uphill battle” to get in and scale. Then, in 2024, the company began paying attention to rural places.

“There wasn’t a lot of existing infrastructure. And that was really good for us because we were able to come in very quickly,” Zhao said. “A lot of the hospitals really needed this kind of service.”

Fast-forward to 2026: Caret Health is about 4 years old and has contracted with about 60 hospitals in 16 states. Pulicharam and Zhao hope to win $3 million to expand into Louisiana.

Louisiana’s Fleig said the state will take an equity stake in each company it invests in. “The dream” is that selected startup companies will also help the state make money to reinvest. If some companies fail 鈥� or fail fast 鈥� that’s to be expected, but the state should still make money because of “the law of averages,” he said.

“If we are good, we’ll make more money than we spent,” Fleig said. “Either way, it’s going to go back into improving healthcare outcomes.”

This article first appeared on 吃瓜不打烊 and is republished here under a .

This article first appeared on 吃瓜不打烊 and is republished here under a .

She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill 鈥� first introduced in New York in 2016 鈥� could become law.

鈥楢 Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years 鈥� Oregon’s law, the first in the country, was enacted in 1997 鈥� the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, 鈥榃e have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

鈥榊ou Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say 鈥榊ou need A, B, and C,’ and Columbia-Presbyterian can say, 鈥榃e also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state 鈥� usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS 鈥� the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease 鈥� rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, 鈥楶eople should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

This article first appeared on 吃瓜不打烊 and is republished here under a .

“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.

吃瓜不打烊 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 吃瓜不打烊 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 吃瓜不打烊.

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.

吃瓜不打烊 correspondents Katheryn Houghton and Samantha Liss contributed to this report.

This article first appeared on 吃瓜不打烊 and is republished here under a .

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

However, CMS clarified that not all billing activities referenced by Oz were presumed to be improper. And a review of the most recent available data shows that there are hotbeds of health care fraud across the country and across practice areas, most of them allegedly perpetrated by health insurers and other domestic actors, and that California outperforms most other states in recovering fraud dollars.

As the temperature heats up in the conflict between the Trump administration and California, a handful of Republican state lawmakers have entered the fray, accusing Gov. Gavin Newsom in of allowing “rampant fraud.” Democratic state officials insist they aggressively combat fraud, and Newsom has filed a against Oz, calling language in the allegations “baseless and racially charged.”

“The Trump Administration is attempting to take the issue of fraud 鈥� a very real, and national issue 鈥� and weaponize it against Democratic states,” California Attorney General Rob Bonta said in an early February statement.

Oz said that he would halt “hundreds of millions of dollars” in payments to California if he didn’t get satisfactory answers from state officials. He and Vice President JD Vance announced in late February that they would delay about $260 million in Medicaid payments , another Democratic-led state, over fraud allegations there, and the state is now suing.

Oz has also launched social media campaigns alleging high-dollar public benefit fraud in Democratic-led Maine and New York. On March 17, he added a Republican-led state to his target list: Florida.

Georgetown University professor Andy Schneider, who served as a senior adviser primarily on Medicaid integrity issues during the Obama administration, said fraud has always been an issue across states, dating back decades. About $3.4 billion in Medicare and Medicaid fraud across the country was , according to the most recent report available. Insurers have paid the highest settlements in alleged health care fraud schemes.

“Bad actors trying to steal public health care funds have been around for a long time,” Schneider said.

How California Stacks Up

The federal government is responsible for Medicare, which primarily benefits older people, while Medicaid, which primarily serves people with lower incomes, is a joint federal-state program. Melissa Rumley, a spokesperson for the Department of Health and Human Services’ Office of Inspector General, said the office could not make state-by-state data on Medicare fraud available because the federal probes often cross jurisdictions.

States file annual reports on actions by Medicaid anti-fraud units that are jointly funded with the federal government and run by state attorneys general. They investigate fraud as well as abuse and neglect of Medicaid patients.

These reports provide a sense of the scale of Medicaid fraud across states. In fiscal 2024, states recovered , compared with $949 billion in total Medicaid spending, according to from the HHS Office of Inspector General. California recouped an outsize share, recovering more than 50% of all the criminal recoveries made by the anti-fraud units nationwide in fiscal 2024 even though the state made up only about 17% of enrollment.

California ranked fourth in the U.S. in 2024 in dollars recovered per Medicaid enrollee across civil and criminal investigations, behind the District of Columbia, Montana, and Delaware. It led all the most populous states, followed in order by Texas, Florida, and New York. (California and federal officials noted that state recovery data varies significantly year to year, often because of the length of investigations.)

