The labor and delivery unit where she used to work in this rural northeastern Georgia community is no longer open. So, she asked former co-workers to be on standby around her anticipated due date. She and her midwife mapped out emergency rooms along the more-than-50-mile trek to the hospital in Greenville, South Carolina, where she planned to give birth. And, to prepare for a worst-case scenario, she curated items to keep in the car in case she went into labor en route.

“That’s a horrible place to put a pregnant woman in,” said Holden, who on Oct. 11 made the painful, hourlong trip to Greenville Memorial Hospital to deliver her son Tucker.

Holden lives roughly midway between Athens and Greenville, two of the nearest cities with labor and delivery units. Owing partly to Medicaid cuts from President Donald Trump’s One Big Beautiful Bill Act, St. Mary’s Sacred Heart Hospital in Lavonia nearly a year ago. Its closure is part of a trend touching rural communities nationwide. From South Dakota to and from to , low Medicaid reimbursement and dwindling birth rates are pushing hospitals to shutter these services. Today, of rural hospitals offer labor and delivery services.

In Georgia, only 36% of rural hospitals have a labor and delivery unit, and four have closed since 2020, according to data from the .

To address the challenge the closings pose to patients seeking care, the state — which ranks among the for maternal health outcomes — has turned to federal money from the $50 billion . This fund was created by congressional Republicans to offset concerns about the outsize fallout Trump’s signature legislation would have in rural communities.

More than $12 million — out of the nearly $219 million approved for Georgia in the program’s first year — will be allocated toward placing obstetric carts in 43 rural hospitals without labor and delivery units. The carts will be outfitted with supplies needed for a birth or obstetric emergency. For example, they’ll have neonatal resuscitation tools, thermal blankets, and essential medications such as oxytocin, which stimulates contractions, and magnesium sulfate, used to treat seizures in pregnant people with high blood pressure.

The delivery carts sound fine, in theory, said Justin Peterson, an OB-GYN who practices in southern Georgia and has seen the pressures rural health institutions face providing maternal care.

Like Holden, Peterson worries that the carts, while helpful, will put supplies in the hands of ER doctors lacking extensive obstetric experience. Instead, he wants the state to fill coverage gaps by investing more to prevent the closure of labor and delivery units in rural areas.

“You’re putting a band-aid on a hemorrhage,” he said.

‘Can’t Practice Scared’

Brittany Mitchell was about seven months pregnant when Sacred Heart’s labor and delivery unit closed. She was reassigned to an OB-GYN in Athens, even though the nearly 50-mile drive from Lavonia was stressful and inconvenient.

That OB-GYN wanted to see Mitchell weekly after finding high levels of protein in her urine — a warning sign of preeclampsia, which can cause organ damage, seizures, and other complications. To make it to those prenatal appointments, she routinely gave up a day of work as a home health aide, a job she said already didn’t pay much.

But if Mitchell were to have another baby, she said, she’d still prefer to drive to Athens to see an OB-GYN than be treated by an ER doctor. When she had her first child nine years ago, the local OB-GYN had to act quickly when her daughter briefly lost oxygen.

“If they were in that situation,” she wondered of ER doctors, “would they know how to do all that?”

In written responses to ³Ô¹Ï²»´òìÈ, Lauren Williams, director of communications for the Georgia Department of Community Health, said that training ER medical staff is the main goal of the obstetric cart initiative. The rollout will include simulation drills, during which ER staff will practice high-risk procedures.

The Georgia Hospital Association will procure and distribute the carts. When exactly that will happen is unknown, but the grant funding must be spent by Sept. 30, 2027, said Anna Adams, the organization’s chief government relations officer.

The concept of obstetric carts is great, said Justin Law, an emergency doctor with SouthlandMD, a physician-owned and -operated healthcare management and staffing company. Most items planned for the carts are already available in ERs. But having them in one organized spot will be helpful, he said.

Still, while ER doctors are more frequently positioned at the front lines as labor and delivery closures persist, advocates argue that they shouldn’t be used as a stopgap in obstetric care.

In the decade he’s worked across rural Georgia, Law said, he’s never delivered a baby in the ER even though he’s trained in emergency obstetrics and has experience delivering babies as a paramedic. When a mother needs an emergency cesarean section or has another high-risk complication, she would likely be transferred to a hospital with labor and delivery capabilities, Law said.

Holden, the former obstetric nurse, said familiarity with obstetric delivery practices and procedures is essential because some complications can’t wait for a transfer. “You’re not going to save anybody’s life just because you got access to some equipment,” she said.

Adams understands the concerns and acknowledged that the ER is not the ideal location for delivering a baby. “But sometimes things happen that are outside of our control,” she said. “And when it does, we want to make sure those hospitals are prepared.”

Robin Clyatt, maternal health community outreach coordinator for , said ER doctors have vast knowledge. But they might see someone with a major maternal health complication, such as a hemorrhage, only a few times a year, and therefore may lack the skills to act immediately, she said.

“You can’t practice scared when it comes to obstetrics,” Clyatt said. “And that’s important, because when you practice scared, you do stupid things.”

Ways To Keep Access

The labor and delivery unit at the Coffee Regional Medical Center in Douglas serves six counties in southern Georgia. The number of live births there increased from to , which shows the impact when nearby facilities close, said Peterson, who practices at the Coffee Regional Hospital Women’s Center.

While he understands that hospitals must consider their bottom lines, business decisions in recent years have often taken precedence over patient care, he said.

“They just say, ‘Oh, you know, the numbers aren’t there. We’re closing,’” he said, adding that when rural labor and delivery units shutter, the chance they’ll reopen is small.

Mark Ralston, public relations manager for St. Mary’s Health Care System, which owns Sacred Heart, did not respond to multiple requests to further discuss the unit’s closure. But in its announcement, the system said the decision followed “an extensive 18-month discernment process that included intensive efforts to recruit additional physicians, create new partnerships, and pursue incremental funding sources.”

