The administration of President Donald Trump has used claims of widespread wrongdoing to justify investigations, suspensions of billions of dollars in payments to states, and the cancellation of Affordable Care Act health coverage for hundreds of thousands of people.

has opened a broader political fight over the extent of fraud and the administration’s response to it. Republicans say they’re safeguarding taxpayer dollars by going after bad actors. Democrats contend the administration has relied on insufficient evidence to target blue states and cut programs Republicans have long tried to shrink. Meanwhile, Trump’s pardons of executives convicted of healthcare fraud, administration moves to weaken some protections against abuses, and a high-profile error by Trump regulators stand in contrast with the administration’s proclaimed fraud-fighting goals.

The dispute is becoming a talking point for both parties leading up to the November election.

Republican candidates are trying to win voters’ confidence by emphasizing their efforts to halt what they say is the misuse of taxpayer dollars in federal health programs.

“Going after fraud gives Republicans a healthcare message when they would otherwise just be defending cuts to Medicaid and the Affordable Care Act,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes 吃瓜不打烊. The approach, he said, helps “blunt” those attacks.

Democrats, however, traditionally have an advantage on healthcare in general, with are with such issues. Now Democrats are portraying Republicans’ fraud crackdown as a cover for the GOP’s weakening of safety net programs. But the GOP messaging could resonate at the ballot box.

About 44% of voters 鈥� and 54% of Republican voters 鈥� say fraud in government programs is “extremely important” for candidates to talk about, conducted in mid-September, suggesting the fraud focus might be connecting with the GOP base. Such fraud is also the top issue rural Republican voters want candidates to talk about, based on a by KFF and the Associated Press.

It’s an issue that is hardly new, and government watchdogs have repeatedly documented fraud by health providers and brokers, as well as improper enrollment in government health programs. A report by the in March warned that the “sheer amount of payments in the Medicare program creates significant fraud risks.” And in a , GAO investigators were able to get subsidized insurance for fake ACA enrollees.

What has changed is the prominence the issue now occupies in national politics.

Administration’s Fraud Targets

Trump administration authorities have this year charged hundreds of people, , in alleged billing schemes. It has announced and increased scrutiny of enrollment in federal programs, withholding in federal Medicaid payments over claims of lax oversight 鈥� with what Democrats say is a laser focus on blue states despite a lack of evidence.

The administration’s more expansive claims about fraud 鈥� and the actions it has taken in response 鈥� have generated fierce political clashes.

Most recently, the Centers for Medicare & Medicaid Services canceled ACA enrollments covering 760,000 people. While Democrats have questioned the methods that found them to be fraudulent, federal officials said they included nonexistent consumers whose applications were submitted by brokers or agents who can earn commissions from insurers.

CMS Administrator Mehmet Oz that the cancellations included people who had coverage through the ACA but hadn’t used it. He also said some had no Social Security numbers, calling that evidence of problems.

“About 35% of current people on the Obamacare system 鈥� 35%, more than a third 鈥� had never used the program. They haven’t bought a prescription medication. They haven’t seen a doctor. That just is not possible,” Oz said. “So we know there is fraud.”

Democrats and some health policy analysts challenge that conclusion. They say that younger and healthier people are much less likely to use their insurance and that not using their coverage doesn’t mean they were improperly enrolled. Critics also say the absence of Social Security numbers doesn’t necessarily establish fraud; for example, newborns can be added to their parents’ plans before receiving a number.

“This is yet another attempt by the Trump administration to kick hundreds of thousands of vulnerable Americans off their healthcare,” on the social media site X. “Millions are already struggling to access healthcare鈥攁nd this is their plan?”

There are political risks for the GOP as well. The disenrollment of alleged phantom accounts is likely to ensnare legitimate consumers, say health analysts and ACA advocates, leading to a potential backlash against Republicans if scores of people lose coverage just before the midterm elections.

States that tend to deliver for GOP candidates will be hit especially hard, they say, because ACA enrollees are concentrated in those states. The 4.5 million people in Florida and 4.1 million in Texas who have marketplace coverage account for nearly 40% of the country’s ACA enrollment, according to .

Conservative health policy advisers say the administration took multiple steps to avoid canceling legitimate coverage, including attempts to contact consumers and requirements that additional criteria be met before coverage was terminated.

“Those criticizing the action either don’t understand it or see some political advantage in mischaracterizing it,” said Brian Blase, president of Paragon Health Institute and a former Trump health policy adviser.

Democrats, meanwhile, highlight inconsistencies in the administration’s broader anti-fraud campaign.

They note that the Department of Health and Human Services last year of insurance brokers and agents who had been suspended in 2024 by the Biden administration for suspected fraud or abuse. The Trump administration also laid off from involved in regional oversight of the ACA marketplace.

On Oct. 3, to pass legislation with mandatory prison terms for defrauding Medicare and Medicaid, eliminating probation as an option.

But Trump has also pardoned health industry executives convicted of major fraud schemes, including people who are connected to his political allies or who spent heavily on lobbying on their behalf. The pardons included a sentenced to three years in prison for a nearly $40 million tax scheme and, in Trump’s first term, convicted for Medicaid fraud.

Trump’s pardons in 2021 of executives who profited from massive public healthcare fraud spurred criticism from the National Health Care Anti-Fraud Association. Critics now say the administration is portraying cuts to Medicare and Medicaid as necessary for weeding out waste, fraud, and abuse while exonerating criminals who have engaged in some of the biggest schemes in federal health programs.

Blue State Allegations

HHS has raised concerns about Medicaid fraud and program integrity in several states, and the administration has deferred or threatened to cut federal Medicaid funding while disputes are investigated.

Democrats say the administration is itself engaging in fraud by using unsubstantiated allegations of abuse to politically target blue states.

One of the most striking clashes occurred in New York.

Federal officials launched an investigation of the state’s Medicaid program after claiming that personal care services 鈥� including help with bathing, dressing, and meal preparation 鈥� had been provided to more than 5 million people, which would have amounted to roughly three-quarters of the state’s Medicaid population 鈥� an almost impossibly large proportion.

“It is time for New York to come clean about its Medicaid program,” CMS’ Oz .

CMS its calculations were wrong. The agency said that it had misunderstood the state’s billing codes and that the actual number of beneficiaries who received the services was closer to 450,000. The administration continued its scrutiny of the New York program, however, and later suspended millions of dollars in federal funding for the state’s Medicaid fraud unit, wasn’t producing enough indictments.

The administration also withheld about from California, citing concerns about program integrity and oversight of some home medical services. State officials deny the allegations, saying has grown because of factors such as higher wages for home health aides and an increase the number of older people receiving care.

The White House announced plans to in federal funds from Minnesota, claiming the state had failed to protect its Medicaid program from abuse. State officials have and gone to court to challenge the decision.

Vice President JD Vance, who chairs Trump’s Task Force to Eliminate Fraud, and other administration officials announced the state deferrals at the White House, giving what traditionally would have been technical disputes between state and federal health officials a much higher political profile. Vance’s office did not respond to 吃瓜不打烊 questions about the administration’s anti-fraud activities related to healthcare.

“I’ve never seen anything like this,” said , a Georgetown University research professor and a senior adviser at CMS during the Obama administration. “It’s a deferral, not a finding of fraud. This is being elevated by political decision-makers.”

Republican candidates have pounced on the investigations and allegations. In Minnesota, Republican gubernatorial candidate , who is speaker of the Minnesota House, released claiming that her Democratic opponent, U.S. Sen. Amy Klobuchar, “has never done anything to stop the fraud here in Minnesota.” Klobuchar has said that as governor she would “launch a top-to-bottom audit of state government to root out fraud.”

In New York, , a Democrat whose office runs the Medicaid fraud unit, criticized the decision to withhold funds and said weakening the operation would benefit criminals. Her Republican challenger in the November election, , has cited the Trump administration’s claims , telling Fox News Digital that James is “totally failing to prosecute Medicaid fraud.”

The administration says its actions are necessary because fraud diverts taxpayer money from people who legitimately qualify for government programs.

“The fraud doesn’t just steal money 鈥� it steals our trust,” Oz said in August on .

Democrats and healthcare advocates say the White House’s anti-fraud crusade is being used by Republicans to distract from criticisms over its to Medicaid, the ACA, and other federal health programs.

Republican-backed legislation enacted last year is projected to reduce federal Medicaid spending by hundreds of billions of dollars over a decade.

Congressional Republicans also declined to extend enhanced ACA premium subsidies that expired , increasing premium costs for many people who buy insurance through the marketplaces. Enrollment has since declined by millions.

Overall, the combined effect of GOP-led changes will result in more uninsured people by 2034, according to an analysis by the Congressional Budget Office.

Those changes have given Democrats an opening to campaign on protecting healthcare coverage and affordability while Republicans seek to shift some of the debate toward fraud and government spending.

“It’s really a way to distract and reframe the cuts in a different way, to say it’s part of an anti-fraud effort,” said Anthony Wright, executive director of Families USA, an advocacy group focused on expanding health coverage. “Fighting fraud shouldn’t result in people losing coverage.”

