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 鈥� 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视频 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视频 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 鈥� 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.”

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Years ago, she taught English as a second language overseas and loved it.

“It’s so exciting to me to watch someone learn a new word or have that spark of understanding,” she said.

Zulick knew she could earn enough money as a substitute teacher to make going back to school financially viable 鈥� except for the cost of health insurance. She didn’t want to risk being unable to see her doctor for her allergies, or for preventative care.

The offered through Montana State University was too expensive, Zulick said, almost as much as her tuition. But then she found a solution that allowed her to make the leap: Medicaid. She wouldn’t have to pay any monthly premiums.

It worked well for a few months, as Zulick taught by day and took online classes at night.

But in June, the state sent a letter that she said left her “completely confused.” She knew Montana was rolling out a system for work requirements over the summer, but she thought she wouldn’t have to prove she met the requirements until next year, when her Medicaid enrollment came up for renewal.

Yet the letter from the Montana Department of Public Health and Human Services outlining the new requirements gave conflicting information on when Zulick would have to prove she was meeting them. First it said at her next renewal, which would be sometime next spring. Lower down it told her she would have to submit paperwork to prove compliance much earlier 鈥� “within 30 days” of the date on the letter, June 26. She wondered: Was it a boilerplate mass-mailing letter she could ignore, or was her insurance on the line?

the new work requirements by Jan. 1, but three states 鈥� Montana, , and 鈥� have already gotten started. Medicaid advocates worry that the expedited timeline in those states will lead to thousands of people losing coverage because they’re confused about the new rules, even if they are eligible for the program 鈥� and that Montana may offer a troubling preview of what will happen nationwide next year.

State health department officials maintain they are well prepared and told state lawmakers they plan to process roughly 5,000 enrollees monthly.

Growing Confusion, Dwindling Help

Rep. of the Montana House has gotten dozens of calls from confused constituents, specifically about letters like the one Zulick received.

“The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on,” said the Democratic legislator, who asked health department leaders about those letters at a hearing in early September. Letters being sent to enrollees have been updated to be clearer, state health officials told lawmakers at the hearing.

In Montana, nearly are subject to the new rules. Medicaid costs are split between the federal and state governments, and states are responsible for administering the program, which provides health insurance for people with low incomes or disabilities.

Under the new work requirements, enrollees must document that they’re working, volunteering, or studying 80 hours per month 鈥� or they must show that they qualify for one of a range of exemptions, such as being “medically frail” or being the primary caretaker for a family member.

Montana began with a soft launch of the work requirements in July and gave enrollees until Oct. 1 to comply.

Critics contend that isn’t enough time, because the state hasn’t finished setting up new computer systems or hiring the staff it said it would need. Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing, adding that numbers had fluctuated amid staff turnover.

State health officials have said they’ll eventually be able to automatically verify that students are enrolled in public universities. However, that computer system isn’t expected to be up and running until next year, leaving students like Zulick to track down and submit the correct paperwork to prove their college enrollment.

However, there are fewer outside resources to help residents with these bureaucratic tasks.

For example, , a nonprofit that helps Montanans fill out such paperwork, lost federal funding last year, going from a staff of 18 to two part-time employees working a phone line.

The state does operate a helpline, but that Montanans stay on hold much longer than the national average and that many callers hang up before they connect with a state employee.

“We were worried about chaos that could be generated by the state rushing,” said , CEO of the Montana Healthcare Foundation, a nonprofit aimed at improving health in the state. “Given how little information the state has provided about what they are doing, I’m much more worried about chaos.”

Wernham pointed to a similar upheaval in 2023, when states undertook a massive process to redetermine the eligibility of all Medicaid enrollees, after regular eligibility checks were paused during the pandemic.

Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork 鈥� roughly 87,000, according to state data from two years ago.

Even vulnerable Montanans who didn’t need to file paperwork, because their coverage should have been automatically renewed, were dropped from the Medicaid rolls, including people who were homeless.

Long-Sought Requirements in State

The Montana Legislature passed a measure expressing its desire to add work requirements to Medicaid, but the state didn’t have permission from the federal government to move forward until now.

Having work requirements creates accountability for people who rely on the social safety net, said Montana Senate President , a Republican.

“In an economy like this, if you’re an able-bodied adult that’s able to work, you really do need to step up,” he said.

Asked about confusion among enrollees about the rules, Regier responded that the Oct. 1 deadline offered more than enough time to work out the kinks in the new system.

In the end, Zulick learned she didn’t need to worry about that deadline, because she got married in July and no longer qualified for Medicaid, although she didn’t know that would be the case when she got the June letter.

But others remain scared about losing coverage, including Heather Reel, who attended a rally at the state capitol in July to push back against Montana’s early rollout.

Reel relies on Medicaid for its mental health coverage. Without it, she said, she would struggle to care for her teenage son, who has autism and is nonverbal. Between her shifts at a fast food restaurant and caring for her son, she’s scared she’ll be too busy to figure out how to report her work hours.

Montana’s Rollout a Potential Preview

The handful of states that are implementing the Medicaid work requirements early are building the plane as they’re taking off, said , who provides Medicaid analysis for The Commonwealth Fund, a nonprofit focused on making healthcare more equitable.

“Montana is going to be an example for what we might see nationally as things roll out,” she said.

Although most other states are sticking to the Jan. 1 deadline to build and test their Medicaid systems, they still might not have all the components in place, she said.

If states can’t automatically renew or deny coverage based on the new rules, state workers will have to do so manually, on a case-by-case basis. That could create backlogs and more disruption, leading more people to lose coverage, Coleman said.

Jon Ebelt, a spokesperson for the state’s health department, said in a statement that Montana’s Medicaid office is ready for the change on Oct. 1.

“We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely,” Ebelt said.

Democratic state lawmakers have repeatedly asked state health officials to extend the Oct. 1 deadline for enrollees to comply with the new rules, but they’ve said they have no plans to do so.

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

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Abortion access is important to McCoomb. She wants her daughter to grow up in a state where the option is available if needed, and the sign was a keepsake from the day Missourians voted to reverse the state’s near-total ban. McCoomb also couldn’t shake the feeling that she’d need to display the sign in her yard again soon.