Nationwide, states are attempting to narrow gaps in maternal healthcare using federal funds. will establish maternal health hubs to determine where resources are needed and help mothers navigate the health system. in rural communities.

In its proposal for federal rural transformation money, Georgia included incentives such as funding 75 new residency slots in various specialties and creating a grant program that would reimburse physicians up to $250,000 in relocation fees if they chose to practice in rural areas.

State legislators could incentivize doctors to stay in rural areas, offer higher reimbursement rates for hospitals, and provide loan forgiveness for physicians, Peterson said. Communities should also look to incorporate certified midwives and community health workers, Holden and Clyatt said, though for both groups to practice. Currently, certified nurse midwives are allowed to practice only in partnership with a physician, which maternal health advocates argue creates a .

Holden had the ability to send her vitals to her doctor and meet with them virtually for prenatal care.

As she adorned bookshelves in baby Tucker’s cozy, sage-green nursery with vintage trinkets and family heirlooms, she said she thought of less-resourced mothers in the area, who may be on Medicaid or not have the luxury to travel an hour for a prenatal appointment.

Holden worries that without prenatal care, conditions like preeclampsia could go undiagnosed more often. “They don’t make it, and their baby doesn’t make it, because they never got that diagnosed and managed,” she said.

People like to remain optimistic that everything will go as planned, but “there are so many things that can go wrong,” she said. “And they can go wrong really quick.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Not all of those kicked off were fraudulently enrolled, ³Ô¹Ï²»´òìÈ has learned. Insurance industry sources said the Centers for Medicare & Medicaid Services has reinstated a small number of people whose coverage should not have been canceled. More could follow in the coming weeks if enrollees discover they are uninsured when they go to use their coverage.

Still, the sweep was long overdue, say supporters such as Brian Blase, whose Paragon Health Institute has of the cited by those who allege in the ACA. But other policy experts question how many legitimate consumers were caught in the dragnet, perhaps because they failed to open a letter from their insurer or answer a phone call.

Questions continue to swirl, even as a second phase of the anti-fraud effort is underway. An additional 419,000 sign-ups are being scrutinized. Insurers must let CMS know how many of those enrollees don’t respond to outreach efforts by “around mid-to-late November, after the midterm elections,” said David Merritt, senior vice president of external affairs at the Blue Cross Blue Shield Association.

He confirmed that some BCBS members are among those who have been reinstated. He also said that CMS has an expedited review process for those who discover they have been improperly disenrolled.

Overall, however, the administration is providing few details about the cancellations, such as how robust the outreach was to those it targeted, how long it takes for people to get reinstated after discovering their coverage was wrongly canceled, and how many such cancellations have been reversed.

“It may be true that some of those enrollments were not authorized, but it can be equally true that people got lost in the shuffle and have a valid enrollment. Without more information, it’s almost impossible to tell,” said , a director of the Center for Health Policy and the Law at Georgetown Law. “That they are not being very transparent is telling too,” she said of the administration.

The enrollment cut comes as part of a larger Republican strategy to focus on fraud in government programs, including and , which resonates with GOP voters.

At an Oct. 14 press conference, Health and Human Services Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz touted the removal this year of subsidies for with duplicate Medicare, Medicaid, or Children’s Health Insurance Program coverage, citing not fraud but a failure to look for concurrent enrollments or continued coverage for dead people. They credited an by the Trump administration to restore more frequent data matching checks than were done under the prior administration.

Unauthorized sign-ups by rogue insurance agents seeking commissions and other potential impropriety in the ACA marketplace — applicants’ providing incorrect income estimates, for example — has been a concern for several years, with much debate over the magnitude of the problem.

Even so, how the recent move to cancel the 760,000 enrollments will play out politically is uncertain. with gas prices as a top concern for voters. It is likely that many removed from the ACA are in red states, such as Texas, Florida, Louisiana, and Mississippi. Those areas in ACA enrollment from 2020 to 2025, driven in part by now-expired enhanced subsidies put in place during Joe Biden’s presidency. Additionally, the cancellations target only enrollees in states that use , the federal ACA marketplace. The fully running their own marketplaces generally have programs, such as multifactor authentication, and have reported few or none of the kinds of unauthorized sign-ups plaguing the federal marketplace.

“To the extent there is a reaction depends on whether the government got it wrong, whether people try to get care and then find out their coverage is no longer active,” said Adrianna McIntyre, assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health.

How It Played Out

According to information the agency provided to ³Ô¹Ï²»´òìÈ, CMS in June selected for further review nearly 1.2 million enrollments that had all of what it deemed four warning signs for fraud:

• The application included no Social Security number or immigration document number.
• A broker was involved in the sign-up process.
• The plan had no monthly premium payment.
• The enrollee had had no contact with their insurer and no claims filed.

Then, as first reported by ³Ô¹Ï²»´òìÈ, CMS sent lists of those ACA accounts to specific insurers, instructing the carriers to review them and use at least two methods of contact — such as a phone call and a letter — to try to reach the enrollees. Policyholders were given 30 days to respond to the insurers’ outreach and provide the missing information. CMS disenrolled those who didn’t respond.

Johnny Wallin, chief operating officer of Texas-based Marketplace Insurance Exchange, which helps clients in about 35 states enroll in coverage, said insurers reached out to his organization for help contacting people on the CMS lists, prompting “an all-hands-on-deck” effort by agents to reach clients, some of whom were vacationing overseas.

“Getting them to answer the phone isn’t easy,” he noted, although he suspects his agents had a better chance of getting a reply than an insurer because their clients are familiar with their phone numbers. Still, they could not reach about 60 of them.

Additionally, his team has been asked by insurers to help contact those targeted in the second phase of CMS’ review. A recent case involved a client who needed to upload his new green card after his previous one expired, but language barriers meant that he had to take time off work to come in for agents to help with the process.

CMS would not provide a list of the insurers it contacted, but publicly available documents show that New York-based Oscar Health was one.

In an August earnings call with analysts and investors, CEO Mark Bertolini said the company was reviewing the files and that “there are a number of cases ” with people on the list. In other words, the company reached enrollees CMS had targeted over fraud concerns.