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

Standing in line for U.S. Senate candidate Abdul El-Sayed’s town hall in the state’s capital in September, she whipped out her phone to pull up a screenshot. It was of the $1,000 cashier’s check she’d picked up at the bank that day to pay down a chunk of her son’s dental bills. An early childhood special education paraprofessional, she still owed $389, even with good dental insurance. Her own cleaning a few weeks before cost $600.

She tried to talk herself down at the bank, to focus on being grateful for what she could afford.

“I’m like, 鈥楾ina, OK, you were in a position for this moment to do this,’” she said. “A lot of people couldn’t do what I had to do today. I couldn’t do it. But I did it. So I need to hear, how are you going to make this better for everyone?”

Many who waited in the hot sun that afternoon in a line stretching blocks through downtown Lansing shared similar anxieties. A man ahead of Starks-Clay talked about watching his brother rack up thousands of dollars in medical debt. A professor emeritus at nearby Michigan State University worried aloud about his grandkids’ medical care, because his adult kids were struggling to meet a $9,000 insurance deductible. Healthcare workers who’d turned up for the event described patients choosing between affording medication or food, or how they themselves had been financially devastated by a medical crisis.

They all knew Michigan Democrat El-Sayed’s rallying cry by heart, chanting it when the candidate took the stage: “Money out of politics! Money in your pocket! Medicare for All!”

Support for Medicare for All is at its highest in at least a decade, according to a . The survey found two-thirds of Americans now favor expanding the government health program that largely covers seniors (about are enrolled in private plans through Medicare Advantage).

But many people don’t actually know how to define Medicare for All. Traditionally, the idea has been to establish a single health insurance program, run by the federal government, that would guarantee coverage for Americans and minimize or even eliminate private insurance. How much people like the idea depends on what they’re told about it, pollsters have found.

Still, at a time when of Americans say they can afford their healthcare, Medicare for All has become a progressive shorthand for radical, systemic change.

“Too many people don’t have health insurance, too many people who do have insurance can’t afford medical care, and many people are terrified about the costs of being sick,” said Jonathan Oberlander, a professor at the University of North Carolina-Chapel Hill who specializes in the politics of healthcare reform.

“And in an electorate that wants change, that is disenchanted with the status quo, Medicare for All is an important symbol,” he said.

That’s why Democrats running for Senate seats in the midterm elections in such states as Maine, Minnesota, and Florida tout their support for scrapping the current health insurance system in favor of broad Medicare coverage. But nowhere is the issue as central to a race as in Michigan, where Medicare for All has become synonymous with El-Sayed.

El-Sayed, who trained as a doctor and served as Detroit’s top public health official, has campaigned on Medicare for All since his unsuccessful bid for governor in 2018. To Starks-Clay, that means he has a plan and will “stick to it,” she said.

That’s appealing to voters right now, said Ashley Kirzinger, director of survey methodology at KFF, a health information nonprofit that includes 吃瓜不打烊. “When we ask people what do they want to hear from candidates in regards to healthcare, it’s a plan to bring down healthcare costs.”

American Dream or Pipe Dream?

Medicare for All has been the shiny object of progressive politics in previous campaigns, including Vermont Sen. Bernie Sanders’ 2016 presidential bid and the 2020 Democratic presidential primary. Its popularity rises and falls in cycles, Oberlander said. And today people are painfully aware their care is getting more expensive and harder to access.

In the first decade or so after the passage of the Affordable Care Act in 2010, the nation’s uninsured rate was cut . Insurance companies could no longer deny people coverage based on preexisting conditions. Since then, to cover more people, 40 states plus Washington, D.C., have expanded Medicaid, the government health program for those with low incomes or disabilities.

Now it feels as if we’re moving backward, Oberlander said. “We are now, in the past two years, in an era where the Trump administration and congressional Republicans have reversed that progress.”

Michigan, a battleground state that President Donald Trump won in 2024, saw some of the after the GOP-controlled Congress allowed enhanced tax subsidies, which helped people afford their premiums, to expire at the end of last year. Insurance companies in Michigan hiked individual marketplace rates by an average of 20%. And up to 355,000 Michiganders are expected to lose their Medicaid coverage in 2028 because of cuts included in Trump’s signature law, the One Big Beautiful Bill Act, according to estimates from the , a left-leaning think tank.

At El-Sayed’s town hall in Lansing, Darleana Ash said patients at the medical diagnostics lab where she works are increasingly skipping tests because they can’t afford them. Others drive hours from rural areas because their local labs have closed or are no longer in their insurance networks. She worries about the patients who must choose between their medications and groceries some months.

“If you got somebody that’s 75, 80 years old, guess what? They’re going to go without the medication, because they got to eat,” she said.

Packed in near the front of the crowded town hall was Cindy Lou Coolich, a boisterous retiree wearing a campaign T-shirt and cowboy hat. She spent years working for a company that helped uninsured people enroll in coverage, until she got sick herself. A bout of sepsis nearly killed her and left her disabled. Suddenly, she was the one enrolling in Medicaid and living on $900 a month from Social Security.

She lost the 15-acre horse farm she’d owned, and then everything else, she said. “Except my car.” The saving grace, oddly, was the death of her ex-husband. Because they’d been married for more than 10 years, she could benefit from his Social Security benefits. “So now I’m doing quite well!” she laughed. But to her, it hardly seemed like the mark of a functioning healthcare system that someone had to die for things to get better.

A Universal Response

Democrats aren’t the only ones responding to voters’ healthcare discontent. Republican Mike Rogers, a former Michigan congressman and El-Sayed’s opponent, recently .

“I just can’t think of a more important issue to the people of Michigan than healthcare and costs, the rising costs,” he said. At a announcing his health platform, he broadly attacked El-Sayed and Medicare for All.

“[If] the government’s going to give you something, they have to take it away from someone else,” Rogers said.

Under Medicare for All, millions of Michiganders with private health insurance would lose that coverage, he said. Pointing to estimates that Medicare for All would cost some $4 trillion per year, he said, “Guess what? People pay for that.” (A recent researchers found that the cost of implementing Medicare for All, estimated at $4.2 trillion, would save about $1 trillion in healthcare spending.) Rogers’ campaign declined an interview request from 吃瓜不打烊.

Concerns about increased taxation, disruption to the current system, and reduced access to services can make Medicare for All a political liability in a close election, Oberlander said. “It doesn’t matter if the fears that they’re spreading are actually accurate,” he said. “Politically, what matters is if they can scare people.”

But even if El-Sayed wins in November, the chances of Medicare for All replacing the current system “remain very remote in the short to medium term,” Oberlander said.

Given the staunch opposition from Republicans and many moderate Democrats, not to mention the lobbying power of the healthcare industry, massively overhauling the U.S. health system won’t suddenly be achievable because of a single Senate candidate.

Thomas “Jermaine” Carey knows this. A self-described activist, he attended a recent El-Sayed town hall in Detroit feeling “kind of sold out” by what he calls the “straight-ticket” Democratic Party. Medicare for All sounds good, he said. “Do I believe it?” He shrugged.

“It’s still America,” he said. “You still have super PACs, the lobbyists that control everything.”

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

Many will be stuck without a lot of options. In some cases, no other companies in their area may offer Medicare Advantage plans to replace them. This isn’t the first time this has happened. Last year, almost 3 million seniors found themselves in similar situations.

An Arm and a Leg host Dan Weissmann and producer Emily Pisacreta looked into what happened when those cancellations hit Minnesota. The collapse of a major Medicare Advantage carrier there led to “total chaos,” according to the director of the state’s Medicare assistance agency. Everyday people stepped up to help one another in the fallout.

Plus, 吃瓜不打烊 senior correspondent Julie Appleby joins to discuss the role of private health insurance companies in Medicare. She explains how these companies shape seniors’ choices, including in Medicare supplemental plans, whose premiums have skyrocketed.

Credits

An Arm and a Leg is a co-production of 吃瓜不打烊 and Public Road Productions.

For more from the team at An Arm and a Leg, subscribe to its weekly newsletter, . You can also follow the show on , , , and . And if you’ve got stories to tell about the healthcare system, the producers would love to .

To hear all 吃瓜不打烊 podcasts, click here.

And subscribe to An Arm and a Leg on , , , or wherever you listen to podcasts.

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

Inside the New Richland Care Center, staff members rushed to move 36 residents out of the building on Sept. 19 while they still could. They pushed elderly residents in wheelchairs through 4-inch-deep water to buses waiting in the parking lot, said nursing home administrator Robert Johannsen.

Inches turned to feet as the last three residents were wheeled out on hospital beds, lifted “as high as they can go” to escape the rising water, Johannsen said. Firefighters and volunteers from a high school football team pushed the beds to safety across the street, he said.

“It’s pretty devastating,” Johannsen said of the now-shuttered nursing home. “There was at least 2陆 feet of water flowing down the hallways.”

The small-town, government-run nursing home is about 100 yards from a drainage ditch in southern Minnesota. It has flooded three times in 16 years, including during the September storm that was large but far from historic, according to the National Weather Service.