Vulnerability of Hospice Care

One aspect of health care fraud that has been at the center of Oz’s attack on California is hospice fraud, which has plagued Republican and Democratic administrations.

The use of hospice, intended to provide care to patients expected to die within six months, increased by over 8% from fiscal 2020 to 2024, to about 1.84 million Medicare beneficiaries, significantly.

To combat fraud, the Biden administration in 2023 of hospices in California, Arizona, Nevada, and Texas. The Trump administration Ohio and Georgia.

CMS spokesperson Chris Krepich did not say specifically what criteria were used to choose which states to monitor, only that the decision was based on “activity typically indicative of hospice-related fraud.” As of June, the agency had revoked the Medicare enrollment of 122 hospices in the original four states, but Krepich said a breakdown by state was not available.

While Oz stated there was some $3.5 billion of fraud in the hospice and home health care industry in Los Angeles County alone, his agency clarified that the number is for overall Medicare billing related to hospice and home health services. Krepich said that “not all billing activity referenced in the remarks is presumed to be improper” and added that the agency could not identify the amount of fraudulent activity until an “evidence-based” investigation was completed.

That’s not to say there is no truth to allegations of hospice fraud.

A published in 2022 found “numerous indicators” of large-scale fraud in Los Angeles County, and a highlighted nearly 500 hospices within a 3-mile radius, including 89 companies registered to a single building in Van Nuys. that “hospice fraud has become an epidemic in California.” He noted that state officials have been aggressively combating it for years, including with .

In January, the state in Monterey County with hospice fraud. That follows hospice scam cases in and .

However, California public health officials are overdue in adopting that were supposed to be . The state’s Department of Public Health is currently revising the regulations, according to spokesperson Mark Smith.

In the interim, the state has revoked the licenses of more than 280 hospices over the past two years and is evaluating an additional 300 hospices, . California had licensed hospice agencies as of 2022, according to the state audit.

Civil Rights Complaint

Meanwhile, Newsom is pushing back on Oz. The governor filed his discrimination complaint with the at HHS, which oversees CMS. The office said it will first decide whether it has the authority to investigate, then, if so, will gather information through interviews and documents. However, the process seems designed to aid individuals who have lost a job to discrimination, or to correct a specific policy, and it is unclear whether there could be any real-world consequences.

The governor wants the agency to address “systematic bias from their leadership,” said Newsom spokesperson Marissa Saldivar.

Krepich said CMS “does not target communities, ethnic groups, or states” and bases its decisions on “confirmed investigative findings.” The allegations of organized fraud refer to “documented criminal cases,” Krepich said, providing a link to in which California residents were convicted of using the identities of foreign nationals to steal almost $16 million from Medicare.

It’s unclear what cases Oz was referring to when he spoke of the Russian and Armenian mafia.

Ciaran McEvoy, a spokesperson for the U.S. attorney’s office for the Central District of California, which includes Los Angeles County, said it doesn’t track whether hospice fraud defendants are alleged to be foreign nationals, but he pointed to the office’s online prosecution announcements. None alleged involvement by foreign influences or organized crime.

The state audit references by the U.S. Justice Department under President Barack Obama that an “Armenian-American organized crime enterprise” was behind a nationwide health care scam.

Federal officials at the time described an “international organized crime enterprise” based in Los Angeles and New York but with roots in Russia and Armenia. The scheme involved billing for unneeded medical treatments, not hospice fraud.

A revealed fraud schemes in which hospice operators recruited patients who were not actually terminally ill, then paid kickbacks to doctors who falsely certified these patients as dying so the hospices could bill Medicare. There was no mention of foreign involvement.

This article first appeared on 吃瓜不打烊 and is republished here under a .

But there are strings attached.

In late December, President Donald Trump’s administration announced how much all 50 states would get under its new Rural Health Transformation Program, assigning them to use the money to fix systemic problems that leave rural Americans without access to good health care. Now, the clock is ticking.

Within eight months, states must submit revised budgets, begin spending, and show the money is going to good use. Federal officials will begin reviewing state progress in late summer and announce 2027 funding levels by the end of October.

The money — divided into unique allocations for each state, ranging from $147 million for New Jersey to $281 million for Texas — represents the first $10 billion installment from the five-year, $50 billion program. Congress created the fund as a last-minute sweetener in Trump’s One Big Beautiful Bill Act last summer to offset the anticipated in rural communities from the statute’s nearly $1 trillion in Medicaid spending cuts over the next decade.