He did not specify how many it had reached. The company declined to comment for this article because it is in a voluntary “quiet period,” when publicly traded companies limit disclosing information before the release of an earnings report.

Still, in with the Securities and Exchange Commission, Oscar Health estimated that 250,000 to 300,000 of its members might be disenrolled because of the CMS effort. Nationally, the company had about 3 million members in the second quarter and reported strong profits.

A Smaller Patient Pool

Overall ACA enrollment has , falling by nearly 3 million in the first few months of the year, due in large part to the expiration at the end of last year of the enhanced subsidies. The Trump administration has also taken some credit, saying its focus on weeding out improper enrollments and other changes, such as eliminating a special year-round low-income enrollment period, led to the decline.

CMS has also suspended some brokers for improper activity and barred new brokers from enrolling clients in ACA insurance on the federal exchange during the upcoming open enrollment period.

CMS did not respond to requests for data on the reasons it canceled enrollments. What percentage of enrollees were deemed ineligible due to incorrect income reporting or because they had other health coverage, such as through their jobs? How many because their ACA applications lacked immigration documents or Social Security numbers?

“Currently, there is no additional data to share,” the agency’s press office said.

But people outside the administration have been vocal.

“This was clearly phantom enrollees,” said Paragon’s Blase. He thinks more than 99% of the cancellations are of zero-premium coverage that people were signed up for by rogue call centers without their knowledge, or for people who don’t exist at all.

Blase said the carriers had a big incentive to get hold of the enrollees because they would lose the subsidies they were being paid if the plans were canceled.

And for any people unfairly caught up, Blase and Trump administration officials say all they have to do to be reinstated is call the marketplace and provide their Social Security number or other missing information.

“Everyone has the political incentive for that process to be that easy,” Blase said. “We’re a month before the election.”

But, as prior reporting has shown, it isn’t always a quick process to get an ACA plan canceled or reinstated following an unauthorized sign-up or switch, even when a consumer discovers it themselves and reaches out to the marketplace.

Brokers and policy analysts note that some of the factors used to question enrollments — such as a plan’s having no claims filed in a year — are not that unusual because many people don’t visit a doctor or hospital in a given year.

Insurers “want those healthy people in the insurance pool to help bring down the rates,” said Ronnell Nolan, president and CEO of Health Agents for America, a trade group for health insurance agents. “We’re against fraud, and CMS has allowed a lot of fraud to happen. But we don’t want people who just didn’t go to the doctor to be canceled.”

And even with the outreach required by CMS, not everyone answers phone calls from unknown numbers or opens their mail or emails.

A found an average “open rate” on emails of 28.6%.

Policy experts also note that, while lack of a Social Security number on an ACA application could indicate a fake enrollee, it might also be an oversight, or the number might not be required, like for a child if the who is not seeking coverage for the child.

“There will be legitimate people who don’t have a claim or don’t respond to an inquiry from an insurer,” said , a senior fellow at the Brookings Institution. “If the goal is to target fraudulent enrollment, what CMS did is better than tossing people at random, but is likely to miss the mark.”

This article first appeared on ³Ô¹Ï²»´òìÈ 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 ³Ô¹Ï²»´òìÈ 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 ³Ô¹Ï²»´òìÈ 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 ³Ô¹Ï²»´òìÈ 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 ³Ô¹Ï²»´òìÈ and is republished here under a .

Next, she drove to meet an 85-year-old and her daughter, who had come in from out of town. The older woman had “pretty advanced dementia” and was scheduled to move into the secure memory care unit of a senior living facility that day, said Martinelli, who works as an aging life care manager with Mir Care Consultants in Central Texas. The three of them had a 9 a.m. meeting with the primary care doctor who would complete the paperwork for the move.

At the meeting, Martinelli explained the situation, and the doctor said he’d fill in the patient’s forms that afternoon. But later in the day, she got a call from a colleague saying that the doctor wouldn’t be able to complete the forms that day after all. That created a scramble because the woman wasn’t safe alone in her house. Martinelli ended up calling a home care agency she trusted. “I begged them to provide me with a caregiver in the next four hours,” she said.

If a combination of appointments, bureaucracy, vigilance, and worry about a vulnerable older person — often interspersed with medical emergencies — sounds familiar, it might help to know about a service its providers ruefully call the best-kept secret in eldercare.

Independent certified professionals like Martinelli used to be known as geriatric care managers. That’s what I called the people who make the 125-mile move from his apartment to a continuing care community near me, and later helped my disabled sister transition from her home to an assisted living facility.

I also used words like “godsend” and “indispensable.” After the moves, the care managers kept tabs on both my father and sister monthly and eased my fears that something urgent might strike the moment I left on a vacation or a work trip.

About a decade ago, these experts rebranded themselves as aging life care managers. It usually takes a couple of years to become one. Most enter the profession as nurses or social workers; some are physical or occupational therapists or gerontologists. They must attain a required combination of before they can take the certification exam.

The Aging Life Care Association, the nonprofit that represents these professionals, was founded in the 1980s and has grown to more than 2,000 members, but care managers still have a persistent public awareness problem.

“When we talk to someone, they say, ‘I wish I could have called you six months ago, but I didn’t know you existed,’” said Susy Elder Murphy, who owns Aging Well Eldercare, a large practice serving Washington, D.C., and its Maryland suburbs.

The caller is typically an adult child, the Aging Life Care Association has reported. Martinelli described a common scenario: “Mom is in the hospital, or the children went to visit and hadn’t realized she was so sick. They’re in a crisis.”

Enter the aging life care manager. What distinguishes her (it is usually a woman) from people with confusingly similar names — senior care advisers, patient advocates, care navigators — is her independence.

Aging life care managers work for the client and the family paying them, not for hospitals or insurance companies. Moreover, the association’s specifically prohibits “accepting or giving referral fees, fee splitting, kickbacks or other similar arrangements in exchange for client referrals.”