New Richland is one of 100 U.S. nursing homes that face some of the nation’s worst flood risk 鈥� where at least 2 feet of water during a big storm could endanger residents 鈥� according to a 吃瓜不打烊 analysis of peer-reviewed flood hazard mapping provided by Fathom, a United Kingdom-based company considered a leader in flood simulation.

The 吃瓜不打烊 analysis builds upon a 2025 investigation that used Fathom’s mapping to identify at least 170 U.S. hospitals at risk of significant flooding. Fathom’s estimates are generally seen as more modern than official flood maps released by the Federal Emergency Management Agency, which are often out of date and don’t account for the changing climate.

“Every community across the United States carries some level of flood risk,” said Oliver Wing, the chief scientific officer at Fathom. “There is this idea that unless you can either see the ocean or the Mississippi from your front room, then you’re not at risk of flooding 鈥� when the reality is that anywhere rain can fall, it can flood.”

The U.S. has nearly 15,000 nursing homes housing more than 1.2 million people. In floods and other disasters, the residents are especially vulnerable because many are medically frail, cognitively impaired, or immobile. Some require daily care that can’t be reliably provided during a disaster, yet they are also so fragile that relocation could send them to the emergency room.

Additionally, many nursing homes were built near coastlines or waterways in the 1970s, before widespread concern about climate change, to keep residents cool and content, said David Dosa, the head of geriatrics at the UMass Chan Medical School.

“It’s a lot more comfortable than being in an urban jungle,” Dosa said. “Obviously, now you’re in places that are a little more at risk.”

Dosa has studied nursing home evacuations since Hurricane Katrina flooded the New Orleans area in 2005. Dozens of people were killed in facilities that tried to ride out the storm and flooded after the levees broke.

After Katrina, the nursing home industry pivoted toward evacuations, although some of those decisions also led to deaths, Dosa said.

In preparation for the next three Gulf hurricanes, more than 270 nursing home evacuations were recorded, according to a Dosa co-wrote in 2011. Within the 30 days that followed each storm, the regions hit saw a cumulative total of 277 more nursing home resident deaths than expected, suggesting a “significant increase in mortality and morbidity associated with evacuation,” according to the study.

“It’s Russian roulette. You’re damned if you do. You are damned if you don’t,” Dosa said of evacuations. “Older adults and disasters don’t mix.”

A similar found a 16% greater chance of ER visits among residents of Florida assisted living facilities who were evacuated before Hurricane Irma in 2017. People in assisted living facilities generally need less care than those in nursing homes.

“Assisted living residents are quite frail in their own right,” said Cassandra Hua, an assistant professor at UMass Lowell, who led that study. “But nursing home residents are usually at higher risk. So anything you see in assisted living might be multiplied in a nursing home setting.”

Even a few inches of flooding can interrupt nursing home care and force an evacuation. For each of the 100 nursing homes identified by the 吃瓜不打烊 analysis, Fathom’s data predicted a 100-year flood event could bring at least 2 feet of water to the buildings.

A 100-year flood is an intense weather event with a 1% chance of occurring in any given year, but it can happen more often. Climate scientists largely agree that extreme weather is worsening as the planet warms, which allows the atmosphere to hold more moisture and causes sea levels to rise.

And storms are drenching regions once considered at lower risk for flooding, where essential facilities and entire communities might be less prepared, said Drew Gronewold, a University of Michigan climate scientist. In other regions, storms are now less frequent but becoming “off-the-charts” powerful, he said.

“Storm tracks are changing their trajectory,” Gronewold said. “These types of, in air quotes, 鈥榰nanticipated events’ are going to be part of our future.”

Some of the nursing homes 吃瓜不打烊 has identified as at risk have flooded in the past five years, including facilities in Florida, Kentucky, Texas, and Washington.

Five of the facilities flooded in 2012 as Superstorm Sandy clobbered New York, according to a report from the , while a sixth, the elevated Seagate Rehabilitation and Nursing Center, narrowly . In Indiana, more than 150 people from the five-story Munster Med Inn during Hurricane Ike in 2008. Members of the National Guard carried some residents down flights of stairs in the dark.

Then there is the New Richland Care Center. Local media reports show it was evacuated due to flooding in 2010 and 2016, then partially surrounded by floodwater in 2023, before the Sept. 19 evacuation.

Storms dropped 4 to 8 inches of rain on much of southeastern Minnesota the day before, setting off widespread flooding, said National Weather Service meteorologist Brennan Dettmann. The rainfall was heavy for September but would not have been out of place in July, he said.

It was too much for New Richland. Storm runoff from nearby farms pooled in a low-lying baseball diamond at the edge of town before swamping nearby streets. Johannsen, the nursing home administrator, said maintenance workers who were trying to fix sewer drains called him in the middle of the night to warn about flooding in the park across the street.

“They said, 鈥榊ou need to come in. The water is rising,’” Johannsen said. “At that point, I think the water was a good 30 feet away from the building. I wasn’t really concerned.”

Wing, the Fathom scientist, said the danger should have been obvious. Although Minnesota’s natural landscape once would have absorbed heavy rains, the farmland around New Richland funnels runoff into creeks and ditches that lead to a low-lying bowl near the nursing home. It’s almost as if the location is designed to flood, Wing said.

“The choice has been made that we don’t want water in our crop fields. We want it in the nursing homes of vulnerable people,” Wing said. “That’s the choice that has been made, politically, in that part of Minnesota.”

Inside the ruined nursing home, receding floodwaters left behind knee-high watermarks, mud-smeared floors, and a lingering smell that Johannsen said reminded him of growing up on a farm. Water destroyed treasured photo albums left behind in a low cabinet, he said.

Johannsen said the nursing home 鈥� which, with 85 employees, is one of the largest employers in town 鈥� will be closed for five months to a year for repairs. He said all its residents were moved into a school gymnasium and have been resettled across about nine area nursing homes.

“It was an awful experience that I hope nobody ever has to go through. Because these people lost homes,” Johannsen said. “My staff is losing their jobs. And I don’t know what to do.”

Methodology

For this analysis, we used data from Fathom, a United Kingdom-based company that specializes in flood-risk modeling worldwide. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been peer-reviewed and used by insurance companies, the World Bank Group, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has validated Fathom’s U.S. data.

Through a data use agreement, Fathom shared U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of coastal, fluvial, and pluvial flooding and accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk nursing homes, we used a Centers for Medicare & Medicaid Services database to map more than 14,000 nursing homes. With GPS coordinates as the center point, we created a circle with a 100-yard radius around each nursing home, which in most cases captured the building and nearby grounds. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for nursing homes where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 750 nursing homes.

Then we visually inspected those facilities using mapping software and Google Maps to confirm that floodwaters were predicted to reach or surround the buildings. We trimmed our list to the 100 nursing homes where the most flooding was predicted, with additional weight given to deeper water.

Our analysis does not account for how flooding beyond a nursing home’s footprint could still affect employees or patients. And it does not assess what steps facilities may have already taken to prepare for severe weather events.

Fathom provided guidance and feedback as we developed our analysis.

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

Carter’s specialty is reeling in grants to support students in the Omaha Nation school district, where she is a finance manager. One paid for the garden that sits next to the district’s campus. Another allowed the school system, in one of Nebraska’s lowest-income counties, to pay students to maintain it.

“They’re out in the sun. They’re watering plants,” she said. “It’s the first time they get a paycheck in their life.”

Carter, 41, is paralyzed from the chest down, an injury she’s lived with since a fall in her early 20s. It didn’t slow her down as she built her accounting career and got a master’s degree in human resource management.

But in November 2023, Carter 鈥� who lives in Sioux City, Iowa 鈥� got a letter from Iowa’s Department of Health and Human Services. It said that her income was too high for her to stay on Medicaid and that she might lose her benefits in two weeks if she didn’t take action.

States are scrambling to get ready for a new federal requirement to double-check that many people on Medicaid qualify for the benefit, by showing they are working, volunteering, or studying at least 80 hours per month. Politicians’ focus on requiring work has angered many people with disabilities who have Medicaid and say current policies that apply to them have the opposite effect 鈥� making them choose between working or receiving benefits.

鈥業 Have No Options’

When Carter got the letter, she was making $110,000 a year, well above Iowa’s 2023 income limit for working people with disabilities: $36,450 for a household of one.

“I had no time at all to prepare,” she said. “I had a decision to make.”

At the time, Carter got her health coverage through Iowa’s , a buy-in program that allows working disabled Iowans to pay part of their income to the state to maintain access to Medicaid benefits. Forty-seven states offer , but eligibility through limits on income and assets.

For years, disability rights advocates have pushed state legislatures to change the limits, arguing they prevent people like Carter from accepting raises or building savings, for fear of losing crucial medical benefits. Massachusetts, Minnesota, New Jersey, and Rhode Island have eliminated such limits over the past five years.