“I have little faith in our Missouri government,” McCoomb said, sitting on her front porch.

Sure enough, just two years later, the state’s Republican-dominated legislature is asking Missouri voters to overturn the abortion protections they recently supported. The conflicting measures even have the same title: Amendment 3. But while a “yes” vote in 2024 supported adding protections to the state constitution, a “no” vote in 2026 would keep them. McCoomb covered the “YES” on her yard sign with a “NO” made from black duct tape before placing the sign back in her yard.

Voters will weigh in on abortion in Missouri, and three other states, in the November general election. Missouri is also one of two states voting on it for the second time since 2024. Nevada will vote again, too.

The spate of referendums comes after the U.S. Supreme Court overturned federal abortion protections with its 2022 decision in Dobbs v. Jackson Women’s Health Organization, leaving each state to make its own abortion policy. The result has been a patchwork of state rules of bans or limitations, and even a series of “shield laws” in states where abortion remains legal that aim to protect providers from prosecution in states where it’s not.

“I just think there’s a constitutional crisis that’s coming,” said , vice president of media and policy for the anti-abortion organization Students for Life Action.

“Can you have 50 state standards on whether or not a human being is a human being? Can you have 50 state standards on whether human beings have legal protection?” Hamrick said.

Advocacy Groups Work To Clarify Ballot Measures

That patchwork of abortion protections is the reason Nevadans for Reproductive Freedom introduced the 2024 ballot measure to enshrine the state’s law allowing abortions up to 24 weeks after conception into the state constitution, said , president of the coalition.

The measure received strong support two years ago, with 64% of voters in favor. Nevada law requires two majority votes to enshrine constitutional amendments, so voters will need to support the expanded protection again in November for it to be enacted.

The Nevada ballot measure wouldn’t change the state’s existing law allowing abortions up to 24 weeks after conception. But the proposal would make it more difficult to overturn abortion access, requiring voter approval of any new ban in two elections.

Lopez said Nevadans for Reproductive Freedom has been campaigning to ensure voters are still mobilized.

“Folks care about it,” she said. “They’re seeing what’s happening at the national level, and they want to make sure that whatever’s happening in our neighboring states, like Idaho and Utah, doesn’t happen here in Nevada.”

Idaho, where a ballot measure establishing abortion rights to go before voters in November, has one of the strictest abortion bans in the country. Voters will decide whether state statute should allow abortion through fetal viability, the point when a fetus can survive after birth, which is generally considered to be around 24 weeks.

In Utah, abortion is allowed up to 18 weeks while legal challenges to the state’s ban continue.

In Virginia, where abortion is already allowed through two trimesters of pregnancy, until 28 weeks, voters will decide whether to amend their state constitution to codify those rights.

Missouri is the only state voting this year on removing abortion protections already on the books. The the 2024 amendment that guaranteed abortion access through fetal viability in the state and replace it with a ban on abortions with exceptions for medical emergencies, fetal anomalies, and pregnancies resulting from rape or incest. Abortions for rape and incest would have to occur before 12 weeks of pregnancy.

Missouri was the first state to ban abortion after the Dobbs decision in 2022. At that time, abortions had already mostly ceased in the state after three decades of state regulations targeting the practice, including a , minimum dimensions for procedure rooms and hallways in clinics that provide abortions, and a mandate that the clinicians have at nearby hospitals, among others. Only were performed in Missouri in 2021, down from , state records show.

Even though Missouri voters backed the abortion amendment in 2024, it took nearly two years for medication abortions to resume in the state.

A Second Vote Causes Confusion

, CEO of St. Louis-based Planned Parenthood Great Rivers, said the whiplash of a second statewide vote on abortion mirrors the confusion that patients have experienced about whether abortion is available in the state.

“Chaos is kind of the point here,” Riphagen-Dunn said, “and it is absolutely a tactic that gets in the way of being able to provide.”

The confusion has presented problems for abortion opponents in the state as well.

“I think it’s unfortunate,” said Reagan Barklage, who is a vice president of Students for Life of America and the treasurer of the Missouri Students for Life Ballot Committee. “People need to be very clear on what they’re voting for.”

Barklage said she has had to correct anti-abortion voters while out canvassing to remind them that they are voting “yes” on Amendment 3 this year even though they voted “no” on Amendment 3 last time.

“It is crazy that it ended up being even the same number. I do not think that was intentional, but we’ve got to deal with what we’ve got,” Barklage said, adding, “I hope the pro-choicers kept their yard signs from last time.”

In Maplewood, Missouri, McCoomb said she was happy that her repurposed sign supporting abortion access had been noticed.

“I hope lots of people see and remember to revote,” McCoomb said.

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

When the Durhams began their practice at the end of 2023 鈥� he as a primary care physician and she as a pharmacist who handles the billing 鈥� the couple bought coverage for themselves and their two kids on the Affordable Care Act marketplace. But they said their monthly premiums for a similar health plan for this year rose several hundred dollars to nearly $1,600.

They decided to pay out-of-pocket for their medical expenses instead, leaning on $50,000 they had set aside in a health savings account over several years.

“It’s nerve-racking,” said Joshua Durham, 47. “It just takes, you know, one little accident, and then you got a big fat bill.”

The healthcare industry traditionally has more of its workforce on medical insurance than many other fields. Nationwide, 7% of all healthcare workers were uninsured in 2024, compared with 11% of all adults under 65, according to a 51视频 analysis of the most recent American Community Survey data. And doctors were especially unlikely to forgo health insurance, with just 2% uninsured.

But even healthcare workers are feeling the pinch as each year, with employers expecting that costs will jump an for 2027.

The Republican-led Congress also opted last year Affordable Care Act marketplace credits enacted during the covid pandemic. While subsidies remain in place for people with low incomes, the pandemic-era credits helped , especially those working in small businesses such as independent medical practices. Nearly half of marketplace enrollees worked for small businesses or were self-employed in 2024; some of the most common occupations included chiropractic care and dentistry.