Federal officials crafted the fund to give states “space to be creative,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said on a call with reporters after announcing the funding Dec. 29. “Some states will fail, and we will learn from that.”

The money was divided according to a complicated formula.

In 2026, each state will receive an equal $100 million share for the first half of the money, plus additional funding from the second half. Oz’s staff steered payouts from the second portion based on each state’s rural score, as well as results from a “technical” scoring system for project proposals.

Within hours of the announcement, academics and researchers began to parse the awards to better understand why some states received more than others, including whether the awards reflected any partisanship or political favoritism.

At first glance, total awards do not appear to favor states governed by either Republicans or Democrats. But teased out the amount awarded for each state’s technical score, which is the part determined by the discretion of agency officials.

The analysis was performed at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which specializes in rural health. A 吃瓜不打烊 review of the Sheps Center data found that states with Republican governors tended to receive more money for the parts of their application based on the technical score. Democratic-controlled states crowded the bottom quarter of those technical score awards.

Overall, though, the state awards reveal wild variation in how much money each state will get per rural resident, almost a hundredfold difference between the top and bottom.

In an emailed statement to , a spokesperson for Arizona’s Democratic Gov. Katie Hobbs accused the administration of shortchanging rural residents in the state, which was awarded $167 million this year from the program.

CMS spokesperson Chris Krepich said in an emailed statement to 吃瓜不打烊 that “politics played no role in funding decisions.”

On the December call, Oz pushed states to start working on policy actions championed by the administration — such as approving presidential fitness tests and restricting food benefits — that could require legislative approval.

Half of states promised to mandate the presidential fitness test, Oz said. Many states also proposed food waivers under the Supplemental Nutrition Assistance Program, known as SNAP, which would limit low-nutrition items such as soda. He also said some states promised to teach health care professionals about nutrition. And others confirmed they will repeal certificate-of-need laws, which require companies to prove that new health facilities they want to open are necessary.

Krepich said CMS’ new Office of Rural Health Transformation is hiring program officers to serve as point people for three or four states. Many states are setting up their own offices to oversee the new funding.

Oz highlighted Alabama’s “big maternity initiative with robotics doing ultrasounds” and said states are tackling issues ranging from behavioral health to obesity.

A 吃瓜不打烊 review of state “” and “” released by CMS shows that many states plan to address the workforce challenges in rural areas. Delaware, for example, plans to use its funding to create the state’s first four-year medical school with a rural primary care track.

A third of states said they want to improve electronic health records, and every state mentioned telehealth.

Many state legislatures to distribute the funding to their state offices. Meanwhile, state officials are hiring staff, , and .

“I’m excited about what’s next,” said Terry Scoggin, former interim chief executive of the Texas Organization of Rural & Community Hospitals, or TORCH. Texas was awarded the biggest allocation. The money will bolster a rural hospital funding bill Republican Texas Gov. Greg Abbott signed last year, Scoggin said.

More than two dozen cash-strapped rural hospitals in Texas to clinics since 2005, a nationwide trend that hit the Lone Star State particularly hard. The state has the largest rural population in the United States. Texas’ allocation amounts to about $66 per rural resident, . By contrast, Rhode Island was granted about $6,300 per rural resident.

Scoggin said he has “a ton of concerns” about companies taking the money instead of it helping rural hospitals and residents. “I was blown away about how many for-profit companies reached out.” The companies have also called rural hospitals and asked to work with them to apply for state money, he said.

The awards should be judged on how they benefit rural residents because “the stated goal of the program is to improve rural health,” said Paula Chatterjee, an assistant professor of medicine at the University of Pennsylvania who co-authored on the transformation fund.

Researchers at the Sheps Center conducted the analysis to estimate how much money states received from the technical score, which is the portion of funding based on the quality of their proposals and state policy actions that align with “Make America Healthy Again” priorities.

New Mexico won the least amount of technical funding, with less than 10% of its award based on the discretionary metrics. Alaska won the largest technical award, according to the Sheps Center data.

Texas, Nebraska, New Hampshire, and Hawaii rounded out the top five recipients of technical funding. In addition to New Mexico, the other lowest technical awards went to Michigan, New Jersey, Arizona, and California.

Mark Holmes, director of the Sheps Center, declined to comment on whether he saw any political bias in the awards but said the nuance in the final portion of discretionary awards based on technical scores is important because those dollars can be redistributed and potentially clawed back in future years.

