“He’s had these problems since he was born, and I couldn’t figure out what was triggering his asthma,” Fabiola Sandoval said of her son, Jorge, now 4. “It’s so hard when your child is hurting. I was willing to try anything.”

In January, community health workers visited Sandoval’s home in Turlock, a city in California’s Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval’s home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor 鈥� goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.

The in-home consultation and supplies were paid for by Medi-Cal, California’s Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves low-income residents on an annual budget of $158 billion.

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups’ ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.

“This is still so new, and everyone is just overwhelmed at this point, so it’s slow-going,” said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.

The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative’s money.

By contrast, CalOptima Health, Orange County’s primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.

“Asthma services are so difficult to get going” because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima’s executive director for Medi-Cal. “We need more community-based organizations on board because they’re the ones who can serve a population that nobody wants to deal with.”

Newsom, a Democrat in his second term, says his signature health care initiative, , seeks to reduce the cost of caring for the state’s sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.

In addition to in-home asthma remediation, CalAIM offers of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, , a sliver of the hundreds of thousands of patients who likely qualify.

“We’re all new to health care, and a lot of this is such a foreign concept,” said Helena Lopez, executive director of , a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.

Tiffany Sickler runs , which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.

“If you want to do this, you have to learn all these new systems. It’s been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding,” she said.

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was “on the cutting edge of health care” and that the state was working to increase “awareness of these new services and support.”

For nonprofits and businesses, CalAIM is a money-making opportunity 鈥� one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers.

In some places, community groups are competing with national corporations for the new funding, such as Mom’s Meals, an Iowa-based company that delivers prepared meals across the United States.

Mom’s Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom’s Meals isn’t reaching everyone who qualifies, because doctors and patients don’t always know it’s an option, said Catherine Macpherson, the company’s chief nutrition officer.

“Utilization is not as high as it should be yet,” she said. “But we were well positioned, because we already had departments to do billing and contracting with health care.”

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom’s Meals. For instance, the New York-based is advising homeless service providers how to get more contracts and expand benefits.

, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.

“We’re allowing organizations to launch these benefits much faster than they’ve been able to do and to reach more vulnerable people,” said Camille Schraeder, chief executive of Full Circle. “Many of these are grassroots organizations that have the trust and expertise on the ground, but they’re new to health care.”

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn’t enough seed money for community groups to hire workers and pay for new technology platforms. “They bring the trust that is needed, the cultural competency, the diversity of languages,” she said. “But there needs to be more funding and reimbursement to build this workforce.”

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group’s chief medical officer.

“They don’t have the staffing to do all this stuff, so we’re helping with that all while teaching them how to build up their health care infrastructure,” he said. “Everyone wants a win, but this isn’t going to be successful overnight.”

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son’s asthma.

“I used to love cleaning with bleach” but learned it can trigger breathing problems, Sandoval said.

Since she implemented the health workers’ recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.

“Having this program and all the things available is amazing,” said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. “Now my son doesn’t have as many asthma attacks and he can run around and be a normal kid.”

This article was produced by 素人色情片Health News, which publishes , an editorially independent service of the .听

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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Working out of a warehouse-like building in a scruffy corner of this former industrial town, Mungenast gently walks patients through health insurance options, financial aid, and payment plans. Most want to pay, said Mungenast, a financial counselor at Rochester Regional Health. Very often, they simply can’t.

“They’re scared. They’re nervous. They’re upset,” said Mungenast, who on one recent call worked with an older patient to settle a $143 bill. “They do think 鈥業 don’t want this to affect my credit rating. I don’t want you to come take my house.’”

At Rochester Regional Health, that won’t happen. The nonprofit system in upstate New York is one of only a few nationally that bar all aggressive collection activities. Patients who don’t pay won’t be taken to court. Their wages won’t be garnished. They won’t end up with liens on their homes or be denied care. And unpaid bills won’t sink their credit scores.

American hospital officials often insist that lawsuits and other aggressive collections, though unsavory, are necessary to protect health systems’ finances and deter freeloading.

But at Rochester Regional, ditching these collection tactics hasn’t hurt the bottom line, said Jennifer Eslinger, chief operating officer. The system has even been able to move staff out of its collections department as it spends less to go after patients who haven’t paid.

Eslinger said there’s been another benefit to the change: rebuilding trust with patients.

“We think and talk a lot and strategize a lot about where is the distrust in health care,” she said. “We have to remove that as a barrier to meaningful health care. We have to get the trust with the populations that we serve so that they can get the care that they need.”

鈥楩olks Cannot Afford This’

Rochester Regional, a large health system serving a wide swath of communities along the south shore of Lake Ontario, is big, with more than $3 billion in annual revenue.

But in a place where once-mighty employers like Kodak and Xerox have withered, finances can be challenging. In 2022, Rochester Regional finished nearly $200 million in the red.

Patients have their own challenges. Unable to afford their bills, many ended up in collections, or even on the receiving end of lawsuits. “We would go to court,” acknowledged Lisa Poworoznek, head of financial counseling at Rochester Regional.

Then, before the pandemic, hospital leaders looked more closely at why patients weren’t paying.

The barriers became clear, Poworoznek said: confusing insurance plans, high deductibles, and inadequate savings. “There are so many different situations that patients have,” she said. “It’s really just not as simple as demanding payment and then filing legal action.”

Nationally, nearly half of adults are unable to cover a $500 medical bill without going into debt, a found. At the same time, the average annual deductible for a single worker with job-based coverage .

Instead of chasing people who didn’t pay 鈥� a costly process that often yields meager returns 听鈥� Rochester Regional resolved to find ways to get patients to settle bills before collections started.

The health system undertook new efforts to enroll people in health insurance. New York has among the most robust safety-net systems in the country.

Rochester Regional also bolstered its financial assistance program, making it easier for low-income patients to access free or discounted care.

At many hospitals, applying for aid is complicated 鈥� long applications that demand extensive information about patients’ income and assets, including cars, retirement accounts, and property, 素人色情片Health News has found. Patients applying for aid at Rochester Regional are asked to disclose only their income.

Finally, the health system looked for ways to get more people on payment plans so they could pay off big bills over a year or two. Importantly, the payment plans are interest-free.

That was a change. Rochester Regional, like some other major health systems across the country such as Atrium Health, used to rely on financing companies that charged interest, which could add thousands of dollars to patients’ debts.

“Folks cannot afford this,” Poworoznek said.

Ending 鈥楨xtraordinary Collection Actions’

Working more closely with patients on their bills allowed Rochester Regional to stop taking them to court.

The health system also stopped reporting people to credit bureaus, a practice many medical providers use that can depress consumers’ credit scores, making it harder to rent an apartment, get a car loan, or even get a job.

In 2020, Rochester Regional adopted a written policy barring all aggressive collections by the system or its contracted collection agencies.

That put Rochester Regional in select company. A 2022 素人色情片Health News investigation of billing practices at 528 hospitals around the country found just 19 that explicitly prohibit what are called extraordinary collection actions.

Among them are leading academic medical centers, including UCLA and Stanford University, but also community hospitals such as El Camino Hospital in California’s Bay Area and St. Anthony Community Hospital outside New York City.

Also barring extraordinary collection actions: the University of Vermont Medical Center; Ochsner Health, a large New Orleans-based nonprofit; and UPMC, a mammoth system based in Pittsburgh. Like Rochester Regional, UPMC officials said they were able to scrap aggressive collections by developing better systems that allow patients to pay off their bills.

Elisabeth Benjamin, a vice president at the Community Service Society of New York, a nonprofit that has led efforts to restrict aggressive hospital collections, said there’s no reason more hospitals shouldn’t follow suit, particularly nonprofits that are expected to serve their communities in exchange for their tax-exempt status.

“The value is to promote health, to care about a population, to promote health equity,” Benjamin said. “Suing people for medical debt or engaging in extraordinary collection actions is really anathema to all those values,” she said. “Forget about your 鈥榗ancer-mobile’ or your child vaccination clinic.”

Rochester Regional’s approach doesn’t eliminate medical debt, which burdens an estimated 100 million people in the U.S. And payment plans like those the system encourages can still mean big sacrifices for some families.

But Benjamin applauded Rochester Regional’s ban on aggressive collections. “I give them big props,” she said. “It never should have been allowed.”

now prohibit all medical bills from being reported to credit bureaus and restrict other collection tactics, such as wage garnishments.

Many hospital finance officials nevertheless say they need the option to pursue patients who have the means to pay.

“Maybe it’s on a very specific case where there is an issue with someone just not paying their bill,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

But at Rochester Regional’s finance offices, officials say they almost never find patients who just refuse to pay. More often, the problem is the bills are simply too big.

“People just don’t have $5,000 to pay off that bill,” Poworoznek said.

On her calls with patients, Mungenast tries to reassure the patients on the other end of the line. “Put yourself in their shoes,” she said. “How would it be if that was you receiving that?”

About This Project

“Diagnosis: Debt” is a reporting partnership between 素人色情片Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.听

Additional research was听, which analyzed credit bureau and other demographic data on poverty, race, and health status for 素人色情片Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute听听from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with 素人色情片Health News on a survey of its clients to explore links between medical debt and housing instability.听

素人色情片Health News journalists worked with 素人色情片public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from 素人色情片Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

“An Arm and a Leg” host Dan Weissmann wants to know how often this happens, where, and how much it costs patients. If you’ve ever seen a charge for a facility fee on your medical bill 鈥� especially for a visit or service that didn’t take place in a hospital 鈥� “An Arm and a Leg” . to share your story. It may be featured on an upcoming episode.

Credits

“An Arm and a Leg” is a co-production of 素人色情片Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,”听. You can also听follow the show on听听and听the . And if you’ve got stories to tell about the health care system, the producers听.

To hear all 素人色情片Health News podcasts, click here.

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

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Turns out, millions of them were also unaware they had been covered by the government program.

Nearly 1 in 3 people enrolled in Medicaid in 2022 鈥� or 26 million people 鈥� didn’t know it, according to by Harvard and New York University researchers published in Health Affairs this month.听

The report estimated that of those who didn’t know they were on Medicaid, about 3 million thought they were uninsured.

They almost certainly had coverage, though, because the federal government from March 2020 to April 2023 prohibited states from dropping anyone from Medicaid rolls in exchange for billions of dollars in pandemic relief money.

“What this means is people could have been accessing health-care services and probably did not because they thought they were uninsured,” said Jennifer Tolbert, deputy director of the 素人色情片Program on Medicaid & Uninsured. “People not understanding that they have Medicaid is not a good thing.”

This lack of awareness has implications for efforts to predict how much the nation’s uninsured rate has changed as a result of the Medicaid “unwinding” 鈥� the process that began last year in which states redetermine whether people enrolled in the program since the pandemic unfolded remain eligible.

States have dropped about 22 million people from Medicaid in the past year, often for procedural reasons like failing to return paperwork. A found about 1 in 4 adults who were disenrolled from Medicaid a year ago remained uninsured.

One group enjoys some upside from Americans’ ignorance about their insurance coverage: the companies that administer Medicaid for most states, including UnitedHealthcare and Centene.听

States pay them a monthly fee for every person enrolled in their plans. But if people don’t know they’re insured, they’re less likely to seek health services 鈥� which means higher profits for the companies.

“Insurers reaped windfalls from this reality,” said Brian Blase, president of the Paragon Health Institute and a former health policy adviser to President . “People who are enrolled but don’t know they are enrolled receive no benefit from the program.”

In March 2022, the Centers for Medicare & Medicaid Services reported that about 88 million people had Medicaid coverage. But census survey data found about 62 million people self-reported Medicaid coverage 鈥� an undercount of 26.4 million, the study said.听

Several factors explain why enrollees may not realize they’re on Medicaid.

