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 .

Hospitals have the ability to proactively screen patients to see if they’re eligible for aid and, if so, automatically wipe out or reduce their bills —

A growing number of and researchers believe requiring hospitals to use presumptive eligibility would protect low-income Americans from falling into medical debt, especially with federal funding cuts expected to increase the number of people without health insurance.

Texas has among the highest , and policymakers in Texas are considering legislation that would require to use presumptive eligibility before sending patients a bill.

In a first-of-its-kind analysis, Tradeoffs examined the presumptive eligibility policies of 166 nonprofit general and children’s hospitals in Texas. The goal was to shed light on how easy or difficult hospitals make it for low-income people to get financial aid without an application.

Scroll to the bottom of the page to explore a searchable table with all 166 hospitals’ policies.

Here’s what we found:

1. Nearly half of nonprofit hospitals in Texas (44%) say they will bill patients before screening them for free or discounted care.

Some hospitals screen patients after sending a single bill. Others may send multiple bills and hire collection agencies to chase after debts before they check whether a patient is eligible for help.

The most common approach is for hospitals to say they will screen patients before taking “,” which include garnishing their wages, selling the debt to a debt collector, or denying further care until outstanding bills are paid.

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they offer 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.”

Just one nonprofit in Texas, Memorial Hermann Health System, has a written policy that requires its hospitals to check and proactively reduce or wipe out what patients owe before sending bills.

Research shows that when patients receive financial aid makes a difference.

A 2022 study found that patients who received hospital financial aid within weeks of care were to return to the doctor and get treatment for conditions like diabetes and depression. Conversely, published in 2024 found that wiping out people’s medical debt years later on their mental and physical health, healthcare use, or financial situation.

2. Most hospitals say they do not reimburse patients who qualify for financial aid for money they have already paid.

Hospitals often put patients on payment plans to chip away at bills they can’t afford. But only 10 of 166 nonprofit hospitals in Texas guarantee a full refund to patients found to be eligible for financial aid. Most others say they won’t return money that patients paid before being screened.

Surveys show patients and to cover what they owe. , one-third of Americans without health insurance said they had borrowed money for medical care in the previous year.

“It is very frustrating,” said Aimee Carlock, who was required to pay $5,500 to Texas Health Resources to schedule uterus surgery. She later qualified for free care, and the hospital wiped out her remaining $16,000 bill. But the $5,500 was gone. “That’s a lot of money to me,” said Carlock, a self-employed housecleaner who was recently approved for food stamps.

offers refunds only in the amount a patient has paid in excess of what the hospital typically charges someone with insurance. All hospitals must offer refunds to patients who qualify for financial aid in these situations to avoid federal penalties.

Texas Health didn’t respond to an interview request after Carlock agreed to grant the system permission to speak about her experience.

In some cases, patients must fill out extensive applications to recoup their money. The application for Abilene-based instructs patients to “completely and precisely” fill in financial and personal details, describing their savings and listing Social Security numbers for family members they live with who might help with the bills. Patients must submit two current pay stubs, a tax return, two months of bank statements, and a justification of why they need help.

“Explain circumstances in which paying this hospital bill would create a hardship,” the .

Hendrick Health didn’t respond to questions about its policy.

3. Many hospitals never tell patients that their debt has been forgiven.

Some of the largest nonprofit hospital systems in Texas don’t notify patients when their bill has automatically been wiped out. That includes , Texas Health Resources, and Texas hospitals owned by , one of the nation’s largest .

Research shows patients who don’t know their debt has been forgiven may skip needed care. A 2026 study found that people with medical debt were as likely to delay future physical and mental healthcare as people without medical debt.

“If the patient doesn’t get some sort of notice,” said Erin Fuse Brown, a health policy researcher at Brown University, the possibility that they could be billed “hangs like a sword over their neck.”

Stelter, with the Texas Hospital Association, said many hospitals have limited staff in their billing departments. “Notifying patients whose bill was completely forgiven that they were presumptively eligible is probably lower on the totem pole than helping somebody who’s trying to complete an application,” she said.

If hospitals offer someone less than the maximum discount available, the hospital to notify the patient, in case they want to appeal for a full write-off.

Texas Health and Christus Health didn’t respond to interview requests about their policies. A CommonSpirit spokesperson declined an interview.

4. Some hospitals say their financial assistance policies don’t reflect how they actually operate. These discrepancies can work to patients’ advantage — or detriment.

AdventHealth says some of its Texas patients get screened for financial assistance before getting bills, a consumer-friendly practice. The system’s however, has no requirement for when hospitals must screen patients.

“We want patients to understand and have access to available financial assistance before receiving a bill whenever possible,” said Tim Reiner, senior vice president for revenue cycle for the system, which owns and operates four hospitals in Texas.

also screens patients for help before sending bills, if they are uninsured, a spokesperson said. There is no requirement for its eight hospitals to do so under the system’s policy.

According to , Covenant Health, a five-hospital system based in Lubbock, must screen patients before sending bills to collection agencies and lists detailed criteria for who is eligible to have bills proactively wiped out.

But in 2019, the system decided not to use presumptive eligibility “due to the regulatory requirements and administrative complexities,” said spokesperson Ainsley Nelson. “Our focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.”

Covenant is owned by Providence, a multistate Catholic health system based in Renton, Washington, which agreed to refund or erase in patient bills after charged that the system of charity care.

Providence said the system fixed the problem identified by investigators, refunded patients, and now coaches its employees to communicate “with compassion and respect.”

5. Who qualifies for presumptive eligibility varies significantly from one hospital to another.

Hospitals in Texas get to decide who is eligible to be automatically screened for and enrolled in financial assistance.

Presumptive eligibility policies often apply to people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with medical care, housing, food, or prescriptions. Some hospitals have additional criteria, including writing off bills for anyone in a religious order who took a vow of poverty.

Some hospitals share little to no public information about who they will proactively screen. Thirteen hospitals owned by , one of the nation’s largest Catholic health systems, say only that it may screen patients “with a sufficient unpaid balance.”