Jack Dillon, executive director of the , which represents 4,000 physician-led practices, said premium increases have become untenable for small businesses, whether employers seek coverage through the marketplace or directly from insurers.

“The cost has become so astronomical,” Dillon said. “You’re looking at it and saying, 鈥榃hat’s the value?’”

As health insurance continues to become less affordable, Dillon said, more healthcare employers may seek alternatives to their standard coverage, such as providing higher hourly wages or providing only minimal plans.

The number of people without insurance in the U.S. is expected to increase by roughly over 10 years because of the expiration of the expanded ACA subsidies and resulting from President Donald Trump’s signature One Big Beautiful Bill Act, according to the Congressional Budget Office.

Healthier people are the most likely to opt out of insurance. That leaves insurance covering a smaller pool of people who tend to be sicker and need more expensive care. So insurers raise prices to cover the remaining enrollees, which fuels even higher premium costs.

鈥楬ealthcare Is a Business’

Samantha LeGault, a nurse practitioner at a health clinic in Boise, said her employer-offered plan’s premium payment rose from $700 to $1,500 a month this year to insure herself, her husband, and four of their kids. LeGault has Crohn’s disease and two of their daughters also have medical conditions, so she said her family has no choice but to continue to pay for that health coverage.

But she decided to skip dental insurance to save money, and she prioritizes dental visits for her children over herself.

She had already struggled to set aside retirement savings and had switched her children from a private school they liked to public school to cut down on costs. Then the new health insurance costs tightened her budget even more. She estimated that about one-fifth of her income now goes toward her monthly premium payments.

“I know how the clinics work, that I am an expensive patient,” LeGault said. “At the end of the day, healthcare is a business in the United States.”

The Durhams have three other employees in their practice. Two of them receive health insurance through their spouses, Ashley Durham said. The Durhams said they pay $420 monthly toward their physician assistant’s premiums.

As a primary care physician, Joshua Durham said he doesn’t need regular doctor visits, because he can diagnose and treat himself 鈥� and, if needed, the rest of his family, though he acknowledged that’s frowned upon. The American Medical Association’s generally discourages doctors from treating themselves or relatives but makes exceptions for emergency situations or short-term, minor problems. Ashley Durham said she’s filled prescriptions for her family.

, a bioethicist and professor emeritus at New York University’s Grossman School of Medicine, said that as more people are “turning toward relatives because they can’t access or easily see a regular doctor,” it may make sense to revisit that aspect of the code of ethics.

Out-of-Pocket Expenses

Healthcare workers with less advanced medical certifications than the Durhams often don’t have the option of treating themselves or family members 鈥� or don’t have savings to fall back on for healthcare expenses. And many healthcare professionals, such as Jill Kordick, a 64-year-old retired healthcare executive in Norwalk, Iowa, aren’t willing to go without the safety net of insurance.

In her work, Kordick saw hospitalizations become financially devastating for patients, so she said she would never opt out of health insurance 鈥� even for just the 16 months before she’d become eligible for Medicare at age 65.

Last year, she qualified for the enhanced Affordable Care Act tax credits, allowing her to pay $75 a month for health coverage. Her premiums rose to $800 a month this year when those subsidies expired.

Because she has a $10,000 deductible, she put off going to the doctor for weeks when she had a sinus infection this year, until it ultimately evolved into an ear infection. She said she regularly rethinks, and sometimes returns, nonessential groceries in her shopping cart. And she keeps her house’s thermostat at 80 degrees in the summer to cut down on air conditioning costs.

Kordick said healthcare is a universal struggle in this country, regardless of how familiar patients are with the industry. “It’s disheartening that it’s as broken and fragmented as it is,” she said.

The Durhams have seen the impact of unaffordable healthcare on their patients. They said they try to lend some leeway to patients when they can 鈥� a luxury they have, operating their own practice. In one case, Ashley Durham said, she wrote off $1,160 in bills for a single father whose son didn’t have health insurance rather than send their bills to a collection agency.

“It’s hard, because as a human I want to help them out,” she said. “At the same time, we need revenue for our office.”

Joshua Durham is more nervous about going uninsured than his wife. As a child, he witnessed his parents struggling to pay medical bills for their family of nine in south-central Idaho. Durham recalled that his dad, who was a carpenter, helped build a surgeon’s house to pay for an operation.

Today, Durham also sometimes exchanges work for care. He said he gets free eye exams from an uninsured optometrist and offers him free primary care.

He worries about a worst-case scenario: a car crash, a sports injury, a serious diagnosis.

“Do I have pancreatic cancer today?” Durham said wryly.

So far, the couple has paid around $9,000 total for expenses out of their health savings account this year, including physical therapy to help with the thoracic outlet syndrome that affects Durham’s neck and shoulder, mental health appointments, and contact lenses. The expenses were higher than the Durhams anticipated. But it was still less than what their monthly premiums would have cost them.

Their decision has paid off, Joshua Durham said. At least for now.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact 51视频 Health News and share your story.

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Still, Montana’s health department decided last year that Hailstone is no longer eligible for low-cost disability health coverage through Medicaid. The department switched her coverage to the state’s Children’s Health Insurance Program, another Medicaid program 鈥� three months before she aged out.

Before making the decision, the state didn’t seek records from the medical team treating Hailstone, according to letters from those doctors reviewed by 51视频 Health News. Rather, the administrative ruling came after state officials learned the now-19-year-old had stopped receiving Social Security disability payments. She said she did that because she hoped to get healthy enough to work and save some money 鈥� beyond what’s allowed under the tethered to those payments. But her health changes day to day, and she said for now she’s still too sick to consistently work.

Hailstone, who lives with her mom, has been able to keep Medicaid coverage while they appeal the case. She said that without Medicaid she can’t afford the treatment to manage the aftermath of her cancer.

“It feels like this process was made to make you give up,” Hailstone said.

Patients with disabilities have long struggled with administrative hoops, blunders, and confusion when trying to qualify for federally subsidized health coverage because of their illness. Now, new federal Medicaid work requirements mean states face the additional task of deciding who qualifies for a medical exemption. That means reviewing medical cases for an even larger swath of Medicaid enrollees.