“We can be fairly certain that every state will get at least a slightly, if not a vastly, different amount next year based on this re-pooling and reallocation piece,” Holmes said.

States now have a limited time to show they’re using the money effectively to secure future funding.

But they can’t start spending yet. CMS followed standard grant procedures and is requiring each state to submit revised budgets before they can draw down money, Krepich said.

States have until Jan. 30 to resubmit their budgets, and CMS then has 30 days to respond, according to the standard . Under that timing, some states may not have cash in hand until March.

“CMS is working closely with states to complete this process as efficiently as possible,” Krepich said.

This article first appeared on 吃瓜不打烊 and is republished here under a .

“When you get shot,” he said, “you stop thinking about the future.”

He is anchored by his wife and child and faith. He once wanted to work as a forklift driver but has built a stable career in information technology. He finds camaraderie with other gunshot survivors and in advocacy.

Still, trauma remains lodged in his daily life. As gun violence surged in the shadows of the covid pandemic, it shook Harris’ fragile sense of security. He moved his family out of Philadelphia to a leafy suburb in Delaware. But a nagging fear of crime persists.

Now he is thinking about buying a gun.

Harris is one of tens of thousands of Americans killed or injured each year by gun violence, a public health crisis that escalated in the pandemic and churns a into a hospital emergency room every half hour.

Over the past two decades, the firearm industry has and stepped up sales campaigns through social media influencers, conference presentations, . An industry trade group acknowledged that its traditional customer was “” and in recent years began targeting and who are disproportionately victimized by gun violence.

The Trump administration has moved to reduce federal oversight of gun businesses, announced by the Bureau of Alcohol, Tobacco, Firearms and Explosives as “marked by transparency, accountability, and partnership with the firearms industry.”

The pain of gun violence crosses political, cultural, and geographic divides 鈥� but no group has suffered as much as Black people, such as Harris. They were nearly 14 times as likely to die by gun homicide than white people in 2021, , citing federal data. Black men and boys are 6% of the population but of homicide victims.

Washington has offered little relief: Guns remain one of few consumer products the federal government for health and safety.

“The politics of guns in the U.S. are so out of whack with proper priorities that should focus on health and safety and most fundamental rights to live,” said attorney Jon Lowy, founder of , who helped represent Mexico in an unsuccessful lawsuit against Smith & Wesson and other gunmakers that reached the Supreme Court. “The U.S. allows and enables gun industry practices that would be totally unacceptable anywhere else in the world.”

吃瓜不打烊 undertook an examination of gun violence during the pandemic, a period when firearm deaths reached an all-time high. Reporters reviewed academic research, congressional reports, and hospital data and interviewed dozens of gun violence and public health experts, gun owners, and victims or their relatives.

The examination found that while public officials imposed restrictions intended to prevent covid’s spread, politicians and regulators helped fuel gun sales 鈥� and another public health crisis.

As state and local governments schools, advised residents to stay home, and closed gyms, theaters, malls, and other businesses to stop covid’s spread, President Donald Trump kept gun stores open, critical to the functioning of society.

White House spokesperson Kush Desai did not respond to interview requests or answer questions about the Trump administration’s efforts to reduce regulation of the firearm industry.

During the pandemic, the federal government gave firearm businesses and groups more than $150 million in financial assistance through the Paycheck Protection Program, even as some businesses reported brisk sales, according to from Everytown for Gun Safety, an advocacy group.

Federal officials said the program would keep people employed, but millions of dollars went to firearm companies that did not say whether it would save any jobs, the report said.

About bought a gun during the first two years of the pandemic, including millions of first-time buyers, according to survey data from NORC at the University of Chicago.

Harris is keenly aware of what drives the demand.

“Guns aren’t going away unless we get to the root of people’s fears,” he said.

most Americans who own a gun feel it makes them safer. But public health data suggests that owning a gun of homicide and triples chances of suicide in a home.

“There’s no evidence that guns provide an increase in protection,” said Kelly Drane, research director for the . “We have been told a fundamental lie.”

Record Deaths

Less than a year into the pandemic, 20-year-old Jacquez Anlage was shot dead in a Jacksonville, Florida, apartment. Five years later, the killing remains unsolved.

His mother, Crystal Anlage, said she fell to her knees and wailed in grief on her lawn when police delivered the news.

She said Jacquez overcame years in the foster care system 鈥� living in 36 homes 鈥� before she and her husband, Matt, adopted him at age 16.

Jacquez Anlage had just moved into his own apartment when he was shot. He loved animals and wanted to become a veterinary technician. He was kind and loving, Crystal Anlage said, with the 6-foot-4, 215-pound physique of the football and basketball player he’d been.