To keep her Medicaid coverage, Carter would’ve had to find a job paying her far less than she was making. Or she could drop her Medicaid coverage and enroll in the school district’s health plan. But that plan didn’t cover many of the disability-related expenses that Medicaid did.

Carter decided to keep her job and leave the Medicaid buy-in program. In the end, the decision felt like a no-brainer, she said.

“I like getting up and going to work every day, and I really like what I do,” she said. “Why would I throw that away?”

But it’s been hard on her finances. Carter said she now spends about $35,000 a year out-of-pocket for expenses her old plan covered, such as the nurse who visits her three times a week, modifications to her car, and wheelchair repairs.

“I had the motors go out on my wheelchair,” she said. “So that was like $4,000 to fix.”

Over the next year, Carter picked up extra jobs and cashed in some of her retirement savings.

“I want to pay my own way. I don’t mind paying taxes,” she said. She doesn’t want to hide her income, either. “I just want an option,” she said. “I have no options right now.”

A Program Intended To Encourage Work

Congress to create Medicaid buy-in programs in the 1990s, intending to incentivize more people with disabilities to work. Iowa was one of the first states to adopt the program.

According to state data, 11,640 Iowans were participating in the buy-in program as of late January, or 1.7% of all Medicaid recipients in Iowa.

The income caps have inched up since Carter got her letter. , set at 250% of the federal poverty level, is $39,900 for a household of one this year.

The rules also restrict recipients from accumulating too much in assets. The is $12,000 for an individual or $24,000 for a married couple, excluding some assets, such as a primary home or vehicle.

Carlyn Crowe, the public policy manager at the , said the limits can prevent disabled Iowans from reaching their goals. “Work full-time and be able to buy a house, live in the community, buy a car,” she said. “Those limits placed on what they can earn and save are keeping them from doing that.”

Crowe’s organization, which has counterparts in every state, is and advocates for people with disabilities. In Iowa, such advocates have asked legislators to drop the hard limits on income and assets. Instead, they suggest that disabled Iowans pay 6% of their income to buy into the Medicaid program, an approach modeled after a 2024 that created a Medicaid buy-in program with no income and asset limits. (Tennessee is waiting on federal approval before starting its program.)

In recent years, these efforts have built bipartisan support and gained traction. An Iowa House committee unanimously in 2025 to remove the income and asset caps, but the bill died after failing to move forward during this spring’s legislative session.

State legislatures now in Medicaid spending estimated at more than $900 billion over 10 years, as part of the One Big Beautiful Bill Act.

, an associate director of KFF’s Program on Medicaid and the Uninsured, said the specific worry is that buy-in programs, though they’re a small part of the larger Medicaid system, could increase overall Medicaid spending if eligibility changes.

“The premiums charged in buy-in programs are nowhere near close to the expected costs of covering people,” Burns said. (KFF is a health policy research, polling, and news organization that includes 吃瓜不打烊.)

Focusing on initial cost increases is myopic, said , the director of disability policy at at Iowa’s Drake University. More workers mean additional income tax revenue for states. It also enables some people with disabilities to earn enough to transition off other government assistance programs, such as the Supplemental Nutrition Assistance Program.

“Three, five, seven years from now, you may be recouping those expenses by having people be able to work their way off,” Van Sant said.

Falling Through the Cracks

Iowa lawmakers tried a more modest adjustment during this year’s legislative session. Instead of removing the income limit entirely, they introduced legislation that would raise the cap to 300% of the federal poverty level and exempt pension accounts and a spouse’s income, among other things, from the asset cap.

In the end, the provision was stripped from a wide-ranging public assistance bill. If it had passed, the new income limit would have been one of the for a buy-in program, according to KFF.

, a former City Council member in Sioux City who was paralyzed from the chest down after a diving accident, told state lawmakers during a hearing in February that the proposal was a step in the right direction, but not enough.

“I fear that we’re going to lose people to other states,” said Watters, who added that he was considering moving to Minnesota, which never had an income cap and eliminated asset caps for its in 2024.

Even if Iowa had raised its income limit, Carter would still have been ineligible.

Carter remains committed to her primary job at the school district. She plans to keep working there and taking on additional jobs, seven days a week, so she can pay for her medical needs and continue helping students.

This article is from a partnership that includes , , and .

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

While knee replacement procedures have become standard, however, the prices charged have not.

At Catawba Valley Medical Center in Hickory, North Carolina, for example, the cost of the procedure under a Blue Cross Blue Shield health plan this year was about $16,000, according to data from Serif Health, a San Francisco startup that collects recently released data from hospitals and insurers. Little more than an hour’s drive west, however, at Mission Hospital in Asheville, the cost of the procedure under the same health plan was around $40,000, or more than double, the data showed.

Formed by the merger of the two largest hospitals in the region, Mission has little competition and more power to demand the higher price.

This comparison between these two hospitals illuminates how large hospital systems created by a in recent decades can dominate the competition and push up healthcare costs.

While many factors affect the price of a medical procedure, hospitals with few competitors can charge more, health economists say.

The hospital price hikes mean patients and their insurers must pay more for an episode of healthcare. But there is an important side effect, too, even for people who don’t require medical care. When insurers face higher hospital prices, they pass the costs on and raise the prices they charge for everyone’s health insurance.

Using Serif Health’s pricing data, it is possible to see how mergers like the one that created Mission Hospital influence costs. For years, it was difficult to determine how much hospital monopolies boosted charges. But since 2021, the Centers for Medicare & Medicaid Services to disclose prices, making it possible to gather comprehensive data such as Serif Health’s.

The connection between market power and prices exists across the country. In Melbourne, Florida, Holmes Regional Medical Center is part of a health system, Health First, that dominates surrounding Brevard County. The center has charged Cigna two times what a hospital two hours north did for a knee replacement this year, the Serif Health data shows.

Banner North Colorado Medical Center, which ranks as the leading healthcare provider in Weld County, Colorado, charged a UnitedHealthcare patient $20,000 more for the surgery in Greeley than a health system an hour’s drive south in Denver, according to Serif’s figures.

The American Hospital Association that hospital mergers can improve quality and reduce healthcare costs by creating “a fiscally sustainable environment.” A Mission Hospital spokesperson said comparing hospitals’ prices was unfair or misleading because their practices and constraints vary so much.

For years, economists suspected that the run of mergers beginning in the late 1990s was a main driver of the rising costs of U.S. healthcare. From 2002 to 2020 alone, unfolded in the United States.

But until the recent federal disclosure rule, the effect of healthcare monopolies on pricing was often overlooked or harder to detect. Hospitals do not advertise their prices, and even when they are revealed on a bill, patients scarcely notice the bottom line because they don’t pay most of it 鈥� their insurers do.

“What the data shows pretty clearly is that when hospitals have bargaining leverage, they tend to have higher prices,” said Zack Cooper, an associate professor of public health and economics at Yale University who has spent more than a decade studying hospital monopolies.

Over the last quarter century, Cooper said, hospital prices have risen faster than those for any other economic sector, and “hospital consolidation is one of the primary drivers.”

Federal and state officials have wavered over when to intervene when hospitals are proposing to merge. Last summer, former President Joe Biden’s that urged federal agencies to challenge mergers that could harm consumers, reversing course from Biden’s more aggressive enforcement of antitrust law. In a , however, Federal Trade Commission Chairman Andrew Ferguson called for a task force on healthcare mergers that are leading to “higher prices” and “decreased quality” of care.

Several states have sought to curb healthcare monopolies. In 2023, Minnesota banning anticompetitive healthcare mergers and bolstering state oversight. In 2022, requiring healthcare businesses to give the state a 90-day notice of large mergers and to investigate their effects on competition. And in 2021 enabling the state health department to block acquisitions and mergers of hospitals.

Nothing has stopped the overall trend, however, as hospitals seek to grow and gain leverage over insurers and competitors. Last year alone, hospital and health systems announced 46 mergers and acquisitions, , a healthcare business consulting firm. Five ranked as “mega-mergers,” meaning they were valued at more than $1 billion. One across Connecticut and New York into a powerful interstate health system. Another linked , a deal that created a 56-hospital system across the Midwest 鈥� including Iowa, Michigan, Minnesota, Wisconsin, and Wyoming 鈥� with combined revenue of about $10 billion.

Other mergers have been proposed in , , and Minnesota.

Asheville’s Dominant Hospital

Few places in the United States better exemplify how hospital mergers reshape healthcare than Asheville.

In 1998, the state authorized a deal that joined the city’s two acute-care hospitals, St. Joseph’s Hospital and Memorial Mission Medical Center, . Ever since, its effects have been studied and its prices fiercely contested.

Marcelle Crago, a nurse and lactation consultant, is one of many patients who have accused Mission Health, which operates Mission Hospital, of gouging consumers. Last year, she tweaked her knee while cross-country skiing.

“My knee went 鈥榩op, pop, pop,’” she recalled. She had torn her meniscus, the rubbery cartilage around the knee that acts as a shock absorber. A doctor advised her to have a portion of it removed.

Two days before the surgery, Mission Health told her the total charge would be over $9,000, according to paperwork on her case filed with the state’s Consumer Protection Division.