Ascension didn’t respond to questions about its eligibility criteria.

This variation means that a patient’s ability to access free care depends greatly on where they go.

6. Some hospitals provide less generous charity care to patients who receive it automatically instead of submitting an application.

At CommonSpirit’s hospitals across southeastern Texas, patients who are auto-enrolled get help with debt from the prior 12 months. Patients who submit an application get the same help with prior bills, plus free or discounted treatment for the next six months.

limits financial assistance for auto-enrolled patients to individual visits. Applicants may be eligible going back 12 months before approval.

North Texas Medical Center didn’t respond to additional questions about its policy.

7. Policies that are supposed to be easily accessible to patients are often difficult to find.

Hospital financial assistance policies are intended to be transparent to patients and the public. For more than a decade, has required nonprofit hospitals to .

In practice, finding these policies and deciphering them is often hard.

To find the policies of all nonprofit hospitals in Texas, Tradeoffs started with a list of hospital financial assistance policy websites maintained by the nonprofit Dollar For. To verify websites were up to date and fill in missing policies, Tradeoffs scoured hospital websites, often clicking through multiple links to locate policies.

In cases in which hospitals did not publish full policies online, Tradeoffs requested copies from hospitals and filed a public records request with the state of Texas, which requires hospitals to submit charity policies annually.

“You would have to know what you’re looking for before you went looking for it, or you’re never going to find it,” said Ray Kluender, an associate professor at Harvard University, who has had to hunt for hospital policies as part of his research on 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 .

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 .

One problem cited: The manufacturer had provided only

As it often does, the FDA in 2021 approved the drug with a proviso: It required the manufacturer to conduct an additional years-long safety study once the drug was on the market.

Today, like many similar “postmarket” studies mandated by the FDA, that additional study is delayed, according to a . As of last fall, only 21 of the planned 300 patients had been enrolled, the FDA said in an and .

Meanwhile, the FDA has dozens of cases of “possibly” or “probably causally associated” with the drug. That was one of the potential side effects the postmarket study was meant to evaluate.

Tavneos illustrates the perils of the FDA’s approach to many drugs and medical devices 鈥� and the frequent lapses in follow-through.

A 吃瓜不打烊 analysis of Food and Drug Administration data found hundreds of postmarket studies listed as delayed. In some cases, the work was delayed by more than a decade or the manufacturer was still developing a plan for the study.

As a result of delays, patients, doctors, and others could be left in a fog about the risks and benefits of the drugs or devices, even as they stake their money, their health, or their lives on the products.

Postmarket study requirements “have often proven toothless,” said cardiologist , an associate professor of medicine at the University of California-San Francisco who has published .

The FDA’s reliance on postmarket studies reflects a balancing act.

Making new treatments available faster can save or improve lives, especially when patients with grim prognoses and no good options have little to lose. The full risks and benefits may be revealed only over the long term, and when therapies are used by far more people than even large clinical trials enroll.

But relying on post-approval studies to resolve questions risks exposing patients to products that do more harm than good. Whoever is paying the bills 鈥� patients, insurance companies, employers, or government health programs such as Medicare and Medicaid 鈥� can end up wasting money and rewarding manufacturers for useless or risky products.

“Doctors rely on this evidence, patients rely on this evidence, and if that evidence is not there, it’s going to lead to a lot of uncertainty,” Dhruva said.

Trump administration policy changes designed to hasten drugs through FDA review could leave more riding on postmarket studies, medical researchers say.

For example, in February, that “the default requirement” for agency approvals will be one clinical trial instead of two.

Reducing pre-approval testing “will inevitably put a lot of pressure on the post-approval system,” said , a professor at Harvard Medical School who postmarket studies.

FDA officials said the new policy would “substantially reduce costs” for manufacturers and “speed drugs to market.” Writing in The New England Journal of Medicine, they denied the change would compromise safety or efficacy, saying that “erroneous conclusions may be reached even with two, three, or four studies.”

In response to questions for this article, a spokesperson for the Department of Health and Human Services, which includes the FDA, said postmarket studies can experience delays for legitimate reasons. “Assessing the significance of any delay requires a case-specific review,” said the spokesperson, Emily Hilliard.

The fact that a study is delayed “should not be treated as evidence that a product has an unresolved safety or effectiveness issue,” Hilliard said.

Amgen, the company that makes Tavneos, is still working on the postmarket research the FDA mandated, company spokesperson Alison Chartan said, adding, “We remain committed to completing this important study.”

Behind Schedule

An FDA database downloaded by 吃瓜不打烊 in August tracks the progress of postmarket studies that makers of 鈥� such as vaccines and gene therapies 鈥� were required to perform or promised to perform.

The database showed almost 600 were running behind schedule.

Of those, more than 250 originally had final reports due before July 31, 2026 鈥� the date that, according to an FDA webpage, the database last had been updated.

About a third of ongoing studies were listed as delayed.

In some cases, the FDA has granted extensions. In others, it has denied them. And in rare instances, the products were discontinued before the studies ran their course.

Postmarket studies can involve clinical trials or other analyses of patient data. They can look at safety or efficacy. A product can be the subject of more than one postmarket study.

The nearly 600 delayed studies involved almost 350 products, 吃瓜不打烊 found.

The FDA has defined delayed as . That can mean off track or overdue.

As of August, other FDA databases tracking listed dozens of postmarket studies as behind schedule.

Products included:

The CustomFlex Artificial Iris, a prosthesis implanted in the eye in place of damaged, defective, or congenitally missing irises. The protocol for a study in children was accepted in 2019, the database said. The study was meant to follow patients for five years. According to an FDA page downloaded in August, zero patients were enrolled.

Barbara Fant of Clinical Research Consultants, to whom the FDA’s 2018 letter approving the product was addressed, said the rarity of an eye disease called aniridia poses challenges for post-approval studies. The German manufacturer, the U.S. distributor, and Clinical Research Consultants are working with the FDA to identify alternative ways to fulfill the postmarket requirements, Fant said.

“Confirming the long-term safety of the device remains a top priority for both the study team and FDA,” Fant said.

