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Rural MAHA Followers Say Trump Health Policies Haven’t Reached Their Communities

Wed, 30 Sep 2026 10:01:00 +0000

About half of rural voters identify with , a sprawling political movement championed by the Trump administration, but most said President Donald Trump’s healthcare policies have not benefited their communities, according to a from The Associated Press in partnership with 51��Ƶ.

About 8 in 10 rural voters — an important voting bloc for Trump and fellow Republicans in recent elections — said the Trump administration’s policies have had a negative effect or no impact on the health of people where they live. Most MAHA supporters, 68%, also feel this way, according to the national survey of more than 2,000 rural registered voters.

The findings signal an apparent disconnect between the Trump administration’s MAHA-branded policy priorities and rural America’s perception of their reach and effectiveness.

Iowa pastor Mike Jager, 58, is a registered Republican and considers himself part of the MAHA movement. The Trump administration’s health policies have had “minimal” impact on the health of his community, Jager said, but he added that Trump’s health secretary, , is moving the needle “in the right direction.”

“It’s a beginning,” Jager said. “It’s a big ship to try and turn around and course-correct.”

Kennedy has used the MAHA label to support various agendas, including , , and investing in regenerative agriculture.

Jager lives in Sumner, Iowa, “less than a quarter mile from where the corn ends and the city begins.” He’s seen family members and neighbors develop diseases that he believes resulted in part from exposure to agricultural chemicals and consumption of unhealthy, processed foods.

In the June Republican primary for governor, Jager voted for Zach Lahn, a businessman and farmer, who ran on a MAHA platform and beat out Trump-backed U.S. Rep. Randy Feenstra. He plans to vote for him again in November.

Jager said that President Donald Trump’s health secretary, Robert F. Kennedy Jr., is moving the needle “in the right direction.” (Miriam Alarcón Avila for 51��Ƶ Health News)

Many Rural Voters Are Prioritizing Health Issues

About two-thirds of rural voters who support MAHA said it’s “extremely” or “very” important to them to vote for a candidate who does, too, while only 4 in 10 rural voters overall said the same.

Trump sought to seize on MAHA support during his campaign for another term two years ago. Now, amid tight midterm races, Kennedy has campaigned to galvanize the movement’s support. In May, he attended a MAHA bill signing with Iowa Republican Gov. Kim Reynolds, and in August, he went fishing with Lahn, posting about it on social media.

Yet the survey indicates voters are noticing “this weird split in the Trump administration” between what Kennedy messages and what Trump says and does, said David Peterson, a political science professor at Iowa State University.

“It’s this mix of things coming out of D.C., out of different pieces of the administration, that’s confusing people,” Peterson said.

In Iowa, concerns about what’s causing are “a big deal,” he said. For many people who identify with MAHA, being healthy includes taking on corporate agriculture and pharmaceutical companies that they think cause cancer, he added.

“The sort of populist messaging around that is appealing right now,” Peterson said.

In the poll, views on healthcare access and costs largely diverged along party lines. Most Democratic and independent voters said the Trump administration’s healthcare policies have had a negative impact on their healthcare costs and the health and well-being of people in their communities. Republicans were likelier to say there hasn’t been an impact.

Talking on the phone from her 200-acre farm in Carroll County, Iowa, 71-year-old Donna Klocke said that her husband had died from cancer and that she has neighbors who also have cancer.

“It’s just very prevalent,” Klocke said. “We’re in a farming community. We use chemicals and pesticides and all kinds of things that aren’t necessarily good for us.”

Klocke, a Democrat, said the MAHA movement is a good idea because she cares about being healthy, but she does not consider herself part of it and will not be voting for a candidate who represents the movement.

Kennedy, who was an anti-vaccine activist before entering politics and has sent to Americans about , scares her.

“Measles are coming back and polio,” Klocke said. “It’s the measles that really gets me. It’s like, do you not understand how dangerous it is?”

Donna Klocke cares about being healthy but does not consider herself part of the Make America Healthy Again movement. Her husband died from cancer after a life spent farming the family’s 200 acres in Carroll County, Iowa. (Kathyrn Gamble for 51��Ƶ Health News)

Survey Reflects Angst Over Healthcare

About half of rural voters said their communities don’t have enough doctors or other healthcare providers, and even more said there aren’t enough mental health workers specifically. The share of rural voters who said their community does not have enough hospitals increased to 35% from 21% in a similar question asked in a 51��Ƶ-Washington Post survey in 2017.

And as with the general population, healthcare, gas, and grocery costs are top pain points. More than 6 in 10 rural voters said they were worried about healthcare costs.

The level of worry varied based on coverage, with rural voters enrolled in employer plans or Medicare less likely to be worried. The survey found that 80% of working-age rural voters on Medicaid were very or somewhat worried about healthcare costs. Last year, Republicans passed that cut over $900 billion in projected Medicaid spending over a decade and mandated new eligibility requirements.

Among rural voters who purchase their own insurance, such as the individual coverage plans available on Affordable Care Act marketplaces, 77% said they were worried.

In the tiny community of Lipan, Texas, west of Dallas, Kim Solis and her husband have a handyman-and-home-remodel business and get their insurance on the marketplace. Since Trump was elected again, their premium payment jumped from zero to $166 a month. Their copays went up, and their deductibles each increased by $2,000.

Solis, 62, said she worries what will happen if they get a big medical bill.

“Certainly, we’d be in a world of hurt trying to take money out of savings or getting it out of our 401(k) just to be able to do something about it,” she said.

Most MAHA Voters Are Also MAGA — But Not All

Like the general population, rural voters said they trust their own doctors and healthcare providers for health information over government agencies or officials, according to the poll.

Trust in Kennedy and Trump fell largely along partisan lines. About 10% of rural Democratic voters reported having a “great deal” or “fair amount” of trust in Kennedy, compared with 74% of rural Republican voters. About 5% of rural Democrats and 69% of rural Republicans said they trust Trump a “great deal” or “fair amount” for reliable health information.

While Make America Great Again and MAHA identities are “linked in a lot of ways,” the rising costs of healthcare and groceries pose a challenge for those committed to the MAHA principles that Kennedy promotes, said Peterson, the Iowa State professor.

Buying healthy food “becomes, ‘I can’t afford to do that because of Trump’s policies,’” he said.

In Stamping Ground, Kentucky, Alma Johnson, 65, works as night security at a horse farm. Johnson said gas had gone up but her overall cost of living had decreased since Trump took office.

Johnson voted for Trump in 2016, 2020, and 2024 and said she “pretty much” likes how Trump is running the country. But she said she is not a MAGA devotee, preferring to “think for myself.”

MAHA, however, is an easy sell for Johnson because, she said, she doesn’t think people should be able to buy junk food through the Supplemental Nutrition Assistance Program, or SNAP.

Still, she said she hasn’t seen much impact from the Trump administration’s healthcare policies, including the .

“It takes a long time to change people, their habits, their thoughts, or the things they do,” Johnson said.

About the Poll

The 51��Ƶ-AP Rural Voters Survey was conducted online and by telephone Aug. 12-24, 2026, among 2,241 registered voters living in rural areas, defined as census tracts that fall within codes 5-10 of the U.S. Department of Agriculture’s 2020 Rural-Urban Commuting Area codes. Voters were reached through a combination of the probability-based SSRS Opinion Panel and a registration-based sample from the L2 voter file. Overall results have a margin of sampling error of plus or minus 3 percentage points, including design effects due to weighting. Error margins are larger for subgroups. In collaboration with the AP, 51��Ƶ researchers worked to design the survey sample and questionnaire and analyze and report findings.

This report is from a collaboration between 51��Ƶ Health News and The Associated Press.

51��Ƶ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 51��Ƶ—an independent source of health policy research, polling, and journalism. Learn more about .

This article first appeared on 51��Ƶ Health News and is republished here under a .

US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims

Phil Galewitz, Andrew Jones and Claudia Boyd-Barrett — Wed, 30 Sep 2026 09:00:00 +0000

Hundreds of thousands of immigrants with legal status are at risk of losing government health coverage starting Oct. 1, state data shows, signaling that the impact of Medicaid changes in President Donald Trump’s signature legislation from 2025 may be greater than anticipated.

Many lawfully present immigrants will be among the first people to lose Medicaid coverage under congressional Republicans’ One Big Beautiful Bill Act, which is expected to cut spending by more than $900 billion through 2034 for the state-federal health program for people with low incomes or disabilities. The law will strip many more immigrants of their Affordable Care Act plan subsidies and Medicare coverage next year.

Those losing their health benefits who were previously eligible include refugees of war, asylees who fled persecution, victims of sex trafficking, and interpreters who risked their lives assisting U.S. service members in Afghanistan — all of whom are in the country with the federal government’s permission. The law does not affect coverage for a few groups, including those who hold green cards.

The Congressional Budget Office, the nonpartisan budget scorekeeper, estimated the law’s changes eliminating Medicaid eligibility for many noncitizen adults with legal status would lead to about 100,000 more immigrants being .

51��Ƶ Health News asked several states how many Medicaid enrollees they had identified as being at risk of losing coverage under the provision. More than 281,000 immigrants from nine states and the District of Columbia are expected to lose Medicaid in October.

While some may be able to obtain coverage elsewhere, the state numbers suggest hundreds of thousands of immigrants nationally are at imminent risk of becoming uninsured.

The CBO declined to comment.

Florida alone identified nearly 177,000 immigrants who would no longer qualify for the state’s Medicaid program starting in October, said Anna Holaday, a spokesperson for the Florida Department of Children and Families. The agency verified the enrollees’ immigration status through government databases and sent notices to people to give them an opportunity to provide more information proving they remain eligible, Holaday said.