They don’t pay monthly premiums, so the cost of the coverage can be invisible. Because it’s administered by private insurers, many Medicaid recipients may believe they have commercial coverage. And states often market their Medicaid programs with a consumer-friendly name, like Husky Health in Connecticut or SoonerCare in Oklahoma.听

“Medicaid having different names should not lead people to think they are uninsured,” said Benjamin Sommers, a health economist at Harvard who was one of the study’s authors.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

The first-time mother, a high school teacher in rural Illinois, had developed high blood pressure, a sometimes life-threatening condition in pregnancy that prompted doctors to hospitalize her. Then Crivilare’s blood pressure spiked, and the baby’s heart rate dropped. “It was terrifying,” Crivilare said.

She gave birth to a healthy daughter. What followed, though, was another ordeal: thousands of dollars in medical debt that sent Crivilare and her husband scrambling for nearly a year to keep collectors at bay.

The Crivilares would eventually get on nine payment plans as they juggled close to $5,000 in bills.

“It really felt like a full-time job some days,” Crivilare recalled. “Getting the baby down to sleep and then getting on the phone. I’d set up one payment plan, and then a new bill would come that afternoon. And I’d have to set up another one.”

Crivilare’s pregnancy may have been more dramatic than most. But for millions of new parents, medical debt is now as much a hallmark of having children as long nights and dirty diapers.

About 12% of the 100 million U.S. adults with health care debt attribute at least some of it to pregnancy or childbirth, according to a 素人色情片poll.

These people are more likely to report they’ve had to take on extra work, change their living situation, or make other sacrifices.

Overall, women between 18 and 35 who have had a baby in the past year and a half are twice as likely to have medical debt as women of the same age who haven’t given birth recently, other conducted for this project found.

“You feel bad for the patient because you know that they want the best for their pregnancy,” said Eilean Attwood, a Rhode Island OB-GYN who said she routinely sees pregnant women anxious about going into debt.

“So often, they may be coming to the office or the hospital with preexisting debt from school, from other financial pressures of starting adult life,” Attwood said. “They are having to make real choices, and what those real choices may entail can include the choice to not get certain services or medications or what may be needed for the care of themselves or their fetus.”

Best-Laid Plans

Crivilare and her husband, Andrew, also a teacher, anticipated some of the costs.

The young couple settled in Jacksonville, in part because the farming community less than two hours north of St. Louis was the kind of place two public school teachers could afford a house. They saved aggressively. They bought life insurance.

And before Crivilare got pregnant in 2021, they enrolled in the most robust health insurance plan they could, paying higher premiums to minimize their deductible and out-of-pocket costs.

Then, two months before their baby was due, Crivilare learned she had developed preeclampsia. Her pregnancy would no longer be routine. Crivilare was put on blood pressure medication, and doctors at the local hospital recommended bed rest at a larger medical center in Springfield, about 35 miles away.

“I remember thinking when they insisted that I ride an ambulance from Jacksonville to Springfield 鈥� 鈥業’m never going to financially recover from this,’” she said. “鈥楤ut I want my baby to be OK.’”

For weeks, Crivilare remained in the hospital alone as covid protocols limited visitors. Meanwhile, doctors steadily upped her medications while monitoring the fetus. It was, she said, “the scariest month of my life.”

Fear turned to relief after her daughter, Rita, was born. The baby was small and had to spend nearly two weeks in the neonatal intensive care unit. But there were no complications. “We were incredibly lucky,” Crivilare said.

When she and Rita finally came home, a stack of medical bills awaited. One was already past due.

Crivilare rushed to set up payment plans with the hospitals in Jacksonville and Springfield, as well as the anesthesiologist, the surgeon, and the labs. Some providers demanded hundreds of dollars a month. Some settled for monthly payments of $20 or $25. Some pushed Crivilare to apply for new credit cards to pay the bills.

“It was a blur of just being on the phone constantly with all the different people collecting money,” she recalled. “That was a nightmare.”

Big Bills, Big Consequences

The Crivilares’ bills weren’t unusual. Parents with private health coverage now face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance, found.

Out-of-pocket costs are even higher for families with a newborn who needs to stay in a neonatal ICU, averaging $5,000. And for 1 in 11 of these families, medical bills related to pregnancy and childbirth exceed $10,000, the researchers found.

“This forces very difficult trade-offs for families,” said Michelle Moniz, a University of Michigan OB-GYN who worked on the study. “Even though they have insurance, they still have these very high bills.”

Nationwide polls suggest millions of these families end up in debt, with sometimes devastating consequences.

About three-quarters of U.S. adults with debt related to pregnancy or childbirth have cut spending on food, clothing, or other essentials, 素人色情片polling found.

About half have put off buying a home or delayed their own or their children’s education.

These burdens have spurred calls to limit what families must pay out-of-pocket for medical care related to pregnancy and childbirth.

In Massachusetts, state Sen. Cindy Friedman has to exempt all these bills from copays, deductibles, and other cost sharing. This would parallel federal rules that require health plans to cover recommended preventive services like annual physicals without cost sharing for patients. “We want 鈥� healthy children, and that starts with healthy mothers,” Friedman said. Massachusetts health insurers have warned the proposal will raise costs, but an independent state analysis estimated the bill would add only $1.24 to monthly insurance premiums.

Tough Lessons

For her part, Crivilare said she wishes new parents could catch their breath before paying down medical debt.

“No one is in the right frame of mind to deal with that when they have a new baby,” she said, noting that college graduates get such a break. “When I graduated with my college degree, it was like: 鈥楬ey, new adult, it’s going to take you six months to kind of figure out your life, so we’ll give you this six-month grace period before your student loans kick in and you can get a job.’”

Rita is now 2. The family scraped by on their payment plans, retiring the medical debt within a year, with help from Crivilare’s side job selling resources for teachers online.

But they are now back in debt, after Rita’s recurrent ear infections required surgery last year, leaving the family with thousands of dollars in new medical bills.

Crivilare said the stress has made her think twice about seeing a doctor, even for Rita. And, she added, she and her husband have decided their family is complete.

“It’s not for us to have another child,” she said. “I just hope that we can put some of these big bills behind us and give [Rita] the life that we want to give her.”

About This Project

“Diagnosis: Debt” is a reporting partnership between 素人色情片Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.听

Additional research was听, which analyzed credit bureau and other demographic data on poverty, race, and health status for 素人色情片Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute听听from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with 素人色情片Health News on a survey of its clients to explore links between medical debt and housing instability.听

素人色情片Health News journalists worked with 素人色情片public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from 素人色情片Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

A new analysis finds that graduating medical students were less likely to apply this year for residency training in states that ban or restrict abortion. That was true not only for aspiring OB-GYNs and others who regularly treat pregnant patients, but for all specialties.

Meanwhile, another study has found that more than 4 million children have been terminated from Medicaid or the Children’s Health Insurance Program since the federal government ended a covid-related provision barring such disenrollments. The study estimates about three-quarters of those children were still eligible and were kicked off for procedural reasons.

This week’s panelists are Julie Rovner of 素人色情片Health News, Lauren Weber of The Washington Post, Joanne Kenen of the Johns Hopkins University schools of nursing and public health and Politico Magazine, and Anna Edney of Bloomberg News.

Panelists

Among the takeaways from this week’s episode:

• More medical students are avoiding applying to residency programs in states with abortion restrictions. That could worsen access problems in areas that already don’t have enough doctors and other health providers in their communities.
• New threats to abortion care in the United States include not only state laws penalizing abortion pill possession and abortion travel, but also online misinformation campaigns 鈥� which are trying to discourage people from supporting abortion ballot measures by telling them lies about how their information might be used.
• The latest news is out on the fate of Medicare, and a pretty robust economy appears to have bought the program’s trust fund another five years. Still, its overall health depends on a long-term solution 鈥� and a long-term solution depends on Congress.
• In Medicaid expansion news, Mississippi lawmakers’ latest attempt to expand the program was unsuccessful, and a report shows two other nonexpansion states 鈥� Texas and Florida 鈥� account for about 40% of the 4 million kids who were dropped from Medicaid and CHIP last year. By not expanding Medicaid, holdout states say no to billions of federal dollars that could be used to cover health care for low-income residents.
• Finally, the bankruptcy of the hospital chain Steward Health Care tells a striking story of what happens when private equity invests in health care.

Also this week, Rovner interviews 素人色情片Health News’ Katheryn Houghton, who reported and wrote the latest 素人色情片Health News-NPR “Bill of the Month” feature, about a patient who went outside his insurance network for a surgery and thought he had covered all his bases. It turned out he hadn’t. If you have an outrageous or incomprehensible medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Nation’s “,” by Amy Littlefield.

Joanne Kenen: The New York Times’ “,” by Carl Elliott.

Anna Edney: ProPublica’s “,” by Anna Maria Barry-Jester.

Lauren Weber: Stat’s “,” by Nicholas Florko.

Also mentioned on this week’s podcast:

• 素人色情片Health News’ “Medical Residents Are Increasingly Avoiding States With Abortion Restrictions,” by Julie Rovner and Rachana Pradhan.
• CNBC’s “,” by Jason Gewirtz.
• The Washington Post’s “,” by Caroline Kitchener.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 素人色情片Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 9, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Lauren Weber of The Washington Post.

Lauren Weber: Hello. Hello.

Rovner: Joanne Kenen of the Johns Hopkins University schools of public health and nursing and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: And Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Later in this episode we’ll have my interview with 素人色情片Health News’ Katheryn Houghton, who reported and wrote the latest 素人色情片Health News-NPR “Bill of the Month.” This month’s patient went out of network for surgery and thought he did everything right. Things went wrong anyway. But first, this week’s news. We are going to start again with abortion this week with a segment I’m calling, “The kids are all right, but they don’t want to settle in states with abortion bans.”

This morning we got the numbers from the Association of American Medical Colleges on the latest residency match. And while applications for residency positions were down in general 鈥� more on that in a minute 鈥� for the second year in a row, they were down considerably more in states with abortion bans, and to a lesser extent, in states with other abortion restrictions, like gestational limits. And it’s not just in OB-GYN and other specialties that interact regularly with pregnant people. It appears that graduating medical students are trying to avoid abortion ban states across the board. This could well play out in ways that have nothing to do with abortion but a lot more to do with the future of the medical workforce in some of those states.

Edney: I think that’s a really good point. We know that even on just a shortage of primary care physicians and if you’re in a rural area already and you aren’t getting enough of those coming 鈥� because you could end up dealing with these issues in primary care and ER care and many other sections where it’s not just dealing with pregnant women all the time, but a woman comes in because it’s the first place she can go when she’s miscarrying or something along those lines. So it could lower the workforce for everybody, not just pregnant women.

Rovner: A lot of these graduating medical students are of the age where they want to start their own families. If not them, they’re worried about their partners. Somebody also pointed out to me 鈥� this isn’t even in my story 鈥� that graduating medical students tend to wait longer to have their children, so they tend to be at higher risk when they are pregnant. So that’s another thing that makes them worry about being in states where if something goes wrong, they would have trouble getting emergency care.

Weber: I would just add, I mean, you know, a lot of these states also overlap with states that have severe health professional shortages as well. You know, my reporting in St. Louis for 素人色情片Health News 鈥� we did a lot of work on how there are just huge physician shortages to start with. So the idea that you’re combining massive gaps in primary care or massive gaps in reproductive health deserts with folks that are going to choose not to go to these places is really a double whammy that I don’t necessarily think people fully grasp at this current point in time.

Rovner: I promised I would explain the reason that applications are down. This is something that’s happening on purpose. There are still more graduating medical students from MD programs and DO [Doctor of Osteopathy] programs and international medical graduates than there are residency slots, but graduating students had been applying to literally dozens and dozens of residencies to make sure they got matched somewhere, and they’re trying to deter that. So now I think students are applying to an average of 30 programs instead of an average of 60 programs.

That’s why it takes so long for them to crunch the numbers because everybody’s doing multiple applications in multiple states and it’s hard to sort the whole thing out. Of course, it may be that they don’t need all of those doctors. Because according to a separate survey from CNBC and Generation Lab, 62% of those surveyed said they probably wouldn’t or definitely wouldn’t live in a state that banned abortion. Seriously, at some point, these states are going to have to balance their state economies against their abortion positions. Now we’re talking about not just the medical workforce, but the entire workforce, .