Paxlovid, a treatment for covid. A study to assess its safety in pregnant women was originally to be completed by the end of 2024, the FDA database said. “The trial completion and final report milestones were missed,” the database said.

Pfizer, the manufacturer, is working with the FDA and remains committed to “submitting results as soon as practicable,” Pfizer spokesperson Jerica Pitts said.

The Scandinavian Total Ankle Replacement system. The device and the original protocol for the clinical trial were approved in 2009. The study was meant to include a minimum of 500 subjects, the database said, but the actual number enrolled was 142. Almost half those patients had one or more adverse events, with dozens of “reoperations,” “revisions,” or “removals,” the database said.

Rachel Colloff and Cristina Pasquino 鈥� spokespeople for Enovis, which markets STAR Ankle 鈥� did not respond to multiple inquiries. Jenny Braga, a spokesperson for Stryker, which previously sold the product, did not answer questions about the postmarket study.

Oxaydo (originally named Oxecta), a form of the potentially addictive opioid painkiller oxycodone . When the FDA approved it in 2011, it required the manufacturer, , to conduct a postmarket study to assess whether it reduces “misuse and abuse, and their consequences: overdose, death and addiction.” The final report was originally scheduled to be submitted in 2016.

The FDA database listing the study as delayed said the agency “issued a failure to respond letter” in 2022.

Today the issue may be all but moot.  

Control of the product passed from company to company over the years until 2023, when Acura Pharmaceuticals said in a that patents on Oxaydo would begin expiring that year and it didn’t intend to continue marketing the drug.

According to another FDA database, Oxaydo .

The FDA has enforcement powers and uses them “where appropriate,” HHS’ Hilliard said. She did not provide requested details, and she did not answer questions about the studies listed above.

Delay Can Pay

For manufacturers, delay can pay, Harvard’s Kesselheim said. While postmarket studies are ongoing, companies can continue to sell the products.

“Medicare and Medicaid spent more than $18 billion from 2018 to 2021 for accelerated approval drugs with incomplete confirmatory trials past their original planned completion dates,” the HHS Office of Inspector General .

The FDA can demand postmarket studies for a variety of reasons, including to address concerns that arise after a product has been approved. Some look at uses not covered by the original approval, and some are meant to shed light on that are already known.

In April, when it approved Foundayo, a weight loss drug made by Eli Lilly, the FDA required the company to conduct additional research to assess a variety of concerns, including “retained gastric contents,” “major adverse cardiovascular events,” and “drug-induced liver injury,” as well as effects of exposure during pregnancy, such as “major congenital malformations,” “spontaneous abortions,” and “stillbirths.”

The FDA said it approved the drug under the new Commissioner’s National Priority Voucher program, intended for products that “.” The program strives for an “” review, the FDA has said 鈥� one to two months, instead of six months or more with other expedited pathways.

“Postmarketing requirements and enhanced safety monitoring are a routine part of the FDA’s approach to evaluating newly approved medicines,” Eli Lilly spokesperson Kristiane Silva Bello said, “including ongoing monitoring in areas identified during clinical development.”

鈥楩alse Hope’

The FDA waded into a world of uncertainty in 2016 when it granted accelerated approval to a drug for Duchenne muscular dystrophy, a degenerative disease that primarily affects boys, disabling them at a young age and ultimately killing them.

Agency scientists had found that the drug, Exondys 51, was unproven and argued against greenlighting it.

Ellis Unger, then a senior drug evaluation official at the FDA, that “thousands of patients and their families would be given false hope in exchange for hardship and risk.”

The manufacturer, Sarepta Therapeutics, . “A clinical benefit of EXONDYS 51 has not been established,” it said when the drug, also known by the generic name eteplirsen, was approved.

The drug, the first FDA-approved treatment for Duchenne muscular dystrophy, targeted a subset of patients with the disease.

The FDA required Sarepta to conduct further studies and it could withdraw approval if postmarket trials failed to verify a clinical benefit or were “not conducted with due diligence.”

Unger issued a warning of his own: “FDA has not succeeded in withdrawing the marketing of a single drug for lack of verification of clinical benefit following accelerated approval. The reality is that if eteplirsen is given accelerated approval, it is highly likely to remain on the market indefinitely, irrespective of whether or not efficacy is verified.”

Sarepta was originally required to submit a final report on a postmarket study by a May 2021 deadline, according to an FDA database and a 2016 FDA letter to the company.

Almost a decade after the drug was approved, and more than five years after that deadline, the study was listed in an FDA database as delayed.

“The final report milestone was missed, because the sponsor requested milestone extensions due to study delays,”  the database said.

Meanwhile, in 2022 the website ranked Exondys 51 as the second-most expensive drug in the U.S., at an annual cost of $750,000 to $1.5 million.

Last year, the drug generated for Sarepta, according to a company presentation to investors.

Sarepta found it difficult to recruit patients for the postmarket clinical trial, company spokesperson Tracy Sorrentino said. The target population is small, patients were hesitant to enroll, and Sarepta was competing with other clinical trials for participants, Sorrentino said.

The study has been fully enrolled since 2023, Sorrentino said, and the company plans to provide an initial look at the data late this year.

鈥楳补苍颈辫耻濒补迟别诲’

Amgen has cited similar challenges, even as Tavneos generated $459 million in global sales last year.

When an approved treatment is available, patients may be reluctant to enroll in a study in which they could be given a placebo, Amgen’s Chartan said.

The clinical trial supposed to be done . As of July 24, just 49 patients had been enrolled, Chartan said.

The FDA has said the study was to include , and each patient enrolled must be followed for five years, said Hilliard, the HHS spokesperson.

Tavneos was approved to treat severe cases of a group of diseases 鈥� known by the shorthand ANCA-associated vasculitis 鈥� in which, as the explains, the immune system inflicts potentially fatal damage on blood vessels and organs. 

“As of January 2026, estimated real-world exposure” to Tavneos “exceeds 25,000 patient-years globally, consisting of over 6,500 in the United States and 19,000 abroad,” Amgen has said. (For context, one patient taking a drug for five years would amount to five “patient-years.”)