Arizona predicts nearly 28,000 could lose eligibility. New Jersey expects 15,000 to 25,000 of its noncitizen residents to lose their Medicaid coverage. In North Carolina, it’s about 29,000, and in Washington state it’s 11,000. Final numbers from states on how many Medicaid enrollees have been terminated from the program won’t be available until later this fall.

Lawmakers rely on the CBO to understand the budgetary and economic impacts of proposed legislation. Yet the federal agency did not publish estimates on the One Big Beautiful Bill Act’s impact on noncitizens enrolled in Medicaid until a month after Congress passed the bill and Trump signed it into law.

Much of the attention around Medicaid changes in the law has centered on implementation of work requirements as a new condition of eligibility for many enrollees starting in January. The CBO estimates the requirements will increase the number of uninsured Americans by about 5 million by 2034.

Without health coverage, immigrants are likely to lose access to doctors, prescription drugs, and most other medical services. They still could qualify for coverage of emergency care under a separate program known as Emergency Medicaid.

“I came here to live a better life,” said Ahin, a refugee who left war-torn Syria for Turkey in 2011 and came to the U.S. in October 2024. She spoke with 51��Ƶ Health News on the condition that she be identified by only her first name, out of concern for her privacy and security.

Soon after arriving in the U.S., she developed severe abdominal pain that required intestinal surgery. Those costs, along with ongoing visits to specialists, were covered by Medicaid.

“I’m really worried about this,” she said. “It’s truly a terrible situation.”

Ahin, 25, said she doesn’t know what she will do if she needs to go to the hospital — she wouldn’t be able to pay the bill. She lives in a small apartment in New Jersey with her mother. Medicaid has also been vital to her mother, who has asthma.

Health Benefits Wane for Immigrants

The federal government required states to notify immigrants who will soon lose coverage, but immigrant rights advocates say some states did not begin sending letters until September. That’s given enrollees little time to react, including to respond if the state was mistakenly ending their coverage.

Cutting off Medicaid coverage is just the first move to drop government health benefits provided to many lawfully present immigrants. Under a change starting in January, the CBO estimates, about 1 million will lose eligibility for government subsidies to buy individual health coverage on Affordable Care Act marketplaces by 2034. And they will also lose access to Medicare, a change expected to affect about 100,000 immigrants, the agency forecasts.

Trump has argued that taxpayer-funded programs should be reserved for American citizens. As Congress debated the legislation in May 2025, the White House with the misleading claim that the One Big Beautiful Bill Act would remove Medicaid coverage for people who are in the country without authorization.

Under long-standing law, people who are in the country without authorization do not qualify for the general Medicaid program that is funded by state and federal dollars.

The health coverage cuts are part of a broader Trump strategy to send a message that immigrants are not welcome in the United States, said Ben D’Avanzo, senior strategist for federal advocacy at the National Immigration Law Center. The Trump administration has also moved to kick people with legal status off the Supplemental Nutrition Assistance Program, or SNAP, and tried to do the same with the children’s program Head Start until a federal judge intervened.

In addition to green card holders, people under age 19 and immigrants from Cuba, Haiti, or certain Pacific Island countries their Medicaid coverage affected by the law.

A Few States Try To Fill in the Gaps

Some states are staving off the coverage loss using their own money. California expects about 148,000 immigrants to lose Medicaid coverage. But the state is spending $365 million for a separate program to keep them covered until July 2027, according to Tony Cava, a spokesperson for the California Department of Health Care Services.

New York and Pennsylvania also have state-funded health coverage for many of the immigrants who are affected.

Carlos Alarcón, health and public benefits policy manager with the California Immigrant Policy Center, an advocacy group, said taking away health coverage for immigrants will affect the health of the state as a whole. The fewer people who have access to healthcare, the easier it will be for contagious diseases to spread, as happened during the covid pandemic, he said.

Alarcón said he hopes the state-funded coverage will be extended under California’s next governor. Polling released in September showed Democrat Xavier Becerra, secretary of the Department of Health and Human Services under President Joe Biden, leading Republican Steve Hilton in the gubernatorial race. Becerra to issue an executive order to maintain health coverage for every Californian affected by federal cuts.

In California Governor’s Race, Voters Face Stark Choice on Immigrant Healthcare

California’s next governor will face tough decisions on a highly controversial piece of healthcare policy: what to do about health coverage for the more than 1.4 million low-income residents without legal status. Democrat Xavier Becerra and Republican Steve Hilton present starkly different choices as public opinion wavers.

By Christine Mai-Duc July 6, 2026

“I believe there’s folks in the legislature that will really want to fight to make sure that we restore things as much as we can,” Alarcón said.

Refugee assistance groups say they have been trying to educate people in their communities and direct them to health clinics that are government-funded or free.

“We’ve just been scrambling trying to find free medical care,” said , co-founder of the . “To not be a welcoming place is the most un-American thing I’ve ever experienced.”

Andrea Mendez Perez, director at Interfaith-RISE, a refugee resettlement organization in southern New Jersey, said the Trump administration has elongated the process for people to get green cards and is now taking away coverage from those without them. Before 2025, it typically took about six months to qualify for a green card, documentation that allows a foreign national to live and work permanently in the United States, she said. Today, it’s well over a year.

For many of these immigrants on Medicaid, losing their ability to get their prescribed medications “is a life-or-death situation,” Mendez Perez said.

Ahin, the Syrian refugee, applied for permanent residency soon after arriving in the U.S. two years ago. Mendez Perez said she should have her green card by now, which would have spared her from being dropped under the GOP law. “She is stuck in the middle and has no control.”

Colleen McCauley, policy and advocacy director at the Camden Coalition, a nonprofit that helps connect people to healthcare in southern New Jersey, said the loss of coverage is devastating.

“None of them did anything wrong,” McCauley said, “and they are losing coverage.”

This article first appeared on 51��Ƶ Health News and is republished here under a .

After Failed Execution, Health Workers Say State’s Rules Flout Medical Ethics

Catherine Sweeney, WPLN — Tue, 29 Sep 2026 09:00:00 +0000

This story describes a lethal injection procedure used in state executions.

In May, a group of healthcare workers spent about an hour trying to establish complete IV access so they could inject Tony Carruthers, an inmate at the Riverbend Maximum Security Institution in Nashville, Tennessee, with a lethal dose of sedative.

Maria DeLiberato, an attorney for Carruthers, was in the room. She said the workers stuck his arms and feet with needles, to no avail. A doctor then tried to insert a central line through his collarbone and shoulder. That didn’t work, either.

Carruthers groaned in pain and blood oozed from puncture wounds, DeLiberato said in a news briefing.

After more than an hour, Gov. Bill Lee called the warden, ordering him to halt the execution attempt. He later granted Carruthers a one-year reprieve.

Now, as another approaches, doctors and nurses in the state say they want medical professionals removed from the execution process. They’ve also joined defense attorneys and nine Republican state lawmakers in demanding a moratorium on the death penalty and an overhaul of the state’s execution methods.

The doctors’ arguments echoed those the American Medical Association has made and in its code of ethics.

Tennessee is where the death penalty is legal, according to the Death Penalty Information Center, a nonprofit that offers data and analysis on issues surrounding capital punishment.

Governors in four of those states have halted all executions, citing and , such as being unable to obtain lethal injection drugs amid pharmaceutical companies’ refusal to sell them for use in executions. Lethal injection is still the primary nationwide, but some states may use , a , or .

Since the beginning of 2020, 170 people have been executed in 17 states, with most occurring in Florida, Texas, and Oklahoma. In that time, six states have had , according to the , which defines those as executions that include a departure from the protocol because of unanticipated problems and that cause more pain for the prisoner than anticipated, whether they ultimately end with a death or not. Several of the stories read like Carruthers’ — protracted but ultimately failed attempts to establish IV access.

Tennessee Health Workers’ Concerns

The IV team gave up on trying to place a typical line into Carruthers after several failed attempts, according to DeLiberato’s account. , physician Mark Fowler, a contractor for the state’s prison system, then tried to place a central line in a deeper vein. That’s a quasi-surgical procedure in which a plastic tube is inserted in the chest, groin, or neck. Fowler used a series of syringes, trying to insert the tube under Carruthers’ collarbone and then through his shoulder.

In an , Fowler said he hadn’t done such a procedure in the 12 years since he had stopped working in an emergency room, and didn’t know that placing a central line could be among his execution duties.

Fowler told NPR by phone on Sept. 24 that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.” He did not have further comment.

Two months after the halted lethal injection, more than 40 doctors and nurses to Lee, calling on the Republican governor to pause executions and redesign the protocol to omit health workers from the process.

The letter said that Tennessee’s rules requiring the participation of pharmacists, physicians, and other healthcare workers in executions are at odds with medical ethics, as well as guidelines explicitly laid out by groups such as the American Medical Association. The doctors are to preserve life when there is hope of doing so and bars participation in executions.

“This means that the health care professionals who agree to take part in Tennessee’s executions are those willing to set aside their professional ethics,” the letter to Lee reads. “The problems that we have seen, such as in Mr. Carruthers’s case, are the predictable result of working with such unscrupulous actors.”

John Greer, a retired Nashville hematologist, said in a news conference about the letter that he wasn’t surprised the central line placement went awry.

“Placing a central line is not just sticking a needle in a person’s arm,” he said.

Greer said the doctor has to tap a large vessel above the heart. He said that it’s a risky procedure in which an error could cause a collapsed lung or heavy bleeding — and that only those with specific training and routine practice should attempt.

“And I cannot imagine that there would be someone who’s doing these routinely who would be involved in this procedure,” Greer said.

Some Republican state senators also hold on executions and an overhaul of the process, saying that “incompetent administration” of capital punishment gives its critics more ammunition.

This summer, Lee said he didn’t want a pause.

“The Department of Correction did exactly what they should,” he said. “It should not affect executions in the future.”