Edney: Yeah. I was thinking about this recently because during the pandemic you had tech or Wall Street companies looking at Texas or Florida for where they wanted to move their headquarters or move a substantial amount of their company. And then when Dobbs [v. Jackson Women’s Health Organization] happened, how is the workforce going to play out? I’m curious what that ends up looking like because many of the people that might want to work for those companies might not want to live there in those states, and I think it could affect how the country is made up at some point. I think what’s still to play out is that over 60% that wouldn’t want to move to a state with abortion restrictions, whether that is something that plays out or whether some people say, “Well, that job’s really good, so maybe I do want to go make a lot more money in this place or whenever.” I’m curious how all of this I think, you know, over the next five years or something, plays out.

Rovner: Yeah. I mean, at some point, this something is better than nothing, that’s true of the residency numbers, too. If the only place you can match is in a state that you’d rather not go, I think most people would rather go somewhere than not be able to pursue their career, and I suspect that’s true for people in other lines of work as well. Well, meanwhile, anti-abortion states are continuing to push the envelope as far as they can. In Louisiana, legislation is moving, it passed the Senate already, to criminalize the act of ordering abortion pills from out of state. It’s scheduling mifepristone and misoprostol in the same category as opioids and other addictive drugs.

Simple possession of either abortion drug without a prescription could result in a $5,000 fine or five years in prison. And in a wild story out of Texas, the ex-partner of a woman who traveled to Colorado for an abortion is attempting to pursue against anyone who helped her, by helping her with travel or providing money or anything else associated with the abortion. Both of these cases seem like they’re trying to more chill people from attempting to obtain abortions than they are really actually pursuing legal action, right?

Kenen: Well, in that case, he’s pursuing legal action. We don’t know how that’s playing out, but I mean, it’s this accumulation of barriers and threats and making it both more difficult and more risky to obtain an out-of-state abortion or obtain medication abortion in-state. But there’s a big thicket and a lot of it, because it’s in court and it takes years to straighten things out, we don’t know what the final landscape’s going to look like, but obviously the trend is toward greater restriction.

Rovner: And I would point out that the lawyer who’s representing the ex-partner who’s trying to find everyone involved with the ex-partner’s abortion is the lawyer who brought us SB 8 [Senate Bill 8] the law, the “bounty hunter law,” that makes it a crime for people to aid and abet somebody getting an abortion in Texas. Lauren.

Weber: Yeah. I just would add too that tactics like this, whether or not 鈥� however they do play out in court, they do have a deterrence effect, right? There’s no way to absolutely tell someone XYZ is legally safe or not. At the end of the day, that can lead to a heck of a lot of misinformation, misconceptions, and different life choices. So I mean, I think the different things that Joanne and Julie are describing lead to people making different choices as all this plays out.

Kenen: I think one of the stories that Julie shared this week 鈥� there was an interesting little aside about disinformation, which is the petition to get an abortion rights ballot initiative in, I think it was Missouri. And one of the things in that article was that the anti-abortion forces were telling people that if you sign this petition, you’re vulnerable to identity theft. Now, so that is not true, but it’s just like this misinformation world we’re living in is spilling over into things like, you know, democratic issues of, “Can you get something on the ballot in your state?” It may lose. Missouri is a very conservative state. I don’t know what the threshold is for passage there. I don’t know that it’s as high as the 60% in Florida. But who knows what’s going to happen?

Rovner: That story was interesting, though, because it was the anti-abortion groups were trying to get people not just to not sign the petition.

Kenen: Unsign.

Rovner: Right. They were trying to get people to take their signatures off. And when all was said and done, they had twice as many signatures as they needed to get it on the ballot, so it will be on the ballot. I don’t know either what the threshold is in Missouri ’cause they were playing with that. Lauren, do you know?

Weber: I don’t know what the threshold is, but I will say what I found interesting about that story was that they said they were going to activate the Catholic Church. And as someone who is Catholic and went to Mass during the Missouri eras of Todd Akin and the stem cell fights, activating the Catholic Church could be very effective on changing how the abortion ballot plays out because I’ve seen what that looks like. So I’ll be very curious to see how that plays out in the weeks and months to come.

Kenen: Right. States doing physician-assisted suicide, aid-in-dying bills, have also 鈥� people fighting them have activated the church and they’re quite effective.

Rovner: Yeah. But I think Ohio also activated the Catholic Church and it didn’t work out. So I mean, we obviously know from polling Catholics, they’re certainly in favor of contraception and more American Catholics are in favor of abortion rights than I think their priests would like to know, at least that’s what they tell pollsters.

Edney: I also think that activating the church, whatever church it is, is at least a above-the-board tactic where in a lot of ways you never know, but this was so scary because they’re really going out and, not assaulting, but like verbally trying to keep these people from even being able to get signatures, saying that why should we let people vote on something that’s bad for them. Like not giving the electorate the right to make their voices heard. It was pretty scary to see that because of things like Ohio and other abortion rights movements that won that this is what they’re resorting to to try to make sure Missouri goes a different way.

Rovner: Yeah. I think this is going to be a really interesting year to watch because there are so many of them. Well, in abortion travel news, a federal district judge in Alabama green-lighted a suit by abortion rights groups against the state’s attorney general, who was threatening to prosecute those who “aid and abet” Alabama residents trying to leave the state for an abortion. “The right to interstate travel is one of our most fundamental constitutional rights,” Judge Myron Thompson wrote. On the other hand, Idaho was in federal appeals court in Seattle this week arguing just the opposite. They want to have an injunction lifted on its law that would make it a crime to help a minor cross state lines for an abortion. So I guess this particular fight about whether states can have control over their residents’ trying to leave the state for reproductive health care is a fight that’s going to continue for a while.

Edney: I mean, I think that 鈥� and sure it’ll continue for a while 鈥� you know, my thought when hearing about these cases is sort of just like, I know people that, when there wasn’t really gambling in Maryland, that would get in the bus and the seniors would all go to Delaware and go to the casino and go gambling. Like, we do this all the time. We go to other states for other things 鈥� for alcohol, in some cases. It’s just interesting that now they’re trying to make sure that people can’t do that when it comes to women’s rights.

Rovner: Yeah. I know. I mean, there are lots of things that are legal in some states and not legal in others.

Edney: Right.

Rovner: This seems to be, again, pushing the envelope to places we have not yet seen. Well, moving on, it is May, which means it’s time for the annual report of the Medicare and Social Security trustees about the financial solvency of the trust funds, and the news is good, sort of. Medicare’s Hospital Insurance Trust Fund can now pay full benefits until 2036. That’s five years more than the trustees estimated last year, thanks largely to a strong economy, more people paying payroll taxes, and fewer people seeking expensive medical care. But of course, Washington being Washington, good news is also bad news because it makes it less likely that Congress will take on the distasteful task of figuring out how to keep the program solvent for the long term. Are we ever going to get to this or is Congress just going to kick the can down the road until it’s like next year that the trust fund’s going bankrupt?

Kenen: I mean, of all the can-kicking 鈥� you know, we’ve used that phrase about Congress frequently 鈥� this is the distillation of the essence of kicking the can when it comes to entitlements, right? Both Social Security and Medicare need congressional action to make them viable and sustainable and secure for decades, not years, and we don’t expect that to happen. I mean, even when things are less partisan than they are now, because obviously we’re in a hyperpartisan era, even when Washington functioned better, this was still a kick-the-can issue. Not only was it kick the can, but everybody fought over how to kick the can and where to kick the can and who could kick it furthest. So five extra years is a long time. I mean, it is. But again, the economy changes. Tax revenues change. It’s a cyclical economy. Next year, we could lose the five years or lose two years or gain one year. Who knows? But in terms of a sustained, bipartisan, sensible 鈥� no, I’m not holding my breath, because I would get very, very red, very fast.

Rovner: Yeah. And also, I mean, the thing about fixing both Medicare and Social Security is that somebody has to pay more. Either there will be fewer benefits or more taxes, or in the case of Medicare, providers will be paid less. So somebody ends up unhappy. Usually in these compromises, everybody ends up a little bit unhappy. That’s kind of the best possible world. Lauren, you wanted to add something?

Weber: Yeah. I mean, I just wanted to add that if it goes insolvent by 2036, it’s not looking very good for my ability to access these programs.

Kenen: But they always fix it. They always fix it. They just fix it at the last minute.

Weber: That’s true. I mean, I think that’s a fair point, but I do think overall, the concern, it does seem like something will have to change. I don’t think that when I 鈥� hope, God willing 鈥� live long enough to access this Medicare benefits, that I think they’ll look very different. Because when there is a compromise or there is something like this, there’s just no way the program can continue as it is, currently.

Kenen: The other thing though is this Medicare date probably means there’ll be less campaign. You know, it was beginning to bubble up a little bit on the presidential campaign. I mean, there were plenty of other health care issues to fight about, but it probably means that there’ll be a little bit of token talk about saving Medicare and so forth, but unlikely that there will become a really hot-button issue with either Trump or Biden putting out a detailed plan about it. There’ll be some verbal, “Yes, I’ll protect Medicare,” but I don’t think it’ll be elevated. If it was the other way, if it had lost five years or lost three years, then we would’ve had yet another Medicare election. I think probably we won’t.

Rovner: Yeah. I think that’s exactly right. If the insolvency date had gotten closer, it would’ve been a bigger issue.

Kenen: And remember that the trend toward Medicare Advantage, which is more than people had anticipated, I mean, it is revolutionizing what Medicare looks like. It’s more than half the people now. So there’s many, many sub-cans to kick on that, with private equity and access and prior authorization. I mean, there’s a million things going on there, and payment rates and everything, but that is a slow-motion, dramatic change to Med[icare], not so slow, but that is a dramatic change to Medicare.

Rovner: We’re figuring out how to do sort of a special episode just on Medicare Advantage because there’s so much there. But meanwhile, let’s catch up on Medicaid, ’cause it’s been a while. As one of my colleagues put it on Slack this week, it was a swing and a miss in Mississippi, where some pretty serious efforts to expand Medicaid came to naught as the legislature closed the books on its 2024 session last week. Mississippi is one of the 10 remaining states that have not expanded Medicaid under the Affordable Care Act, which could expand health coverage to an estimated 200,000 low-income residents there who lack it now. It feels like these last states, mostly in the South, are going to hold out as long as they can, even though they’re basically giving up a gigantic handout from the federal government.

Edney: It’s billions of dollars they’re leaving on the table and it doesn’t really make sense. This seemed to maybe come down to a work requirement. Maybe there was more there. It was more of a poison pill in that Senate bill instead, but it doesn’t seem to make sense. I mean, even one of the earlier bills the Senate in Mississippi had come up with would have left billions of dollars on the table as well. So I think the idea of this being the central part of Obamacare is still strong in some places.

Kenen: And it also is worth pointing out that these are states not just with the gap in coverage, but most of these states don’t have great health status. They have a lot of chronic disease, a lot of obesity, a lot of addiction, a lot of diabetes, etc. The se are not the healthiest states in the country. You’re not just leaving money on the table; you’re leaving an opportunity to get people care on the table and 鈥�

Rovner: And exacerbating health inequities that we already have.

Kenen: Yes. Yes. And when North Carolina decided to, which took many years of arguing about it 鈥� that’s a purple state; there were some people who thought it would be a domino: OK, North Carolina stopped holding out; the rest of the South will now. I, never having reported in North Carolina on that, you know, having spent time in the state, I never thought it was a domino. I thought it was just something that went on in North Carolina. Do I think eventually most or all of them will accept Medicaid? Yes. But, you know, we’ve mentioned this before: It took almost 20 years for the original Medicaid to go to all 50 states.