Contrast that with companies that promise free advice on senior living, like A Place for Mom. Care facilities pay A Place for Mom fees for steering new residents their way, as the organization . Advisers for companies that receive fees may be unlikely to recommend places that don’t pay, or to recommend home care, unless the company also contracts with local agencies.

“They’re really marketers, salespeople,” Julie Wagner, chief executive of the Aging Life Care Association, said about the referral companies. Some companies are about these financial incentives.

“If you want to buy a car and you go to the Ford dealer, they will not say, ‘I really see you in a Subaru,’” Murphy said. “You should be talking to someone who’s objective, neutral, and experienced.”

Care managers don’t come cheap. Wagner said association members’ hourly rates range from $150 to $350, with big geographic variations. In Texas, Mir’s standard rate is $185 an hour, billed in 15-minute increments. In Washington, Murphy’s practice charges $210 an hour. Sometimes families share the cost, as my sister and I did. And in some cities, social service agencies provide these specialists on a sliding scale.

Aging life care managers serve as coordinators, not hands-on caregivers, and the range of services they provide is quite broad.

They can, for example: Arrange and oversee a move to or within a senior living facility. Deal with insurers, including Medicare and Medicaid. Drive a client to the dentist. Recommend not only local residential communities and home care agencies but elder law lawyers, medical specialists, therapists, , and hospice organizations. Visit weekly or monthly to see that everything is going smoothly. Alert family members if it isn’t.

“A part of our job is mediating between family members, acting as a sounding board,” Martinelli said.

In fact, care managers like Murphy find their clients often seem more willing to listen to them than to their adult children — even if the advice is the same. “Your mom didn’t change our diapers or teach us to talk,” she said. “It’s a different relationship.”

In a of clients and families commissioned by the Aging Life Care Association, “the responses were overwhelmingly positive,” said Jullie Gray, a co-author of the study who teaches at the University of Washington School of Social Work.

The nearly 200 respondents did not constitute a representative national sample, Gray said. But 93% said the benefits of hiring an aging life care manager outweighed the costs, and 99% said they would recommend such a manager to someone else. The survey’s findings were presented at the 2025 meeting of the Gerontological Society of America.

Jeffrey Bernstein, an engineer in Middleton, Massachusetts, has for years relied on Aging Well Eldercare for help with his parents, two older siblings, and an aunt, all in Maryland. Like many people who eventually learn about care managers, “I had no idea such a person existed,” he said, until his wife read about them in a magazine.

Bernstein, 65, was unable to relocate to care for his family directly. But with care managers, “when something came up, they were there, they stepped up,” he said. “More importantly, they knew what to do when I wouldn’t have. It was tremendously helpful for my peace of mind.”

The same was true with Martinelli’s 85-year-old client in Austin. She spent the night with temporary caregivers and moved into her new home in the memory care unit that Tuesday, after her doctor finally produced the necessary documentation. “She went in just before noon,” Martinelli reported. “She had lunch.”

How was the new resident adjusting? “It’s been OK,” Martinelli said, sounding relieved. “So far, so good.”

The New Old Age is produced through a partnership with .

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Daniel said she wondered: “Am I cheating on him? Am I going behind his back? Am I acting like I don’t trust him by seeking a second opinion?”

Many patients find themselves in this position, but family medicine physician Jen Caudle said patients shouldn’t feel awkward about asking for a second opinion. In fact, in her practice in New Jersey, she encourages people to have open conversations with their care team.

“We shouldn’t be offended,” Caudle said. “We should support you.”

Patients can also think of their primary care provider as the quarterback of their care team, Caudle said, and ask that doctor for help navigating opinions or diagnoses from specialists.

Cara Anthony and Blake Farmer, hosts of the HealthQ series, spoke with Caudle about the sometimes-awkward art of asking for a second opinion.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

They share an enemy, though. They dislike social media’s effects on children’s mental health. Talarico, who did not respond to a request for comment, has for kids under 16, while denouncing “predatory algorithms that divide us on an hourly, daily basis.” As a legislator, he targeting explicit deepfakes — digital imitations of individuals that are often made or manipulated by artificial intelligence and used for harassment on social media.

Paxton has been suing Big Tech, alleging the companies on their apps or from being viewed by kids. “When elected to the U.S. Senate, he will continue his proven record of advancing policies that protect children online, strengthen parental rights, and hold Big Tech accountable when it breaks the law,” Paxton campaign spokesperson Madison Cercy said in a statement to ³Ô¹Ï²»´òìÈ.

Youth mental health is in decline. Even as researchers explore what’s causing the problem, momentum is gathering among policymakers from both parties to crack down on social media companies. Several major companies are being sued, investigated, and, soon, potentially regulated. That they may be harming kids’ mental health is a key reason.

Companies are starting to feel the bite. In late August, the social media conglomerate Meta with a coalition of 48 states, the District of Columbia, and three territories and promised to change its policies and settings to protect children. Meta immediately took out advertisements in major newspapers, pressuring its competitors to adopt similar guardrails. Children’s health advocates want to go further, with federal legislation.

Indeed, at least 35 nominees for the U.S. Senate this year have sponsored bills to curb social media, initiated investigations, or publicly lambasted Big Tech companies that, in their telling, have exploited teens and kids.

“We’re protecting our children, not those profiting off their online presence,” Juliana Stratton, the Democratic lieutenant governor and Senate candidate in Illinois, , trumpeting state legislation.

Congress is edging closer to passing the Kids Online Safety Act, the vanguard social media regulation bill. The bill would require social media companies to implement various safeguards, such as limiting users’ ability to communicate with minors. to pass a version of the bill earned 91 yes votes in the Senate. Donald Trump Jr., the president’s son, that the bill needed to be passed “ASAP.”

Amid the momentum toward new federal regulations, Big Tech companies are lobbying for their preferred policy. Apple supports the bill, a spokesperson told ³Ô¹Ï²»´òìÈ, while Meta, which owns Facebook and Instagram, has spent $10 million on television advertising touting its teen accounts.