“He was just getting to a point in life where he felt safe,” Crystal Anlage said.

Gun violence researchers say parents like Crystal Anlage carry trauma that destroys their sense of security.

Anlage said she endures post-traumatic stress disorder and anxiety. She is terrified of guns and fireworks.

But she has made something meaningful of her son’s killing: She co-founded the Jacksonville Survivors Foundation, which works to raise awareness about the impact of homicide and to support grieving parents.

“Jacquez’s death can’t be in vain,” she said. “I want his legacy to be love.”

His legacy and that of other young men killed by guns is muted by firearm manufacturers’ powerful message of fear.

During the pandemic, gun marketers told Americans they needed firearms to defend themselves against criminals, protesters, unreliable cops, and , filed by gun control advocacy groups with the Federal Trade Commission.

In a since-deleted June 18, 2020, from Lone Wolf Arms, an Idaho-based manufacturer, a protester is depicted being confronted by police officers in riot gear between the words “Defund Police? Defend Yourself,” the petition shows. The caption says, “10% to 25% off demo guns and complete pistols.”

Impact Arms, an online gun seller, on Instagram on Aug. 3, 2020, showing a person putting a rifle in a backpack, the document says. “The world is pretty crazy right now,” the caption reads. “Not a bad idea to pack something more efficient than a handgun.”

The National Rifle Association in 2020 posted on YouTube a of a Black woman holding a rifle and telling viewers they need a gun in the pandemic. “You might be stockpiling up on food right now to get through this current crisis,” she said, “but if you aren’t preparing to defend your property when everything goes wrong, you’re really just stockpiling for somebody else.”

The messaging worked. Background checks for firearm sales soared 60% from , the year the federal government declared a public health emergency.

The same year, more than , the highest number up till then. In 2021, was broken again.

Weapons sold at the beginning of the pandemic were more likely to wind up at crime scenes within a year than in any previous period, according to by Democrats on Congress’ Joint Economic Committee, citing ATF data.

Gun manufacturers “used disturbing sales tactics” following mass shootings in Buffalo, New York, and Uvalde, Texas, “while failing to take even basic steps to monitor the violence and destruction their products have unleashed,” according to a released by congressional Democrats in July 2022 following a House Oversight and Reform Committee investigation of industry practices and profits.

The firearm industry has marketed “to white supremacist and extremist organizations for years, playing on fears of government repression against gun owners and fomenting racial tensions,” the House investigation said. “The increase in racially motivated violence has also led to rising rates of gun ownership among Black Americans, allowing the industry to profit from both white supremacists and their targets.”

In 2024, then-President Joe Biden’s Department of the Interior provided a to the National Shooting Sports Foundation, a leading , to help companies market guns to Black Americans.

The Federal Trade Commission is responsible for protecting consumers from deceptive and unfair business practices and has the power to take enforcement action. It issued warnings to companies that made unsubstantiated claims their products could prevent or treat covid, for instance.

But when families of gun violence victims, lawmakers, and advocacy groups in 2022, during Biden’s term, how firearms were marketed to children, people of color, and groups that espouse white supremacy, officials did not announce any public action.

This summer, the National Shooting Sports Foundation pressed its and derided “a coordinated 鈥榣awfare’ campaign” that it said gun control groups have waged against “constitutionally-protected firearm advertising.”

FTC spokesperson Mitchell Katz declined to comment, saying in an email that the agency does not acknowledge or deny the existence of investigations.

Serena Viswanathan, who retired as an FTC associate director in June, told 吃瓜不打烊 that the agency lost at least a quarter of the staff in its advertising practices division after Trump came into office in January.

Gun companies Smith & Wesson, Lone Wolf Arms, and Impact Arms did not respond to requests for comment. Neither did the National Shooting Sports Foundation or the NRA.

In an August 2022 , Smith & Wesson President and CEO Mark Smith said gun manufacturers were being wrongly blamed by some politicians for the pandemic surge in violence, saying cities experiencing violent crime had “promoted irresponsible, soft-on-crime policies that often treat criminals as victims and victims as criminals.”

He added, “Some now seek to prohibit firearm manufacturers and supporters of the 2nd Amendment from advertising products in a manner designed to remind law-abiding citizens that they have a Constitutional right to bear arms in defense of themselves and their families.”

Guns and Race

In 2015, the National Shooting Sports Foundation gathered supporters at a conference in Savannah, Georgia, and urged the firearm industry to diversify its customer base, according to a and reports from and the .