A clinical trial sponsored by ChemoCentryx to secure approval of Tavneos failed to prove it was effective, the FDA now alleges. Instead of disclosing that outcome to the FDA, company personnel “” the , the FDA alleged in an to Amgen.

Amgen, the parent company of ChemoCentryx, has denied the results were manipulated and has said the data “.”

Nonetheless, the recently of Tavneos.

The FDA is trying to , and Amgen is fighting that effort.

The company has a lot riding on the outcome. Tavneos can cost more than $220,000 per year, according to the , and when Amgen in 2022 for $3.7 billion, Tavneos was the only drug ChemoCentryx had brought to market.

In a June , Amgen said the benefits of Tavneos outweigh the risks.

The FDA disagrees.

The FDA “can no longer conclude that there is, or has ever been, a valid demonstration of substantial evidence of effectiveness for TAVNEOS,” .

Citing 76 cases of DILI 鈥� 鈥� the agency said it was “increasingly concerned about the safety profile of TAVNEOS.” Without proof of effectiveness, at least for its approved use, “the drug’s benefits its known risks,” the FDA wrote.

Data reporter Maia Rosenfeld contributed to this report.

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

吃瓜不打烊 worked with three Louisiana news outlets 鈥� , , and 鈥� to ask all 64 sheriffs in the state how they’ve spent their opioid settlement funds. The responses were shared and presented in a data table for all four newsrooms to use. Reporters then conducted individual reporting for separate articles.

Every state is from companies accused of flooding the nation with prescription painkillers and fueling overdose deaths. But only one state is directing 20% of those payouts to sheriffs 鈥� the largest carve-out for law enforcement nationwide.

In Louisiana, sheriffs are elected, do not serve at the pleasure of another local official, and have independent budgets. They’re also not required to proactively report to the public or another authority how they spend billions in opioid settlement cash.

Short of filing public records requests or waiting for official audits, that has made it difficult for the average person to track the windfall. Many consider the dollars to be “blood money” and believe the spirit of the settlements is to spend it all on abating the addiction crisis.

吃瓜不打烊 worked with three Louisiana news outlets 鈥� , , and 鈥� to track those dollars. The newsrooms contacted all 64 Louisiana sheriffs over five months, often filing public records requests, to produce the first detailed accounting of millions spent.

The findings include:

• Thirty-eight sheriffs reported spending more than $8.1 million total. Much of it went to crime-fighting equipment, such as surveillance cameras and drug detection products, though smaller amounts funded mobile apps, addiction treatment in jails, and educational programs for youth.
• $5.4 million, about 66% of reported spending, was deemed inappropriate by a three-person review panel. The panel, assembled by 吃瓜不打烊 and its partners, included a Louisiana resident in recovery who lost his son to a fentanyl overdose, an addiction medicine doctor, and a public health policy analyst who has been tracking settlement dollars since 2022. They judged the expenditures using their professional and personal expertise. Expenditures the panel disapproved of included salaries and overtime pay for homicide detectives and officers conducting jail shakedowns to find contraband.
• $4.7 million, nearly 60% of reported spending, went to items or services that other states say should not be purchased with opioid cash. Six states have , such as technology to extract data from cellphones and automated external defibrillators, which are . Although Louisiana does not have its own “unallowable” list, the state’s 鈥� a five-member body that advises sheriffs and parishes but does not control the money 鈥� said it has shared the guidance from other states.
• Nine sheriffs stood out for promising uses: All of their expenditures, totaling nearly $1.8 million, were deemed appropriate by the review panel and allowable in other states. These included providing addiction treatment in jail, training officers to respond to overdoses, and increasing public awareness of addiction resources.
• Twenty sheriffs did not provide their expenditures, leaving roughly $10.7 million that hidden from public view. The Jefferson Parish Sheriff’s Office, which covers an area just outside New Orleans and was allotted the highest amount 鈥� nearly $4 million through 2025 鈥� did not respond to more than a dozen calls and emails.

Nationwide, debates over law enforcement’s role with opioid settlement money have been underway since the funds began flowing significantly in 2022 and have continued as the pool of money has grown. Purdue Pharma, , finalized its this year, and various settlements are set to pay out for an additional decade-plus.

Since the earliest days, these dollars have been viewed across government agencies and the private sector as a pot of gold for which many are vying.

Law enforcement agencies are part of this scrum. They say seizing drugs and arresting dealers save lives, but that costs money and the addiction crisis has burdened their budgets. However, many recovery advocates staunchly oppose any opioid cash flowing to what they see as the .

Since there are few guardrails on how the money is spent, decisions often come down to how local politicians and residents see addiction and what type of approach they believe will be effective in combating it.

Louisiana provides a natural experiment to see which priorities prevail when money is handed directly to sheriffs.

The state’s agreement with parishes and sheriffs receiving settlement cash contains broad categories for , including “law enforcement expenditures relating to the opioid epidemic.”

But even if the sheriffs’ spending is legal, that doesn’t mean it’s appropriate or effective, addiction and public health experts say.

“What’s happening here is they have a lot of money and they want to distribute it to all the wrong places,” said Danny Bolner Jr., a Jefferson Parish resident who has been in recovery from addiction for more than two decades and lost his 28-year-old son to a fentanyl overdose in 2016. On the panel that reviewed expenditures, Bolner represented the view of families who have lost loved ones to the crisis.

The purchase of drones and vehicles struck a nerve for him. He’d prefer for opioid cash to support programs that educate youth about healthy ways to process emotions, provide job training to people in recovery, and distribute overdose reversal medications.

“This money is what we have to save lives,” he said. If sheriffs use it in other ways, the finite pot “is going to be gone and then they won’t have nothing to help.”

A Safe, a Scanner, and Surveillance Cameras

For , a public health policy analyst and national opioid settlement expert who was a member of the review panel, determining if expenditures fit the spirit of the settlements often centered on whether they facilitated arrests or prevented overdoses.

