If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Eight days before my 33rd birthday in April, a social worker at a crisis clinic near Denver determined I was an imminent danger to myself. She placed me on an involuntary 72-hour mental health hold.

What came next wasn’t treatment, but a search for a bed. Clinic staffers called area hospitals with inpatient psychiatric units, asking if they had available beds. They didn’t. So, I was told I had to spend the night at the clinic, which is open 24/7. I settled into a recliner, trying to make myself comfortable as my mind drifted in a blank, disassociated haze. Sleep came in brief bursts.

Since the 1950s, the United States has seen a nationwide due in part to deinstitutionalization and the rise of antipsychotics. But that has created a critical shortage for those needing help. From 2011 to 2023, the number of hospitals with inpatient psychiatric units , according to a 2025 study. Another study from that year found that this country has 28.4 inpatient psychiatric beds per 100,000 people — not even half the 60-bed ratio researchers frequently refer to as the .

The shortage has created what the American Psychiatric Association : emergency rooms overwhelmed with people suffering from severe mental health illnesses, inpatient stays prematurely shortened to speed up bed turnover, and acutely ill individuals left without critical care.

“Where are these people going?” said , an assistant health policy professor at Rutgers University, who co-authored those 2025 studies. “For people who don’t receive this care, they don’t just go away. How is it affecting them? Society? Their families?”

Meanwhile, the White House shut down the part of the national suicide hotline catering to LGBTQ+ youth, President Donald Trump’s 2027 budget proposal calls for cuts to agencies , and Health and Human Services Secretary Robert F. Kennedy Jr. recently announced a plan to .”

A Fractured System

I was already intimately familiar with the country’s fractured mental healthcare system before I was involuntarily committed. What I had yet to experience myself, I saw through my wife: waitlists, outpatient programs stretched beyond capacity, and inpatient psychiatric care so scarce that access often depends on surviving a crisis severe enough to justify it.

She died by suicide after we had separated.

As the years passed, grief and anxiety pushed me from observer to patient.

At the crisis clinic, I woke up the following morning disoriented and groggy. In the bathroom — its door deliberately unable to latch, swinging both ways so staffers could enter in case of an emergency — I stood at the sink and watched the faucet run, trying to piece together how I had ended up here.

America’s history of treating mental illness is long and complicated.

The 19th and 20th centuries saw the removal of people with severe mental disorders from jails and — squalid facilities designed to house the poor — to state asylums that (though they ultimately became ). From the 1860s to the 1930s, the number of psychiatric hospitals increased dramatically, according to the American Psychiatric Association, and by 1955, the number of psychiatric beds in the U.S. peaked at more than half a million.

However, owing to the development of antipsychotics, the belief that psychiatric institutions were inhumane, and President John F. Kennedy’s 1963 to free thousands of Americans from a life in institutions, many state hospitals shut down. An estimated for adults and kids are left in a country where more than 14 million experience severe mental illness each year.

Two years after JFK’s legislation passed, a new policy prohibited federal Medicaid funds from covering inpatient psychiatric care in facilities . The goal was to encourage states to move patients out of large, often substandard psychiatric institutions into community-based care settings.

The consequences of these changes, however, have been far-ranging. People with severe mental illnesses are often forced to as they wait for a bed to open. The length of stay in state psychiatric hospitals , according to research by the Treatment Advocacy Center, a national organization focused on eliminating barriers to the treatment of severe mental illness. And some people with mental illness .

From 1986 to 2014, as the behavioral health crisis intensified, mental health expenditures in the U.S. rose from $32 billion to $186 billion — though the proportion of that spending allocated to inpatient care .

This period also recorded major policy shifts affecting inpatient hospitalization rates, notably the 1999 U.S. Supreme Court decision in Olmstead v. L.C. The ruling shifted care away from psychiatric facilities by mandating states to people with developmental and mental disabilities.

“The road to hell is paved with good intentions,” said Leslie Carpenter, legislative advocacy manager at the Treatment Advocacy Center. “A lot of these bills, including the Community Mental Health Act, were really well intended and ended up with adverse consequences.”