“Any youth safety legislation must put parents in the driver’s seat — blanket social media bans do not do that,” said Meta spokesperson Ed Patterson, who argued blanket bans push youths onto less safe platforms. “We support legislation that empowers parents — not the government — to approve the apps their teens can download from the App Store.”

Meta and other industry groups are scrambling to shape regulations for social media, and tech in general. Meta also gave some $10 million to a President Donald Trump-aligned campaign nonprofit, Securing American Greatness. Based on a ³Ô¹Ï²»´òìÈ search of the Senate’s lobbying database, about 70 corporations, trade groups, nonprofits, and other groups have been lobbying senators about the bill.

According to The Washington Post, the Trump administration has the online safety bill to other parts of its AI agenda, which includes legislation that would make it harder to regulate the technology at the state level. The White House did not respond to requests for comment.

The public’s views of major tech companies are souring. In 2024, the 78% of Americans said tech companies had too much influence in politics, while 64% said social media had a mostly negative effect on the country.

A widespread movement encompassing much of the public health establishment, parents’ groups, attorneys general, and whistleblowers is calling for greater regulation, as parts of the tech industry fight back by spending big on lobbying and marketing.

“You have the whole industry and all their lobbying dollars,” said Allison Ivie, chief policy officer at the Eating Disorders Coalition. that social media, by showing kids images of unrealistically thin peers and by amplifying content encouraging extreme diets, helps fuel eating disorders. “It’s not a balanced fight by any means,” Ivie said of the lobbying muscle. “How do you compete against that on any given day?”

Growing Up Online, Breaking Down Offline

from the Centers for Disease Control and Prevention, a third of youth have persistent feelings of sadness or hopelessness — about 10% more than a decade earlier. But many researchers question whether social media is causing the trouble. (Other metrics tracked by the agency show improvement.)

“The science is crude and messy,” said Sandro Galea, dean of public health at Washington University in St. Louis, who previously chaired a on the effects of social media on kids’ mental health. and have proposed a wide variety of causes for the crisis, like changes in the economy, decreasing social connections, access to firearms, and the pandemic.

Despite the uncertainty, much of the public health establishment is massing against social media. In early September, the Department of Health and Human Services advising parents and children to live life off-screen. It’s only the latest in a series of warnings from the U.S. surgeon general’s office — under both the Biden and Trump administrations — about these technologies.

“The evidence keeps building on the real and potential dangers of unregulated access for children,” Jerome Adams, Trump’s first surgeon general, told ³Ô¹Ï²»´òìÈ. These include, he said, “serious risks like higher rates of anxiety, depression, sleep problems, and developmental concerns. Kids spending too much time on these platforms face real challenges during key stages of growth.”

The policy backlash against social media has extended worldwide. The United Kingdom and Australia recently banned social media for kids under 16. The European Union has with a potential fine, up to 6% of revenue, for pushing “addictive designs” in a breach of the confederation’s regulations.

Besides the $17 billion settlement with Meta, other lawsuits in the United States have targeted Snapchat, owned by Snap, and TikTok, a short-video app owned by a consortium of American and Chinese companies. A won a $27 million settlement from social media companies; , including in Los Angeles, have , citing alleged addictive effects on youth, among other harms.

Coalitions of state attorneys general, including Paxton, have sued Big Tech companies, in some cases winning settlements related to allegations of mental health harm and addiction. In early August, to pay nearly $950 million after a New Mexico state court found it to be a “significant contributing factor to the current mental health crisis.” This preceded the multibillion-dollar settlement.

And a broad base of companies are feeling effects from the government and civil suits. The online gaming company Roblox in legal settlements, including expenses targeting “youth-related consumer protection and digital safety matters,” in the first half of 2026. YouTube, the video hosting website, multiple youth-related cases this year.

Taking Big Tech to Task

Yet the push in Congress has garnered much of the attention. Congressional committees on occasion have summoned tech company executives — sometimes with a friendly ear, but more often to berate them.

Accompanying the push for legislation are ongoing investigations, many of which collect testimony from whistleblowers. In 2025, Sarah Wynn-Williams — a former United Nations diplomat who later joined Meta — testified before the Senate about the company’s record.

Asked about allegations the company covered up or denied its knowledge of harms, : “Facebook was targeting 13- to 17-year-olds. It could identify when they were feeling worthless or helpless or like a failure, and they would take that information and share it with advertisers.”

For example, Wynn-Williams told lawmakers, “if a 13-year-old girl would delete a selfie, that’s a really good time to try and sell her a beauty product.”

Meta has been dogged by claims it has attempted to hide relevant internal research, including from the government. In a series of rulings in 2025 and 2026, a judge in Washington, D.C., found the company’s lawyers directed employees to “remove portions of research showing Meta’s knowledge of teen users’ developmental vulnerability because the research could be used by government enforcers investigating Meta.” But it has approved three dozen studies on social issues related to young people, and that they have “made real changes to protect teens online,” like creating teen accounts, whose settings parents can control.

Complicating any regulatory push, though, are protections for speech and privacy. For the legislation to work, said Jenna Leventoff, senior policy counsel with the American Civil Liberties Union, “the platforms are going to want to know who is a kid and who isn’t.” Simply asking users will not be enough, she said. “I know when I was a kid, I always said I was older than I was to try to create accounts.”

But the momentum for constraints continues. Over time, Ivie said, “we get all this damning evidence. It shifts perspectives.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

But in recent months, ’s proposed plans for a natural gas pipeline have exposed how population growth, here and across the nation, is driving a divide between wealthy newcomers and longtime residents.

Chatham has grown into one of North Carolina’s , fueled by an influx of new residents in its northeastern corner. Yet the pipeline would run from to , two communities where the per capita income is roughly $25,000 a year, or about half the income typical for the region.

And it’s raising familiar concerns. A from the Chatham County Public Health Department stated that “unjust, unfair, and uneven distribution of social and economic resources” in the county, including exposure to environmental hazards, limited people’s “ability to achieve optimal health.”