“The impetus of this opioid settlement money is to spend on innovative ways to not let this happen again,” she said, referring to the overdose crisis that has claimed since 2000. She said sheriffs should be asking, “How could we use this to reinvest in the community, not just build up our office?”

Many of the sheriffs’ equipment purchases didn’t meet her bar.

For example, the East Baton Rouge Sheriff’s Office bought a safe to store evidence from opioid investigations and a scanner for their traffic division to identify narcotics in hidden compartments. The Terrebonne Parish Sheriff’s Office spent $465,000 on , which are automated license plate readers that capture data about passing vehicles and share them with law enforcement agencies nationwide. The Bossier Parish Sheriff’s Office purchased 130 body cameras and 50 dash cameras.

Sheriffs already receive taxpayer dollars and federal grants to buy law enforcement tools, Christensen said. Opioid cash, which is finite and has a specific purpose, should not be used for that, she and the other reviewers said. In fact, some states don’t allow it.

But taxpayer money may not cover everything sheriffs need, said , executive director of the Louisiana Sheriffs’ Association. “Our budgets are overloaded,” he said.

Complex investigations to dismantle drug trafficking syndicates can require advanced equipment, , a spokesperson for the East Baton Rouge Sheriff’s Office, wrote in a statement.

“While treatment and recovery services are indispensable components of addressing opioid addiction, they address the consequences of addiction after these drugs have already reached our community,” she wrote. “Law enforcement has a different, but equally essential, responsibility: preventing those deadly drugs from reaching potential victims in the first place.”

First Lt. Blake Tabor, a spokesperson for the Terrebonne sheriff’s office, similarly wrote, “Our role as a law enforcement agency is primarily focused on disrupting the criminal activity that fuels addiction in our community.” That effort complements other entities’ work in prevention, treatment, and recovery, he added.

The Bossier Parish Sheriff’s Office declined to comment.

Where Public Health Meets Public Safety

Not all sheriffs spent the money on enforcement.

Acadia Parish Sheriff directed all his settlement cash to provide treatment in jail. He said he hopes to break cycles of addiction and crime.

“I want people back into society, being productive,” he said.

Research shows for opioid use disorder behind bars and .

In St. Martin Parish, settlement funds helped launch a of officers that connects people with substance use disorders or related mental illness to treatment, said Chester Cedars, chief legal counsel for its sheriff’s office. Officers also try to coordinate support services for family members and assist with questions around paying for care.

“We’re not clinicians,” Cedars said, but we “serve as a broker” between people who need services and those who provide them.

, an addiction medicine doctor and the West Virginia drug czar, who was the third member of the review panel, said he loved the comprehensive nature of the program. Addiction “is a family issue,” he said. “Every time that phone rings, it’s a potential family crisis.”

It’s not a coincidence that these parishes earned top marks from the reviewers. Cedars is the former chair of the , and Gibson is the current chair. That’s the body meant to guide others on priority uses of settlement cash.

Cedars was clear that the St. Martin sheriff’s office was not using “one penny for any enforcement activity,” because that’s not what the settlement “intended to accomplish.”

Gibson was more hesitant, saying the legal guidelines are broad and “I’m not here to criticize anybody.”

He has advised about a dozen sheriffs who have reached out with questions, but he knows they’re not required to heed his guidance.

A from the Louisiana Legislative Auditor found that the task force has no teeth to enforce its recommendations.

If people want stronger guardrails on the opioid cash, state lawmakers need to enact new rules, Gibson said.

Stepping Up Oversight

The Louisiana state legislature in May calling for the legislative auditor to review how all parishes and sheriffs are handling their opioid settlement money and report to lawmakers prior to the 2027 legislative session.

State Sen. , a Republican who co-authored the resolution, said the goal is to shed light on where dollars are flowing, if jurisdictions are spending them at all, and which funded programs are effective.

With that information, Myers said, he and others could “absolutely” introduce bills “to tighten up how funding is spent.”

Meanwhile, the Louisiana Opioid Abatement Task Force is trying to strengthen its oversight.

Curtis Nelson is executive counsel for the Louisiana Opioid Abatement Administration Corporation, a nonprofit that supports the task force. He said the body is seeking quotes from accountants to conduct ongoing forensic audits of parishes and sheriffs. The goal is to audit 10 to 15 entities annually, starting with those receiving the most money. If the audits turn up misuse, the task force could withhold future payments from those parishes or sheriffs, Nelson said.

The task force is also exploring creating its own unallowable list, like those in other states, Nelson said.

Louisiana Gov. Jeff Landry and Attorney General Liz Murrill did not respond to questions about whether they’d support an unallowable list or take other actions to address opioid settlement spending.

But many advocates are hopeful that an unallowable list could curb spending they found concerning.

“You’re keeping them on the track when you tell them what they can’t use it for,” said Bolner, the Jefferson Parish resident who lost his son to overdose and is raising his son’s daughter.

While he awaits greater oversight for sheriffs, Bolner plans to continue the work he’s been doing for years: distributing overdose reversal medications at schools, hospitals, and bars; participating in grief support groups with other families; and showing up at community events to raise awareness about addiction. He said he’ll keep speaking with sheriffs and parishes about what he considers the best use of settlement money.

“If I save one life, it’s accomplished,” he said.

Methodology

The Current’s Alena Maschke, Gulf States Newsroom’s Drew Hawkins, and Verite News’ Katie Jane Fernelius contributed to the database featured in this article.

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

Ladonna Johnson was rocking A’mahri to sleep in March when he was shot in the head with a gun she kept for protection.

A’mahri loved going outdoors and taking rides in his pull-along wagon. His mother called the toddler “sweet” and “affectionate.” When he was around, she said, “you just felt love.”

The child was close with Steven Dodson Jr., his mother’s boyfriend, who had reached for the gun during an argument. Dodson, 21, in June to murder and aggravated child abuse and was sentenced to life in prison.

A’mahri died in one of Florida’s most violent places for children: Jacksonville. This city has three ZIP codes that rank among the 10 worst in the state for firearm injuries involving children.