“It’s one of the most difficult things that we do in this state,” Lee said later. “But I am committed to making sure that it is done in the way that it should be.”

The state’s lethal injection protocol orders the prison to keep a curtain over the media witnesses’ viewing window until the IVs are established, so none of them could offer a visual account of the failed execution attempt.

A has been filed has been filed by the Reporters Committee for Freedom of the Press and news outlets including NPR member station WPLN. The lawsuit argues the lack of transparency during the IV placement process obscures problems like the ones that happened in Carruthers’ case.

There’s a broad understanding in the U.S. that the medical establishment doesn’t participate in executions, said , director of the Center for Bioethics and Humanities at the University of Colorado’s medical school.

“We came out of World War II with a whole bioethics and medical ethics enterprise that is really strongly opposed to medicine serving as an arm of the state and using specialized medical skills to hurt people or kill people,” Wynia said.

A history of medical abuses by government doctors — such as and unethical studies of in the U.S., and in Nazi Germany — forged that consensus, he said.

Wynia mentioned other nations where medical professionals still participate in executions.

“But they are, you know, Iran and Saudi Arabia and Russia, sort of authoritarian states, where medicine is an arm of the government,” Wynia said. “Medical involvement in executions ends up happening because medicine is unable to say, ‘No, we don’t do that.’”

Upcoming Execution

On Sept. 30, Tennessee is scheduled to execute Christa Pike, who was 18 years old when she and her boyfriend killed Colleen Slemmer.

Pike’s attorneys this year raised several concerns that the state’s lethal injection protocol would violate her rights. Among them is their contention that because she suffers from a platelet disorder, it’s likely she will need a central line placed. They also argued that she was at risk of needless suffering, alleging Carruthers’ execution showed that Fowler — who has that he will oversee Pike’s execution — is incompetent at placing central lines.

In June, they put all of those concerns to the Tennessee Supreme Court, asking for a special investigator to collect evidence and hold hearings to determine whether they warranted an order to delay her execution and design a method for only her.

The court did appoint a special investigator, Senior Judge Mark Ward. He held a series of hearings in Knoxville last month. Ward said he didn’t believe Pike’s rights would be violated by the process and submitted to the court.

On Sept. 23, the Tennessee Supreme Court , agreeing with Ward, saying none of the concerns amounted to a constitutional violation. On Sept. 28, Lee announced he would not grant her clemency.

This article is from a partnership that includes , , and 51��Ƶ Health News.

This article first appeared on 51��Ƶ Health News and is republished here under a .

Economic Frustration Tests Trump’s Standing With Rural Voters, New 51��Ƶ-AP Poll Finds

Wed, 23 Sep 2026 10:01:00 +0000

About half of rural American voters believe the economy is worse off now than when President Donald Trump returned to office, according to a that points to economic frustration among a key group that has backed Trump and other Republicans in recent elections.

The poll of more than 2,000 rural registered voters by The Associated Press in partnership with 51��Ƶ found broadly negative views on the national and local economies, including from many Republicans. The costs of groceries, gas, and healthcare rank as top pain points for the rural voters, who were surveyed over two weeks starting in mid-August. And a larger share than among voters overall say they are worried about being able to afford groceries or gas.

At the same time, about half of rural voters approve of Trump’s job performance, more than among U.S. adults overall in separate AP-NORC polling.

The findings suggest that many rural voters haven’t turned on Trump but that they also largely don’t think he has delivered the economic renaissance he promised on the campaign trail.

Ed Westrick, a registered Republican and veteran, rates Trump’s job performance as “mediocre, middle-of-the-road.” Westrick, who lives in rural Texas, isn’t sure he will cast a midterm ballot, a troubling sign for Republicans in a key state in their fight to keep control of Congress.

Rural Americans skew Republican and historically have been an instrumental group of voters for Trump. The survey reveals that while rural voters seem unlikely to support Democrats on a large scale, Trump and the Republican Party could face challenges with them in November.

Deep Unhappiness About the Economy

As the election approaches, only about 4 in 10 rural voters approve of Trump’s performance on the economy. They rate him similarly on his handling of the Iran war, an entanglement that has proved expensive for the U.S. and increased oil and gas prices. And rural voters rank pocketbook concerns and fraud in government programs higher among the things they want to hear about from politicians than other perennial issues, such as gun policy and abortion.

Westrick, 59, is a technical trainer in the electronics industry and has seen an increase in business in part because he works with defense contractors, but he said he’s concerned about the cost of living.

“I hear the politicians talk about making groceries more affordable and making healthcare more affordable but yet none of them are addressing the issues,” Westrick said.

Westrick adjusts a roof on a small building at his home in rural Texas. (LM Otero/AP)

In the poll, about three-quarters of rural voters rated the cost of living in their communities as “only fair” or “poor” — up from about half in a 51��Ƶ-Washington Post survey in 2017. Rural Americans, who have consistently lower wages than those who live in suburban and metro areas, have been hurting economically for decades, according to Tim Slack, a professor of sociology at Louisiana State University and co-author of the book Rural and Small-Town America.

“Many folks are connecting the cost-of-living crisis to many of the Trump administration’s policy choices: the war in Iran, tariffs, trade wars,” Slack said. “None of those things are going to bring down prices at the pump or the local Walmart.”

“Trump promised to lower prices on Day 1, and instead the cost of living’s continued to climb. And that’s especially painful in rural America,” Slack said, adding that he expects many working-class Republicans to skip voting in November.

Rural Republicans do have a brighter economic perspective than rural Democrats or independents, particularly about the U.S. as a whole, according to the survey. About 6 in 10 rural Republican voters say Trump has improved the national economy, compared with only about 2 in 10 independents and fewer than 1 in 10 Democrats.

But only 45% of rural Republican voters say Trump has made their local economies better off. About 1 in 4 said there are fewer good-paying jobs where they live than five years ago.

In Michigan, 37-year-old independent voter Brittainy Sosebee said she isn’t sure if she will vote in the state’s midterm election, which includes a tight Senate race seen as crucial to the Democratic Party’s push to win back a majority. Sosebee voted for Trump in 2016 and Democratic candidate Joe Biden in 2020; she didn’t vote in 2024.

Sosebee, who lives in St. Johns, a small town just north of Lansing, said she used to have extra money to take a vacation or buy a new pair of jeans without worrying. Now, she scrutinizes every expense, cringing at the rising cost of fresh produce when she shops for her three children.

“We hunt, so we have a lot of venison and things like that, so we don’t have to buy meat from the grocery store, but it’s still crippling,” she said.

Healthcare Policies Go Unnoticed

The 51��Ƶ-AP poll found that rural voters overall don’t perceive much positive impact from the Trump administration’s healthcare policies even as they have been a top priority for Republican leaders, who have promoted efforts to lower drug costs and touted a $50 billion rural health program.

Only 17% of the voters said the Trump administration’s healthcare policies have had a “positive impact” on their healthcare costs, while 41% said they’ve had “no impact” and another 41% said they’ve had a “negative impact.”

Sitting on her front porch in Woolwich, Maine, 71-year-old Democrat Kathleen Hanning sipped a chai tea latte in the sun and recalled how she stopped voting for Republican Sen. Susan Collins in 2020.

Collins and Trump are “intertwined,” Hanning said. “She is not independently voting on what’s best for Maine.”

Hanning, a retired federal worker, said she hadn’t paid much attention to the health policies in Trump’s signature tax-break-and-spending-cut bill passed last year. The law reduces federal Medicaid spending by roughly $900 billion over a decade but also includes the billions of dollars for the Rural Health Transformation Program, which it created.

A year after the law’s passage, more than 8 in 10 rural voters said they’d heard either “a little” or “nothing at all” about the health fund. About 60% said they had heard nothing, according to the survey.

Rather than transforming, Hanning said, “hospitals up here in Maine are consolidating.” She travels an hour to see a specialist and noted that mothers will now have to drive farther for care because the hospital in nearby Damariscotta announced it would soon close its labor and delivery center.

Nine in 10 rural voters said it was “extremely” or “very” important for candidates to talk about healthcare costs, with more than half saying it’s “extremely important.” Mirroring the general population, rural voters ranked healthcare costs and gas prices as top economic worries.

Rural Republican Voters Still Trust GOP More

When asked which political party they trusted to do a better job handling issues such as the cost of healthcare or the cost of living, rural voters tended to side with their own party. The finding signals that Democratic candidates are more likely to benefit from rural Republicans’ staying home this November than from their voting across party lines in large numbers.

Republicans are more ambivalent about their party’s ability to handle key healthcare issues, compared with Democrats. About 8 in 10 Democratic voters say they trust the Democrats to address healthcare costs, while closer to 6 in 10 Republican voters say the same of the Republicans.

In Manassas, Georgia, a tiny town about an hour’s drive inland from Savannah, Republican voter Wanda Rogers feels the Trump administration is doing the best it can to clean up what she sees as an economic mess that Democrats left behind when they lost power.

“I kind of think people think like I do, that he knows what needs to be done,” she said. “It’s just taking them a while to get it there.”

Still, the 66-year-old said, “gas prices, they’re eating me alive right now.” She said she has stopped traveling to the beach because it has become too expensive.

Pamela Shaw, an independent voter who lives in a rural area near Asheville, North Carolina, said she sees the impact of rising costs in her community.

“When hamburger is over $7 a pound and steak is $15 or more a pound, a lot of people are not able to buy some of the things that they are used to buying,” the 59-year-old said in an interview.

Trump’s Rural Standing Has Slipped

Trump remains relatively popular among rural voters in the 51��Ƶ-AP poll, with 48% approval — substantially higher than in a July AP-NORC poll of U.S. adults overall, in which only a third approved of his performance. But he’s also down slightly, from 56% approval, among rural voters, based on a similar question asked in the earlier 51��Ƶ-Washington Post survey.