And it’s not just 鈥� because North Carolina is North Carolina and South Carolina is different. They have different dynamics. And it’s not over by any means, and there’s no 鈥� Mississippi got close. Are they going to pick up where they left off and sort it out next year? Who knows? There’s elections between now and then. We don’t know what the makeup and who is the driver of this, and which chamber there, and who’s retiring, and who’s going to get reelected. We just don’t know exactly. It’s not going to be a dramatic shift, but in these close fights, a couple of seats shifting in state government can change things.

Rovner: That’s what happened in Kansas, although Wyoming came close, I think it was a couple of years ago, and then there I haven’t seen any action either, so.

Kenen: You still hear talk about Wyoming considering it. Like, that’s not off the 鈥� I don’t think any of us would be totally shocked if Wyoming is the next one, but I mean it didn’t happen this year, so.

Rovner: Well the other continuing Medicaid story is the “unwinding,” dropping those from coverage who were kept on during the pandemic emergency by a federal requirement. A new report from the Georgetown Center for Children and Families finds that as of the end of 2023, the number of children covered by Medicaid or the Children’s Health Insurance Program was down by 10%, or about 4 million. Yet an estimated three-quarters of those kids are actually still eligible. They were struck from the rolls because of a breakdown in paperwork. Texas alone was responsible for more than a million of those disenrollments, a quarter of the total. Texas and Florida together accounted for nearly 40% of those dropped. And Texas and Florida are also the largest states that haven’t expanded Medicaid to the working poor. At some point the problem with the uninsured is going to be back on our radar, right? I mean, we haven’t talked about it for a while because we haven’t sort of needed to talk about it for a while because uninsurance rate has been the lowest it’s been since we’ve been keeping track.

Weber: I just can’t get over that three-quarters of kids lost their coverage due to paperwork issues. I mean, I know we talk about it many times on this podcast, but just to go back to it again: I miss mail. We all miss mail. I’m not someone also that’s moving frequently. That would make it easier to miss mail. I mean, that is just 鈥�

Kenen: You speak English.

Weber: Yeah, and I speak English. That is a wild stat, that 75% of these children lost this coverage because of paperwork issues. And as that report discusses, you know, some states did work to mitigate that and other states worked to not mitigate it. And I think that’s an important distinction to be clear about.

Rovner: And I will link to the report because the report shows the huge difference in states, the ones that sort of did it slowly and carefully. I think the part of it that made my hair stand on end was not so much the kids who came off because, you know, the whole family did, because the paperwork issues, but it’s the kids, particularly kids in CHIP who were still eligible when their parents aren’t. And there were some states that just struck families entirely because the parents were no longer eligible without realizing in their own state that parents’ eligibility and kids’ eligibility isn’t the same. And that apparently happened in a lot of cases. And I think the federal government tried to intercede in some of those because those were kids who, by definition of how these programs work, would still be eligible when their parents were not.

Kenen: The one thing it’s always good to remind people that, I mean, this is an extraordinary mess. I mean, it’s not the unwinding, it’s the unraveling. But unlike employer-sponsored insurance and the Obamacare exchanges, there’s no enrollment season for Medicaid. You can get in if you qual 鈥� so it can be the unwinding could be rewound. If a child gets sick and they are in an ER or they’re in a hospital or in a doctor’s or whatever, they can get back in quickly. It is a 365-day, always-open, for both Medicaid and CHIP in I believe every state. There may be an exception I’m not aware of, but I think it’s everywhere.

Rovner: I think it’s everywhere. I think it’s a requirement that it’s everywhere.

Kenen: I think it’s federal, right. So yes, it’s a mess, but unlike many messes in health care, it is a mess that can be improved. Although of course not everybody knows that and somebody will be afraid to go to the doctor ’cause they can’t pay, etc., etc. I’m not minimizing what a mess it is. But if you get word out, you can get word out to people that, you know, if you’re sick, go to the doctor. You’re still being taken care of.

Rovner: And also when people do go to the doctor, at the same time they’re told, uh-oh, your Medicaid’s been canceled, they can be reenrolled if they’re still eligible.

Kenen: Yeah, right. I mean, community health clinics know that. Hospitals know that. I don’t know that all private physicians’ offices know that, but 鈥�

Rovner: Although they should 鈥�

Kenen: They should.

Rovner: 鈥� because that’s how they’ll get paid.

Kenen: They should.

Rovner: So I suspect 鈥� providers have an incentive to know who’s eligible because otherwise they’re not going to get paid.

Kenen: So that should be the next public campaign. If you lost your Medicaid, here’s how you get it back. And we don’t see enough of that.

Rovner: Last week we talked about a lot of health-related regulations the Biden administration is trying to finalize. If it seems they’re all happening at once, there is an actual reason for that. It’s called the Congressional Review Act. Basically the CRA lets a new Congress and administration easily undo regulations put in place by an earlier administration towards the end of a presidential term. Basically that means any regulations the Biden administration doesn’t want easily overturned by the next Congress and president, should it return to Republican hands, those regulations need to be completed roughly by the end of this month. Towards that end, and as I said, speaking of looking at the problem of the uninsured, last week the administration finalized a rule that would give people here under DACA, that’s the Deferred Action for Childhood Arrivals immigration program, access to subsidized coverage under the Affordable Care Act.

These are about 100,000 so-called Dreamers, those who are not here legally but were brought over as children. In general, those who are not in the country legally are not able to access Affordable Care Act coverage. That was a gigantic fight when the Affordable Care Act was being passed. In some ways, though, I feel like this addition of Dreamers to the ACA is an acknowledgement that they’re not going to get full legal status anytime soon, which has also been a fight that’s been going on for years and years.

Kenen: Yes. And I was wondering, like, who’s going to sue to stop this or introduce legislation? I mean, somebody will do something. I’m not sure what yet. I mean, I would be surprised if nobody tries to block this because there’s obviously controversy about normalizing the status of the Dreamers or the DACA population and it’s been going on for years. We’ll see. I mean, it’s just another, I mean, immigration is such a flash point in this year’s election. Maybe people will say, “OK, this portion of the Dreamers has legal status and they can get health insurance” and people won’t fight about it. But usually nowadays people fight about 鈥� I mean, if the intersection of health care and immigration, I would think somebody will fight about it.

Rovner: Yeah. I would, too. And also, I mean obviously the people who are preventing legislation from getting through to legalize the Dreamers’ status, there seems to be, I believe, there is overwhelming support in both houses, but not quite enough to get it through. I suspect those people on the other side might not be very happy about this. Well, finally this week in business, or more specifically this week in private equity in health care, the multistate hospital chain Steward Health [Care] filed for bankruptcy this week, putting up for sale all 31 of its hospitals, which normally wouldn’t be really big news. Lots of hospitals are having trouble keeping their doors open. But in this case, we’re talking about a chain that was pretty large and stable until it was bought by Cerberus Capital Management, a private equity firm.

Cerberus sold off the land the hospitals were on, requiring them to pay rent to yet another company, and then Cerberus got out. The details of the many transactions that took place are still kind of murky, but it appears that many investors did quite well, including acquisitions of some private yachts, while the hospitals, well, did not do so well. This all has yet to play out fully. But this seems to be pretty much how private equity often works, right? They buy something, take the profit that they can, and leave the rest to the whims of the marketplace, or in this case billions of dollars in debt now owed by these hospitals.

Weber: Yeah. I mean, I think when you look at private equity the question is always when is the multipliers going to run out? Like, when are you going to run out of things to sell to get the multipliers out? And the question is, when you do this with health care, you know, we’ve seen some emerging research show that the patient outcomes for private equity-owned health care systems can be impacted by infection rates and so on. And I mean, I thought it was particularly interesting at the end of this Wall Street Journal story, they also noted how UnitedHealthcare, there is some investigations over 鈥�

Rovner: They’re tangentially involved.

Weber: They’re tangentially involved, but the government appeared 鈥� the story seems to allude to the government is interested in whether there’s some antitrust concerns on selling the doctors’ practices, which is obviously an ongoing issue as well as we talk about health care and acquisitions and consolidation in the country. So, 31 hospitals’ being insolvent is a lot of hospitals in a lot of states.

Rovner: Yeah. And I mean, the idea, I think, was that one of the ways they were going to pay off some of their debts was by selling the doctor practices to United. United, of course, now under the microscope for antitrust, might not be such an eager buyer, which leaves Steward holding the bag again with all of this debt. They owe literally billions of dollars to this company that now owns the land that their hospitals are on. It is quite the saga.

Kenen: It’s very complicated. I mean, I had to read everything more than once to understand it, and I’m not sure I totally understood all of it. It’s also sort of like the, you know, if you were writing, if you were teaching business school about what can go wrong when private equity buys a health system, this would be your final exam question. It is very complicated, extremely damaging, and the critics of PE in health care 鈥� I mean this is everything they warn about. And I would also, since all of us are journalists, I mean the same thing is going on with private equity in owning newspapers or newspaper chains: wreckage. Not everyone is a bad actor. There’s wreckage in health care and there’s wreckage in the media.

Rovner: Yeah. We will watch this one to see how it plays out. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Katheryn Houghton and then we will be back with our extra credits. I am pleased to welcome to the podcast my 素人色情片Health News colleague, in person, here in our Washington, D.C., studio, Katheryn Houghton, who reported and wrote the latest 素人色情片Health News-NPR “Bill of the Month.” It’s about an out-of-network surgery the patient knew would be expensive, but not how expensive it would be. Welcome, Katheryn.

Houghton: Hi.

Rovner: So tell us about this month’s patient, who he is, and what kind of treatment he got.

Houghton: So I spoke with Cass Smith-Collins. He’s a 52-year-old transgender man from Vegas, and he wanted to get surgery to match his chest to his gender identity, so he got top surgery.

Rovner: This was a planned surgery and he knew he was going to go out of network. So what kind of steps did he take in preparation to make sure that the surgery would be at least partially covered by his health insurance?

Houghton: Well, he actually took a really key step that some patients miss, and it’s making sure that you get prior authorization from insurance, so a letter from them saying we’re going to cover this. And he got that. He also talked with his surgeon beforehand, saying what do I need to do to make sure we can submit a claim with insurance? And he signed paperwork saying how that would happen.

Rovner: Then, as we say, the bill came. What went awry?

Houghton: Yeah. Or in this case the reimbursement didn’t come. For Cass’ case there are two key things that kind of went awry here. First off, covered doesn’t necessarily mean the entire bill. So what insurance says is a fair price is not going to match up with what the surgeon always says is a fair price. So when Cass saw that his procedure was covered, it didn’t say the entire amount. It didn’t say how much was covered. The second thing is that that provider agreement that he signed with the surgeon beforehand actually says you’re not guaranteed reimbursement. And that provider agreement also stated there are two different bills here. One is the cost that Cass paid up-front for his surgery, and the other was the bill submitted to insurance.

Rovner: And how much money are we actually talking about here?

Houghton: We’re talking about $14,000. And he expected to get about half of that back.

Rovner: Because he assumed that when he got to his out-of-network maximum the insurance would cover, right?

Houghton: Exactly.

Rovner: And that’s not what happened.

Houghton: Not at all.

Rovner: How much did the surgeon end up charging for the surgery and what did his insurance say about that?

Houghton: If you’re looking at both bills, the surgeon charged more than $120,000 for the surgery and insurance said ah, no, we’re not going to cover that. And it was a little over $4,000 that insurance said, this is the fair price.

Rovner: So that’s a big difference.

Houghton: A very big difference.

Rovner: Was Cass expected to pay the rest?

Houghton: He could have. The agreement that he signed actually said that he could be on the hook for whatever insurance didn’t cover. That being said, he didn’t get a bill this time around.

Rovner: So what eventually happened?

Houghton: So eventually, when 素人色情片Health News started asking questions about this, insurance increased how much that they paid the provider. And with that increased reimbursement, which was $97,000, the provider gave Cass a reimbursement of about $7,000.

Rovner: So he ended up paying about $7,000 out-of-pocket.

Houghton: It was more towards the line of what he was expecting to pay for this.