Every year, hundreds of children are hospitalized in Florida with gunshot wounds, and overwhelmingly, they come from a tiny number of ZIP codes, an exclusive analysis of hospital data by 吃瓜不打烊 and The Trace found.

Hospital billing data obtained from the Florida Agency for Health Care Administration shows that from 2018 to 2024 more than 4,000 children 17 or younger were hospitalized for firearm injuries — a rate of about 1.5 a day.

The newsrooms gathered data that the state’s hospitals use to collect payments from insurance companies or the government. The information does not identify patients but includes details about where they lived and their age, race, and other demographics.

The number of children killed in Jacksonville has grown so large that , Families of Slain Children, built a “Wall of Compassion” memorial listing hundreds of people killed by gunfire in the city. Memorial organizers have stood up a second wall nearby that is filling with names.

The numbers reflect how Florida’s long history of racial discrimination and permissive gun laws undermine public health, said researchers, public officials, community activists, and grieving parents.

Jacksonville kids were shot most often in racially segregated neighborhoods — a legacy from the early 20th century of state-sanctioned discrimination in housing, banking, and investment. These areas today are plagued by pollution from defunct city-run trash incinerators, garbage-strewn lots, dilapidated housing, poverty, and other problems that local leaders have been promising to fix for more than 50 years.

Nearly all the Florida ZIP codes with the highest rates of firearm injuries for children have large Black or Latino populations.

Perhaps nowhere is the toll of gun violence more evident than at UF Health Jacksonville, a safety net hospital and the only Level I trauma center in northeastern Florida.

As chief of acute care surgery, sees firsthand the toll exacted by guns.

“You see it day in and day out,” Madbak said. “I’m working tonight, and I suspect I’ll see a couple victims.”

, a UF Health pediatrician and former health director for Duval County, which includes Jacksonville, said state and local leaders have failed to address what he called the “root causes” of preventable firearm injuries and deaths, such as poverty, lack of opportunity, and neglect.

“The bottom line is nobody gives a flying f— about these young men,” Goldhagen said.

Gun violence victims and their families of depression, anxiety, post-traumatic stress disorder, and other mental health problems.

Throughout U.S. history, local governments have pushed industrial plants, , and highways through Black neighborhoods even as to increased risks of cardiovascular and respiratory diseases, cancer, preterm births, and gun violence.

But the Florida Department of Health does not focus on gun violence as a public health threat, Goldhagen said, despite its being the nation’s for children and teens.

The , a set of goals developed by the health department and an advisory committee, does not mention guns, the toll they take on children, or efforts to reduce firearm deaths and injuries to young people.

Instead, its goals include preventing or reducing sudden unexpected infant deaths and youth drownings, emergency room visits for motor vehicle crashes, and hospitalizations for traumatic brain injuries.

And yet, no one with the authority to address this public health crisis would agree to talk to 吃瓜不打烊 about gun violence and its toll on Jacksonville’s children — not the Florida health department, Gov. Ron DeSantis, Mayor Donna Deegan, or 18 of 19 members of the Jacksonville City Council.

()

Only Council member Jimmy Peluso responded. Peluso said the city has long ignored the needs of neighborhoods with high rates of firearm injuries among children.

“A lot of these neighborhoods have just felt like the wealth has left them,” he said, “and the city didn’t come in to put in the amount of work they needed to.”

DeSantis, a Republican, in public comments has called for few limits on how people purchase or carry firearms. He to allow Floridians to carry concealed weapons without a permit.

When then-U.S. Surgeon General Vivek Murthy declared firearm violence a public health crisis in 2024, DeSantis called the advisory an “.”

DeSantis said Florida would not follow the advisory, which recommended policies including universal background checks for gun purchases and requirements for secure storage.

DeSantis spokesperson Molly Best declined an interview request and to answer questions about the governor’s gun policies.

“There isn’t an agenda to end gun violence in the state of Florida,” said Jean Francis, a former pediatric nurse who leads the Jacksonville chapter of Moms Demand Action, part of a nonprofit that advocates for stronger firearm laws.

Research has linked increases in pediatric gun deaths from 2011 to 2023 to state-level gun policies.

States with permissive gun policies, such as “stand your ground” and open carry laws, reported higher rates of firearm deaths among children than states with strict regulations, such as weapon and age restrictions, according to a .

The study ranked Florida among a group of 30 states with the most permissive gun policies. Four states with comparatively strict gun laws — California, Maryland, New York, and Rhode Island — saw a decrease in pediatric gun deaths over the same time period.

prevents cities and counties from enacting stricter gun safety measures.

kids in disadvantaged neighborhoods are up to 20 times more likely to suffer firearm injuries than their peers in the most advantaged areas.

“It’s disheartening,” Madbak said. UF Health Jacksonville treated 255 patients for gunshot wounds in 2024, including 32 who were 17 or younger, he said.

In 2025, the hospital treated 269 patients for firearm injuries, including 22 who were under 18, according to Dan Leveton, a hospital spokesperson. As of Aug. 19, the hospital has treated 137 patients for gunshot wounds this year, including 18 who were 17 or younger.

Preventing gun violence “shouldn’t be a political issue, even though it is,” Madbak said, adding that there is a lot of room for more effective advocacy for violence prevention.

“It’s really an American issue,” Madbak said, “and our state has been impacted tremendously by this kind of violence.”

The Pain of Mothers, Grandmothers, and Aunts

In Orlando, one ZIP code — 32805 — had the state’s highest rate of children under 18 hospitalized for a gunshot wound from 2018 through 2024, with a total of 25 children, or 125.8 per 100,000.

On New Year’s Day 2018, Bryce Williams, 17, was in Casselberry, an Orlando suburb. He was found dead after crashing his blue Kia into a home near the park.

Williams’ death devastated his family, his grandmother Kim Crow told WFTV in Orlando.

“First off, you can’t believe that someone is taken from you so violently,” Crow said. “It’s heartbreaking.”

In April, Daesean Moctezuma Orland, 18, was while attending a house party outside Orlando. Two others wounded in the shooting were taken to the hospital. Police arrested a 16-year-old boy about a month after the shooting and charged him with Moctezuma Orland’s death.