In September, the Chatham County Board of Commissioners , saying that “protecting public health, safety, environmental resources, and private property rights remains a priority.” states that the proposed pipeline could affect areas occupied by vulnerable, low-income residents. Under state law, Enbridge could still attempt to take land through eminent domain, and low-income communities affected would have fewer resources available to fight back.

The state Department of Environmental Quality typically would review applications for permits to build a natural gas pipeline. That department has not yet received a permit application for the pipeline, said Onotse Omoyeni, senior press secretary for the office of Gov. Josh Stein. The North Carolina Utilities Commission declined to comment.

Enbridge says the is needed to meet growing energy demands in the area, including Chatham, where the population has soared 21% since 2016, as well as neighboring Lee County.

Yet the proposed pipeline has set off protests at and attracted hundreds of people to a to express their opposition, many of them , retirees, or their relatives. They argue the pipeline would pose an environmental threat to wells used for drinking water and expose people in less affluent areas to that could increase the risks of cancer, preterm births, and asthma — all for the benefit of people who live nowhere near the proposed route.

“Nobody wants to be next to a pipeline,” Dorasue Burns Christian, a retired dental hygienist, told ³Ô¹Ï²»´òìÈ. She said the proposed route cuts across the roughly 22-acre farm where she has lived for more than 50 years. “I’m stressed and I can’t sleep at night. I have been pushed as far as I can be pushed.”

Enbridge Gas North Carolina is a subsidiary of the Canadian energy company Enbridge. Residents point to other communities in which Enbridge has operated — such as ; and — where oil spills and a natural gas pipeline rupture led to evacuations, injuries, and at least one death.

Enbridge declined an interview request to answer questions about the location of the North Carolina pipeline and the company’s safety record. In a statement, spokesperson Persida Montanez said the pipeline is needed to accommodate population and business growth in Chatham and neighboring Lee County.

A says safety will be prioritized during construction and operation, including monitoring, maintenance, and compliance with regulatory rules.

Many residents believe the company is attempting to profit from a , which many . The company website says that Enbridge does not intend to use the pipeline for that purpose and that serving a data center would require a pipeline at least twice the size of the one planned for Chatham.

The pipeline would connect to existing natural gas infrastructure in Siler City and near Moncure, the company said.

Still, pipeline opponents say they are fed up.

“They chose this route because they probably thought people would not fight back,” said Amanda Clark, a protest organizer who grew up in Chatham. Her family roots in the county date to the 1700s. “In rural communities, we are seen as disposable.”

‘Collateral Damage’

Chatham County’s fight comes amid a in the natural gas pipeline industry and the of “American energy dominance.”

The U.S. produces more natural gas than any other country, about as much as .

Research shows natural gas pipeline leaks are concentrated in where people experience higher rates of poverty and physical disabilities and have fewer means to respond to crises.

Nationwide, there were nearly from 2010 to 2021 that were serious enough that they were required to be reported to the federal government, including fires and explosions that killed 122 people and injured more than 600.

In 2019, and six were injured in Kentucky when an Enbridge natural gas pipeline ruptured, according to a federal government report.

Enbridge reached a with the federal government after the 2010 oil spills in Michigan and Illinois. In the Michigan spill, a pipeline discharged 1 million gallons of oil into Talmadge Creek, in one of the largest inland oil spills in U.S. history.

“No Pipeline. No Compromise,” read the red T-shirts worn by some of the more than 300 people who attended a Chatham County Board of Commissioners meeting in Pittsboro, North Carolina, in early August. Outside the building, they displayed signs that said “People NOT Pipelines” and “Save Our Farms.”

Under , private utilities and pipeline companies can , which give them the right of way to construct, operate, and maintain pipelines without outright taking ownership.

Enbridge will propose the final route for the pipeline based on field surveys, environmental studies, and engineering analysis, Montanez said. “The utility is also focused on delivering safe, reliable natural gas service that supports long-term economic vitality,” Montanez said.

Some residents, like Clark, argue that while the pipeline would power more housing and business development in wealthier parts of Chatham, it would create a public health risk in rural, poorer areas.

Clark, who works as the drug and injury prevention manager for the public health office in nearby Guilford County, said her great-grandparents were full-time farmers and passed down land near Siler City where her grandparents, dad, aunt, and cousin live.

Her grandfather retired from a hosiery mill and farmed part-time. He gave land to his children when they married, Clark said, because it was the only major asset he owned.

Clark said she is now in line to inherit land from her family and wants to protect the legacy of people who worked as farmers, mechanics, and schoolteachers from profit-taking by a company.

“We’re the collateral damage,” Clark said. “It makes people feel like they don’t have value.”

A Class Divide

Northern Chatham — which is an easy drive from major universities and , home to more than 250 companies — has seen a rush of newcomers.

Many have settled into places like , a community with boutique shops, gardens, and homes that can cost nearly $1 million. Another master-planned community nearby, , is expected to bring up to tens of thousands of new residents over the next 20 years.

Not far outside the county’s borders are Chapel Hill, home to the University of North Carolina; the state capital of Raleigh, home to North Carolina State University; and Durham, home to Duke University.

As those places have , Chatham has become a cheaper alternative.

But prosperity is fleeting in many parts of the county. A quarter of residents are considered low-income, and on average there are 24 candidates for every job opening, according to a by the NC Budget and Tax Center.

Christian, an 85-year-old widow who lives a few miles south of Pittsboro, spends her days on her farm, raising hay and caring for chickens, birds, dogs, and cats. She has received letters from Enbridge saying the company wants to survey her property, where she lives with her 66-year-old son, who has a disability.

Christian said she needs money to care for her son and worries that she may one day need to move to a nursing home because of declining health. She said she has been diagnosed with macular degeneration, an eye disease that blurs straight-ahead vision, making it difficult to recognize faces or read.

She had planned to make ends meet by selling multiple parcels of land, but she said potential buyers backed out once they heard about the pipeline. At the in August, she pleaded for local officials to try to stop Enbridge.