For me, that next day at the clinic passed both painfully slowly and in a blur. A staff member I hadn’t met before told me they were still reaching out to hospitals across the region. The search for a bed continued.

‘No One Wants To Pay for Any of This Care’

Last year, members of Congress introduced two bills to change the 16-bed Medicaid funding cap at inpatient psychiatric facilities, the and the , which would increase the cap to 36 beds. Both have stalled in the House.

According to the Congressional Budget Office, a federal agency that analyzes budgetary and economic issues, eliminating the 16-bed limit would increase Medicaid expenditures from 2024 to 2033.

“No one wants to pay for any of this care that people need,” said Colorado state Sen. , a Democrat who has witnessed limitations to Colorado’s mental healthcare system firsthand because her son has schizoaffective disorder.

In lieu of federal action, states are stepping up to bridge the gaps.

Colorado, 15 other states, and Washington, D.C., now operate under waivers allowing Medicaid to fund inpatient facilities for mental health treatment, according to KFF data. Seven additional states have waivers pending. One 2025 study found that these waivers may be tied to fewer hospitalizations, emergency department visits, and incarcerations .

Yet even local efforts to improve mental healthcare face resistance. In California, Colorado, Iowa, Missouri, Nebraska, and New York, locals have pushed back against proposed psychiatric facilities for minors, claiming such facilities will worsen safety and lower property values. Behavioral health advocates have disputed these claims and argued they are rooted in stigma.

That psychiatric facility in Colorado was . The state has nearly 20 inpatient beds per 100,000 people, , according to 2022 data across all 50 states plus Washington, D.C., collected by the Treatment Advocacy Center. Wyoming ranked first with 47.3 beds per 100,000 residents, although, as the least populous state, it has only 275 total inpatient beds compared with California’s 5,703. Minnesota ranked last, with only 4.3 inpatient beds per 100,000 residents.

While increasing the number of inpatient psychiatric beds is vital, mental health advocates are also calling for , such as peer support specialists and clubhouses, where people with serious mental illnesses can learn life skills and find community.

When it came time for me to use our mental health safety net, I was among the fortunate ones: At noon the day after my hold began, a bed opened at a hospital in Denver — a rare stroke of luck in a system in which many people wait days or weeks for the care they need. An ambulance transferred me to the hospital at 3 p.m., marking 21 hours into my 72-hour hold.

Two days later, on my last day at the psychiatric hospital, I stood outside the nurse’s station awaiting discharge papers.

A man I had not seen before looked at me and asked, “Are you leaving?”

“Yes,” I said. “Are you being admitted?”

“Yeah,” he responded. “This is my third time being hospitalized in a year.”

I shook his hand. “Good luck,” I said, and I walked out the door.

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In preliminary filings with state regulators, insurers are seeking a median rate increase of 14% for 2027, according to in 16 states and the District of Columbia by the Peterson-Ñî¹óåú´«Ã½Ò•îl Health System Tracker.

If those rates are ultimately approved, it would be the second-highest increase since 2018.

That would be a “triple whammy“ for consumers, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF, because they have already had to pay higher premiums in 2026 and saw the expiration of more generous tax credits to offset their premiums at the end of last year.

President Joe Biden sought to bolster the program known as Obamacare by enacting more generous tax subsidies, driving down out-of-pocket costs for consumers and increasing enrollment to more than 20 million Americans. But under President Donald Trump, Republicans have sought to scale back taxpayer support for ACA coverage, allowing the Biden-era enhanced subsidies to expire.

As of February, ACA enrollment had fallen by about 3 million people compared with the same time last year. While Cox and other policy experts say that’s because increased costs for the plans drove out people who feel they can get by without insurance, the Trump administration asserts that much of the enrollment growth under Biden .

The main factor driving proposed premium increases for 2027, as in most years, is the rising cost and use of medical care.

There’s growing demand for costly specialty medications and for the weight loss drugs known as GLP-1s, the Peterson-KFF report notes.

But the report also said that about 4 percentage points’ worth of the premium increases insurers proposed are due to lasting effects of the expiration of enhanced subsidies. Insurers expect that with young and healthy people leaving the program rather than paying higher premiums, their remaining customers will be older, sicker, and therefore costlier on average.