Attorneys, researchers, and advocates who specialize in public aid said disability cases like Hailstone’s 鈥� though separate from the incoming work requirements 鈥� are an indication that states aren’t ready. As a result, they said, more people will be denied coverage in an opaque process.

“This will be the story of millions of people,” said Anthony Wright, who heads Families USA, a national nonprofit that advocates for ways to make healthcare more accessible.

Jon Ebelt, a spokesperson with the Montana Department of Public Health and Human Services, said the state doesn’t comment on individual Medicaid cases.

An will have to meet the new rules requiring them to prove they’re working, going to school, or volunteering to keep their Medicaid coverage, according to the Congressional Budget Office. of those enrollees live with a chronic health condition, according to 51视频. Some will be excused from those rules if they can prove they’re too sick to work.

More than 5 million people are expected to lose Medicaid coverage by 2034 because of the work requirements, according to the CBO.

Work Requirements Become Law

Many Republican policymakers and the Trump administration have touted Medicaid work requirements to preserve coverage for the neediest. Congress made that national policy through last year’s One Big Beautiful Bill Act and gave states until January 2027 to implement work-for-coverage rules.

Some states are starting those checks early. Montana began in July. Nebraska initiated work requirements in May.

In the federal law creating the work requirements, Congress allowed states to exempt people who have an illness that qualifies them as “medically frail.” Many states created plans for those judgment calls, only to be surprised when federal officials released rules for the requirements that went beyond what Congress outlined, by also requiring enrollees to prove their illness makes it too hard to work.

Families USA and other organizations have argued the new rules force states to set up a patchwork of systems that, together, would be larger and more complicated than the Social Security Administration’s own disability review system. Last year, that federal program cost to administer to roughly 7 million people nationally. For comparison, Wright said, the federal law provided $200 million for states to share as they implement the work requirements. States are paying contractors millions of dollars to prepare often already flawed public aid systems to meet the new standards.

In June, 25 states over the medical frailty rules, arguing they’re too hard for patients to meet and for states to assess. That case is ongoing.

Hailstone was diagnosed with blood cancer at age 10. Her intestines tore, which led to their partial removal. As a result, her body struggles to process food and she can face severe dehydration. She said lingering side effects from her cancer treatment can leave her mind foggy and cause her hands and feet to swell enough that it’s hard to grip a fork or walk across a room.

Cancer dominated nearly half her life. It left mental scars, too.

“Some days you feel fine and then you suddenly crash,” Hailstone said.

Hailstone and her mom live in Roundup, a central Montana town of roughly 2,000 people. They regularly make the nearly two-hour round-trip drive to Billings for specialized care. She typically has three medical appointments a week to see her physical and occupational therapists and a mental health counselor.

Hailstone said she’s lucky she has her mother’s help navigating Medicaid. Her mom, Kyla Hailstone, said that the state hasn’t clearly defined how it determined her daughter’s disability status and that its appeal process has been slow and dysfunctional.

Taya Hailstone would qualify for Medicaid based on her income if she can’t prove her eligibility for disability coverage. But that would mean proving she’s too sick to meet the work requirement 鈥� putting her in the same position of having to rely on a state review of her illness.

“If I lose this, this is life-changing,” Hailstone said.

鈥楾hings Fall Through the Cracks’

Hailstone qualified as disabled through the federal government as recently as 2024, about a year before the state said it was dropping her coverage. State officials can do their own medical review to determine whether someone meets the federal definition of a disability to access Medicaid.

“Whether that happens is always a bit of a crapshoot just based on state capacity,” said Megan Dishong, deputy director of the Montana Legal Services Association, which helps low-income people navigate public programs. “Things fall through the cracks.”

Ebelt said the state health department accepts disability decisions from the Social Security Administration. The state agency can conduct an internal disability determination if a person doesn’t have one from the SSA, but Ebelt said it doesn’t have to if a person qualifies for coverage another way.

“We are committed to treating every client with respect and helping those who are eligible receive appropriate Medicaid coverage,” Ebelt said.

Montana instituted a three-month grace period for the work requirements. State officials won’t begin disenrolling people for noncompliance until October.

a University of Michigan social policy professor who has studied bureaucratic obstacles to public benefits, said convoluted disability cases are common enough for attorneys to specialize in accessing aid.

“When we’ve designed public programs in ways that people can’t figure out whether they’re eligible without consulting lawyers, we’ve done something wrong,” Herd said. “That has huge, huge implications for what’s to come.”

Montana officials have said they’ll automatically review medical records that could help patients qualify for an exemption. Even so, the federal guidelines released in June mean patients will probably still face additional steps to guarantee an exemption.

Meanwhile, already overstretched doctors worry they’ll face the burden of judging whether someone’s illness qualifies them for a work exemption.

Dishong said that between now and October, Montana officials could offer more clarity on how the process will work. She said she’s worried the state will end up “with a slow-roll mess” instead.

“This is a problem that’s just starting,” Dishong said.

As for Hailstone, she’s now reapplying for Social Security disability payments. That aid would limit how much she can work. But it would also guarantee access to Medicaid.

Have you tried to prove your eligibility for Medicaid under new rules that require people to show they are working, going to school, or participating in another qualifying activity? Click here鈥痶o contact 51视频 Health News.

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Transparency “is really important to help protect the integrity of the program, ensure funds are reaching the communities they’re meant to serve,” said Maya Sandalow, director of health policy for the Bipartisan Policy Center, a nonprofit think tank.

The federal government and states are compelled by public records laws to share documents when requested. But those requests can take months to fulfill, making their release too late for meaningful oversight as states rush to spend their allotments under tight federal deadlines.

In the meantime, the Centers for Medicare & Medicaid Services 鈥� which oversees the Rural Health Transformation Program 鈥� and some states aren’t proactively sharing information about where the funding is going and how it will be used.

CMS spokesperson Timothy Foster said the agency “will publish an annual report on state progress.”