“I was shocked at the number,” she said.

Crago’s insurance policy from UnitedHealth Group had a high deductible, so she would have had to pay most of the cost. She decided to postpone the surgery and shop around, eventually arranging to have it done at an outpatient center not affiliated with Mission. There, the bill came to less than a third of the price Mission Health charged, according to paperwork she kept.

“The way Mission Health handled the whole thing felt predatory,” Crago recalled, noting that when she balked at the $9,000 figure, the hospital offered a 20% discount if she paid up-front. “It makes you wonder how much they are playing with prices.”

In responding to Crago’s complaint with the state, an attorney for Mission and HCA Healthcare, which owns the hospital, wrote that hospital charges “represent the cost for supporting the entire episode of care” and must cover the hospital’s investments in advanced technology, training, staff, and other critical needs.

“Patients are certainly entitled to 鈥榮hop around’ for surgical procedures,” wrote the attorney, Phillip Jackson.

It is not just patients who bear the burden of rising hospital prices.

Over time, anyone who pays for health insurance pays a price for hospital monopolies, as insurers boost premiums as medical costs rise. The full cost for an employer to pay for an average family health insurance plan rose to more than $27,000 in 2025, up from $21,000 just six years ago, according to .

Around Asheville, employers and employees complain that their insurance premiums are higher because Mission’s prices are so high.

As the chef and co-founder of Cúrate restaurant in Asheville, a business with about 100 employees, Katie Button provides employee health coverage and believes she has been paying for Mission Hospital’s excessive prices, according to a pending class-action lawsuit she filed in 2021 with five residents who say the monopoly has harmed them.

Any insurance plan in Asheville must include Mission Hospital, she said, because it is the only one around. This makes the burden of its prices unavoidable.

“We are where we are because we don’t have a choice of hospitals,” Button said. “There is no other option.”

The steady creep of healthcare costs is top of mind not just in Asheville but for most U.S. voters, according to . Nearly two-thirds of U.S. adults were worried about being able to afford healthcare, the poll found.

Yet while federal law allows regulators to step in and block mergers deemed to create monopolies, the FTC intervened in only from 2002 to 2020 to stop a hospital merger, according to a Yale University study. The FTC has since announced challenges to five other hospital mergers.

Birth of a Monopoly

When Mission Health was formed by a merger in 1998, state officials recognized that Asheville’s new dominant hospital system would have the power to raise prices and required Mission to sign an agreement to limit spending and profit margins.

Even with these restrictions, the hospital , according to economic research cited by the FTC. But Mission’s prices were about to go up even more. In 2015, Mission Health lobbied the state legislature to drop the state restrictions, abandoning the profit limits.

“After 20 years of the hospital behaving itself, the state decided to terminate its oversight,” said Mark Hall, a professor emeritus at Wake Forest University who of the hospital’s merger history. Then, three years later, HCA, the largest hospital corporation in the country, bought Mission Health. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund 吃瓜不打烊’ coverage.)

“This put a prepackaged monopoly into the hands of the world’s largest for-profit hospital corporation,” Hall said.

Across a range of services, Mission Hospital charges more than other North Carolina hospitals, according to figures from Serif Health.

Consider the prices that Mission negotiated with UnitedHealthcare compared with those the insurer pays at Catawba Valley Medical Center. For a breast biopsy, UnitedHealth pays $7,500 at Mission and $1,700 at Catawba, according to Serif. For a hernia repair, it pays $17,700 at Mission and $9,600 at Catawba.

“The prices hospitals charge are one of the leading drivers of rising healthcare costs,” according to a UnitedHealthcare statement sent by spokesperson Cole Manbeck.

Mission spokesperson Katie Czerwinski, in a statement, said that it can be misleading to compare one hospital with another.

Mission Hospital is almost three times as large as Catawba Valley Health and is a Level 1 trauma center serving a different population, Czerwinski said. She also said that pulling individual rates for comparison paints an incomplete picture.

But other figures indicate that prices at Mission Hospital are relatively high, even when viewed collectively.

A team at the think tank Rand, led by Christopher Whaley, now a Brown University health economist, uses commercial insurance records to compare average hospital prices across the U.S. relative to those paid by Medicare. , Mission Hospital in 2024 charged prices that were 334% of prices set by Medicare. Catawba Valley Medical Center charged 237%. The state benchmark for prices is 280% of Medicare, Rand figures showed.

“The prices we pay for healthcare vary tremendously and are uncorrelated to the value we receive,” according to the Rand website.

For many in Asheville, the primary complaints about Mission Hospital focus on the quality of patient care. This is consistent with showing that the quality of care declines when hospitals have little competition.

Amid rising complaints about hospital services, North Carolina state Sen. Julie Mayfield, a Democrat, helped launch a nonprofit organization two years ago called Reclaim Healthcare WNC to hold Mission “accountable for its harmful practices.”

“Within a year of the HCA sale, I started hearing stories from physicians and other friends about all the terrible things that were happening there,” Mayfield said, most of them caused by severe staff cuts and physicians leaving.

Three times since 2024, state health inspectors working on behalf of CMS have issued “immediate jeopardy” findings to Mission Hospital, indicating problems so severe that they posed an imminent risk of serious injury or death to patients.

In the most , an 88-year-old woman recovering from a fall and hip surgery at Mission Hospital died after going a night without receiving a blood transfusion.

Czerwinski, the Mission Hospital spokesperson, said a proposed plan of correction “allows Mission to address the findings from the survey and complete a comprehensive review of operations.”

As more hospitals across the United States plan to merge, Mayfield said, the experience in Asheville represents a cautionary tale.

“Unregulated monopolies have never gone well for the public.”

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

The race is in Iowa, whose Medicaid program has been plagued with controversy since 2016, when the state hired national insurance companies to manage billions of dollars’ worth of benefits.

That shift was made by then-Gov. Terry Branstad, a Republican. With his executive order, Iowa joined most other states in privatizing the management of Medicaid, which covers healthcare for more than 67 million Americans with low incomes or disabilities.

The arguments have resurfaced this year during the competition to replace Republican Gov. Kim Reynolds, who was Branstad’s protégé and continued contracting with private companies to manage Medicaid benefits. Zach Lahn, the Republican candidate to succeed the retiring governor, supports the practice. Rob Sand, the Democratic candidate, wants to end it.

“It’s been a disaster,” said Sand, Iowa’s state auditor. “The number of complaints has been catastrophic.”

Pros and Cons

Supporters of privatization say the insurers, known as managed-care organizations, make Medicaid more effective and efficient. Critics contend the companies pad their profits by denying payment for crucial health services and by shortchanging agencies and professionals who provide care.

Iowa is among 41 states, plus the District of Columbia, that contract with outside companies to run at least part of their Medicaid programs. Overall, private insurers manage the benefits of more than three-quarters of Medicaid patients. Connecticut is the only state that has fully reversed course after privatizing its Medicaid system.

Sand has criticized privatized Medicaid for years. As state auditor, he alleging that the national insurers systematically deny or delay payment for services to which Medicaid participants are entitled.

He has vowed not to renew state contracts with the three insurers managing care for more than 600,000 Iowans on Medicaid, which is jointly financed by the state and federal governments. He would rather have state employees or nonprofit agencies review and pay bills from clinics, hospitals, and other healthcare providers.

Lahn told 吃瓜不打烊 that Sand’s pledge to resume state administration of Medicaid “is the exact wrong idea.”

Lahn is a former activist for Americans for Prosperity, a national pro-business group affiliated with the Koch family. He contends that state governments and Medicaid participants benefit when insurers compete to serve them.

“There are very few things that government does more efficiently than the private sector,” he said.

Lahn, who is a businessman and farmer, emphasized that state officials should strictly enforce contract requirements, ensuring that the insurers treat Medicaid recipients fairly and make prompt payments to care providers. He also said he would bar insurers from using artificial intelligence systems to determine whether to pay for medical claims under Medicaid. “Iowans deserve to have a human looking at their case,” he said.

Sand said in a recent interview that he doesn’t want Iowa to fully return to a “fee-for-service” Medicaid system, in which hospitals, clinics, and other healthcare agencies would effectively be paid piecemeal for whatever services they provided. Instead, he said, state employees or nonprofit organizations could take over operation of a managed-care system, in which administrators review services to help ensure Medicaid participants receive what they need without wasting public money on ineffective services.

A few months ago, Republicans controlling the Iowa Legislature considered a bill to require the state to have a privately managed Medicaid system. That proposal would have blocked future governors from unilaterally shifting back to public management of the program. But the bill

Sand, a former assistant state attorney general, said he is confident he would have legal authority as governor to stop contracting with private Medicaid managers, although he cautioned that the transition would be complicated and could take time.

A Toss-Up Race

National political observers say the Iowa governor’s race

This June, Lahn won an underdog primary campaign to beat a sitting congressman backed by President Donald Trump. Lahn gained Trump’s endorsement after winning the Republican primary. He is a vocal supporter of the Make America Healthy Again movement, led by Health and Human Services Secretary Robert F. Kennedy Jr., which aims to improve Americans’ diets and reduce environmental poisons.