 “It’s likely that the people who dropped their coverage were also the healthier people, because sicker people were probably going to try to make it work however they could, to stretch their budget to keep their health insurance,” said Cox, of KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

In their rate filings, some insurers also said they had to raise premiums partly because of policy changes by the Trump administration that are expected to make it harder for some people to enroll.

Together with the expiration of the larger subsidies, the new rules “account for 12.7% of the requested rate change,” the insurer UnitedHealthcare wrote in its rate filing with New York state, according to the Peterson-KFF report.

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Each year, Amgen, which makes the drug, called , sent the coupon card worth thousands of dollars, and that counted toward Gruber’s health insurance deductible and out-of-pocket maximum.

Using the card, Gruber usually met that maximum by February, leaving his health insurance to fully cover his in-network medical costs and reducing his cost for the drug to $0 for the rest of the year.

But this year, his new health insurer, , pocketed the coupon card and required Gruber to pay for the drug until he satisfied the cost-sharing requirements on his own.

If Oscar Health had applied Amgen’s coupon toward Gruber’s cost sharing, he would have been on the hook for about $3,000 in covered services. Without it, he had to use his savings to meet the plan’s $10,600 out-of-pocket maximum.

“The real insult here is that they’re taking the money that’s intended to help you,” said Gruber, who had planned to buy a home next year with his savings. “I feel desperate, pressed against the wall, and squeezed.”

Oscar Health is one of many commercial health insurers that use what are often called copay accumulator programs to keep funds that are meant to defray patients’ out-of-pocket costs for expensive specialty drugs. Over the past decade, more insurers have to reduce their prescription drug costs, according to Avalere Health, a consulting company.

Patients who rely on copay assistance from drugmakers are typically heavy users of healthcare for whom delays in treatment or worsening conditions can lead to higher costs, according to patient advocates.

, Florida market president for Oscar Health, did not comment on the specifics of Gruber’s case. He said the company uses copay accumulators to manage rising medical and prescription costs and “to keep monthly premiums as low as possible.”

Drugmakers argue that insurers and pharmacy benefit managers use copay accumulators and other strategies to delay or deny care and steer patients toward medicines that insurers prefer instead. Insurers counter that coupon cards and other patient financial assistance from drug manufacturers drive up premiums and encourage patients to use higher-priced, brand-name drugs instead of less-expensive generics.

Meanwhile, patient advocates say it’s difficult for consumers to find out if their plan uses a copay accumulator or to understand how they work. Not only do the programs make medications unaffordable for consumers, critics argue, but they allow insurers to double-dip.

“They’re collecting the money twice and they’re hurting patients,” said , executive director of the HIV+Hepatitis Policy Institute, a patient advocacy group.

“Why does it make a difference to Oscar if they get the money from a drug company or, you know, his mother or him?” he said of Gruber’s experience. “They’re still getting the money.”

Controlling Costs or Harming Patients?

Not all insurance types use copay accumulators. Medicare and Medicaid prohibit copay assistance because federal anti-kickback laws forbid drug manufacturers from offering financial incentives to influence patients’ choices. And the Internal Revenue Service prohibits such help for high-deductible plans with health savings accounts. But individual and commercial group plans can use them.

Regulation of copay accumulator programs has fallen largely to states, which oversee individual and small-group plans sold on the Affordable Care Act marketplace.

For 2026, of ACA marketplace plans have such a program, according to a review from The AIDS Institute, a nonprofit group that opposes the programs. Of the 16 insurers that sell plans on the marketplace in Florida, 10 use copay accumulator programs, the review found.

Patients who take brand-name specialty drugs for conditions such as autoimmune disorders, multiple sclerosis, diabetes, HIV, and cancer are most likely to encounter these programs. Health insurers say that making patients share the costs for specialty drugs encourages them to choose value over brand.

But Gruber doesn’t have a choice because there is no medically equivalent generic for Enbrel. Gruber’s livelihood as a trainer depends on his athleticism. The weekly injections, which he has to take for the rest of his life, prevent his joints from getting stiff. When he was diagnosed in 2010, Gruber said, he couldn’t shake hands or lift his knee to get into bed. Without treatment, he said, “I ache from my neck down to my toes.”