Rovner: Right. I was just going to say that was about what his out-of-pocket maximum was. But in this case he was kind of just lucky, right?

Houghton: Yes. I mean the paperwork that he signed in advance 鈥� it was really confusing paperwork. We had several experts look over this and say, yeah, there are things in this we don’t fully understand what it means.

Rovner: What’s the takeaway here? A lot of people want to go to a particular provider who may be very good at what they do but don’t take insurance. Is there any way that he could have better prepared for this financially or that somebody looking at a similar kind of situation and doesn’t want to end up having someone say, oh, you owe us $80,000?

Houghton: Right. Yeah. So for this case it was really important for Cass to go to a surgeon that he felt like he could trust. And so if you do have that out-of-network provider, there are a few steps you can actually take. There’s still no guarantees, but there are steps. First off, patients should always ask their insurance company what covered actually means. Are you talking the entire bill here? Are you talking just a portion of it? Try to get that outlined. You can also ask your insurance company to spell out the dollar amount that they’re willing to pay for this. That’s a really helpful step. And lastly, on the provider side, you can also say, “Hey, whatever insurance deems as a fair payment, can we count that as the total bill?” You can always ask that. They’re not required, but it’s worth checking.

Rovner: Yeah. So at least you go in with your eyes open knowing what your maximum is going to be.

Houghton: Exactly. Especially if you’re paying out-of-pocket to begin with. You really want to know what is insurance reimbursing for this? What is the provider going to charge me more at the end of this?

Rovner: Well, I’m glad this one had a happy ending. Katheryn Houghton, thank you very much.

Houghton: Thank you so much.

Rovner: OK, we are back. It’s time for our “extra credit” segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Anna, why don’t you go first this week?

Edney: Sure. So mine is from ProPublica by Anna Maria Barry-Jester and it’s “.” And I think we have even heard over the last few years the story of syphilis rates rising and in this specific look at the Great Plains, there are Native Americans there, that the syphilis rates are even worse. And this is resulting in deaths of babies, like wanted children. And it seems like the federal government has been pretty lackluster in its response, to put it mildly, sending a few CDC [Centers for Disease Control and Prevention] workers for a couple of weeks, and the tribes have been asking for basically a national emergency so they can get more help. And they’ve gone straight to HHS [Health and Human Services] Secretary [Xavier] Becerra, and at least in the last several weeks as this was being reported, they haven’t gotten any response or any help. So I think it’s an important story to spread far and wide.

Rovner: It is. Joanne?

Kenen: There was a very interesting op-ed in The New York Times this week by Dr. Carl Elliott, who is a physician and bioethicist at the University of Minnesota: “.” It’s a little hard to summarize, but it’s very subtle. It’s the culture of medicine, of being a medical student or a resident, and the things you see, so much of what you see, shocks you anyway because it’s something you have to get used to. But there are outrages. He begins, the opening anecdote is a woman is unconscious and anesthetized before her surgery and the doctor in charge invites all the med students to come and like, “Oh, why don’t you come touch her cervix? She’ll never know. See what it’s like.”

And to that, to really the larger, even larger questions about how did Willowbrook [State School] survive for all those years? How did the Tuskegee studies go on for all those years? You know, at what point, what are the sort of cultural and peer pressure and dynamics of these outrages, big and large, becoming normalized? And, you know, as we know, like recently HHS just said you have to have a written consent for a pelvic exam, particularly if you’re going to be unconscious. But that’s only one example 鈥� it was a very disturbing piece actually.

Rovner: Yeah. It really was. Lauren?

Weber: I chose Nicholas Florko’s piece on how “,” in Stat. Great piece. He dug through a bunch of the Juul legal documents that have been revealed to show how two prominent NYU public health professors were communicating with Juul about their comments in both a congressional hearing and then public comments to many, many journalists defending vaping and saying that, you know, it had public health benefits because it got people off of cigarettes. And it raises up a lot of thorny questions about conflict of interest. These public health officials say they were not paid by Juul, but they did accept dinners. And the question is, you know, a lot of the studies they submitted, one of them they even sent to Juul. It’s a lot of thorny questions about academic review and disclosures. It’s a great piece, too, and a warning for all journalists of who are you interviewing, what are their ties, and what are the disclosures that they may or may not be sharing? It was a great story.

Rovner: Yeah. Super thought-provoking. I will say, every time I speak 鈥� and we don’t take money for speaking 鈥� all of my speeches are for free. But I constantly, you know, they now have to fill out that, “Do you have any conflicts of interest?” And it’s like, no, I don’t take any money from any industry. But it’s all basically self-reported, and I think that’s one of the big problems with this whole issue. Well, my story this week is from The Nation. It’s by Amy Littlefield. It’s called “.” And it’s not the first story like this, but it’s a very comprehensive look at the fight that’s shaping up between blue states that are passing shield laws to protect doctors who are providing abortion medication to patients in red states where, as we discussed earlier, prosecutors would like to reach back to punish those blue-state providers. It’s a fairly small group of providers operating in what is still a legally gray area.

As we mentioned, this is all still under 鈥� in court, in various places at various levels 鈥� but I do think it’s one of the next big battles that are shaping up in reproductive health. It’s a really good piece. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, , or at Bluesky and at Threads. Joanne, are you hanging anywhere on social media?

Kenen: A little bit on Twitter , not even that much. But more on Threads .

Rovner: Anna?

Edney: on Twitter and on Threads.

Rovner: Lauren?

Weber: Still only on Twitter, . HP is for health policy.

Rovner: Don’t apologize. You can find us all if you really want to. We will be back in your feed next week. Until then, be healthy.

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Sarai Holguín, de 71 años y originaria de México, ha aceptado la bala alojada cerca de su rodilla como su “compa”, es decir, una amiga cercana.

A Mireya Nelson, de 15, la alcanzó una bala que atravesó su mandíbula y le rompió el hombro, donde quedaron fragmentos. Por ahora vivirá con ellos, mientras los médicos monitorean los niveles de plomo en su sangre por al menos dos años.

A casi tres meses del tiroteo en el desfile del Super Bowl de los Kansas City Chiefs, que dejó al menos 24 personas heridas, recuperarse de esas heridas es algo profundamente personal e incluye una sorprendente área gris de la medicina: si las balas deberían o no extraerse.

El protocolo médico no ofrece una respuesta clara. Una encuesta de 2016 entre cirujanos reveló que de los encuestados trabajaban en instalaciones médicas que tenían normas sobre la extracción de balas.

Los médicos en Estados Unidos a menudo dejan las balas enterradas profundamente en el cuerpo de una persona, al menos al principio, para no causar más trauma.

Pero a medida que la violencia armada surge como una epidemia de salud pública, si esa práctica es la mejor.

Algunos de los heridos, como James Lemons, quedan en una situación precaria. “Si hay una manera de sacarla y se saca de forma segura, sáquenla fuera de la persona”, dijo Lemons. “Hagan que esa persona se sienta más segura consigo misma. Y que no tengas que estar caminando con ese recuerdo dentro de tí”.

Lemons, Holguín y Nelson están sobrellevando las cosas de manera muy diferente.

El dolor se convirtió en un problema

Tres días después de que los Chiefs ganaran el Super Bowl, Lemons condujo las 37 millas desde Harrisonville, Missouri, hasta el centro de Kansas City para celebrar la victoria. Lemons, quien trabaja en un depósito, llevaba a su hija de 5 años, Kensley, en sus hombros cuando sintió una bala entrar en la parte posterior de su muslo derecho.

Los disparos se desataron en un área abarrotada de fans, , después de una “confrontación verbal” entre dos grupos. Los detectives encontraron “múltiples cartuchos de bala calibre 9 mm y .40” en el lugar. Lemons dijo que entendió inmediatamente lo que estaba sucediendo.

“Conozco mi ciudad. No estamos lanzando fuegos artificiales”, dijo.

Mientras se tiraban al听 suelo, Lemons protegió el rostro de Kensley para que no golpeara sobre el cemento. Su primer pensamiento fue llevar a su familia 鈥攕u esposa, Brandie; su hija de 17 años, Kallie; y su hijo de 10 años, Jaxson鈥� a un lugar seguro.

“Me dispararon. Pero no te preocupes”, recordó Lemons que le dijo a Brandie. “Tenemos que irnos”.

Llevó a Kensley en sus hombros mientras la familia caminaba una milla hasta su auto. Al principio su pierna sangraba a través de sus pantalones, pero después paró, dijo. Ardía de dolor. Brandie insistió en llevarlo al hospital, pero el tráfico estaba estancado, así que encendió las luces de emergencia y condujo en la dirección opuesta.

Lemons recordó que ella dijo: “’Te estoy llevando al hospital. Estoy cansada de que la gente se interponga en mi camino'”. “Nunca había visto a mi esposa así. La miré y pensé, 鈥榚sto es algo sexy'”.

Contó que le sonrió a su esposa y aplaudió, a lo que ella respondió: “驴Por qué estás sonriendo? Acaban de dispararte”. Se mantuvo en silenciosa admiración hasta que los detuvo un sheriff, que llamó a una ambulancia, recordó Lemons.

Lo llevaron a la sala de emergencias de University Health, que ese día , incluidos ocho con heridas de bala. Las placas mostraron que la bala apenas había esquivado una arteria, dijo Lemons.

Los médicos limpiaron la herida, pusieron su pierna en un aparato ortopédico y le dijeron que regresara en una semana. La bala todavía estaba en su pierna.

“Me sentí un poco desconcertado, pero pensé, 鈥楨stá bien, lo que sea, saldré de aquí'”, recordó Lemons.

Cuando regresó, los médicos le quitaron el aparato ortopédico pero le explicaron que a menudo dejan balas y fragmentos en el cuerpo, a menos que se vuelvan demasiado dolorosos.

“Entiendo, pero no me gusta eso”, dijo Lemons. “驴Por qué no la sacarías si pudieras?”

Leslie Carto, vocera de University Health, dijo que el hospital no puede comentar sobre la atención de pacientes debido a las leyes federales de privacidad.

Los cirujanos generalmente extraen las balas cuando las encuentran durante la cirugía o cuando están en lugares peligrosos, como en el canal espinal, o a punto de dañar un órgano, explicó , cirujano pediátrico del Connecticut Children’s.

Campbell también preside el Comité de Prevención y Control de Lesiones del Comité de Trauma del Colegio Americano de Cirujanos, que trabaja en la prevención de lesiones por armas de fuego.

, cirujano entrenado en trauma y fundador de la 听en St. Louis, dijo que los orígenes de la atención del trauma también ayudan a explicar por qué las balas generalmente no se extraen.

“La atención del trauma es medicina de guerra”, dijo Punch. “Está preparada para estar lista en cualquier momento, todos los días, para salvar una vida. No está equipada para cuidar la curación que se necesita después”.

En la encuesta a los cirujanos, las razones más comunes dadas para extraer una bala fueron el dolor, una bala palpable alojada cerca de la piel o una infección. Mucho menos comunes fueron la intoxicación por plomo y las preocupaciones de salud mental como el trastorno de estrés postraumático y la ansiedad.

Los cirujanos dijeron que lo que querían los pacientes también impactaba en sus decisiones.

Lemons quería que le quitaran la bala. El dolor en su pierna se irradiaba desde su muslo, lo que le dificultaba moverse durante más de una hora o dos. Era imposible trabajar en el depósito.

“Tengo que levantar 100 libras cada noche”, recordó Lemons que le dijo a sus médicos. “Tengo que levantar a mi hijo. No puedo trabajar así”.

Ha perdido sus ingresos y su seguro de salud. Otro racha de mala suerte: el dueño de la casa que alquilaban decidió venderla poco después del desfile, y tuvieron que encontrar un nuevo lugar para vivir.

La casa actual es más pequeña, pero era importante mantener a los niños en el mismo distrito escolar con sus amigos, dijo Lemons en una entrevista en el dormitorio rosa de Kensley, el lugar más tranquilo para hablar.