States’ individual reports to CMS are “intended to be” shared upon request, but the agency won’t be proactively publishing the individual state reports, according to a CMS document.

Foster didn’t respond to questions about whether the agency will share examples of projects that are and aren’t working or create a tracker of funding recipients, award amounts, and what organizations plan to do with their funding 鈥� ideas that health and government transparency advocates have requested.

Instead, much of the program’s transparency thus far has been up to state governments, and “the level of details that states have publicized really varies,” said Sandalow, who co-wrote a on how the federal government can strengthen the rural health program, including through transparency.

Some states are sharing information with lawmakers, holding public meetings, and explaining where organizations plan to invest their money.

Others are more secretive, with multiple states declining to release public records in response to 51视频 Health News’ requests. Mississippi’s governor , West Virginia holds closed-door advisory meetings, and a South Dakota official wrote that he hoped CMS would keep its application from public view.

“I just don’t believe in all this secrecy,” said Mississippi state Sen. Hob Bryan, who chairs his chamber’s public health committee. “If they’re not up to something nefarious, why do they have to do it all in secret?”

Bryan, a Democrat, said there’s about the lack of transparency in his state.

Reaching Rural Patients

Congressional Republicans created the five-year Rural Health Transformation Program last summer as an eleventh-hour sweetener to President Donald Trump’s signature One Big Beautiful Bill Act. The money was intended to offset concerns about the anticipated in rural communities from the law, which is expected to by more than $900 billion over a decade.

Sandalow said some states may be struggling to share information since they’re busy rushing to hire staff and meet the program’s tight deadlines, including an annual report due Aug. 31.

In the meantime, a slew of media outlets, nonprofits, and businesses are stepping in to make it easier for the public to track the rural health program.

51视频 Health News is collecting states’ applications and approved plans and budgets, not all of which have been posted on state websites.

Rural Health Payout

Tracking Applications聽for Rural Health Transformation聽Funds

51视频 Health News is working to collect and post complete application materials, by state, here and will update this repository as new materials, released in response to public records requests, arrive.

Dec. 4, 2025

Rural Health Payout

Tracking State Rural Health Transformation Plans

51视频 Health News is working to collect and post approved plans as more states respond to emails and public records requests for their documents.

July 27, 2026

And several and have created trackers that , post funding opportunities, or list award recipients. But some resources are available only through paid services, aimed at helping businesses interested in applying for money.

Sandalow said previous federal programs “tend to draw attention for gaps in transparency and oversight rather than for doing it well.”

As an example, she pointed to the lack of oversight and transparency with the CARES Act and other covid relief programs, which saw .

In March, CMS published proposed quarterly and annual state reporting requirements for the rural health program, and a . At least three groups replied with letters expressing concerns about transparency.

CMS should share states’ progress reports, funding recipients, and what organizations plan to do with their awards, , the Bipartisan Policy Center’s vice president for health policy.

Sharing this information would make it easier to track progress, identify successful programs that other states may want to replicate, and “ensure funds reach the rural communities they are intended to serve,” he wrote.

Molly Smith, group vice president for public policy at the American Hospital Association, “to be as detailed as possible” about the “final destinations of these funds, given the complexity of the grant funding process.”

In , Charlene MacDonald, who leads the Federation of American Hospitals, noted that some funding recipients, such as large health systems and academic medical centers, will be distributing their awards to other entities.

CMS should collect those “downstream subrecipients,” wrote MacDonald, whose group represents for-profit hospitals and healthcare systems.

Without this information, she said, it will be difficult to know if “funding is reaching the rural hospitals, providers, and communities primarily intended to benefit from the program.”

It can also be difficult to know which for-profit companies are being paid with rural health money.

For example, and have listed hospitals and other health facilities that received funding to purchase telehealth, scanning devices, and other health technology. But the states list only some of the companies from which recipients will buy those products.

States won’t have to report “downstream” funding in their August reports to CMS but will have to do so for all future reports, according to the agency’s recently finalized .

The CMS documents say states must list subrecipients that receive subawards as well as vendors or contractors paid by an organization using rural health funding. Although states must report how much money these downstream recipients receive, they don’t have to describe which specific services or products the recipient is providing.

DIY Dashboards

As groups ask CMS to share more information, some states have created their own rural health spending dashboards or recipient lists, with varying levels of detail.

Alaska, , and other states list which organizations receive funding, their award amounts, and detailed descriptions of how recipients will spend the money.

and , however, are among the states that don’t share what awardees plan to do with their funding.

New Hampshire is that detail projects and their budgets on its Rural Health Transformation Program website. Some other states have uploaded contracts and grants on general procurement or award databases, which can be difficult to navigate.

, , and have used press releases to announce awards. But the announcements aren’t posted on their Rural Health Transformation Program websites, which could make it difficult to find this information.

Many states created advisory groups to provide transparency and accountability for their programs. Most committees host public meetings and upload minutes, recordings, or other materials from the discussions.

But the West Virginia Department of Health won’t share what’s discussed in its rural health advisory panel’s closed-door meetings, according to spokesperson Gailyn Markham.

“The panel is intended to serve as an informal forum for discussion and feedback among invited participants and program staff,” Markham said.

South Dakota, North Dakota, and Mississippi are among the states without advisory committees.

In response to public records requests, South Dakota released a nearly completely redacted version of its budget for the rural health program while Mississippi declined to release its budget.

Mississippi’s he vetoed a because it would “create an unnecessary layer of bureaucracy” that would have slowed the award process, which could cause the state to lose out on future funds. Mississippi is “ in all this secrecy,” Bryan, the state lawmaker, told 51视频 Health News.

Sandalow said it’s important for states to publish the impact of their rural health projects, adding that CMS should share which rural health projects are and aren’t working.

She said national and state health organizations are creating networks and holding conferences to help spread this information. States should “be able to learn from each other, get a sense of lessons learned and best practices, and then be able to pivot their initiatives accordingly,” Sandalow said.

Michael Cannon, who oversees health policy studies at the libertarian Cato Institute, said people should know how their $50 billion in taxes is being spent on the rural health program, and whether state projects are making rural patients healthier.