Asunta Washington, 38, is a truck driver who lives in South Texas. He said he is not against voting for Republican candidates if he wholeheartedly agrees with what they stand for, but he has not seen that. Instead, he has seen a lot of flip-flopping, he said.

“Like, a lot of people that are giving us promises and the moment they get elected, all that’s out the window,” Washington said.

Asunta Washington, a truck driver in New Braunfels, Texas, says he’d be open to voting for Republican candidates if their views aligned with his. (AP Photo/Eric Gay)

This year’s competitive elections feature key Senate races in states including Ohio, Michigan, and Maine, all of which have large rural populations. In close races, Democrats may have a chance to “show up and give a message that rural people might find appealing,” said Nicholas Jacobs, a political scientist at Colby College and co-author of the book The Rural Voter.

“But it’s nothing more and it’s nothing less than that — an opportunity,” Jacobs said. “And time and time again, Democrats have shown a certain proclivity for not seizing that opportunity.”

Many rural voters don’t think the major parties or the president respect people like them. About half, 48%, of rural voters say the GOP respects people like them “a lot” or “some,” while 45% of rural voters say this about Trump and 37% say this about the Democratic Party.

On a recent Thursday, registered Republican Nate Lawrence answered his phone after paying $57 to fill up his Chevy Equinox in New Concord, Ohio, a village of fewer than 3,000 people about an hour’s drive east of Columbus.

Lawrence, a middle school English teacher, said the candidates should be talking about spending power: “I need to be able to go to the store and feed my family on what I make as a teacher,” Lawrence said. “I should be able to pay for a house on a teacher’s salary.”

Lawrence has voted for Trump in the past but didn’t in 2024. For Ohio’s Senate race, Lawrence said he is torn and not sure whether to pick Democrat Sherrod Brown or Republican Jon Husted.

Still, even if the politicians say they will lower prices, Lawrence said, he won’t believe them.

“Trump said that, and it didn’t happen,” he said.

About the Poll

The 51��Ƶ-AP Rural Voters Survey was conducted online and by telephone Aug. 12-24, 2026, among 2,241 registered voters living in rural areas, defined as census tracts that fall within codes 5-10 of the U.S. Department of Agriculture’s 2020 Rural-Urban Commuting Area (RUCA) codes. Voters were reached through a combination of the probability-based SSRS Opinion Panel and a registration-based sample from the L2 voter file. Overall results have a margin of sampling error of plus or minus 3 percentage points, including design effects due to weighting. Error margins are larger for subgroups. In collaboration with the AP, 51��Ƶ researchers worked to design the survey sample and questionnaire and analyze and report findings.

This report is from a collaboration between 51��Ƶ Health News and The Associated Press.

This article first appeared on 51��Ƶ Health News and is republished here under a .

Insurance Coverage Lags as Cancer Science, Treatment Move Forward

Arthur Allen — Tue, 22 Sep 2026 09:00:00 +0000

Mason Henderson with his mother, Tabitha Lowe, in November during a visit to New York, where Henderson was participating in a clinical trial to treat his brain cancer. Henderson died in May after a two-year battle with the disease. (Jerry Lowe)

Eighteen months after his initial diagnosis, chemotherapy hadn’t slowed 21-year-old Mason Henderson’s rare brain tumor, which had spread to his spinal fluid. So he left his home in southeastern Texas to spend three weeks in a clinical trial in New York City.

But that failed, too, leaving a murky path for Henderson, whose cancer was so rare the World Health Organization had only in 2021. So early this year, Henderson’s doctors, evaluating his tumor’s deep genetic language, turned to a drug made by Merck and AstraZeneca called Lynparza.

It was not the standard of care for Henderson’s condition — there wasn’t really any standard, which is not unusual for rare cancers. And Henderson’s insurance would not pay for it, despite the careful justification given by the two specialists treating him.

“They have no guidelines for his cancer,” Henderson’s mother, Tabitha Lowe, said in a March interview with 51��Ƶ Health News. “They’re discriminating against him because his cancer is so rare.”

Tabitha Lowe and her son Mason Henderson. Lowe spent six weeks trying to get an $8,700-a-month drug for her son that the family’s pharmacy benefit manager wouldn’t cover. (Tabitha Lowe)

Every year, tens of thousands of people — representing about a — are diagnosed with tumors that differ enough from frequently identified ones to be called rare. In determining whether to reimburse treatment for such ailments, insurers turn to Food and Drug Administration labels and expert guidelines.

But these rare afflictions often lack targeted, FDA-approved treatment options, even though in many cases, molecular tests offered by diagnostic companies and university labs can provide a strong suggestion of what will work.

“Insurance coverage routinely trails behind what genomic testing reveals about a patient’s cancer and what the science supports,” said Olivier Elemento, director of Weill Cornell Medicine’s Englander Institute for Precision Medicine.

Henderson’s neuro-oncologists, Jacob Mandel of the Baylor College of Medicine and Jessica Schulte of NYU Langone Health, decided to try Lynparza, also known by the generic name olaparib, in combination with chemotherapy. There wasn’t a wealth of evidence behind the drug but there was a “biologically reasonable” assumption it would help, Schulte said, because cells in tumors like Henderson’s have a flaw that drugs like Lynparza can target. Providers in several previous cases had seen brain cancers like Henderson’s respond well to the drug.

“In general, we try to base our treatment decisions on large patient studies” involving hundreds of patients, Schulte said. But large clinical trials will probably never be conducted for a cancer as rare as Henderson’s.

Schulte, who specializes in brain cancers in young adults, sees only a few of Henderson’s type each year, she said.

Mandel prescribed the drug on Jan. 16. Liviniti, Henderson’s pharmacy benefit manager, responded with a quick refusal on Jan. 30. Two weeks later, the company sent an explanation: “Lynparza is not approved for the diagnosis provided.” Out-of-pocket, the drug would cost about $8,700 per month, Lowe said. Liviniti did not respond to phone calls seeking comment.

Before his diagnosis, Henderson was a healthy, athletic young man with a big heart, faith in Jesus, and a tight group of friends, his mother said. At Evadale High School, north of Beaumont, Texas, Henderson played baseball and football and was homecoming king in 2022. After graduating, he worked at the local paper mill, spending his free time hunting, fishing, and exploring the woods on an all-terrain vehicle. He wanted to be a police officer, Lowe said.

Henderson was 20 on March 15, 2024, when his brother Gunner found him at the top of the stairs in the family home with his head in his hands. “He was in the post-seizure state,” Lowe said. “He couldn’t talk. Was crying. Trying to hug me. Could not communicate.”

At an emergency room in Beaumont, an MRI revealed a large tumor. He was transferred to Baylor St. Luke’s Medical Center in Houston and diagnosed with a form of brain cancer called diffuse hemispheric glioma (H3-G34 mutant).

Surgery a few days later cut out 90% of the tumor, but brain cancers are almost impossible to remove entirely, because of the delicacy of the tissue they’re embedded in, Schulte said.

After 16 months of radiation and chemotherapy, a September 2025 scan showed the cancer had spread to his spinal cord, a condition called leptomeningeal disease that usually proves fatal within a few months. Mandel contacted Schulte about a clinical trial she was leading. It consisted of 11 days of brutal craniospinal irradiation, which left Henderson exhausted. When it was over, the cancer was still there.

“The family was wonderful,” Schulte recalled. “They were trusting in their team, but they asked appropriate questions to make sure that we were thinking about Mason as a person.”

Coverage Refused

Lynparza, approved by the FDA in 2014 for ovarian cancer, works by interfering with tumor cells’ ability to multiply. After Liviniti, the pharmacy benefit manager, refused coverage for Henderson, his family turned to Jefferson County. Henderson’s stepfather, Jerry Lowe, flies helicopters for the county sheriff’s office.

The county, which had the final say on reimbursement because it pays claims directly for its employees’ family health coverage, also refused. When Henderson’s family appealed, the county review board authorized an independent medical reviewer to look at the case. The nonspecialist supported the board’s finding and recommended another drug, but Henderson’s doctors disagreed. The board didn’t respond to a request for comment.

AstraZeneca had also turned down the family’s request for a donation of the drug. By then it was March, six weeks after Lynparza was prescribed.

Cancers that start in the brain are unusual — only about 25,000 cases are diagnosed in the U.S. each year, compared with 320,000 breast cancers and 229,000 lung cancers. Only a few hundred people each year, mostly young adults, are diagnosed with Henderson’s type, according to Schulte.

Treatment options for diffuse hemispheric glioma are few; brain cancers in general are often excluded from clinical trials. They represent a relatively small market for a pharmaceutical company. Testing drugs against them is risky, because of the brain’s sensitivity, and difficult because the drug must pass through the tightly packed cell walls lining the blood vessels, known as the blood-brain barrier.

Patients like Henderson often struggle to get medications that are prescribed off-label based on recent scientific findings. (Tabitha Lowe)

Still, drugmakers are increasingly homing in on narrower and potentially more accurate drug targets as science reveals more of cancer’s remarkable molecular diversity.

Under , the FDA has approved to be used for patients whose tumors have specific mutations, regardless of the organ where the cancer first appeared. These “tissue agnostic” drugs are still a tiny minority, but as genome sequencing becomes more common — order it for patients — insurers will have to keep up, Weill Cornell’s Elemento said.

Several U.S. research groups are hosting clinical experiments known as “basket trials,” in which mostly late-stage cancer patients are put on drug combinations based on tumor genetics, rather than the organ of origin.

The American Society of Clinical Oncology has recruited more than 3,000 patients into one of the biggest efforts, the Targeting Agent and Profiling Utilization Registry, , which began in 2016. It provides off-label treatments at no cost to advanced-staged cancer patients at more than 270 U.S. oncology practices.