Sand noted that Lahn’s past political activism included a failed 2014 attempt to defeat a proposal to cover more people under Montana’s Medicaid program.

Lahn said that at the time he worried the federal government would reduce how much money it would contribute to such Medicaid expansions, leaving states to foot much of the bill. He said he also didn’t want to see public programs such as Medicaid giving benefits to adults capable of providing for themselves. But he said those concerns have been allayed, partly by the Trump administration’s moves to require millions of Medicaid recipients to prove they are working, volunteering, or going to school.

If elected governor, he said, he would not try to reverse Iowa’s expansion of Medicaid, which happened in 2014 under Branstad.

Branstad also is the governor who decided in 2016 to hire private insurers to manage Medicaid.

Branstad, who declined to comment for this article, did not need the legislature to approve his momentous decision. He weathered controversy over the change, including allegations that the companies systematically denied payment for care that people with disabilities needed to remain in their homes.

Andy Schneider, a who studies health policy issues, said it’s understandable that many government leaders see an advantage in hiring private Medicaid management companies. Each state’s Medicaid program pays claims for hundreds of thousands or even millions of members, and administrators must scrutinize bills from thousands of hospitals, clinics, and other healthcare organizations. “That’s a heavy lift,” said Schneider, who worked in federal Medicaid administration when Barack Obama was president.

Schneider noted that Medicaid expenses are among the biggest parts of any state’s budget. The costs can vary dramatically year to year, he said, which is hard for legislators and governors to plan for. Management companies sign contracts for set amounts of money per enrollee, depending on people’s ages and health conditions. Managed-care companies say they can improve Medicaid members’ health and reduce expenses. But Schneider said have been unable to confirm or disprove those claims.

Federal law gives states flexibility in how they run their Medicaid programs, including whether they hire private insurers to manage the programs. “Unwinding those arrangements might take a little time, but there’s no question they can do it,” Schneider said.

Connecticut of private insurers to run Medicaid in 2012. to contract only with nonprofit insurers, starting in 2025, and that state’s governor doing away with private management altogether.

Gary Jessee, a former Texas Medicaid director who helped transition that state’s program into managed care, noted that most Americans’ health coverage is managed by some kind of insurance company, whether they obtain it on their own or get it through a government or employer plan.

Jessee now helps run a whose clients include Medicaid managed-care companies. He said states rarely talk about totally scrapping contracts with such companies. Instead, he said, states have options to change the contracts, including to increase oversight or limit profits.

Overall, Jessee said, managed-care companies help Medicaid enrollees obtain the services they need to stay healthy. But it’s hard to calculate how much money the companies save states, he said, because all healthcare costs have been rising, and new members of managed-care plans may at first use more services as the insurance companies encourage them to get regular checkups instead of waiting for emergencies.

Iowa’s Medicaid program is managed by three insurers: Molina Healthcare, Elevance Health subsidiary Wellpoint, and Centene subsidiary Iowa Total Care.

None responded to requests for comment for this article.

Catherine Gray of Des Moines helps run a Facebook page for families who use Iowa’s Medicaid system. Her adult son, John, is on Medicaid because of a disability. Gray said the managed-care companies have made it much harder for people to obtain services, including mental healthcare, dental care, and transportation to health appointments. Iowa’s shift to the private system was abrupt and chaotic, she said. “We know people have died,” she said.

Gray said she probably will vote for Sand for governor, even though she doesn’t agree with every nuance of his stance on Medicaid. She suspects many other Iowans who use the program will do the same. “They’ve really been put through the wringer for 10 years, and they’re exhausted.”

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 .

The Consumer Product Safety Commission, responsible for tracking and issuing recalls of dangerous products sold in the U.S., began discreetly pressuring hospital executives this year to share personally identifiable health data with a private contractor. But hospital lawyers and other industry experts have questioned the agency’s authority to collect, its ability to safeguard such a swath of sensitive information, and whether it has followed the legal process to overhaul its surveillance system.

After 吃瓜不打烊 asked the CPSC about the new system, the the program on July 21. Left unmentioned, however, is the alarm it has raised among hospital executives, as well as the nature and extent of the agency’s data demands.

In a stark departure from its product-focused mission, the agency’s goal is to obtain millions of Americans’ medical records from emergency room visits for most injuries, from a broken bone to a childhood vaccine reaction or even a suicide attempt, according to documents and emails obtained by 吃瓜不打烊, as well as interviews with five people involved or familiar with the discussions.

A CPSC official also insisted in the emails that the institutions provide all ER patients’ identifiable information — such as names, addresses, diagnoses, and other personal details — to the contractor, Konza Health, for analysis. In correspondence with , Konza representatives described participation as “mandatory” or “required.”

As a condition of viewing the correspondence, 吃瓜不打烊 agreed not to republish some of the emails it obtained.

The CPSC wants at least 100 hospitals to start sending detailed medical records by the end of this year, according to an .

“The whole thing is troubling,” said Sharona Hoffman, a professor of health law at Case Western Reserve University who noted that giving a private entity access to a sweeping collection of data will introduce risks to patient privacy. “If this company really is collecting identifiable information, that is worrisome for patients.”

The new project was launched amid upheaval at the traditionally independent agency, which is without a governing board since President Donald Trump fired the CPSC’s three Democratic board members. Nearly 1 in 5 career staffers left the CPSC in the first 16 months of the new administration, according to a 吃瓜不打烊 analysis of federal workforce data.

The initiative also comes as the Trump administration has sought unprecedented access to millions of Americans’ medical records, with the Office of Personnel Management requesting federal workers’ sensitive health information and Health and Human Services Secretary Robert F. Kennedy Jr. using a private organization to collect more medical records for his studies on vaccines and autism.

Steve Roney, CPSC spokesperson, said in an emailed statement on July 10 that the CPSC is “modernizing” its surveillance system. Asked whether the CPSC will file complaints against hospitals that do not participate, he said only that while the previous system “operated as a voluntary program, the ability of hospitals to opt out limited the sample size and usefulness of the data.”

Roney also acknowledged that the agency had not yet notified the public, as “required by law.”

Federal law requires the agency to provide notice and a public comment period before requesting information from 10 or more entities, a step it has not taken despite plans for 100 hospitals to join the surveillance system. 吃瓜不打烊 independently confirmed with over a dozen hospitals that they had been approached.

Federal public health authorities that private health data be reported. But CPSC officials have that if hospitals decline to share data with the new surveillance system, they could be subject to strict penalties from a data-sharing regulation known as “information blocking.”

Yet some hospital executives say they are reluctant to share patients’ sensitive data because they’re concerned about a different violation — that of .

AI Takes Over

Dozens of ERs across the country already participate in the CPSC’s voluntary National Electronic Injury Surveillance System, or NEISS, through which trained hospital workers report injuries involving consumer products, almost always stripped of patients’ identifiable information. The system helps the CPSC identify products, such as baby loungers, toys, and household appliances, with a pattern of injuring consumers.

The new injury surveillance program goes much further.

At a toy industry trade event in February, acting CPSC Chairman Peter Feldman said the agency is “investing in AI-enabled workflows that improve the quality and quantity of injury surveillance data, while also building up digital infrastructure to handle a massive new volume of electronic health records.”

Konza Health, a Kansas-based organization that runs the state’s health data exchange, will automatically pull and analyze medical records of all patient visits from ERs nationwide. Konza won a worth up to $15.9 million with the CPSC last fall.

In email correspondence with hospital technology officials, Konza Health President and CEO Laura McCrary also has described ERs’ participation as “required,” stipulating that they share patients’ records with identifying information.

McCrary told 吃瓜不打烊 by email that the company is not using AI to process the records it receives, saying instead that Konza will use “advanced analytic parsing and filtering capabilities.” Roney, the CPSC spokesperson, did not answer questions about the .

For years, agency officials moving away from human contractors and automating NEISS to save time and money.

But without workers on-site, hospital staffers may no longer receive training to determine what clinical information is important to include for the CPSC. In short, the changes could dilute the quality of the product safety data the agency collects.

“They want to suck in as much data as possible, but I’m not sure how thoughtful they’re being about what is collected and what is actually needed by the agency,” said former CPSC chair Alexander Hoehn-Saric, one of the Democratic appointees Trump fired last year.

Wanted: Injuries From Vaccines and Stingrays

The CPSC’s new data collection appears to contradict its own 214-page , which instructs hospitals not to include identifiable information “such as names, birthdates, or addresses” when reporting cases.

The agency is supposed to receive patients’ identifying information only when needed for follow-up investigations, which happens in fewer than 1% of reported cases, according to the manual.

The CPSC has also historically limited the records it collects to minimize privacy violations in case of a data breach.

The risk is not hypothetical: From 2017 to 2019, the agency improperly released personal health information of around 30,000 people, a disclosure that a top Republican at the time

Konza, however, will receive even more sensitive information on many more people. McCrary said in a statement that Konza will remove patients’ names, addresses, and medical information “not needed by CPSC” before sharing records with the agency.