“They should be ashamed of themselves,” she told ³Ô¹Ï²»´òìÈ. “It’s disheartening. They are stealing from poor people.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

According to a , nearly 60% of Americans favor a system of Medicare for All, while 85% of Democrats support it. For years, Democrats in Congress symbolic that have had no chance of passage but have been supported by dozens of members.

Democratic Sen. Chris Van Hollen of Maryland added his support in December. “I was listening to my constituents,” he said. “It’s just reached the complete breaking point. Our system is unaffordable and unsustainable with premiums going up, copays going up and up.”

At a time when more than 100 million Americans carry medical debt, it’s easy to get behind a promise of free, or free-ish, no-hassle health care. But turning an inspirational slogan into law gets gnarly. Those three words, Medicare for All — a pledge to bring universal healthcare to every American — mean not one thing to supporters but many. And all versions of such a system face considerable obstacles to enactment.

“Medicare for All is a slogan, not a concrete proposal, so it’s hard to have an opinion on,” said Amy Finkelstein, a Massachusetts Institute of Technology economist who, with Stanford’s Liran Einav, wrote , which laid out what the pair considered a realistic and fiscally responsible plan for providing basic insurance to every American.

“What we can afford is a basic plan — what we call a shack, not a chateau,” Finkelstein said. Its bedrock would be a government-funded skinny plan less generous than Medicare, with potential constraints such as a limited number of physical therapy visits or stricter criteria for getting a knee replacement, but guaranteed robust basic coverage for catastrophic medical conditions. She estimated that most Americans would opt for supplemental coverage.

The most high-profile political proponent of Medicare for All this election season is Abdul El-Sayed, the Democratic senatorial candidate in Michigan, who has made a more sweeping proposal central to his platform — far more chateau than shack. It would create one plan that covers a suite of medical needs with no cost to patients, including dental and vision care, which traditional Medicare doesn’t cover.

(Traditional Medicare has increasingly come to resemble private insurance with premiums and coinsurance, and, unlike standard commercial plans, it has no annual out-of-pocket maximum. To fill such gaps, patients buy separate Medigap and drug plans.)

“The most important thing is just to make Medicare whole — meaning no charge for medical care — rolling back the complexity and costs of the last 10 years,” El-Sayed told ³Ô¹Ï²»´òìÈ.

His program would start off covering children and adults five years younger than the current eligibility age for Medicare and close the gap over a period, he has estimated, of eight years. To ease the transition for the healthcare system, he would initially set the Medicare payment rates to mirror the totals doctors and hospitals receive now to avoid a “price shock” to their operations. Future increases would be limited to the rate of inflation.

One big question is how to make the financing work in a highly profitable industry. National health spending was projected to hit in 2025, or nearly 20% of the U.S. gross domestic product.

The United States as much on healthcare per person than many peer countries. And health insurance is often a company’s second-largest expense after payroll.

But how will the government divert financial outlays of employers and households into a new Medicare for All system without new taxes or massive government spending?

When polls ask voters whether they would support Medicare for All if it meant losing their insurance or paying new taxes, support often drops.

“You could decide to raise taxes and cover more,” Finkelstein said. “If you don’t want to cut current Medicare benefits, you could decide to bust the budget, which seems to be a common practice.”

Joe Biden said that, as president, he any Medicare for All bill, given the cost, which was estimated at up to . The bills in Congress don’t include very detailed financing plans.

Economists who have mapped out the possibilities are divided on a realistic path.

A group of that converting to a Medicare for All program could save $450 billion annually. That’s in part because a government plan could negotiate — or simply set — far better prices for hospitals, doctors, drugs, and devices than private insurers. It would reduce the overhead created by private insurance with its army of negotiators, coders, and claim deniers — and reduce profits.

Strong forces are pushing back against such “rightsizing” of exorbitant prices, most notably: insurers, hospitals, and drug and device manufacturers. In 2022, they spent on lobbying and have been a powerful force for job creation. But a grand Medicare for All proposal may simply be a strategy to open the debate to lesser possibilities. President Barack Obama’s initial Affordable Care Act proposal contained ambitious ideas — such as drug price negotiation — that fell by the wayside to get the votes for passage.

Texas Democratic Senate candidate James Talarico supports what he calls “Medicare for Y’all” — allowing people under 65 to buy into Medicare.

“There are versions of Medicare for All that could potentially include our proposal, and versions that could look extremely different,” Finkelstein said.

Support in some parts of the industry is growing.

According to one survey, more than have said they’d prefer some sort of single-payer system. Though the American Medical Association is opposed, its student and resident sections are the opposition. The , the nation’s second-largest physician group, also supports Medicare for All. Obama called the ACA a “starter house.” It was “an improvement, but it has not met the need,” Van Hollen said.

Now the growing number of Medicare for All proponents will have to define exactly what kind of new house they can accept and afford.

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Nationally, an estimated were enrolled in the Supplemental Nutrition Assistance Program, also known as SNAP or food stamps, this June than in July 2025, when the law was enacted. Louisiana saw one of the most precipitous declines, dropping about 170,000 people, or 21% of state enrollees, according to federal data.

“We haven’t seen a decline of this magnitude in about three decades,” said , senior director of research on food assistance at the left-leaning Center on Budget and Policy Priorities, which did the analysis.

Meanwhile, food prices from August 2025 to this August, according to the U.S. Department of Agriculture.

Elected officials, policy analysts, and anti-hunger advocates are pressing Congress to delay provisions in the law that will cut federal funding for food benefits and steeply increase the cost for states. They want to insert the delay in the Farm Bill, which is pending in the Senate.

The provisions required states to start paying for 75% of the cost to operate SNAP on Oct. 1. Previously, the USDA and states split SNAP’s administration cost 50-50.

Beginning in October 2027, some states may also have to cover part of the cost of SNAP benefits that had been paid fully by the federal government. The amount that a state pays toward benefits will depend on its , or how often it underpays or overpays enrollees. The higher the error rate, the higher the state’s share of SNAP benefit costs.