If investors put that much money into a project, there is “no way” they “would let the recipients of those funds get away with the shoddy approach to transparency and accountability that the states are taking,” he said.

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

The cool, mossy spring lies just across the highway from White Mesa Mill, the nation’s , which produces yellowcake for nuclear power fuel.

For decades, the mill has sparked debate over whether radioactive contamination threatens human health by getting into the water and the air. Concerns run especially deep in the White Mesa Ute Community, where Lehi and about 200 members of his tribe live some 5 miles south of the facility.

State regulators and the company that owns the mill contend that any pollution associated with it is contained. That’s little consolation to nearby tribal members, who 鈥� aware of uranium’s deadly legacy across the Colorado Plateau 鈥� have raised questions about the potential spread of toxic waste. Many won’t drink the local water, relying on bottled water instead.

Now the tribe’s concerns have taken on new urgency as the U.S. pushes to revive domestic uranium production. A federal law, passed in 2024, by 2028, increasing pressure to develop domestic fuel supplies. President Donald Trump U.S. nuclear energy capacity by 2050. He to prioritize mining on federal lands and fast-track approval of mining projects. The Velvet-Wood uranium mine in Utah, for instance, in 11 days, to the who were given one week to offer input.

Trump’s goal of quadrupling nuclear power capacity will be hard to meet, because it would require constructing more reactors 鈥� which are difficult to build and often meet local opposition, said , a senior fellow for climate and energy at the Council on Foreign Relations. But data centers and rising electricity demand have intensified interest in nuclear power as a low-carbon energy source, he said. And are to it.

So the effort to obtain the key ingredient, uranium, is underway.

The White Mesa Mill, built in 1980 near what is now in southeastern Utah, is a focal point of this latest uranium boom 鈥� and the tensions between local tribal concerns and national economic interests. Increased demand draws a steady flow of trucks carrying uranium ore to the mill from regional mines, including one near the Grand Canyon where the Havasupai Tribe lives. That ore is trucked through the Navajo Nation. And the mill plans to expand its waste storage, as well.

A former tribal councilmember, Lehi is part of a growing opposition that includes members of the Havasupai and Navajo (Diné) tribes, who are now linked by the uranium trucking routes passing through their lands. The Havasupai and Ute Mountain Ute tribes share concerns that toxic wastewater from uranium mining and milling may move through the ground and poison drinking water for future generations.

A History of Distrust

One spring morning in White Mesa, Yolanda Badback gazed out an open door not far from the highway and watched three uranium trucks drive by.

“There goes another one,” Badback said with a tone of exhaustion. She is a Ute Mountain Ute member and leader of the advocacy group that has been fighting the mill.

The mill receives 10 to 15 trucks each weekday, said Curtis Moore, senior vice president of marketing and corporate development at , which has owned the facility since 2012. The majority pass through White Mesa.

The mill’s business is picking up after a quiet 15 years, Moore said. The White Mesa Mill produced 1 million pounds of yellowcake last year; the company that this year, he said. The mill has also diversified into processing radioactive waste from as far away as and Japan, and received a from the Defense Department to scale up its domestic processing of rare earth elements.

The new rare earths business alone could create 100 permanent jobs, Moore said. About half of the mill’s 105 workers are Indigenous; Moore estimated that no more than two belong to the Ute Mountain Ute Tribe.

“When it comes to tribes in the area, I do very much understand their skepticism of uranium,” Moore said. “They’ve been lied to before.”

A uranium boom driven by the U.S. government from the 1940s through the 1980s, much of it concentrated around the Four Corners area of Arizona, New Mexico, Utah, and Colorado, exposed miners to from lung and other cancers. Federal reviews found that the miners, many of them Navajo (Diné), even after government scientists understood the dangers. Mining companies left behind thousands of abandoned waste sites that have leached contamination into surrounding soil and water, including on and near the Navajo Nation.

But Moore said things have changed a lot since the 1950s. He said workers today are exposed to 15% to 20% of allowable radiation limits, and outside the mill it’s “effectively zero.”

Government agencies and Energy Fuels officials have said there’s no evidence that the mill is affecting White Mesa’s drinking water supply, which comes from a deep aquifer protected by a thick rock barrier known as an aquitard.

“It really is the perfect site for a uranium mill,” Moore said.

Scott Clow, environmental programs director of the Ute Mountain Ute Tribe, said that deep aquifer does have quality issues 鈥� including arsenic, iron, and manganese 鈥� but the public drinking water is filtered and safe to drink.

Adam Wingate, uranium recovery manager at the , said he understands why some residents are concerned. White Mesa is downslope in terms of underground water flow from the uranium mill.

If locals hear about the plume of contamination in a different, shallower aquifer beneath the mill 鈥� even if it’s not the source of their drinking water 鈥� and their own water tastes funny, “that’s a scary spot to be in,” he said. But based on available evidence, Wingate said, locals’ “health is not at risk because of the mill.”

Even so, Lehi and Badback said that the tap water smells of sulfur and has a milky color, and that people in White Mesa typically don’t drink it.

“I don’t trust it,” said Badback, whose family has been fighting the mill for decades. “My main goal is to shut the mill down.”

An sponsored by Badback’s group has grown over the past decade amid deep distrust rooted in uranium mining’s history. Much of the opposition centers on the mill’s toxic waste, which is stored in five lined pits called tailings cells occupying 284 acres of land.

Badback vows to fight expansion plans that include new tailings cells located about a quarter-mile closer to the White Mesa community than the current ones. Moore said the cells will be triple-lined per modern standards.

“They want to expand south towards my reservation,” Badback said. “That’s the reason why I am standing up and doing whatever I can to stop that from happening.”

Concerns About Air Quality

At a No Kings rally in March in Moab, about 80 miles north of White Mesa, Badback gave a speech and staffed a table offering T-shirts and information.

“No Uranium,” the T-shirts read. “Protect White Mesa Ute Community.”

In 2021, her tribe stating that the White Mesa Mill “has had severe health impacts on the residents of White Mesa and should cease entirely.”