About half the participants have benefited, and in rare cases the treatment kept patients alive for a year or more or seemingly cured them, said Richard Schilsky, the program’s founder and its principal investigator until recently. The results have led to changes in several treatment guidelines, he said, and a change in guidelines “usually is sufficient to create a pathway to reimbursement by insurance.”

Research has uncovered “quite a few” cases in which Lynparza was effective against a variety of tumor types, Schilsky said. But like many clinical trials, TAPUR excludes patients with primary brain tumors — like Henderson’s.

Oncologists disagree on how broadly genetics discoveries will transform cancer diagnosis. Cancers are currently identified as breast, colon, lung, etc., because those are the cells that pathologists see when diagnosing a tumor, said Razelle Kurzrock, the associate director of clinical research at the Medical College of Wisconsin Cancer Center.

But that’s a “mistake of history,” she said. “You’re making the diagnosis based on the pathologist’s view of the surface of the cell rather than what’s actually driving the cancer.”

A Dutch father and son invented the first light microscope to peer at cells around 1590. The Human Genome Project finished in 2003. If genome-enabled next-generation sequencing, now used for molecular tumor scans, had come before the light microscope, “no one would look at organ of origin,” she said.

Kurzrock leads a clinical trial in which every patient gets individualized cancer therapy based on DNA, RNA, and protein patterns in their tumor. Instead of getting drug combination A or B, “in our trial everyone gets a different set of drugs,” she said. Physicians can instead use standard therapies, she said, and their patients are the study controls.

Other oncologists see limitations to purely genetic diagnosis. Certain cancer centers advertise by saying, “‘We’ll sequence your tumor better than anyone else, and therefore you’ll live longer and do better if you come here,’” said Kathy Miller, a professor of oncology at Indiana University. “But the evidence doesn’t support those claims right now.”

‘I Wouldn’t Give Up’

In Henderson’s case, the problem was never diagnosis; Baylor clinicians identified his cancer type quickly. But its rarity and location made the tumor hard to fight, and the lack of financial help made it even harder.

On March 8, Tabitha Lowe went on Facebook, LinkedIn, and Instagram with photos of her son and descriptions of his plight. She tagged AstraZeneca, Liviniti, and the county board that had denied his reimbursement. “Rare cancer patients are denied treatment simply because their cancers are rare,” she wrote in one of the posts, which were shared hundreds of times.

“I hated to take this route, but when it comes to my kids there’s nothing I won’t do,” she told 51��Ƶ Health News. “I’ve cried, I’ve stressed out, but I wouldn’t give up.”

Tabitha Lowe took to Facebook to try to get her son Mason Henderson access to the brain cancer treatment his doctors sought for him. (Tabitha Lowe)

The next day, AstraZeneca’s patient assistance program, which had turned down her request for the drug two weeks earlier, emailed her with good news: A bottle of 60 Lynparza pills had been shipped to her pharmacy. Company spokesperson Tara Parsell said patient confidentiality prevented her from commenting on its actions.

Lowe’s six-week battle had paid off. Now, “it’s in God’s hands,” she said in an April interview. By mid-April, however, Henderson could no longer walk. Then came issues with his speech. “It all happened so fast.”

On May 4, in the family’s living room, where his bed had been moved, Henderson died, after taking the drug for nearly two months. Hundreds attended his memorial service; their cars made a procession seven minutes long.

The family has created a college scholarship in Henderson’s name for graduates of the local high school. An online campaign and bass fishing tournament had raised nearly $24,000 by September. Willie Robertson of Duck Dynasty, professional pickleballer Tyson McGuffin, and pro fisherman Hank Parker donated items for a raffle. Country singer Mark Chestnutt sent two signed guitars, Lowe said.

“Faster treatment would have been better,” although it’s hard to know whether it would have extended Henderson’s life, NYU’s Schulte said.

“I will always wonder,” Lowe said in a phone interview this summer. “Cancer don’t pause while the paperwork’s in progress.”

“There’s something especially painful thinking about how much time I spent fighting healthcare instead of being with Mason,” she added. “I was forced to become a PBM, insurer, research expert, all while trying to be his mother.”

This article first appeared on 51��Ƶ Health News and is republished here under a .

Outcome of Suit Against Department of Labor Could Boost Skimpy Employer Health Plans

Julie Appleby — Wed, 16 Sep 2026 09:00:00 +0000

A long-running lawsuit challenging what it means to be an employee and therefore have access to work-based health plans is being closely watched by health policy analysts. Its outcome could spur the availability of lower-cost but potentially skimpier health coverage that skirts some consumer protections.

Court papers indicate a settlement in the case against the Department of Labor , although the parameters of any such deal are unknown.

It would come amid premium surges on Affordable Care Act marketplaces that have led millions to drop coverage this year. The Trump administration has also been sharply focused on expanding access to alternative coverage, such that avoid ACA rules on preexisting conditions and benefit requirements.

“Depending on what happens with the settlement, this could be an even bigger expansion,” said , director of the Center for Health Policy and the Law at the Georgetown University Law Center. “People are worried that it is the opening salvo into promoting junk plans that don’t meet the ACA requirements.”

The plaintiff, Data Marketing Partnership, against the Department of Labor in 2019, during the first Trump administration. It wants official recognition as an employer so it can continue to allow its limited partners to buy into a type of job-based health insurance that doesn’t have to comply with state insurance rules or offer coverage as robust as required under the ACA.

But to grasp the claim, one also has to understand how the coverage works.

A consumer shopping for health insurance may come across information online or from a marketer about this concept, sometimes called “limited partnership” coverage. The pitch? Buy insurance offered through Data Marketing Partnership and handled by LP Management Services. To qualify, the consumer must download an app that tracks their internet searches. The company could then sell that data.

Some potential consumers may be turned off by the thought of their internet searches being tracked, but others may find it appealing because it allows them to become a limited partner eligible to buy into the company’s employee health insurance plans. But can these partners be considered employees?

The court’s answer has potential implications for regulators and consumers. Some health policy and market experts warn that a green light could lead to a proliferation of aggressively marketed and potentially questionable insurance with limited recourse for consumers because the plans would be exempt from state oversight.

“If this took off, you logically could see the rise of a whole bunch of what, functionally, would be unregulated insurance companies,” said , who was the principal deputy assistant secretary of the Department of Labor’s Employee Benefits Security Administration during Joe Biden’s presidency and now runs his own consulting outfit.

No one knows if the department is going to change its long-running stance defending the case. But any settlement could add more uncertainty to insurance markets.

Already insurers are requesting double-digit increases in ACA premiums again next year, partly because declining enrollment often means that the healthiest policyholders are leaving. That trend could accelerate in coming years as more people are drawn into alternatives such as limited-partnership policies.

States Act as Federal Case Plays Out

The Department of Labor defended the case throughout the first Trump administration and the Biden era, issuing a sharply worded in early 2020 stating that people who simply download software to “capture data as they browse the Internet” are not “employees or bona fide partners.”

A district court judge in Texas, the ACA unconstitutional in a decision ultimately rejected by the Supreme Court, called the advisory opinion “” in a 2020 ruling in favor of the data marketer. The U.S. Court of Appeals for the largely upheld the lower court’s decision but ordered it whether someone who downloads software is either a “working owner” or a “bona fide partner.”

The employer-employee relationship is at the heart of the case because of a designed to help large, self-insured employers offer retirement and health benefits to workers without having to meet varying rules from multiple states.

That law — the Employee Retirement Income Security Act — allows such plans to avoid most rules set by the states, which generally regulate most other types of insurance and assist consumers who report problems with their policies. As self-insured employer plans, the policies also don’t have to comply with some ACA rules, such as the 10 broad categories of “essential health benefits.”

“If the case goes the wrong way, it could impact consumers or hamstring the states,” said Marie Grant, Maryland’s insurance commissioner.

Arguments over what constitutes an employer plan are not new, and other organizations have tried offering such coverage. Some states have taken action against purveyors of limited-partner policies.

Maryland in 2024 , The Vitamin Patch, for offering limited-partnership insurance after investigating complaints and determining it was not licensed to sell coverage in the state.

Washington in 2021 to stop offering its plans in the state and fined it $25,000.

and in 2024 warned consumers about this type of coverage.

“These plans do not provide comprehensive medical coverage and can leave consumers with large, unpaid medical bills,” according to Connecticut’s notice.

Maine’s announcement noted that entities offering these types of health insurance included The Vitamin Patch as well as Affiliated Workers Alliance, Consumer Data Partners, Employers Business Alliance, Socios Buenos, and Strategic Limited Partners.

State insurance commissioners in the Department of Labor case citing their concerns about losing the ability to enforce consumer protections.

“This is not a Republican-Democrat thing,” Khawar said. “It’s really a story about state authority, the way such authority would be significantly undermined in insurance markets.”

What’s the Risk?

Still, these limited-partnership plans are viewed by proponents as a needed additional choice for consumers, at potentially lower cost than ACA plans.

When the case was filed, attorneys general , for example, urged the Department of Labor to back Data Marketing’s request to designate its limited partners as employees. That would provide an option for people who “earn too much to qualify” for ACA subsidies and be an interim solution until the ACA could be repealed and replaced, they wrote. They argued that states would retain some regulatory authority and added that the Department of Labor, which oversees self-insured employer plans, could set requirements to “encourage” stable companies to enter the market.

Critics, the attorneys general wrote, might fear that ACA alternatives will draw away younger or healthier people, thus affecting those who remain, but they argued that had already happened.

Data Marketing’s attorneys emailed 51��Ƶ Health News that they could not provide a comment for this article because the case is in active litigation. Neither the White House nor the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, responded to questions from 51��Ƶ Health News about whether the Department of Labor has changed its stance and how the administration views limited-partnership health plans.