In Louisiana, the state may have to cover up to $199 million of the cost for benefits, according to an analysis by the . Its error rate increased from 6.62% in fiscal year 2024 to 8.14% in FY 2025, the most recent data available.

Many states, including Louisiana, have placed pressure on applicants to submit more information more often to verify their eligibility to reduce the state’s payment error rate and limit how much the cost of benefits shifts to the state.

“It’s been a race to drive down those error rates,” Llobrera said.

He said the challenge of implementing new program restrictions and requiring more documentation has increased the burden on applicants and state agencies. The agencies have to process more paperwork on a tight timeline without enough staff. This can increase the likelihood of errors when processing applications, potentially leading to rejection of benefits for more people. It’s also harder for applicants to meet additional verification requirements.

The One Big Beautiful Bill Act expanded work requirements for SNAP, made it harder for states to waive the work requirements, and revoked access for many noncitizens with legal status.

The Louisiana Department of Health did not respond to requests for comment.

Tia Fields, the safety net policy analyst for the nonpartisan Invest in Louisiana think tank, said the cost increase to the state has contributed to two crises: a projected shortfall in the state budget and eligible families’ losing access to help.

In Louisiana, state data shows that 75% of people who lost SNAP from July 2025 to June 2026 did so for . When the program’s strict deadlines for documentation and verification aren’t met, applications and renewals are closed.

Fields said applicants may miss forms and interviews or fail to recertify or report changes in their status. Other times, the problem is on the state’s side. Agency notices may reach applicants past the deadline due to mail delays, they may be sent to the wrong address, or caseworkers may have backlogs in processing paperwork.

“Families are still hungry, and they’re actually eligible for the program,” Fields said. “This is a tax bill that we really cannot afford.”

The additional administrative burden and the financial penalties tied to having a high payment error rate give states an incentive to deny more applications, Llobrera said.

“The pressure that states feel now to really get their error rates down is pushing states to just ask for a lot more verification and more frequently,” Llobrera said.

Anti-hunger advocates say the need for food assistance has increased as barriers to SNAP have grown.

A Steadily Increasing Need

Aaranika Macon and her son received SNAP benefits for more than three years, continuing when she began nursing school last year. But she no longer qualified when she took a job in healthcare. After three months of trying to juggle work and school, her grades started to slip and she quit the job to focus on school.

So she reapplied to SNAP in February but did not receive benefits until April.

“I’m waiting, like, two months with nothing, because I stopped working,” Macon said. “Usually when you fill out, they’ll get back with you in, like, two weeks.”

According to the Food and Nutrition Act of 2008, SNAP-eligible households are required to receive benefits within 30 days of application.

When Macon’s SNAP application was finally processed, she received less assistance than she previously did. She was deemed ineligible as a student, though she’s taking the same number of classes as she did last year when she was considered eligible. In Louisiana, higher education students are eligible for SNAP if they attend school at least half-time and meet other requirements.

Only her 11-year-old son was approved for benefits. Instead of the roughly $500 a month for two people that she received previously, she said, the $298 for her son feeds them both.

She said she had to stretch a $5 balance in her SNAP account over six days at one point this summer.

“I’m in the same position as before the job. So, why is it cut?” Macon said. “You’ve got to fight to communicate with them.”

Lindsay Hendrix, chief impact officer for in southern Louisiana, said the organization has seen the need for food increase steadily for several years. Even before the passage of the SNAP changes last year, anti-hunger advocacy group Feeding America in food insecurity in Louisiana from 2022 to 2024.

“What we’re seeing is actually that more of our neighbors are coming to the food pantries longer than they used to before,” Hendrix said, and “the frequency of their visits have increased.”

Hendrix said last year’s government shutdown — which halted federal SNAP distributions and left states scrambling to fill the gap — illustrated the necessity of the food assistance program.

“Every politician was like, ‘Oh, just go to your food bank,’” Hendrix said. “And all of us working in food banks just around the country were like, ‘We will run out of food.’”

Instead, some states, including Louisiana, ensured SNAP benefits weren’t disrupted by distributing the benefits themselves until the federal government reopened and the agencies could be reimbursed. Hendrix said food banks complement SNAP and can’t compare with the scale of the program.

“We could not absorb that level of need without that program operating at its best, most effective level,” Hendrix said.

Cushion Against Higher Costs for States

Policy advocates and anti-hunger groups have been pressuring legislators in Congress to amend the latest Farm Bill or appropriations bill to delay any new costs to the states for SNAP by two years.

“We’re asking for every state to be able to have that cushion to try to get their systems in order, lower their error rate, and then give us time to reset, so that we’re not penalized for not yet having a strong enough system in place,” Fields said.

In September, the Senate Committee on Agriculture, Nutrition, and Forestry sent a to the full Senate that would give states another year before they may have to help pay for SNAP benefits. The cost would shift to — and penalties would be set in — 2028 instead of 2027. The legislation would still require states to start paying more for the cost of administering the program this year starting in October.

Sen. (D-Minn.) and other Democrats on the committee for a two-year delay.

The committee chair, Republican Sen. of Arkansas, told an in September that he expects negotiations on the bill to continue in October, with the goal of having legislation that can pass the House and Senate by the end of the year.

Anti-hunger advocates say a one-year delay isn’t enough. Jordan Baker, a spokesperson for the , said the financial strain of the impending administrative costs could eventually cause some states to opt out of SNAP altogether. Four states said they might withdraw from or pause the program if they have to start paying for benefits, according to a by the American Public Human Services Association.

Fields and Hendrix said it’s unlikely that Louisiana would completely drop SNAP. Hendrix said Louisiana’s SNAP program has been understaffed for a long time, straining the state’s ability to administer the program and do community outreach. That’s why Second Harvest’s food banks also help people with their SNAP applications. Fields said she also believes the state Department of Health is doing the best it can under a tight deadline.

“We just have to work out the kinks again,” Fields said. “That’s why we’re asking for that cost shift delay, so that the agency can have the opportunity to get it right and to keep the families fed here in Louisiana.”

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