Han pedido dinero prestado y recaudaron para ayudar con el depósito y las reparaciones del automóvil, pero el tiroteo del desfile ha dejado a la familia en un profundo pozo financiero.

Sin seguro, Lemons temía no poder pagar para que le extrajeran la bala. Luego se enteró que su cirugía sería pagada por donaciones. Programó una cita en un hospital al norte de la ciudad, donde un cirujano tomó medidas en su radiografía y le explicó el procedimiento.

“Necesito que estés involucrado tanto como yo voy a estar involucrado”, recordó que le dijeron, “porque 鈥攁divina qué鈥� esta no es mi pierna”.

La cirugía está programada para este mes.

“Nos hicimos amigas”

Sarai Holguín no es gran fanática de los Chiefs, pero aceptó ir al rally en Union Station para mostrarle a su amiga el mejor lugar para ver a los jugadores en el escenario.

Era un día inusualmente cálido, y estaban paradas cerca de una entrada donde había muchos policías. Había papás con bebés en cochecitos, los niños jugaban al fútbol americano y Holguín se sentía segura.

Un poco antes de las 2 pm, escuchó lo que pensó que eran fuegos artificiales. La gente comenzó a correr lejos del escenario. Se dio vuelta, tratando de encontrar a su amiga, pero se sintió mareada. No se dio cuenta que le habían disparado. Tres personas rápidamente la ayudaron a tirarse al suelo, y un extraño se quitó la camisa e hizo un torniquete en su pierna izquierda.

Holguín, originaria de Puebla, México, ciudadana estadounidense desde 2018, nunca había visto tanto caos, tantos paramédicos trabajando bajo tanta presión. Fueron “héroes anónimos”, dijo.

Los vio atendiendo a Lisa López-Galván, una conocida DJ de 43 años y dos hijos. López-Galván murió en el lugar, y fue la única víctima mortal. A Holguín la llevaron a University Health, a unos cinco minutos de Union Station.

Allí, la operaron, pero dejaron la bala en su pierna. Holguín se despertó en medio de más caos. Había perdido su bolso y su teléfono celular, así que no pudo llamar a César, su esposo. La internaron en el hospital bajo un alias, una práctica común en los centros médicos para comenzar a atender al paciente de inmediato.

Su esposo e hija no la encontraron hasta cerca de las 10 pm, unas ocho horas después de que le dispararan.

“Ha sido un gran trauma para mí”, dijo Holguín a través de un intérprete. “Estaba herida y en el hospital sin haber hecho nada malo. [El rally] era un momento para jugar, relajarse, estar juntos”.

Holguín estuvo una semana internada, e inmediatamente tuvo dos cirugías ambulatorias más para eliminar el tejido muerto alrededor de la herida. Usó un dispositivo especial durante varias semanas y tuvo citas médicas cada dos días.

Campbell, el cirujano de trauma, dijo que esos dispositivos, llamados “de cierre asistido por vacío” son comunes cuando las balas dañan tejidos que no se pueden reconstruir fácilmente en la cirugía. (Ayudan a acelerar el proceso de cierre de la herida)

“No son solo las lesiones físicas”, dijo Campbell. “Muchas veces son las lesiones emocionales, psicológicas, que muchos de estos pacientes también experimentan”.

La bala sigue cerca de la rodilla de Holguín.

“La tendré por el resto de mi vida”, dijo, agregando que ella y la bala se han convertido en “compas”, amigas cercanas. “Nos hicimos amigas para que ella no me haga ningún otro daño”, dijo Holguín sonriendo.

Punch, de la Bullet Related Injury Clinic en St. Louis, dijo que algunas personas como Holguín pueden tener la fortaleza mental para vivir con una bala en el cuerpo.

“Si puedes crear una historia sobre lo que significa que esa bala esté en tu cuerpo, eso te da poder; te empodera”, dijo Punch.

La vida de Holguín cambió en un instante: está usando un andador para moverse. Su pie, dijo, actúa “como si hubiera tenido un derrame cerebral”, se queda colgando y es difícil mover los dedos de los pies.

La consecuencia más frustrante es que no puede viajar para ver a su padre de 102 años, que está en México. Lo ve en video a través de su teléfono, pero eso no ofrece mucho consuelo, dijo, y pensar en él la hace llorar.

En el hospital le dijeron que sus facturas médicas serían cubiertas, pero luego muchas de ellas llegaron por correo. Intentó obtener ayuda para las víctimas del estado de Missouri, pero le costo entender todos los formularios que tenía porque estaban en inglés.

Solo alquilar el dispositivo de cierre asistido por vacío costaba $800 al mes.

Finalmente escuchó que el Consulado de México en Kansas City podía ayudar, y el cónsul la remitió a la Oficina del Fiscal del condado de Jackson, donde se registró como víctima oficial. Ahora todas sus facturas están siendo pagadas, dijo.

Holguín no buscará tratamiento de salud mental, ya que cree que uno debe aprender a vivir con una situación determinada o se convertirá en una carga. “He procesado este nuevo capítulo en mi vida”, dijo Holguín. “Nunca me he rendido y seguiré adelante con la ayuda de Dios”.

“Vi sangre en mis manos”

Mireya Nelson llegó tarde al desfile. Su madre, Erika, le dijo que se fuera temprano, por el tráfico y el millón de personas que se esperaba en el centro de Kansas City, pero ella y sus amigos adolescentes ignoraron el consejo. Los Nelson viven en Belton, Missouri, aproximadamente a media hora al sur de la ciudad.

Mireya quería sostener el trofeo del Super Bowl. Cuando ella y sus tres amigos llegaron, el desfile que había pasado por el centro ya había terminado y había comenzado el rally en Union Station. Estaban atrapados entre la multitud y se aburrieron rápido, dijo Mireya.

Mireya y una de sus amigas intentaron llamar al conductor de su grupo para irse, pero no tenían señal en el celular, por la gran multitud.

En medio del caos de personas y ruido, Mireya de repente se desplomó.

“Vi sangre en mis manos. Así que supe que me habían disparado. Sí, y simplemente me arrastré hacia un árbol”, dijo Mireya. “En realidad, al principio no sabía dónde me habían disparado. Solo ví sangre en mis manos”.

La bala rozó la barbilla de Mireya, atravesó su mandíbula, le rompió el hombro y salió por su brazo. Quedaron fragmentos de bala en su hombro. Los médicos decidieron dejarlos porque la joven ya había sufrido mucho daño.

Por ahora, la madre de Mireya apoya esa decisión, señalando que eran solo “fragmentos”. “Creo que si no la van a dañar el resto de su vida”, dijo Erika, “no quiero que siga volviendo al hospital y teniendo cirugías. Eso es más trauma para ella y más tiempo de recuperación, más terapia física y cosas así”.

Punch dijo que los fragmentos de bala, especialmente los que son solo superficiales, a menudo se abren paso como astillas, aunque a los pacientes no siempre se les dice eso. Además, agregó, las lesiones causadas por las balas se extienden más allá de aquellos con tejido dañado a las personas a su alrededor, como Erika. Pidió un enfoque holístico para recuperarse de todo el trauma.

“Cuando las personas permanecen en su trauma, ese trauma puede cambiarlas para toda la vida”, dijo Punch.

Mireya será sometida a en su sangre durante al menos los próximos dos años. Ahora sus niveles están bien, dijeron los médicos a la familia, pero si empeoran, necesitará cirugía para remover los fragmentos, dijo su madre.

Campbell, el cirujano pediátrico, dijo que el plomo es particularmente preocupante para los niños pequeños, cuyos cerebros en desarrollo los hacen especialmente vulnerables a sus . Incluso 鈥�3.5 microgramos por decilitro鈥� es suficiente para informar a las autoridades de salud estatales, según los Centros para el Control y Prevención de Enfermedades (CDC).

Mireya habla sobre adolescentes lindos, pero todavía usa pijamas de Cookie Monster. Parece confundida por los tiroteos, por toda la atención en casa, en la escuela, de los periodistas. Cuando le preguntaron cómo se siente sobre los fragmentos en su brazo, dijo: “Realmente no me importan”.

Después de su estadía en el hospital, Mireya tomó antibióticos durante 10 días porque los médicos temían que hubieran bacterias en la herida. Ha tenido terapia física, pero es doloroso hacer los ejercicios. Tiene una cicatriz en la barbilla. “Una muesca”, dijo, que es “irregular”.

“Dijeron que tuvo suerte porque si no hubiera girado la cabeza de cierta manera, podría haber muerto”, dijo Erika.

Mireya enfrenta una evaluación psiquiátrica y sesiones de terapia, aunque no le gusta hablar de sus sentimientos.

Hasta ahora, el seguro de Erika está pagando las facturas médicas, aunque espera obtener algo de ayuda del fondo , que recaudó casi $1.9 millones, o de una organización de fe llamada .

Erika no quiere limosnas. Tiene un trabajo en atención médica y acaba de tener un ascenso.

La bala ha cambiado la vida de la familia de muchas maneras. Ahora forma parte de sus charlas. Hablan sobre cómo desearían saber qué tipo de munición era, o cómo se veía.

“Como si quisiera quedarme con la bala que atravesó mi brazo”, dijo Mireya. “Quiero saber qué tipo de bala era”. Eso provocó un suspiro de su mamá, quien dijo que su hija había visto demasiados episodios de “Forensic Files”.

Erika se culpa por la herida, porque no pudo proteger a su hija en el desfile.

“Me duele mucho porque me siento mal, porque ella me suplicó que dejara el trabajo y no fui allí porque cuando tienes un puesto nuevo, no puedes simplemente irte del trabajo”, dijo Erika. “Porque yo hubiera recibido la bala. Porque haría cualquier cosa. Es lo que hace una mamá”.

素人色情片Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

James Lemons, 39, wants the bullet removed from his thigh so he can go back to work.

Sarai Holguin, a 71-year-old woman originally from Mexico, has accepted the bullet lodged near her knee as her “compa” 鈥� a close friend.

They Were Injured at the Super Bowl Parade. A Month Later, They Feel Forgotten.

In the first of our series “The Injured,” a Kansas family remembers Valentine’s Day as the beginning of panic attacks, life-altering trauma, and waking to nightmares of gunfire. Thrown into the spotlight by the shootings, they wonder how they will recover.

Mireya Nelson, 15, was hit by a bullet that went through her jaw and broke her shoulder, where fragments remain. She’ll live with them for now, while doctors monitor lead levels in her blood for at least two years.

Nearly three months after the Kansas City Chiefs Super Bowl parade shooting left at least 24 people injured, recovery from those wounds is intensely personal and includes a surprising gray area in medicine: whether the bullets should be removed.

Medical protocol offers no clear answer. A 2016 survey of surgeons found that of respondents worked at medical facilities that had policies on bullet removal. Doctors in the U.S. often leave bullets buried deep in a person’s body, at least at first, so as not to cause further trauma.

But as gun violence has emerged as a public health epidemic, if that practice is best. Some of the wounded, like James Lemons, are left in a precarious place.

“If there’s a way to get it out, and it’s safely taken out, get it out of the person,” Lemons said. “Make that person feel more secure about themselves. And you’re not walking around with that memory in you.”

Lemons, Holguin, and Nelson are coping in very different ways.

Pain Became a Problem

Three days after the Chiefs won the Super Bowl, Lemons drove the 37 miles from Harrisonville, Missouri, to downtown Kansas City to celebrate the victory. The warehouse worker was carrying his 5-year-old daughter, Kensley, on his shoulders when he felt a bullet enter the back of his right thigh.

Gunfire erupted in the area packed with revelers, , after a “verbal confrontation” between two groups. Detectives found “multiple 9mm and .40 caliber spent shell casings” at the scene. Lemons said he understood immediately what was happening.

“I know my city. We’re not shooting off fireworks,” he said.

Lemons shielded Kensley’s face as they fell to the ground so she wouldn’t hit the concrete. His first thought was getting his family 鈥� also including his wife, Brandie; 17-year-old daughter, Kallie; and 10-year-old son, Jaxson 鈥� to safety.