In court filings, however, Data Marketing said that without an employer designation, it would have to end the insurance coverage, affecting about 50,000 policyholders. That would also hurt its ability to generate revenue, it argued, because offering insurance is “a significant attractor” to get people to join its partnership and let it access their electronic data.

, who helped oversee ACA implementation in the Biden administration and is now a managing director at consultancy Manatt Health, had a different take. “The only reason why these sorts of products exist is because they aren’t beholden to consumer protection rules of the ACA and can essentially make money by attracting good risk, people who are healthy,” she said.

Maryland’s Grant echoed this warning, saying that proliferation of such plans could lead to even higher premiums in the ACA markets, if those who remain are older or sicker than those who leave.

Nineteen patient advocacy groups to the Department of Labor Aug. 11 urging it to continue its defense in the case, warning that a settlement that says such arrangements create an employer-employee relationship could “significantly” undermine “both state regulatory authority and decades of bipartisan efforts to promote stable, well-functioning health insurance markets.” Some of those groups in support of the department in 2021.

Days after the August letter, U.S. Rep. Bobby Scott (D-Va.), the ranking member of the House education and workforce committee, warned the department against increasing the availability of “questionable employment relationships” and the insurance they offer.

He cited reports of call centers’ misleading consumers “who think they are enrolling in comprehensive health insurance but instead sign up for junk coverage under the guise of creating an employment relationship with what the consumer believed to be a traditional health insurer.”

This article first appeared on 51��Ƶ Health News and is republished here under a .

Indigenous Groups Are Exempt From Medicaid Work Rules, but Native Hawaiians Aren’t

Ashley Mizuo — Fri, 11 Sep 2026 09:00:00 +0000

WAIANAE, Hawai‘i — Native Hawaiians will need to comply with new work requirements to qualify for Medicaid after being excluded from exemptions carved out for other Indigenous groups, an omission that clinicians fear will exacerbate the challenges the marginalized population already faces in getting healthcare.

In , President Donald Trump’s signature One Big Beautiful Bill Act will require most adults to work, go to school or enter a training program, or volunteer for at least 80 hours a month. Native Americans and Alaska Natives are exempt from the mandates, which take effect in January.

Of the nearly in the U.S., around 47% live in Hawai‘i. Within the contiguous United States, California, Washington, Nevada, Texas, and Oregon have the largest populations of Native Hawaiians.

Hawaiʻi’s Medicaid administrator, Meredith Nichols, said the Centers for Medicare & Medicaid Services didn’t respond to the state’s request to include an exemption for Native Hawaiians but said she believes the decision came down to the population’s lack of recognition as a tribal nation. Hawai‘i has about , 15% of whom identify as Native Hawaiian, Nichols said.

“We know that when we’ve asked similar questions in the past, it all comes down to federal recognition,” she said.

Hawaiʻi health administrators met with Trump administration officials in June. Some unsuccessfully pushed to add an exemption to the new law, which would need congressional approval.

White House spokesperson Kush Desai did not respond to requests for comment. In a statement, CMS spokesperson Timothy Foster confirmed that the agency met with 16 health centers in Hawai‘i about Medicaid changes but didn’t respond to other questions.

Barriers to Care

Native Hawaiians face many of the same as , including higher risks during pregnancy, higher infant mortality rates, and higher rates of being uninsured than the white population. And in Hawaiʻi, Native Hawaiians have the among ethnic groups after other Pacific Islanders.

Kapono Chong-Hanssen is the medical director of Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i that also serves the privately owned island of Ni‘ihau, whose 170 full-time residents are predominantly Native Hawaiian. Chong-Hanssen said he anticipates many of his patients will no longer receive the care they need once the new work requirements take effect.

Chong-Hanssen says new Medicaid work requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients. (Ashley Mizuo/51��Ƶ Health News)

Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i, operates out of multiple locations, including its clinic in Waimea on the west side of the island. Kaua‘i and Ni‘ihau were impacted by Hurricane Lowell this week, forcing Ho‘ōla Lāhui to temporarily close facilities. (Ashley Mizuo/51��Ƶ Health News)

The new requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients, who, in response to , are more likely to disengage and “throw the whole system out” when they run into barriers, Chong-Hanssen said. “It just flies in the face of everything that we’re trying to do.”

Beyond medical services, Medicaid covers transportation expenses when patients travel between islands for care. A round-trip ticket between Kaua‘i and O‘ahu, for example, can cost hundreds of dollars.

Congress placed over 200,000 acres of land in a trust for Hawaiian homesteads in 1921 to bring Hawaiians back to their native lands after the U.S. backed the 1893 . Nearly 30,000 Native Hawaiians , while, as of the , more than 34,000 people lived on Hawaiian homelands. The homesteads are often far from Honolulu, where most health services are located.

Waianae Coast Comprehensive Health Center primarily serves the west side of O‘ahu, which is home to the island’s largest Native Hawaiian population, near four Hawaiian homesteads.

Waianae Coast Comprehensive Health Center CEO Rich Bettini (right) and Vice President Leinaala Kanana demonstrate how to use pods throughout the campus that connect patients via phone to an employee who will help them submit needed information and applications to the state’s Medicaid program. (Ashley Mizuo/51��Ƶ Health News)

The center’s vice president, Leinaala Kanana, said that many of its patients are geographically isolated and that few jobs are available in the area. Patients also have trouble securing transportation to get to work or finding affordable childcare.

The center’s CEO, Rich Bettini, said Hawai‘i’s high living costs and depressed wages have pushed many people into homelessness, creating another barrier to complying with the new Medicaid requirements. Native Hawaiian and Pacific Islanders make up about 60% of O‘ahu’s . The center estimated about 2,800 of its patients may be affected by the requirements, half of whom are Native Hawaiian.

The annual “cost of living for a family of four in Hawaiʻi on O‘ahu is $100,000-plus. The average income of our patients is under $30,000 a year,” he said. “That is an enormous gap.”

‘Bigger Fish To Fry’

Native Hawaiians face obstacles to being granted the same exemptions as other Indigenous groups. While several federal laws refer to Native Hawaiians as an Indigenous group, they are not among the 575 tribes recognized by the federal government. Federal recognition can be granted either by Congress or administratively through a process established by the . Native Hawaiians about whether they would even want , with some fearing it would jeopardize their ability to restore Hawaiian independence.

Laws governing Medicaid also don’t acknowledge Native Hawaiians, aside from the 2021 , signed by former President Joe Biden. In the covid-era law, the federal government fully reimbursed Native Hawaiian health centers for Medicaid services for two years. However, all the qualifying Native Hawaiian health centers were in Hawai‘i, where in the country now live.

The federal government fully reimburses Indian Health Service and tribal facilities for healthcare services provided to Native Americans and Alaska Natives. Native Hawaiian instead receive the same reimbursement rate as in the rest of Hawaiʻi.

Waianae Coast Comprehensive Health Center CEO Rich Bettini said Hawai‘i’s high cost of living and depressed wages have pushed many people into homelessness, creating another barrier for Native Hawaiians to comply with new Medicaid requirements. (Ashley Mizuo/51��Ƶ Health News)

Keolamaikalani Dean, the CEO of the King Lunalilo Trust, which provides services for Native Hawaiian elders, pointed to the new Medicaid requirements as just one of many federal policies limiting Native Hawaiians’ healthcare.

“It’s horrible as a policy, but there are bigger fish to fry,” he said.

Dean said he’d rather advocate for giving Native Hawaiian healthcare systems the same full Medicaid reimbursement that the Indian Health Service receives. The change would have greater impact on patients seeking care, he said.

Native Hawaiian advocates said they have been overextended as they work to guard against an onslaught of threats to revoke other federal funding by the Trump administration.

In Trump’s proposed 2027 budget, cuts to Native Hawaiian programs cited the group’s lack of federal recognition as a “tribal nation.” The proposed cuts coincide with challenging education programs and that provides homestead land to some Native Hawaiians at almost no cost, alleging the programs racially discriminate against other groups.

, a nonprofit that oversees the Native Hawaiian healthcare systems in the state, declined to comment for this article. The group is involved in a lawsuit filed by a conservative group aiming to stop a university scholarship for Native Hawaiians pursuing healthcare careers.

U.S. Rep. Jill Tokuda (D-Hawaiʻi) viewed the exclusion of Native Hawaiians from the exemptions to Medicaid work requirements as an attempt to further erode Native Hawaiians’ Indigenous status, pointing to recent challenges by the Trump administration and lawsuits.

“These are not one-offs,” Tokuda said. “This is a targeted, coordinated attack to undercut the Indigenous status of Native Hawaiians.”

This article first appeared on 51��Ƶ Health News and is republished here under a .

Rural Americans Wait After Judge Delivers Mixed Ruling on Digital Equity Dollars

Sarah Jane Tribble — Thu, 10 Sep 2026 09:00:00 +0000

A federal judge in July gave digital equity advocates a partial victory against President Donald Trump, stopping his attempt to unilaterally kill a multibillion-dollar grant program Congress created.

But U.S. District Judge John D. Bates, in a , also agreed with the administration that it was unconstitutional for the government to use race or ethnicity as the basis to award money under a program created to expand internet skills and access.

“It was definitely disappointing,” said Angela Siefer, executive director of the National Digital Inclusion Alliance, a nonprofit that filed suit last year after not receiving a award meant to bolster digital and internet skills nationwide. “With this administration it’s really worrisome.”

Congress passed the $2.75 billion Digital Equity Act in 2021 as the skill development component of a multilayered “” initiative under President Joe Biden’s signature infrastructure law, which included a bigger pot of money for expanding internet infrastructure.

A few months into his second term, Trump directly attacked the Digital Equity Act on social media, pledging “” and calling the program “illegal.” The language echoed two Trump executive orders characterizing diversity, equity, and inclusion programs .