Leaving a private organization to collect sensitive information introduces risks, including that it could be stolen or used for business purposes, said Hoffman, the Case Western professor.

“Very often, they will use information for marketing because now they’re going to know what conditions people have,” she said.

Roney said that its contract with Konza, which has not been made public, prohibits the organization from selling or marketing the data it collects.

The CPSC’s manual also identifies types of ER visits that should not be reported to the CPSC, which has jurisdiction over only certain consumer products. Excluded injuries are those caused by food, illegal drugs, medical devices, alcohol, or plants, as well as injuries that did not involve consumer products — such as a cut from a rock or broken bones from a fall on the ground — and suicide attempts by adults.

But in a to one hospital and reviewed by 吃瓜不打烊, Konza set no such limits on the information it would gather from ER records and said it would hold on to patient health information for at least 30 days.

In an email sent to hospital technology officials, McCrary wrote that Konza would provide the CPSC with records when a patient is treated in the ER for any of more than 10,000 conditions. The expansive list of diagnostic codes Konza provided in the email includes injuries that do not involve consumer products.

Child injuries resulting from “poisoning by” vaccines or contact with stingrays, neither of which is regulated by the CPSC, are included in the list.

A limited number of hospitals once shared deidentified data on all injuries — regardless of product involvement — through the NEISS using the Centers for Disease Control and Prevention’s injury-tracking program. But the CDC halted that data collection, after funding and staffing were cut last year, and has not restarted it.

Pressure on Hospitals

CPSC Chief Data Officer Elizabeth Puchek, who joined the agency late last year after engineering U.S. Citizenship and Immigration Services’ data system, has told hospitals in emails that they must seek an exemption from the program if they decline to share patients’ emergency room records with Konza.

The CPSC’s targeted outreach has included some of the nation’s largest urban and rural health systems, as well as small, publicly owned hospitals.

Staff members at Mary Greeley Medical Center in Ames, Iowa, said that Konza and federal officials told them their participation in the new program was mandatory. The hospital, which has long participated in NEISS, signed a new contract in April to share its ER records with Konza.

Yet the hospital is reevaluating its participation after being notified that the funds it received to participate in NEISS were “no longer available,” spokesperson Steve Sullivan said.

Several hospital executives, lawyers, and others have raised doubts about the CPSC’s claimed authority.

Harborview Medical Center spokesperson Susan Gregg said the Seattle hospital’s emergency room has “voluntarily submitted de-identified data for many years, but we are not obligated to report this information.”

In Boston, Mass General Brigham has declined to participate in the new program, with spokesperson Kelly Mitchell saying that “to protect patient privacy, we are unable to provide these medical records.”

Henry Ford Health in Detroit; St. Luke’s in Boise, Idaho; and Sanford Health based in Sioux Falls, South Dakota — which together handle over a million ER visits a year — are among the health systems that have been approached but not yet entered into an agreement with Konza, according to representatives. Several of the nation’s busiest hospital systems targeted for the program — including the Mayo Clinic in Minnesota, Yale New Haven Hospital in Connecticut, Nationwide Children’s Hospital and the Cleveland Clinic in Ohio, and Baylor Scott & White Health in Texas — declined to answer questions about whether they’re participating.

Hoehn-Saric, the agency’s former chairman, said he was surprised that the CPSC would insist that hospitals provide identifiable records from all emergency room visits.

“This idea that they can simply demand patient information from a hospital and that the hospital would provide it — I really don’t understand the basis for that,” he said.

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

Overnight, a nurse aide walked into their room and saw blood splattered on the floor, walls, and ceiling, according to a grand jury transcript. Cecchetto’s face “looked twisted and smashed,” the aide testified. A Banning city police officer testified that Timaloa, 77, told him that he had punched Cecchetto twice.

“He just kept saying that Attilio was being too loud: ‘He talks too much,’” the officer said.

Cecchetto died two days later from blunt force facial trauma.

“You get placed in a facility like this to be taken care of, not to be murdered,” one of his sons, Gino Cecchetto, said in an interview. “This was completely preventable at many different points.”

Timaloa pleaded not guilty to assault. The charges were later upgraded to murder, and a judge ordered a mental health evaluation. The judge will rule as early as August on whether Timaloa is competent to stand trial.

PACS Group, the nursing home chain that owns Sunrise, denied negligence. “We strive to provide quality care to everyone we serve, and our hearts continue to go out to the Cecchetto family for their loss,” PACS spokesman Brooks Stevenson said in an email.

In nursing homes primarily occupied by impoverished people as well as posh assisted living facilities that cost upward of $10,000 a month, agitated residents have shoved, punched, bit, and kicked others. They have wielded canes, walkers, pens, a plate, a mop stick, a shoe, a belt buckle, and even the footrests of wheelchairs as weapons, federal inspection reports show.

How often these altercations take place nationwide is unknown, but an of 14 assisted living facilities in New York state led by Cornell University researchers estimated 1 in 7 residents experienced aggression within a month, including verbal, physical, or sexual acts. Their of 10 New York state nursing homes estimated 1 in 5 residents experienced an altercation in a month. Researchers have found that these assailants are to have dementia.

The diseases that cause dementia can impair brain circuits involved in impulse control and threat perception, raising the risk of aggressive behavior. Residents with Alzheimer’s disease and other dementias constitute more than living in these settings, many of which include specialized units.

Often, altercations involving a resident with dementia erupt after danger signals are missed or ineffectively addressed, according to a 吃瓜不打烊 examination of court records, police reports, and state and federal inspection reports.

Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show. The federal records do not include assisted living facilities, which are regulated by states.

In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees, the reports show.

The long-term care industry says not every clash can be averted. Presbyterian Homes & Services, a nonprofit Christian chain of senior living facilities, said in a statement: “Caring for individuals living with advanced dementia is complex, and behaviors can change in ways that are difficult to fully predict or prevent, even with clinical interventions in place.”

Eilon Caspi, a and researcher who studies resident-on-resident altercations, said that usually there is a specific unmet need that precedes an altercation. “In the vast majority of incidents,” he said, “there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”

Fertile Battlegrounds

One about Alzheimer’s, the most common dementia disease, holds that as the brain’s networks deteriorate, the balance shifts between the prefrontal cortex, which helps govern judgment and self-control, and limbic regions including the amygdala, which helps process fear and threat responses.

As cognition clouds, people lose the ability to understand what is happening around them and to put distress into words, researchers say. Pain, infection, medication side effects, and other physical and emotional distresses through shouting, intimidating gestures, kicking, pushing, or punching. Long-term care facilities can be triggering environments, with intimate care often delivered by a changing stream of aides whom residents can’t recognize. Amid noise, close quarters, and rigid routines, interactions become flash points.

“You don’t feel safe, because you don’t know these strangers who are coming in and taking off your clothes,” said Al Power, a geriatrician and an advocate for alternative models of care for people with cognitive issues. “These things will be distressing to anybody.”

The Cornell researchers found verbal altercations were the most common type of aggressive interaction but estimated 4% of assisted living residents and 5% of nursing home residents in their studies experienced physical assaults in a month.

Another Cornell study found that Connecticut police were called to nursing homes for more often than allegations of staff abuse, theft, and residents wandering away without supervision combined. A national analysis of survey data from the Centers for Disease Control and Prevention calculated in assisted living facilities engaged in physical aggression or abuse toward other residents or staff members.

Many of the physical aggressions 吃瓜不打烊 identified in CMS inspection reports were perpetrated by residents with diagnoses of dementia, schizophrenia, or other cognitive disorders. In some physical altercations, both residents were aggressors, while other fights were one-sided. Sometimes the residents were roommates.

Laura Mosqueda, a geriatrician at the University of Southern California’s Keck Medicine in Los Angeles and a senior adviser to the National Center on Elder Abuse, said: “What worries me is that we just end up blaming two people who have either cognitive impairment or severe, uncontrolled mental health issues, when they’re supposed to be in an environment where people are safe.”

‘Only a Matter of Time’

Gladys Lynch, a retired department store accountant, transferred into the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, in September 2025. Her monthly cost was more than $10,000, according to an invoice provided by the family.

One of Lynch’s daughters, Rebecca Norton, installed web cameras in her room and often saw another resident inside. “Every day I looked at it, this woman would be walking into my mom’s room, harassing her, digging through her things, using her bathroom, yelling at her,” Norton said in an interview. She informed Harbor Crossing’s administration, and the facility said it would start locking her mother’s door.

Norton emailed a Harbor Crossing administrator a list of issues with her mother’s care. “My biggest concern,” she wrote, was that her mother’s door was not consistently locked and the webcam showed the woman had again entered, rummaged through the bathroom, and taken a couple of adult diapers.

Unknown to Norton, Harbor aides had raised concerns about the other resident, who like Lynch was new to Harbor Crossing’s memory unit, according to a . Diagnosed with Alzheimer’s, severe dementia with agitation, depression, and anxiety, the woman was confused, had difficulty communicating her needs, and hit aides.