“I’m hit. But don’t worry about it,” Lemons recalled telling Brandie. “We gotta go.”

He carried Kensley on his shoulders as the family walked a mile to their car. His leg bled through his pants at first then stopped, he said. It burned with pain. Brandie insisted on driving him to the hospital but traffic was at a standstill so she put on her hazard lights and drove on the wrong side of the road.

“She’s like: 鈥業’m getting you to a hospital. I’m tired of people being in my way,’” Lemons recalled. “I’ve never seen my wife like that. I’m looking at her like, 鈥楾hat’s kinda sexy.’”

Lemons clapped and smiled at his wife, he said, to which she replied, “What are you smiling for? You just got shot.” He stayed in quiet admiration until they were stopped by a sheriff, who summoned an ambulance, Lemons said.

He was taken to the emergency room at University Health, which from the rally, including eight with gunshot wounds. Imaging showed the bullet barely missed an artery, Lemons said. Doctors cleansed the wound, put his leg in a brace, and told him to come back in a week. The bullet was still in his leg.

“I was a little baffled by it, but I was like, 鈥極K, whatever, I’ll get out of here,’” Lemons recalled.

When he returned, doctors removed the brace but explained they often leave bullets and fragments in the body 鈥� unless they grow too painful.

“I get it, but I don’t like that,” Lemons said. “Why wouldn’t you take it out if you could?”

University Health spokesperson Leslie Carto said the hospital can’t comment on individual patient care because of federal privacy laws.

Surgeons typically do remove bullets when they encounter them during surgery or they are in dangerous locations, like in the spinal canal or risking damage to an organ, said , a pediatric surgeon at Connecticut Children’s.

Campbell also chairs the Injury Prevention and Control Committee of the American College of Surgeons’ Committee on Trauma, which works on firearm injury prevention.

, a trauma surgeon by training and the founder of the in St. Louis, said the origins of trauma care also help explain why bullets are so often left.

“Trauma care is war medicine,” Punch said. “It is set to be ready at any moment and any time, every day, to save a life. It is not equipped to take care of the healing that needs to come after.”

In the survey of surgeons, the most common reasons given for removing a bullet were pain, a palpable bullet lodged near the skin, or an infection. Far less common were lead poisoning and mental health concerns such as post-traumatic stress disorder and anxiety.

What patients wanted also affected their decisions, the surgeons said.

Lemons wanted the bullet out. The pain it caused in his leg radiated up from his thigh, making it difficult to move for more than an hour or two. Working his warehouse job was impossible.

“I gotta lift 100 pounds every night,” Lemons recalled telling his doctors. “I gotta lift my child. I can’t work like this.”

He has lost his income and his health insurance. Another stroke of bad luck: The family’s landlord sold their rental home soon after the parade, and they had to find a new place to live. This house is smaller, but it was important to keep the kids in the same school district with their friends, Lemons said in an interview in Kensley’s pink bedroom, the quietest spot to talk.

They’ve borrowed money and raised to help with the deposit and car repairs, but the parade shooting has left the family in a deep financial hole.

Without insurance, Lemons worried he couldn’t afford to have the bullet removed. Then he learned his surgery would be paid for by donations. He set up an appointment at a hospital north of the city, where a surgeon took measurements on his X-ray and explained the procedure.

“I need you to be involved as much as I’m going to be involved,” he remembered being told, “because 鈥� guess what 鈥� this ain’t my leg.”

The surgery is scheduled for this month.

鈥榃e Became Friends’

Sarai Holguin isn’t much of a Chiefs fan, but she agreed to go to the rally at Union Station to show her friend the best spot to see the players on stage. It was an unseasonably warm day, and they were standing near an entrance where lots of police were stationed. Parents had babies in strollers, kids were playing football, and she felt safe.

A little before 2 p.m., Holguin heard what she thought were fireworks. People started running away from the stage. She turned to leave, trying to find her friend, but felt dizzy. She didn’t know she’d been shot. Three people quickly came to her aid and helped her to the ground, and a stranger took off his shirt and made a tourniquet to put on her left leg.

Holguin, a native of Puebla, Mexico, who became a U.S. citizen in 2018, had never seen so much chaos, so many paramedics working under such pressure. They were “anonymous heroes,” she said.

She saw them working on Lisa Lopez-Galvan, a well-known DJ and 43-year-old mother of two. Lopez-Galvan died at the scene, and was the sole fatality at the parade. Holguin was rushed to University Health, about five minutes from Union Station.

There doctors performed surgery, leaving the bullet in her leg. Holguin awoke to more chaos. She had lost her purse, along with her cellphone, so she couldn’t call her husband, Cesar. She had been admitted to the hospital under an alias 鈥� a common practice at medical centers to begin immediate care.

Her husband and daughter didn’t find her until about 10 p.m. 鈥� roughly eight hours after she’d been shot.

“It has been a huge trauma for me,” Holguin said through an interpreter. “I was injured and at the hospital without doing anything wrong. [The rally] was a moment to play, to relax, to be together.”

Holguin was hospitalized for a week, and two more outpatient surgeries quickly followed, mostly to remove dead tissue around the wound. She wore a wound VAC, or vacuum-assisted closure device, for several weeks and had medical appointments every other day.

Campbell, the trauma surgeon, said wound VACs are common when bullets damage tissue that isn’t easily reconstructed in surgery.

“It’s not just the physical injuries,” Campbell said. “Many times it’s the emotional, psychological injuries, which many of these patients take away as well.”

The bullet remains near Holguin’s knee.

“I’m going to have it for the rest of my life,” she said, saying she and the bullet became “compas,” close friends.

“We became friends so that she doesn’t do any bad to me anymore,” Holguin said with a smile.

Punch, of the Bullet Related Injury Clinic in St. Louis, said some people like Holguin are able to find a way to psychically live with bullets that remain.

“If you’re able to make a story around what that means for that bullet to be in your body, that gives you power; that gives you agency and choice,” Punch said.

Holguin’s life changed in an instant: She’s using a walker to get around. Her foot, she said, acts “like it had a stroke” 鈥� it dangles, and it’s difficult to move her toes.

The most frustrating consequence is that she cannot travel to see her 102-year-old father, still in Mexico. She has a live camera feed on her phone to see him, but that doesn’t offer much comfort, she said, and thinking about him brings tears.

She was told at the hospital that her medical bills would be taken care of, but then lots of them came in the mail. She tried to get victim assistance from the state of Missouri, but all the forms she had were in English, which made them difficult to comprehend. Renting the wound VAC alone cost $800 a month.

Finally she heard that the Mexican Consulate in Kansas City could help, and the consul pointed her to the Jackson County Prosecutor’s Office, with which she registered as an official victim. Now all of her bills are being paid, she said.

Holguin isn’t going to seek mental health treatment, as she believes one must learn to live with a given situation or it will become a burden.

“I have processed this new chapter in my life,” Holguin said. “I have never given up and I will move on with God’s help.”

鈥業 Saw Blood on My Hands’

Mireya Nelson was late to the parade. Her mother, Erika, told her she should leave early, given traffic and the million people expected to crowd into downtown Kansas City, but she and her teenage friends ignored that advice. The Nelsons live in Belton, Missouri, about a half hour south of the city.

Mireya wanted to hold the Super Bowl trophy. When she and her three friends arrived, the parade that had moved through downtown was over and the rally at Union Station had begun. They were stuck in the large crowd and quickly grew bored, Mireya said.

Getting ready to leave, Mireya and one of her friends were trying to call the driver of their group, but they couldn’t get cell service in the large crowd.

Amid the chaos of people and noise, Mireya suddenly fell.

“I saw blood on my hands. So then I knew I got shot. Yeah, and I just crawled to a tree,” Mireya said. “I actually didn’t know where I got shot at, at first. I just saw blood on my hands.”

The bullet grazed Mireya’s chin, shot through her jaw, broke her shoulder, and left through her arm. Bullet fragments remain in her shoulder. Doctors decided to leave them because Mireya had already suffered so much damage.

Mireya’s mother supports that decision, for now, noting they were just “fragments.”

“I think if it’s not going to harm her the rest of her life,” Erika said, “I don’t want her to keep going back in the hospital and getting surgery. That’s more trauma to her and more recovery time, more physical therapy and stuff like that.”

Bullet fragments, particularly ones only skin-deep, often push their way out like splinters, according to Punch, although patients aren’t always told about that. Moreover, Punch said, injuries caused by bullets extend beyond those with damaged tissue to the people around them, like Erika. He called for a holistic approach to recover from all the trauma.

“When people stay in their trauma, that trauma can change them for a lifetime,” Punch said.

Mireya will be tested for for at least the next two years. Her levels are fine now, doctors told the family, but if they get worse she will need surgery to remove the fragments, her mother said.

Campbell, the pediatric surgeon, said lead is particularly concerning for young children, whose developing brains make them especially vulnerable to . of lead 鈥� 3.5 micrograms per deciliter 鈥� is enough to report to state health officials, according to the Centers for Disease Control and Prevention.

Mireya talks about cute teenage boys’ being “fine” but also still wears Cookie Monster pajamas. She appears confused by the shootings, by all the attention at home, at school, from reporters. Asked how she feels about the fragments in her arm, she said, “I don’t really care for them.”

Mireya was on antibiotics for 10 days after her hospital stay because doctors feared there was bacteria in the wound. She has had physical therapy, but it’s painful to do the exercises. She has a scar on her chin. “A dent,” she said, that’s “bumpy.”

“They said she was lucky because if she wouldn’t have turned her head in a certain way, she could be gone,” Erika said.

Mireya faces a psychiatric evaluation and therapy appointments, though she doesn’t like to talk about her feelings.

So far, Erika’s insurance is paying the medical bills, though she hopes to get some help from the United Way’s , which raised nearly $1.9 million, or a faith-based organization called .

Erika doesn’t want a handout. She has a job in health care and just got a promotion.

The bullet has changed the family’s life in big ways. It is part of their conversation now. They talk about how they wish they knew what kind of ammunition it was, or what it looked like.

“Like, I wanted to keep the bullet that went through my arm,” Mireya said. “I want to know what kind of bullet it was.” That brought a sigh from her mom, who said her daughter had watched too many episodes of “Forensic Files.”

Erika beats herself up about the wound, because she couldn’t protect her daughter at the parade.

“It hits me hard because I feel bad because she begged me to get off work and I didn’t go there because when you have a new position, you can’t just take off work,” Erika said. “Because I would have took the bullet. Because I would do anything. It’s mom mode.”

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But while the drug has helped keep him alive, its side effects have gradually narrowed the confines of his life, said Crosslin, 76, who lives in Ocala, Florida: “My appetite has been minimal. I’m very weak. I walk my dogs and get around a bit, but I haven’t been able to golf since last July.”

He wonders whether he’d do better on a lower dose, “but I do what my oncologist tells me to do,” Crosslin said. Every day, he takes eight of the 120-milligram pills, sold under Amgen’s brand name Lumakras.

Crosslin’s concern lies at the heart of an FDA effort to make cancer drugs less toxic and more effective. Cancer drug trials are structured to promote high doses, which then become routine patient care. In the face of evidence that thousands of patients become so ill that they skip doses or stop taking the drugs 鈥� thereby risking resurgence of their cancers 鈥� the FDA has begun requiring companies to pinpoint the right dosage before they reach patients.

The initiative, Project Optimus, launched in 2021 just as Amgen was seeking to market sotorasib. At the time, the FDA’s leading cancer drug regulator, Richard Pazdur, co-authored an editorial in the New England Journal of Medicine that said Amgen’s trials of the $20,000-a-month drug were “hampered by a lack of robust dose exploration.”

The FDA conditionally approved sotorasib but required Amgen to conduct a study comparing the labeled dosage of 960 mg with a dosage of 240 mg. The trial, published in November, showed that the 960-mg dose may have given patients a month more of life, on average, but caused more severe side effects than the lower dose.