The National Telecommunications and Information Administration, which oversees implementation of the law, responded by Digital Equity Act grant programs, leaving states and organizations like the National Digital Inclusion Alliance in limbo.

Joe Burgei (left) helps Shaunta Harris Jr. with an online digital literacy course at a soup kitchen and homeless shelter in Defiance, Ohio. Burgei is a grant-funded digital navigator for the Northwestern Ohio Community Action Commission, which operates the shelter. (Northwestern Ohio Community Action Commission)

In response to Bates’ decision, federal attorneys said the government would reinstate the NDIA-related competitive grant program without racial classification. The government aims to release a new grant application in December, according to a filed in the case.

The NDIA now must reapply for the grant award, which was slated to be disbursed among more than a dozen organizations and tribes, including the Cherokee Nation in Oklahoma, El Centro Hispano in Arkansas, Portland Community College in Oregon, and Community Service Programs of West Alabama. The grants are meant to go toward digital navigator programs, in which community workers teach technology and internet skills, according to the NDIA.

In western Ohio, Jamie Huber said her organization was a subrecipient of the NDIA grant funds. Huber, director of community services at the Northwestern Ohio Community Action Commission, said that without the funding, she is left searching for money to continue navigator programs such as one she runs for people who are unemployed, homeless, or both.

“How do you find a home? Well, you got to look online. And how do you find a job? You have to look online,” Huber said.

Huber’s digital navigators also teach internet skills at 10 senior centers in rural counties stretching along the corner of Ohio bordering Michigan and Indiana. They help active older adults learn how to go online to pay bills and get healthcare, so they “continue having agency over their own life,” Huber said.

Rural residents live sicker and die younger on average than people in the rest of the country when they live in counties lacking high-speed internet access and healthcare, an analysis by 51��Ƶ Health News found.

At Computer Reach in western Pennsylvania, Executive Director Dave Sevick said his organization has cut staff and programs. He said the nonprofit, which started in 2001, has refurbished more than 24,000 computers, giving them away to families it finds through schools and churches.

“We’re aware that affordability is the biggest issue around, and this doesn’t make it any better for folks,” Sevick said. “We’re helping a little bit by getting a free computer out to people.”

The Digital Equity Act the money should benefit, including low-income households, older people, some incarcerated people, rural Americans, veterans, and members of racial or ethnic minority groups.

According to by the Pew Research Center, people in rural communities were less likely to have internet subscriptions compared with their urban and suburban counterparts.

The Pew Research polling that home broadband use among Black and Hispanic adults lagged that of white and Asian adults. While 81% of white adults surveyed said they subscribed to broadband at home, only 71% of Black adults and 68% of Hispanic adults said the same.

Megan Hahn teaches class attendees how to use an online health portal at the Swanton Senior Center in Swanton, Ohio. Hahn is a digital navigator with the Northwestern Ohio Community Action Commission. The group’s work is supported by local, state, and federal grants. (Northwestern Ohio Community Action Commission)

In court, lead federal attorney Patrick Butler argued that Congress failed to prove a compelling government interest when including the racial or ethnic criteria. Congress did not “identify anything close to” a specific instance of discrimination in the broadband industry, Butler said, .

Butler then surprised the court, if the racial or ethnic status could be severed from the law, “we would obviously apply the grant program without considering race.”

In his opinion severing the race factor, Bates that “the President lacks the power to cancel laws passed by Congress based on his bald disagreement with Congress’s policy determinations.”

Sen. Patty Murray (D-Wash.), a primary , said she will be “watching very carefully to ensure this administration does what Congress intended.”

“It is indisputable that these challenges are particularly pronounced in low income, rural, and Tribal communities — and there’s a reason Democrats and Republicans across the country support this program so strongly,” Murray said in a statement to 51��Ƶ Health News.

Sen. Ted Cruz (R-Texas) Biden’s infrastructure bill in 2021 and to the National Telecommunications and Information Administration in late 2024 asking the agency to pause the $1.25 billion competitive grants program, arguing the use of racial classifications “does not serve a compelling governmental interest.” Cruz did not respond to requests for comment.

Arielle Roth, administrator of the agency, previously worked as the telecommunications policy director for the Senate Commerce, Science, and Transportation Committee’s majority staff under Cruz. She was to lead the agency.

Burgei gives Paul Helbling (right) tips for using his smartphone during a session at the Henry County Senior Center in Napoleon, Ohio. Burgei’s job as a digital navigator has been supported by local, state, and federal grants. (Northwestern Ohio Community Action Commission)

In June, during a House committee hearing, Roth had tense exchanges with Democrats who took issue with changes to the Biden-era infrastructure law’s internet deployment program, which now allows more satellite services rather than prioritizing fiber-optic cable lines.

Lawmakers also asked about the Digital Equity Act’s grant programs.

“Communities across the country deserve a clear answer and a path forward,” Rep. Nanette Barragán (D-Calif.) said during the hearing. While the National Digital Inclusion Alliance’s lawsuit does not include the state grants, Barragán asked how those grants would be rolled out, considering the federal judge’s decision on race.

California was awarded a $70 million state capacity grant. Early this year, the Justice Department to Congress asserting that the state grant and the competitive grant program both are illegally based on race, citing the Supreme Court’s decision invalidating affirmative action in higher education admissions. Roth declined to answer Barragán’s question, noting there is active litigation.

Barragán said she was “extremely” frustrated by “some of the responses or nonresponses.”

Stephen Yusko, a spokesperson with the National Telecommunications and Information Administration, declined to comment or respond to questions for this article.

The government and the National Digital Inclusion Alliance agreed to pause court proceedings to give the agency time to reinstate the competitive grant program. The NDIA has also proposed that the agency provide status reports every 30 days during the court pause “to ensure prompt attention to reinstatement,” according to the most recent .

“We need to make sure it’s all moving forward,” Siefer said.

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Nonprofits Are Helping Musicians Pay for Insurance in Austin, Texas, and Beyond

Olivia Aldridge, KUT — Wed, 09 Sep 2026 09:00:00 +0000

AUSTIN, Texas — Musician jokes that when he lost his corporate job in 2015, it was like being pushed off a cliff. For years, he said, he’d been playing both sides of the Austin coin: tech worker by day, funk keyboardist by night.

“Maybe this is my sign to try the full-time music thing,” Morgan recalled thinking. “Step one in that was: Get health insurance again.”

Austin bills itself as “the Live Music Capital of the World,” but it for the artists who provide the city with its cultural cachet — and help drive its tourism revenue.

Morgan has supported himself by patching together gigs with a number of bands. To help pay for health insurance, he turned to a local nonprofit, the , or HAAM.

“That’s part of being able to make this whole thing work,” Morgan said.

HAAM subsidizes the monthly insurance premiums of local musicians who purchase plans through the Affordable Care Act marketplace. To fund the roughly $4 million program, it works with Central Health, a public agency that provides healthcare resources for low-income residents of Austin and surrounding Travis County. Many of the performing artists pay $0 toward monthly premiums.

After more than a decade, including through the coronavirus pandemic, the assistance program has become an established and reliable financial support for Austin’s musician community.

This year, after Congress failed to extend pandemic-era subsidies, premiums skyrocketed for many ACA plans. A recent report found that 5 million people nationwide had . HAAM helped blunt the impact for its members. It has emerged as a potential model for other cities hoping to make healthcare more affordable for key populations and industries.

Morgan plays keyboard with pop singer Ruthie Craft at the Saxon Pub in Austin on July 27. (Ysa Mendoza/KUT News)

A Growing Idea

Texas had the among states, with 19% of people age 64 and under uninsured, as of 2024.

Even before the launch of the ACA marketplace in 2014, HAAM had spent a decade connecting musicians with free and low-cost care at clinics and hospitals in and around Austin. But roughly 85% of HAAM members remained uninsured, leaving them exposed when traveling to gigs in other cities and states.

“When the Affordable Care Act came out, and we knew it was here to stay, it really made sense for us to start getting our musicians fully insured,” said , HAAM’s chief strategy officer.

Similar nonprofits in other U.S. cities with strong live music cultures, such as , , and , help musicians get medical care. With the advent of the ACA, some of these organizations began helping musicians navigate the sometimes complex enrollment process for the online marketplaces, though they stopped short of pitching in on premiums.

But the team at HAAM recognized that without direct support to help pay premiums, many of their members would still struggle to retain coverage.

“When you think about the average HAAM member making about $30,000 a year, there’s no way that they would be able to spend a third of their income on healthcare,” Blair said.

The organization’s membership has grown by 77% to more than 3,300 people since HAAM began offering premium assistance, and more than 90% of members are now insured.

To help subsidize costs for members, HAAM partnered with Central Health, which is Travis County’s public hospital district — a type of health agency in Texas charged with using tax dollars to fund safety net healthcare for low-income residents. Central Health also operates the nonprofit , which offers marketplace insurance to Travis County residents.

To qualify, HAAM members must enroll in one of Sendero’s silver-level, or benchmark, plans. If their income is between one and two times the federal poverty level, Central Health pays the balance of their monthly premium after federal tax credits are applied. For members who fall above that income range, HAAM offers a more limited subsidy, covering 50% of their premium balances.

Each year, the Health Alliance for Austin Musicians hosts the HAAM Day Music Festival, its annual event to raise money to help local musicians afford insurance premiums and other healthcare services. Bands play in common spaces across the city, from grocery stores to the Texas Capitol steps. (Shunya Carroll/KUT News)

In 2017, HAAM helped set up a similar program in Denton, a college town north of Dallas that has served as a , from Meat Loaf to Norah Jones.

The Denton Music and Arts Collaborative works differently: It connects members with an independent insurance agent who helps them find the best health plan for their needs. The nonprofit then offers members a monthly subsidy of $100.

The subsidies are a way of keeping Denton’s culture of jazz and “weird art rock” alive, said the collaborative’s president, Jennifer Kapinos.