Moctezuma Orland’s grandmother Iveliz Moctezuma told WFTV that a friend of her grandson’s called her and daughter Noemi Moctezuma to tell them that he had been shot. The women drove to four hospitals, including one in Tampa, searching for him.

“My every day is crumbled,” Iveliz Moctezuma said. “It’s hard to work. You sit there and you watch the news. You’re like, oh my God, there goes another kid getting killed by gun violence.”

“It’s a hole in my chest, a hole in my mind,” Noemi Moctezuma said. “It’s like the biggest void that you could ever possibly imagine, that not even the happiest moments can fill a void like that.”

Jacksonville, a city of about 1 million, is particularly treacherous for children living in areas north and west of downtown.

The victims include a gunned down while playing in front of a house, a fatally wounded coming home from a football tryout, and a killed by a stray bullet as she sat in a parked car.

Advocates for victims said that gun violence has ripped any sense of normalcy from families and entire neighborhoods. Grieving mothers fear fireworks and other loud noises that sound like gunshots. Grappling with their own emotions, they said, they sometimes struggle to help their surviving children cope with the loss.

“When you hear their stories, you think, ‘This is the worst thing I have ever heard,’” Francis said, “until you hear the next one.”

Hours after graduating from Jacksonville’s Raines High School in May 2022, , 18, was shot and killed while arriving at a friend’s celebration. Fields was walking into the party when a car pulled up and opened fire, his mother, Yvonne Fields, told Action News Jax in an interview.

A defensive lineman on his high school football team, Fields had been offered a full scholarship to play for Keiser University in West Palm Beach. His parents were planning a party for the following day to celebrate his graduation.

“Everybody loved him,” Yvonne Fields said of her youngest son, calling him “the life of the party.”

“Rashaud loved to dance. He was a joke teller. He was funny,” Fields said.

At the time, Rashaud Fields was at least the ninth 17- to 19-year-old homicide victim in the city that year, according to the , the local newspaper. Yvonne Fields said she has kept her son’s room exactly as he left it the day he was killed. She smells his shirt every day.

“I know he’s not coming back,” she said, “but I can feel the spirit.”

Two days after celebrating his 18th birthday, Maurice Hobbs was fatally shot in January 2017 as he waited for his mother to pick him up.

“I was not even a block away,” Latasha Hobbs said to Action News Jax.

A singer, rapper, and poet, Maurice Hobbs wanted to perform and launch a clothing line. He dreamt of making enough money to give homes to everyone in his family so they could all live on the same street.

His mom recalled celebrating his birthday with cake and dancing in the kitchen and his reaction to turning 18.

“He was like, ‘Oh my God, Mom, I made it to 18,’” Latasha Hobbs said. “So it’s hard to swallow knowing that my baby didn’t make it to 19. It’s not fair. My baby deserves to be here.”

Pamela Howard has struggled for nearly two decades with the pain of the killing of her son Derrell Baker at age 17.

Howard, a mother of five, called her son energetic and an anchor for his younger siblings. Baker excelled at football, she said, and was on track to graduate high school despite having severe attention-deficit/hyperactivity disorder.

Someone shot Baker in September 2008 as he walked to school. A passerby found him by the road.

Howard said she thought Baker was at school and later football practice. The family learned something might be wrong only when a sibling heard that Baker had been shot.

Howard called area hospitals in search of her son. By the time she found him at UF Health Jacksonville, it was too late, she said: He had died hours earlier.

“I don’t remember anything after they told me” he was dead, Howard said. “My friends say they just heard me scream.”

For the mothers Fields, Hobbs, and Howard, the sudden, unexpected death of their children cut deep. The lack of closure is painful. Police have not made an arrest in any of the cases.

“When I get justice,” Yvonne Fields said, “maybe I’ll be a little at peace.”

()

Leading Cause of Death

, chief of pediatric surgery and trauma at Children’s Hospital of Philadelphia, said there has to be an appetite in state capitals to regulate firearms and protect children from gun violence.

Nance co-authored a in JAMA Pediatrics finding that the number of states where guns were the leading cause of death for children and teens increased from zero over the period 2004 to 2008 to 24 from 2019 to 2023.

Motor vehicle deaths among children, once the leading cause of death in that group, have declined primarily because of safety interventions undertaken by governments and car manufacturers, he said, from seat belt laws and speed limits to air bags and antilock brakes.

“That progress has been pretty universal across the U.S.,” he said, “but firearm stuff is just all over the map.”

Guns don’t have federal safety standards, Nance noted. They aren’t regulated by the Consumer Product Safety Commission, a federal agency that protects the public from dangerous products, and they can’t be recalled the way unsafe toys or cars can be.

“We’ve really done almost nothing to change the trajectory of firearm injuries in kids,” Nance said.

Goldhagen, the UF Health pediatrician, said Jacksonville leaders tried to address gun violence through the Jacksonville Journey, an initiative launched in 2008 — when Duval County was the murder capital of Florida — under former Mayor John Peyton.

The program for children at risk of violence provided mentorship, summer camps, job training, and nonpolice strategies such as neighborhood beautification projects and community center programs. The Journey also partnered with the Jacksonville Sheriff’s Office on gang intervention focused on young people.

Officials credited the effort with a nearly 40% reduction in homicides in Duval County in its first four years.

After Peyton left office in 2011, program spending of about $15 million was slashed to $8.6 million in 2012 and about $2.3 million in 2014. The scaled-back program was eventually combined with another children’s initiative to form the , which uses city, state, and federal grants to fund youth services and intervention programs.

Duval County is the only large county in Florida that does not have a child services tax dedicated to programs for children, including efforts to reduce youth crime.

City leaders believe “public safety is about fire and police, but not social services,” said Vicki Waytowich, executive director of the , a nonprofit funded through grants and contracts that provides health and juvenile justice services for children and families in Jacksonville.

“There is absolutely zero political will to do anything that remotely resembles a child services tax,” she said.