Amgen is keeping the 960-mg dosage as it conducts further tests to get final approval for the drug, spokesperson Elissa Snook said, adding that the dose showed superiority . Whether medically justified or not, the heavier dosage allows the company to protect 75% of its revenue from the drug, which brought in nearly $200 million in the United States last year.

And there appears to be nothing the FDA can do about it.

“There’s a gap in FDA’s authority that results in patients getting excess doses of a drug at excess costs,” said Mark Ratain, a University of Chicago oncologist who has pushed for more accurate cancer drug dosing. “We should do something about this.”

Deciding on Dosage

It may be too late for the FDA to change the sotorasib dosage, although in principle it could demand a new regimen before granting final approval, perhaps in 2028. Under Project Optimus, however, the agency is doing something about dosage guidelines for future drugs. It is stressing dose optimization in its meetings with companies, particularly as they prepare to test drugs on patients for the first time, spokesperson Lauren-Jei McCarthy said.

“When you go in front of FDA with a plan to approve your drug now, they are going to address dosing studies,” said Julie Gralow, chief medical officer of the American Society of Clinical Oncology. “A lot of companies are struggling with this.”

That’s largely because the new requirements add six months to a year and millions in drug development costs, said Julie Bullock, a former FDA drug reviewer who advocated for more extensive dosing studies and is now senior vice president at Certara, a drug development consultancy.

In part, Project Optimus represents an effort to manage the faults of the FDA’s accelerated approval process, begun in 1992. While the process gets innovative drugs to patients more quickly, some medicines have proved lackluster or had unacceptable side effects.

That’s especially true of the newer pills to treat cancer, said Donald Harvey, an Emory University pharmacology professor, who has led or contributed to more than 100 early-phase cancer trials.

in the Journal of the American Medical Association showed that 41% of the cancer drugs granted accelerated approval from 2013 to 2017 did not improve overall survival or quality of life after five years.

Many of these drugs flop because they must be given at toxic dosages to have any effect, Harvey said, adding that sotorasib might work better if the company had found an appropriate dosage earlier on.

“Sotorasib is a poster child for incredibly bad development,” Harvey said. The drug was the first to target the KRAS G12C mutation, which drives about 15% of lung cancers and was considered “undruggable” until University of California-San Francisco chemist Kevan Shokat in 2012.

Given the specificity of sotorasib’s target, Harvey said, Amgen could have found a lower dosage. “Instead, they followed the old model and said, 鈥榃e’re going to push the dose up until we see a major side effect.’ They didn’t need to do that. They just needed more experience with a lower dose.”

The 960-mg dose “is really tough on patients,” said Yale University oncologist and assistant professor Michael Grant. “They get a lot of nausea and other GI side effects that are not pleasant. It hurts their quality of life.”

The FDA of sotorasib that in phase 1 studies tumors shrank when exposed to as little as a fifth of the 960-mg daily dose Amgen selected. At all doses tested in that early trial, the drug reached roughly the same concentrations in the blood, which suggested that at higher doses the drug was mostly just intensifying side effects like diarrhea, vomiting, and mouth sores.

For most classes of drugs, companies spend considerable time in phases 1 and 2 of development, homing in on the right dosage. “No one would think of dosing a statin or antibiotic at the highest tolerable dose,” Ratain said.

Things are different in cancer drug creation, whose approach originated with chemotherapy, which damages as many cancer cells as possible, wrecking plenty of healthy tissue in the bargain. Typically, a company’s first series of cancer drug trials involve escalating doses in small groups of patients until something like a quarter of them get seriously ill. That “maximum tolerated dose” is then employed in more advanced clinical trials, and goes on the drug’s label. Once a drug is approved, a doctor can “go off-label” and alter the dosage, but most are leery of doing so.

Patients can find the experience rougher than advertised. During clinical trials, the side effects of the cancer drug osimertinib (Tagrisso) were listed as tolerable and manageable, said Jill Feldman, a lung cancer patient and advocate. “That killed me. After two months on that drug, I had lost 15 pounds, had sores in my mouth and down my throat, stomach stuff. It was horrible.”

Some practitioners, at least, have responded to the FDA’s cues on sotorasib. In the Kaiser Permanente health system, lung cancer specialists start with a lower dose of the drug, spokesperson Stephen Shivinsky said.

Smaller Doses 鈥� And Revenue

Amgen was clearly aware of the advantages of the 240-mg dosage before it sought FDA approval: It on that dosage before the agency gave breakthrough approval for the drug at 960 mg. The company the patent filing to investors or the FDA. McCarthy said the FDA was prohibited by law from discussing the particulars of its sotorasib regulation plans.

Switching to a 240-mg dosage could register a huge hit to Amgen’s revenue. The company markets the drug at more than $20,000 for a month of 960-mg daily doses. Each patient who could get by with a quarter of that would trim the company’s revenue by roughly $180,000 a year.

Amgen declined to comment on the patent issue or to make an official available to discuss the dosage and pricing issues.

Crosslin, who depends on Social Security for his income, couldn’t afford the $3,000 a month that Medicare required him to pay for sotorasib, but he has received assistance from Amgen and a charity that covers costs for patients below a certain income.

While the drug has worked well for Crosslin and other patients, its overall modest impact on lung cancer suggests that $5,000, rather than $20,000, might be a more appropriate price, Ratain said.

In the company’s phase 3 clinical trial for advanced lung cancer patients, sotorasib kept patients alive for about a month longer than docetaxel, the current, highly toxic standard of care. Docetaxel is a generic drug for which Medicare pays about $1 per injection. The trial was so unconvincing that the FDA sent Amgen back to do another.

Ratain, of Amgen’s , told Centers for Medicare & Medicaid Services officials at a recent meeting that they should pay for sotorasib on a basis of 240 mg per day. But CMS would do that only “if there is a change in the drug’s FDA-approved dosage,” spokesperson Aaron Smith said.

Drug companies generally don’t want to spend money on trials like the one the FDA ordered on sotorasib. In 2018, Ratain and other researchers used their institutions’ funding to conduct a dosing trial on the prostate cancer drug abiraterone, marketed under the brand name Zytiga by Johnson & Johnson. They found that taking one 250-mg pill with food was just as effective as taking four on an empty stomach, as the label called for.

Although , the evidence generated in that trial was strong enough for the standards-setting National Comprehensive Cancer Network to change its recommendations.

Post-marketing studies like that one are hard to conduct, Emory’s Harvey said. Patients are reluctant to join a trial in which they may have to take a lower dosage, since most people tend to believe “the more the better,” he said.

“It’s better for everyone to find the right dose before a drug is out on the market,” Harvey said. “Better for the patient, and better for the company, which can sell more of a good drug if the patients aren’t getting sick and no longer taking it.”

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Fighting the problem presents tension for the administration: how to thwart the bad actors without affecting ACA sign-ups.

Complaints about these unauthorized changes 鈥� which can cause affected policyholders to lose access to medical care, pay higher deductibles, or even incur surprise tax bills 鈥� rose sharply in recent months, according to brokers who contacted 素人色情片Health News and federal workers who asked not to be identified.

Ronnell Nolan, president and CEO of the trade association Health Agents for America, said her group has suggested to the Centers for Medicare & Medicaid Services that it add two-factor authentication to healthcare.gov or send text alerts to consumers if an agent tries to access their accounts. But the agency told her it doesn’t always have up-to-date contact information.

“We’ve given them a whole host of ideas,” she said. “They say, 鈥楤e careful what you wish for.’ But we don’t mind going an extra step if you can stop this fraud and abuse, because clients are being hurt.”

Some consumers are pursued when they respond to misleading social media marketing ads promising government subsidies, but most have no idea how they fell victim to plan-switching. Problems seem concentrated in the 32 states using the federal exchange.

CMS about unauthorized ACA plan switches and enrollments in the first quarter of 2024, according to the agency.

The problem is big enough that CMS says it’s working on technological and regulatory solutions. Affected consumers and agents have filed a civil lawsuit in federal district court in Florida against private-sector firms allegedly involved in unauthorized switching schemes.

Biden has pushed hard to make permanent the enhanced subsidies first put in place during the covid pandemic that, along with other steps including increased federal funding for outreach, helped fuel the strong enrollment growth. Biden for the ACA with the stance of former President Donald Trump, who supported attempts to repeal most of the law and presided over funding cuts and declining enrollment.

Most proposed solutions to the rogue-agent problem involve making it more difficult for agents to access policyholder information or requiring wider use of identity questions tied to enrollees’ credit history. The latter could be stumbling blocks for low-income people or those with limited financial records, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

“That is the knife edge the administration has to walk,” said Corlette, “protecting consumers from fraudulent behavior while at the same time making sure there aren’t too many barriers.”

Jeff Wu, acting director of the Center for Consumer Information & Insurance Oversight, said in a statement that the agency is evaluating options on such factors as how effective they would be, their impact on consumers’ ability to enroll, and how fast they could be implemented.

The agency is also working closely, he wrote, with insurance companies, state insurance departments, and law enforcement “so that agents violating CMS rules or committing fraud face consequences.” And it is reaching out to states that run their own ACA markets for ideas.

That’s because Washington, D.C., and the 18 states that run their own ACA marketplaces have reported far fewer complaints about unauthorized enrollment and plan-switching. Most include layers of security in addition to those the federal marketplace has in place 鈥� some use two-factor authentication 鈥� before agents can access policyholder information.

California, for example, allows consumers to designate an agent and to “log in and add or remove an agent at will,” said Robert Kingston, interim director of outreach and sales for Covered California, the state’s ACA marketplace. The state can also send consumers a one-time passcode to share with an agent of their choice. Consumers in Colorado and Pennsylvania can similarly designate specific agents to access their accounts.

By contrast, agents can more easily access policyholder information when using private-sector websites that link them to the federal ACA market 鈥� all they need is a person’s name, date of birth, and state of residence 鈥� to enroll them or switch their coverage.

of such “enhanced direct enrollment” websites run by private companies, which are designed to make it easier and faster for agents certified to offer insurance through healthcare.gov.

last June requiring agents to get written or recorded consent from clients before enrolling them or changing their coverage, but brokers say they’re rarely asked to produce the documentation. If CMS makes changes to healthcare.gov 鈥� such as adding passcodes, as California has 鈥� it would need to require all alternative-enrollment partners to do the same.

The largest is San Francisco-based HealthSherpa, which assisted 52% of active enrollments nationally for this year, said CEO George Kalogeropoulos.

The company has a 10-person fraud investigation team, he said, which has seen “a significant spike in concerns about unauthorized switching.” They report problems to state insurance departments, insurance carriers, and federal regulators “and refer consumers to advocates on our team to make sure their plans are corrected.”

Solutions must be “targeted,” he said. “The issue with some of the solutions proposed is it negatively impacts the ability of all consumers to get enrolled.”

Most people who sign up for ACA plans are aided by agents or platforms like HealthSherpa, rather than doing it themselves or seeking help from nonprofit organizations. Brokers don’t charge consumers; instead, they receive commissions from insurers participating in state and federal marketplaces for each person they enroll in a plan.

While California officials say their additional layers of authentication have not noticeably affected enrollment numbers, the state’s recent enrollment growth than in states served by healthcare.gov.

Still, Covered California’s Kingston pointed to a decreased number of uninsured people in the state. In 2014, when much of the ACA was implemented, 12.5% of Californians were uninsured, , according to data compiled by KFF. That year, the share of people uninsured nationwide was 8%.

Corlette said insurers have a role to play, as do states and CMS.

“Are there algorithms that can say, 鈥楾his is a broker with outlier behavior’?” Insurance companies could then withhold commissions “until they can figure it out,” she said.

Kelley Schultz, vice president of commercial policy at AHIP, the trade association for large insurance companies, said sharing more information from the government marketplace about which policies are being switched could help insurers spot patterns.

CMS could also set limits on plan switches, as there is generally no legitimate need for multiple changes in a given month, Schultz said.

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