Aides repeatedly reported that the woman had “ongoing aggression, entered other residents’ apartments, invaded others’ personal space, and was difficult to redirect,” the health report said. They said medications had been ineffective and pressed for new ones. The report said one nurse told the woman’s doctor it was “only a matter of time before” she “hurts another resident.”

Captured on Camera

On the last day of September, she entered Lynch’s room and resisted leaving, the state report said. The next morning, she reappeared. Video of the incident was described in the police and state reports and reviewed by 吃瓜不打烊. It shows Lynch guided the woman out and appeared to attempt to lock the door, but the woman opened it and returned once more.

The woman declared it was her house, went into Lynch’s bathroom, used the toilet, and then returned to the room Lynch was in. Lynch can be seen repeatedly pressing the alert pendant around her neck to signal nurses for help.

The video shows the woman was almost out of her apartment door when she attempted to touch an object near the door. Lynch put her hands up to block her. The woman slapped at her hands and said, “I’m going to kill you if you don’t quit it.” She pushed Lynch, who fell, her head hitting the floor and blood seeping out.

Aides arrived 13 minutes after she had initially pressed her pendant, the state report said. Lynch suffered a brain hemorrhage and fractures to her eye socket and ribs, according to the state report. She died in the hospital five days later at age 96; the medical examiner’s office declared it a homicide.

Norton said her mother was kind and pleasant and never combative. “My mom deserved better than what they gave her,” she said.

Prosecutors declined to bring charges, according to the police report. The Harbor Crossing was responsible for neglect because it was aware the woman “exhibited violent and aggressive behaviors” and yet had failed to put in place effective interventions. Harbor Crossing has requested the state reconsider its findings.

In June, Suzanne Scheller, the attorney for Lynch’s family, filed a wrongful death lawsuit against Presbyterian Homes, which owns Harbor Crossing.

Presbyterian said in a statement: “We are deeply saddened by the loss of Ms. Lynch, and our thoughts remain with her family and all those impacted.” It declined to comment further on the incident or the lawsuit.

Preventive Tactics

Geriatricians, researchers, and resident advocates say long-term care homes should to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces.

Each resident should have a care plan, and homes should train staff to be alert to a resident’s triggers and intervene quickly, dementia specialists say. Organized activities are essential to keep residents occupied and engaged. Antipsychotics and other psychotropic medications are often prescribed, but they can increase the risk of falls, strokes, and .

An aide can be assigned to watch a particularly challenging resident one-on-one, but many places lack enough staff for protracted, dedicated supervision. Some assisted living facilities will tell a resident’s family they must hire a personal aide, who can cost thousands of dollars extra each month. In extreme situations, facilities might send a resident to an emergency room for evaluation or to a psychiatric hospital, or .

Camille Russell, who served as Kansas’ long-term care ombudsman until 2024, said she observed nurses and aides were often “woefully undertrained” in basic elements of dementia care.

“We’ve gotten too far away from making decisions that are caring decisions,” Russell said. “There has to be a balance, and the balance has gotten too far to the profit side.”

A Debilitating Kick

Many physical altercations between residents result in a scratch or a bruise, but nonfatal scraps can leave permanent damage on deeply frail residents.

Linda Twiddy’s first weeks in a Chesapeake, Virginia, memory care unit in August 2024 were happy, her daughter, Barbara Howerin, said in a May interview. Twiddy, a former church secretary with vascular dementia, sang along with a visiting church choir, decorated pumpkins, and visited a cat cafe. The facility, The Vero at Chesapeake, charged Twiddy a one-time $6,825 move-in fee and monthly charges of $7,475, according to the lease.

Seven weeks after Twiddy started living there, a nurse called Howerin. She told her that her mother had been kicked in an altercation with another resident and was being sent to the hospital.

When Howerin arrived at the hospital, she was shocked by the extent of the injury. “It was like 10 inches long by 6 inches wide, the whole front of her shin,” she said. “The calf was just like dangling down.”

According to an internal facility incident report the family obtained, an aide heard Twiddy scream for help and raced over to see a male resident with dementia trying to hit Twiddy as she sat on the floor in “a pool of blood.” The report said, “Linda was screaming get him away from me, he pushed and kicked me.”

The man had prior episodes of aggression, according to documents Twiddy’s family obtained in a lawsuit they brought against The Vero in Chesapeake Circuit Court. At his previous facility, a progress note from 2023 stated, he was “becoming very aggressive in tone and actions to residents and staff.” He “grabbed another resident by the wrists and pushed her,” according to the note. He was sent to an emergency room for evaluation of agitation, according to a hospital report. It did not make clear whether he was discharged back to the facility or elsewhere.

Agitation Tied to Pain

The male resident’s medical records at The Vero said he was diagnosed with late-onset Alzheimer’s disease, agitation, and anxiety, according to his doctor’s deposition. He had chronic pain in his back and trouble sleeping. He could answer simple yes-or-no questions but had trouble providing more extensive answers and couldn’t communicate that he was in pain, she testified. His behavioral changes usually occurred when he had a urinary tract infection, the doctor said.

When he was agitated, aides could sometimes calm him by turning on the television so he could watch his beloved New England Patriots, one aide testified in a deposition. A former aide said she tried to avoid dealing with him altogether. “If you go up to him and he was agitated, he’d reach out to try to grab you,” she testified. “If he had that cane, he would swing that cane or he would punch at you.”

In a court filing, The Vero denied allegations by Twiddy’s family that it should have protected residents from him. The filing said The Vero complied with all standards of care and that any injuries Twiddy sustained “were caused by her own negligence” or acts of others.

In their investigation of the incident, Virginia regulators alleged The Vero had for the health, safety, and well-being of its residents. The inspection report said The Vero pledged to appropriately staff the memory care unit based on the number of residents and to ensure someone completed rounds at least every two hours during sleeping hours.

Twiddy underwent three surgeries at the hospital for her leg, including a skin graft, then spent a month in rehabilitation. “She was never able to walk again,” her son, Doug Twiddy, said in a May interview.

The family moved Linda Twiddy to a different memory care facility where the nursing station had a clear view of all the rooms. She lived there until her death earlier this year.

The lawsuit was settled on confidential terms in early June. Carlton Bennett, the family’s attorney, declined to comment. In an email, Lauren Rogers, a spokesperson for Sinceri Senior Living, which operates The Vero, said the company was pleased the legal case had been resolved but could not comment further, citing confidentiality and patient privacy.

“The Vero at Chesapeake is committed to providing a caring, supportive environment where resident health, safety, and well-being remain our highest priorities,” she said.

A History of Violence

After Attilio Cecchetto was fatally bludgeoned at Sunrise Post Acute, his adult children and their attorney, Jody Moore, discovered disturbing details about Sam Ato Timaloa. He had been imprisoned in 1999 after being convicted of raping an underage girl and sentenced in 2008 to 24 years in prison for attempted murder involving domestic violence, according to Riverside County court records. His public defender declined to comment.

Cecchetto’s sons, Moore, and her colleagues at Moore Hutchins Moore also learned more about the home’s owner, PACS Group, a publicly traded company with more than 300 long-term care facilities. Last year, PACS earned $191 million on revenue of $5.3 billion, according to its .

In the Cecchettos and their father’s widow filed against PACS, they accused the company’s founders, Jason Murray and Mark Hancock, of draining resources from their nursing homes to pay for the chain’s expansion and swell their personal wealth.

The two had earned more than $650 million through stock sales since taking the company public and bought two private luxury jets, according to the lawsuit and securities filings. PACS has also purchased corporate sponsorships for Utah sports teams even though it owns no nursing homes in the state, the lawsuit said.

California regulators fined Sunrise $120,000 for Cecchetto and for not taking Timaloa’s articulated dislike of noise into account when assigning rooms. Medicare issued its own $62,810 fine.

In responding to the Cecchettos’ lawsuit, PACS denied negligence for his death and alleged he “failed to exercise ordinary care on his own behalf for his own safety.” It has sued to overturn the $120,000 state fine, saying it was issued too late and that Sunrise “did what might reasonably be expected of a long-term health care facility licensee acting under similar circumstances” to comply with state rules.

The Cecchettos’ lawsuit asks for a judge to impose robust procedures PACS homes must follow for admissions, staff training, room changes, and the reporting of altercations between residents. The suit asks for a court-appointed monitor to oversee compliance. In its written statement to 吃瓜不打烊, PACS said “important context” would come out during the process and declined further comment.

In an interview, Cecchetto’s three sons, Dino, Gino, and Marco Cecchetto, described their father’s life. He spent his childhood on a farm in Italy, growing up under Benito Mussolini. After World War II he moved to Canada, where he learned to tile and lay marble and terrazzo, a decorative flooring material made of chips of stone, glass, or other materials embedded in cement or resin. He relocated to California in the early 1960s, became naturalized, and worked as a tile journeyman and a contractor for decades.

“We don’t want this to happen to somebody again,” Gino Cecchetto said. “With the life he led, he deserved a quiet, dignified death. Instead, he ended his life in pain and fear.”

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