In 2024, on a gun violence prevention program called Cure Violence, which tried to squash beefs between youths before they escalated to shootings. A city Office of Inspector General report and sound financial practices.

“We have a public health system that doesn’t focus on this as a public health or population health issue,” Goldhagen said.

Waytowich said crime is a symptom of much deeper problems on the north side of Jacksonville, from neighborhood decay to generational trauma and lack of job opportunities.

“We don’t really have the funds to address the root causes,” she said. “What we’re doing is slapping a band-aid on things.”

Unlike in Mandarin, a predominantly white neighborhood on the south side of Jacksonville with easy access to about seven grocery stores, children of the city’s north side have poor nutrition, Waytowich said, and many walk more than a mile to get to school.

“We can see that kids don’t have hope,” Waytowich said. “When kids believe they’re going to die at 21, then what’s the use of goal-setting and résumé-building workshops?”

In 2025, Jacksonville Mayor Deegan launched a program to address gun violence called .

But like its predecessor, Journey Forward does not have a dedicated, ongoing source of funding.

Hard Memory

On March 22, Ladonna Johnson said, she broke up with Dodson because she saw that he was sharing location information with other women on his cellphone.

She said she went into a bedroom where A’mahri and his sister were watching television and put her son on her lap. Dodson followed Johnson into the room, she said, then went into a closet and retrieved the gun.

“He just kept asking me, ‘What are we doing?’” Johnson said.

Moments later, Johnson said, she heard a loud bang. Her daughter started to cry.

They will both need therapy, she said. She is dedicated to preserving A’mahri’s memory: “I want people to know how adorable and sweet my son was.”

Still, she said, “I feel like I will never be OK.”

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.

For years, Washington, D.C., has paid for Medicaid 鈥� the state-federal health insurance program for low-income people 鈥� out of its general budget. But next year, the city is shifting part of that recurring multimillion-dollar cost to a new funding source: opioid settlement dollars.

That’s raising red flags for addiction recovery advocates, people directly affected by the crisis, and the commission in charge of recommending how the city uses its share of the settlement money.

The come from a host of companies that made or distributed prescription painkillers and were accused of fueling the overdose crisis. State and local governments nationwide are set to receive more than $50 billion over almost two decades. Washington, D.C.’s cut is expected to .

The money is meant to remediate the addiction crisis, often by increasing services or funding new programs.

But many states are facing increasing fiscal pressures as they are squeezed by inflation, federal funding cuts, and rising costs. Some officials have been tempted to turn to opioid settlement cash as a budget stopgap 鈥� an idea that can trigger opposition and outrage from recovery advocates and people who have struggled with opioid addiction and their family members.

“These funds were awarded to D.C. for very specific reasons and with a specific mandate, which are to remediate issues related to the opioid crisis in new and innovative ways,” said Queen Adesuyi, a partner at , a consulting group for community-based organizations, who is crying foul over the proposed fiscal year 2027 budget.

A document provided to 吃瓜不打烊 shows line items in the district’s fiscal 2027 budget that would direct about $2.3 million in opioid settlement funds to help pay for the city’s Medicaid contribution and at least $5.5 million to support addiction treatment centers previously funded through the general budget. Substituting opioid settlement dollars for general funding keeps overall spending on treatment flat instead of increasing.

“Opioid settlement dollars are not meant to be a rainy-day fund for existing government obligations,” said , associate director of the Center on Addiction and Public Policy at Georgetown Law’s O’Neill Institute.

More than 80 individuals and 30 city organizations protesting this use of settlement dollars, saying the district’s planned to spend opioid cash to “pay off its own debts.” The letter was sent to DBH Director Barbara Bazron; the chair of the D.C. Council’s Committee on Health, ; and Attorney General .

Chad Jackson, himself in recovery, chairs the district’s , which was created to advise the city on how to spend its settlement dollars. Jackson called the latest move supplantation, a budgeting tactic that shifts money from one fund to another to free up dollars.

“If the opioid settlement funds were not there, I feel pretty confident that these things would have been funded, because they have to be funded,” Jackson said.

What’s happening now is against the district’s opioid litigation law, he said.

The that money from the district’s opioid abatement fund “shall supplement, and not supplant.”

“It’s a pretty tightly written law where the intent is very clear: Do not supplant,” Weizman said.

Adesuyi, an advocate for programs that help people who use drugs, said the council is flouting that law and that it’s a “slap in the face.”

Councilmember Henderson and Attorney General Schwalb weighed in too.

“We are also concerned that DBH may be using the settlement monies for other unauthorized purposes,” they wrote in a to the department. They highlighted the $2.3 million used to cover the city’s Medicaid contribution and asked the department to explain by July 31 how it determined that was legal.

It’s unclear whether the Department of Behavioral Health met that deadline. DBH, Henderson’s office, and the attorney general’s office did not respond to that specific question.

However, DBH spokesperson said in a statement that the department is “committed to compliance with all statutory requirements governing opioid settlement funds.” The department’s general position has been that its budget was approved by the council, and that the funding supports efforts that counter opioid addiction.

The council “passed a legally-certified budget for the next fiscal year that makes the best use of all local resources, including the opioid settlement fund, to award grants to 17 community-based providers who last year served nearly 9,800 residents including 3,500 in medication-assisted treatment for opioid addiction,” Reed told 吃瓜不打烊.

The district’s budget is pending a 30-day “congressional review,” which is the last step in its .

Still, some residents like Adesuyi want more accountability for how the opioid money is spent.

“The drug supply is getting a lot more unpredictable, which calls for some nimbleness, and it calls for interventions that are more courageous. Unfortunately, DBH is not meeting the mark when it comes to that,” Adesuyi said, adding, “It’s frustrating, it’s disappointing, and it’s enraging because people are dying unnecessarily in the district to overdose.”

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

Now, the same pain had returned 鈥� on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an , which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed . There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are .

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance 鈥� But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs 鈥� except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient , which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to 吃瓜不打烊, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations 鈥� or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off 鈥� sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

Bill of the Month is a crowdsourced investigation by 吃瓜不打烊 and that dissects and explains medical bills.聽Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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 .