While their psychological stress is palpable, other health effects have been hard to prove.

A 2023 concluded that radiation levels measured at the tribe’s air monitor in the center of White Mesa from 2013 to 2019 were unlikely to harm human health. But the authors said they could not evaluate whether the mill’s radon emissions could affect bordering properties or residents. They recommended that the tribe collect air samples closer to the mill, during times of heightened mill activity.

In December 2021, the Environmental Protection Agency found the mill was violating the Clean Air Act by failing to cover one of its tailings cells with liquid to limit emissions of radon, a known cause of lung cancer. The EPA called the violation “egregious in nature and duration” and temporarily barred the mill from receiving waste from Superfund cleanup sites.

The mill corrected the problem, according to state regulators, and passed its latest in 2025.

Still, some White Mesa residents remain uneasy. Badback and Lehi complained of odors, which they attribute to the mill, that smell like chemicals or rotten eggs. She has raised concerns about air quality and rates of cancer and asthma, which are being explored by a University of Utah health survey.

Moore denied that any odors from the mill could be smelled beyond the mill parking lot.

Utah air quality officials said the state does not conduct ambient air monitoring in White Mesa and does not regulate odors.

Watching the Water

That spring day, Lehi continued to look for Entrance Spring. On the horizon lay the silhouette of Sleeping Ute Mountain, a landmark of the Ute Mountain Ute Tribe, said to be the body of a great warrior god.

Along the way, Lehi pointed out a circle of stones that he thought looked like an ancestral burial site. After parking the Jeep, he walked down a faint trail through a lush grove of willows and found his way into a streambed that he reckoned would lead to the spring.

The tribe doesn’t rely on the spring for drinking water. But it’s one of the seeps and springs that the tribe, the state, and the company monitor, because they offer clues to whether the mill’s waste ponds are leaking into a less protected aquifer.

In the late 2000s, an found elevated contamination by radionuclides 鈥� atoms that emit radiation as they decay 鈥� at Entrance Spring. EPA water samples found that uranium concentrations at times exceeded the federal drinking water standard. EPA and U.S. Geological Survey fieldwork suggested the uranium at Entrance Spring came not from leaking waste ponds but from dust that blew off the mill’s ore storage pads.

The from 2025 showed Entrance Spring had uranium levels at 22.5 micrograms per liter (碌g/L) 鈥� within the federal drinking standard of 30 碌g/L but still elevated.

Clow said the tribe continues to keep a close eye on the seeps and springs.

“We’re concerned about the pollution of those springs,” he said. “We are looking towards many generations in the future here.”

Clow is also closely watching the Burro Canyon Aquifer, which lies beneath the mill’s toxic waste cells and feeds the local springs. A plume of chloroform and another of nitrates already pollute the aquifer, said Wingate, with the state. He said Energy Fuels is pumping out the contamination.

When contaminants increase, it’s hard to prove whether they stemmed from natural causes or mill activity, since substances such as sulfate and manganese occur naturally in the local bedrock. So Clow, the company, and state officials continually debate whether the tailings ponds are leaking. What’s not in dispute is that the mill produces radioactive waste 鈥� and once that exists, it can linger for tens of thousands of years.

Lehi followed the stream to where it ends in a curved grotto 鈥� the site of Entrance Spring. Water oozed from a rock face into a pool, offering cool relief from the desert. Lehi looked around with wonder at the dripping green moss. A descendant of medicine men, Lehi said he feels a duty to protect the landscape as his ancestors did, even if the tribe doesn’t currently use this spring for drinking water.

鈥�“Water is life,” Lehi said, “because that’s where we all began.”

This article was supported by , an independent journalism initiative based at the University of Colorado-Boulder’s Center for Environmental Journalism.

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

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 鈥� and angry on principle 鈥� 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 鈥� 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” 鈥� also known as out-of-network 鈥� 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视频 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视频 is a health information nonprofit that includes 51视频 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 鈥� 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鈥攁nd often reducing鈥攖he probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins 鈥� 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视频 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视频 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, 鈥極h, 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视频 Health News and is republished here under a .

Health secretary Robert F. Kennedy Jr. that AI nurses can provide “concierge care” to rural patients. Mehmet Oz, who leads the Centers for Medicare & Medicaid Services, “the best way to help some of these communities is going to be AI-based avatars” that connect rural patients to mental health services.

And many state health leaders agree. They are using some of their funding from the $50 billion federal Rural Health Transformation Program to expand AI among rural health organizations.

AI is computer technology that performs tasks that typically rely on human intelligence by finding patterns or generating words. It has the potential to improve the healthcare system by automating back-office work or identifying patients at risk, but several reports contend there’s little evidence AI can improve access to care and patient health in rural areas. It’s unclear how well states will track and share outcomes of the tech they invest in.

Meanwhile, some rural Americans are skeptical, according to interviews with people in Hot Springs, South Dakota, a city of about 3,400 residents at the southern end of the Black Hills.

“I get artificial intelligence for certain things, but for personal healthcare 鈥� no,” Tara Haffner said while standing outside the American Legion.

Haffner said she’s worried about AI making mistakes and wants healthcare to stay between her and her doctor.

But Phillip Mues, who oversees technology at Cherry County Hospital and Clinic in rural Valentine, Nebraska, said AI is already helping clinicians save time, reduce burnout, and focus more on patient care.

“I think it will help reduce burden on actual staffing,” he said. “It won’t replace people, but I think it will help in rural communities.”

Still, Mues said, AI can’t fix every challenge. Rural hospitals at risk of closing or ending certain services probably can’t use AI to save enough money to prevent those consequences, he said.

Congressional Republicans created the five-year Rural Health Transformation Program last summer as a last-minute sweetener to President Donald Trump’s signature One Big Beautiful Bill Act. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is by more than $900 billion over a decade.

The Word on the Street

Hot Springs, which has a 25-bed independent hospital and a Department of Veterans Affairs hospital, is known for its sandstone buildings, veterans’ services, and, yes, hot springs. Residents must drive at least an hour for more advanced care.

Six people interviewed there by 51视频 Health News said the biggest problem in rural healthcare is the cost or long wait times caused by staffing shortages.