“More and more people were maybe graduating college and leaving and going to find better opportunities in other places,” Kapinos said. “People who had lived here a long time suddenly were finding it harder and harder to afford to be here.”

In Austin, other sectors have been watching HAAM’s work. In 2025, , a nonprofit that advocates for restaurant workers, launched a small pilot program with Central Health to help local food workers enroll in Sendero plans and cover their premiums.

Kit Abney Spelce, vice president of operations for Central Health, said partnering with an advocacy group focused on a particular workforce is key because simply announcing “free insurance for you” doesn’t mean people will sign up.

“We are very much dependent on our partner entity to go out and connect with the community, to have that relationship and that trust,” she said.

Navigating Federal Headwinds

Though premium payments often increase year over year, the 2026 plan year was particularly expensive, .

Citing medical and pharmacy costs, Sendero by an average of 16% for its enrollees. At the same time, Congress allowed the pandemic-era enhanced premium tax credits to expire, reducing the federal subsidies that many marketplace customers relied on.

“Our premiums for our members went up 60% from one year to the next,” Blair said.

HAAM stepped up its fundraising into 2026, but it wasn’t enough to cover everyone who requested assistance. They had to turn away hundreds of qualified people. Still, they were able to buffer existing members, said Spelce with Central Health.

“We’re going to make sure their monthly premium is paid every month,” she said.

Austin-based Latin-folk singer Gina Chavez plays on the steps of the Texas Capitol in 2025 for the HAAM Day Music Festival, an annual fundraiser for the Health Alliance for Austin Musicians. (Shunya Carroll/KUT News)

A Viable, if Limited, Model

Beyond the eligible musicians they turned away in 2026, another population remains out of HAAM’s coverage reach for premium assistance: Austin’s poorest residents.

Under the ACA, the marketplace plans that HAAM helps subsidize are for low- and middle-income earners, but the people with the very lowest incomes — below 100% of the federal poverty level, set at — are supposed to be covered by expanded Medicaid.

But Texas is one of 10 states that chose not to expand Medicaid after the ACA became law, so many of the poorest Texans remain uncovered.

With no federal subsidies available for that group, HAAM and Central Health have tried to develop separate solutions for this subpopulation. Central Health has its , an alternative to health insurance that gives low-income, uninsured people access to a network of local care providers. HAAM has also with primary care providers to serve its uninsured members — but Blair acknowledges it’s not an equivalent benefit to what Medicaid expansion would offer.

“It’s not a very sustainable solution, especially when there’s a really good alternative,” Blair said.

This article is from a partnership that includes , , and 51��Ƶ Health News.

This article first appeared on 51��Ƶ Health News and is republished here under a .

Hospital Prepayment Requirements Add New Wrinkles to Patients’ Financial Responsibility

Julie Appleby — Wed, 12 Aug 2026 09:00:00 +0000

Thomas Zordani flew from his home in Denver to Phoenix for a consultation with a Mayo Clinic neurosurgeon, hoping to find out what could be done to treat his debilitating headaches after worrisome brain scan findings.

When making the appointment, Zordani said, he’d been told the clinic was in his insurer’s network. Upon arrival, Zordani was summoned to the clinic’s financial office and told he had to make a $5,000 preservice deposit, because Mayo had since determined it did not accept his insurance. He was automatically designated “self-pay,” even though his plan had out-of-network benefits.

Not having that kind of cash on hand — and angry on principle — he refused. His appointment was canceled.

“I was so livid,” Zordani said, recalling that day in early April 2024. He later learned that Mayo had sent a message to him in his insurance carrier’s patient portal shortly before his visit with an estimate of the cost: $565, not the larger amount it later demanded.

Traditionally, patients usually receive bills for their share only after getting treatment. But what Zordani faced is becoming increasingly common — hospitals or other medical providers seeking prepayments.

“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in an emailed statement. “When prospective patients don’t have clarity that Mayo Clinic is not in-network with their health plan, unexpected pre-service deposit requests may result.”

says it requires prepayments in a variety of cases, including for “noncontracted” — also known as out-of-network — insurance plans.

The trend of hospitals asking for money up front represents a double whammy for patients.

Medical providers are collecting larger shares of what patients might owe at a time when rising deductibles mean patients are owing more for care. The preservice charge could be all or part of a remaining deductible, for example, or a sizable percentage of what the visit or treatment might cost. Those deductibles go up when hospital prices, drug costs, and labor expenses increase, as insurers try to slow premium growth by shifting more costs to patients.

People are “basically being asked to self-insure,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an organization for finance professionals.

As that happens, hospitals figure more patients will have trouble meeting those deductibles, so they want to get as much up front as possible.

“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” said Chip Kahn, a visiting senior fellow at 51��Ƶ and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals. “That will make it harder on the provider, the clinician, and harder on the patients.”

The deposits can’t be viewed in isolation, Gundling said: It’s a bigger issue than just hospitals asking for money up front. The challenge, he said, is: “How do we maintain access to care when more patients can’t absorb the level of out-of-pocket costs?”

Already, consumers are increasingly worried about paying for healthcare. A recent found that lower out-of-pocket costs ranked as the top change insured adults would like to see from their coverage plans. 51��Ƶ is a health information nonprofit that includes 51��Ƶ Health News.

The average deductible in family coverage offered by employers is $3,762 per person, , while the average deductible in Affordable Care Act plans to a similar amount, $3,786.

A Consumer Concern

, a health insurance consumer assistance program in New York state, hears from people who are concerned about prepayments, said Diane Spicer, a supervising attorney.

“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said, “and also sometimes for care that is not covered.”

Just how many hospitals collect what are often called point-of-service payments is not known, according to Kodiak Solutions, a technology company that provides services to health systems to help manage their revenue.

“But it is becoming more and more the center of many of our conversations with health systems,” said , a vice president leading Kodiak’s revenue cycle intelligence team.

In addition to Mayo, Baltimore-based says that “it is our policy to collect all amounts owed before services are rendered” for non-emergency care. University of Texas-affiliated in Houston, one of the nation’s premier cancer treatment centers, says patients who pay for their own care “will be asked to pay an initial deposit determined by the care center, based on the type of cancer.”

On average, hospitals collect about a quarter of what they expect the patient will owe, Szaflarski said, based on what they estimate the insurer will pay — a percentage that has grown in recent years.

For example, if a person is coming in for imaging and the insurer will reimburse $1,000 for that scan, the hospital will seek $250 from the patient up front, he said. “That used to be closer to $150.”

It also varies by hospital, and sometimes by state.

“The state of Indiana has some of the lowest cash collections in the country. They are Midwest nice,” Szaflarski said. He added that California and Texas are among those that collect more.

Even as hospitals increasingly collect more upfront payments, however, their uncollected debt is also rising, according to data Kodiak collected from more than 2,300 hospitals nationwide.

said that’s because of a “fundamental shift” in coverage as plans “increasingly feature higher deductibles, greater coinsurance, and more complex cost-sharing structures: all elements that increase the nominal patient responsibility without improving—and often reducing—the probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins — and things could soon tighten further as cuts to ACA and Medicaid funding lead to more people being uninsured.

As a result, hospitals “have to be concerned” about every cost-sharing dollar, Kahn said.

After Zordani returned to Denver, he said, it took a while to find another specialist. He eventually had a procedure in late June 2024, at a Denver hospital not affiliated with Mayo, to fix a .

The following fall, he filed a in Arizona civil court. He was awarded $47,500 in economic damages and attorney fees after an arbitrator in September 2025 determined Mayo violated a state consumer fraud law because it failed to reach him to say that his plan was not in-network before he traveled. Mayo’s statement to 51��Ƶ Health News did not include any reference to the settlement.

“Had they notified me in timely fashion as required, I would not have flown there,” Zordani said. He’s still angry that the clinic didn’t ask his permission before designating his care as self-pay, which meant he wasn’t going to use his insurance, and he’s still unclear on how they calculated the $5,000 preservice amount.

When Do Consumers Have to Make Preservice Payments?

There is one clear rule: In emergency situations, hospitals that accept federal Medicare financing cannot, , demand upfront payment before stabilizing a patient who arrives at an ER, said , a senior fellow and health policy researcher at the Brookings Institution.

Other consumer protections are less clear.

Patients who get in-network care may have some recourse in their contracts with their insurers, so they should check the fine print, experts told 51��Ƶ Health News.

“In out-of-network settings, I’m not aware of any barriers that would prevent a provider from doing this,” Fiedler said of preservice deposits.

How those amounts are calculated also appears widely up to the provider and can be opaque.

“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” said , senior director of healthcare campaigns at PIRG, a national federation of independent consumer advocacy groups.

Yet, she added, the patient might be scheduling three months in advance, so the provider wouldn’t know how much was left on the deductible. She recommends consumers ask for an itemized bill and call their insurer to find out whether it has rules regarding the charges.

Also unclear are how and when patients get their money back if they overpay.

Overpayments can happen if patients don’t require the services originally estimated or when insurers pay other bills first, such as the anesthesiology cost or a surgeon’s fees. If those payments are counted toward a patient’s deductible, yet the patient had already made a prepayment to the hospital for the expected deductible, to the hospital.

How soon they get their money back can vary and can depend on state laws, though a small number of states directly address the issue. As of this year, medical providers to reimburse patients within 30 days of a determination of an overpayment. Some states, including Maryland, prohibit certain hospitals from requiring prepayment simply to avoid offering financial assistance.

After alleging that some patients had to wait more than a year to get reimbursed, Arizona Attorney General Kris Mayes recently under state consumer protection laws against SimonMed Imaging, which has 170 locations in 10 states.

, SimonMed agreed to issue refunds within an average of 60 days.

This article first appeared on 51��Ƶ Health News and is republished here under a .