Competitive shooter Chris Cheng gave a presentation called “Diversity: The Next Big Opportunity.” Screenshots from the conference include slides purporting to show “demographics,” “psychographics,” and “technographics” of Black and Hispanic shooters.

The slides described Black shooters as “expressive and confident socially, in a crowd” and “less likely to be married and to be a college grad.” They said Hispanic shooters were “much more trusting of advertising and celebrities.”

Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety, said industry marketing shifted in the latter half of the 20th century as the popularity of hunting declined. The new sales pitch: guns for personal safety.

“They said, 鈥榃e need to break into new markets,’” Suplina said. “They identified women and people of color. They didn’t have a lot of success until the pandemic, the Black Lives Matter movement, and the death of George Floyd. The marketing says, 鈥榊ou deserve the Second Amendment too.’ They are selling the product as an antidote to fear and anxiety.”

Gun manufacturers were harshly criticized in the Oversight Committee’s 2022 investigation for marketing products to people of color, as gun violence remains a leading cause of death for young Black and Latino men.

At the same time, some companies also promoted assault rifles to white supremacist groups who believe a race war is imminent, the investigation found. One company sold an AK-47-style rifle called the “Big Igloo Aloha,” a reference to an anti-government movement, it said.

Still, Philip Smith wants more Black people to get guns for protection.

Smith said he was working as a human resources consultant a decade ago when he got the idea to form the , which helped the National Shooting Sports Foundation compile its report on communicating with Black consumers.

Smith encourages Black people to buy firearms for self-defense and get proper training on how to use them.

After 10 years, Smith said, his group has about 45,000 members nationwide. Single members pay $39 a year and couples $59, which gives them access to discounts from the organization’s corporate partners, including gunmakers, and raffles for gun giveaways, according to its website.

The police killing of Michael Brown in Ferguson, Missouri, and the shooting death of Florida teenager Trayvon Martin helped spark early interest from doctors, lawyers, and others in joining the group, he said. But interest took off during the pandemic, he said, even among Democrats who had resisted the idea of owning a gun.

“Hundreds of people called me and said, 鈥業 don’t agree with anything you’re saying, but what kind of gun should I buy,’” Smith recalled.

Smith, describing himself as “quiet, nerdy, and Afrocentric,” said criticism of guns misses the point.

“My ancestors bled for us to have this right,” he said. “Are there some racist white people? Yes. But we should buy guns because there is a need. No one is forcing us to buy guns.”

鈥楢merican Amnesia’

During the pandemic, gun violence took its greatest toll on racially segregated neighborhoods in places such as Philadelphia, where roughly residents live in poverty.

A says a one-year period in the pandemic saw more than 2,300 shootings, or about six a day. Many of the cases haven’t been solved by police.

City officials cited the boom in gun sales in the report: Fewer than 400,000 sales took place in Pennsylvania in 2000, but in 2020 it was more than 1 million.

Gun sales since the pandemic ended, but the harm they’ve caused persists.

At a conference last year inside the Eagles’ football stadium, victims of firearm violence or their relatives joined activists to share accounts of near-death experiences and the grief of losing loved ones.

Paintings flanked the stage and the meeting space to commemorate people who had been fatally shot, nearly all young people of color, under messages such as “You are loved and missed forever” and “Those we love never leave.”

Marion Wilson, a community activist, said he believes the nation has forgotten the suffering Philadelphia and other cities endured during the pandemic.

“We suffer from the disease of American amnesia,” he said.

Harris was on his way home from a job at Burlington Coat Factory nearly two decades ago when robbers followed him from a bus stop and demanded money. He said he had none and was shot.

Harris had spent his early life fixing cars with his grandfather, when he wasn’t at school or attending church. He remembers lying in a hospital bed, overcome with a sense of helplessness.

“I had to learn to feed myself again,” he said. “I was like a baby. I had to learn to sit up so I could use a wheelchair. The only way I got through it was my faith in God.”

Harris endured years of rehabilitation and counseling for PTSD. As someone in a wheelchair, he said, he sometimes fears for his safety 鈥� and a gun may be one of the few ways to protect himself and his family.

“I’m mulling it over,” Harris said. “I’m afraid of my trauma hurting someone else. That’s the only reason I haven’t gotten one yet.”

If you or someone you know has experienced the pain of a gunshot wound, and are willing to talk about the medical experience, please fill out our form .

This article first appeared on 吃瓜不打烊 and is republished here under a .