Doug Nikkila, a heavy equipment operator, said AI and other technology come with benefits and risks.

“If it’s not utilized correctly, it becomes a burden,” he said.

Nikkila, who’s concerned about nursing home residents being neglected amid staffing shortages, said he thinks AI should send reminders to staff when their residents are due for diaper changes or other care. He also wondered whether AI-powered video monitors could send alerts when they detect falls or illness symptoms.

The healthcare industry is rapidly adopting AI despite the tools being “poorly evaluated,” according to a , a Stanford- and Harvard-led group that evaluates health-related AI. The report says that while some AI has been successful in controlled settings, there’s less evidence it can perform in the real world. It also said few studies track patient outcomes.

Evidence is especially lacking in rural areas. A found that only 26 peer-reviewed studies about AI in rural healthcare were published from 2010 through April 29, 2025. Few analyzed implementation or outcomes.

Despite the dearth of results, some states appear interested in bold experiments 鈥� such as using AI to suggest diagnoses or recommend treatments. Utah officials said in their application to the rural health program that they are interested in funding a in AI-powered prescription refill requests.

Even tools proven to work in urban settings may not work in rural ones, said Qian Huang, an assistant professor at the Center for Rural Health and Research at East Tennessee State University.

She said the technology is usually tested at large, academic hospitals and trained on data from urban patients, who may not have the same health issues and obstacles 鈥� such as a lack of transportation 鈥� as rural patients.

A 51视频 Health News review of states’ plans for the Rural Health Transformation Program shows they’re interested in using AI to automate time-consuming, behind-the-scenes tasks, such as medical charting, coding, referrals, and prior authorization requests. Some states also mentioned ways AI can save money, such as Washington, which discussed tools that “identify and recover” money it’s owed.

Mues said the Valentine clinic has been using AI scribes that record appointments and generate notes describing the visit. He said surveys of clinicians before and after they started using the technology show the scribes have helped reduce burnout by letting providers focus on patient care with “eye contact on the patient, not the computer.”

States also mentioned funding AI that directly affects patient care, such as tools that recommend possible diagnoses and treatment options to clinicians. Mississippi wants to use predictive AI algorithms to “guide” emergency medics with “triage, routing, and treatment decisions.”

Several states want to use AI to analyze patients’ medical charts and remote monitoring devices to identify immediate or future health risks. North Dakota’s plans mention AI to “detect early signs of chronic disease and behavioral health conditions,” while New Hampshire’s discusses AI that identifies patients “at high risk of adverse drug events.”

Some states plan to give patients access to chatbots or wearable devices that transmit data to their clinicians. Utah is interested in funding AI-powered fetal-monitoring devices, while Kentucky will explore using AI chatbots to “deliver personalized nudges and education” through “health coaching, gamified incentives, and rewards.”

Whether the technology appeals to consumers is another matter. Hot Springs resident Stephanie Keller wears a smartwatch to track her fitness but has no interest in an AI chatbot using her data to encourage her to reach her health goals.

“I don’t have the time to chat with AI every day. I mean, are you kidding me? I don’t want to spend my time on a cellphone,” she said.

Rural health facilities also face challenges in implementing AI.

Huang, who has AI in rural healthcare, said rural hospitals and clinics may not have the hardware or IT staff needed to support the technology. She said clinicians and staff may already be doing three jobs at once and not have time to go through AI training.

Rural health facilities may not have fast-enough internet to use AI, while patients may have slow connections at home 鈥� if they have internet at all 鈥� or may not feel comfortable using AI, Huang said.

“In rural communities, trust and a personal relationship is essential,” she said.

Roy Ehlers, a Hot Springs resident, said he doesn’t trust AI in healthcare, or anywhere else.

“I’m old-fashioned. I don’t believe in it. Technology is not my forte,” Ehlers said.

Mues said that while some rural patients are “scared of AI,” most have let their clinicians at the Valentine facility use the scribing technology to record patients’ visits.

Will States Share AI Results?

Despite questions about implementation, the boom is on. Jordan Everson, an assistant professor at the Georgetown University Department of Family Medicine, said both urban and rural health facilities are rushing to use AI.

“The risk of signing contracts that rural healthcare organizations come to regret is pretty high,” said Everson, who previously worked in the information technology office at the U.S. Department of Health and Human Services.

Several states are addressing that risk by using their rural health funding to create groups that will help rural health facilities vet, select, or monitor AI tools while offering training, ongoing assistance, or funding for upfront costs.

CMS spokesperson Timothy Foster said the agency doesn’t have any AI-specific reporting requirements but is working on a form for states to report their overall progress and outcomes.

Abraham Pritzker, who works at Julota, a company that helps health organizations track data, said states should measure more than how often AI programs are used.

For example, states can measure whether the tech reduces falls, 911 calls, or hospital admissions, said Pritzker, a former paramedic. Huang said it’s also important to ask clinicians and patients about their experiences using AI.

Yet many states’ applications to the rural health program mention tracking only AI adoption metrics, not what happens after facilities deploy the tech. Some of these states may add further reporting requirements down the road.

Vermont spokespeople did not respond when asked why their state’s requires organizations to report only how many clinicians and patients are served by the tech, not how much time they save.

States requiring recipients to report outcomes include , which will track how often AI-powered patient monitoring devices trigger accurate alerts. organizations to track cost savings, while Wisconsin lists “patient outcomes” and “productivity and efficiencies” as possible metrics.

Huang said that after collecting results, states need to share them so other states and healthcare organizations can learn from their experiences.

“We do not have a lot of resources to waste on tools that don’t work in rural areas,” she said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other mergers have been proposed in , , and Minnesota.

Asheville’s Dominant Hospital

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Birth of a Monopoly

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

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

“After 20 years of the hospital behaving itself, the state decided to terminate its oversight,” said Mark Hall, a professor emeritus at Wake Forest University who of the hospital’s merger history. Then, three years later, HCA, the largest hospital corporation in the country, bought Mission Health. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund 51视频 Health News’ coverage.)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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