If manufacturers priced their drugs affordably, patients like Gruber wouldn’t need financial assistance, said , a senior vice president for AHIP, a trade association representing insurers.

“Drugmakers offer short-term ‘discounts’ to justify overcharging Americans in the long term, driving up healthcare costs for everyone,” he said in a statement. “Research shows limiting copay coupons can reduce premiums and lower consumers’ out-of-pocket costs.”

Sarah Ryan, a spokesperson for Pharmaceutical Research and Manufacturers of America, a trade association for the pharmaceutical industry, said copay assistance helps patients access medications free of charge or at reduced cost.

“Health insurance is supposed to protect patients,” Ryan said, adding that insurers and pharmacy benefit managers that refuse to count copay assistance toward cost sharing are “leaving patients facing unexpected costs and disrupting their care.”

Insurance companies already have tools to control costs without keeping financial assistance intended for patients, said , deputy executive director for The AIDS Institute.

Insurers choose what drugs to cover, whether they are medically necessary, and if a patient must try a cheaper alternative first.

“They are the ones making the decisions,” Klein said. “Now the individual is left trying to figure out how they’re going to pay for it.”

Consumers Stuck in the Middle

Before moving to Florida in 2024, Gruber said, he had bought coverage on the ACA marketplaces in Illinois and Louisiana, which prohibit copay accumulators. Gruber said he hadn’t encountered one until his experience with Oscar Health.

He complained to the office of Florida’s insurance consumer advocate, which informed him that the practice is legal in the state and that Oscar Health had disclosed its use of a copay accumulator program. Page 127 of his 168-page evidence of coverage states, “Third party assistance will not count towards your out-of-pocket maximum or deductible.”

Gruber said he selected his coverage using a tool on that listed all the Florida ACA plans that cover Enbrel. “I always choose the one with the highest deductible to get the lowest premium,” he said, “because I know I’m going to meet it.” His monthly premium is about $315 after subsidies.

Adding to Gruber’s confusion, he said, was that his patient portal with Oscar Health was counting his coupon card at first. He said he met his out-of-pocket maximum in February, and in March Oscar covered all the cost for the medication.

But when he ordered his refill for April, the pharmacy told him that Oscar would cover only $1,000 of the medication’s cost for that month. He would have to pay the remaining $6,700.

Gruber then received a letter from Oscar Health, telling him that an incorrect amount had been applied to his deductible.

“They sent me a letter that basically stated they made a mistake,” he said. “The fact that they’re allowed to sort of change things midstream is also, I think, a little galling.”

He began rationing the injections, taking them every other week instead of weekly. By May, he had dipped into his savings to pay for the drug.

States Step Up While Federal Oversight Stalls

The first state laws banning copay accumulators were adopted in 2019, and since then more states have moved to regulate the programs, said , public policy director for the Alliance for Patient Access, an advocacy group.

“The goal is to build upon that progress at the federal level and to continue to drive this momentum forward,” he said.

Twenty-six states, Washington, D.C., and Puerto Rico have adopted laws banning copay accumulators or prohibiting them for drugs that do not have a generic equivalent. Colorado also prohibits copay accumulators for drugs without a biosimilar. In states that have not banned or restricted the programs, insurance companies decide whether to use them.

But federal regulation of the programs, which would apply to all states, remains at a standstill.

A federal court in 2023 struck down a policy enacted during President Donald Trump’s first term that had permitted insurers to use copay accumulator programs. As a result, the Department of Health and Human Services reverted to that restricts their use to brand-name drugs with a medically appropriate generic equivalent.

After the court ruling, the Biden administration pledged to address copay accumulators in future rulemaking. But HHS has yet to do so, said Schmid, whose group, the HIV+Hepatitis Policy Institute, led a coalition of patient advocacy groups that sued to overturn the rule.

“The Trump administration can stop this once and for all at the national level,” Schmid said. “If they really care about patient affordability, this is something they can do.”

Bipartisan legislation in Congress called the would require financial assistance to count toward deductibles and other out-of-pocket costs on plans regulated by the federal government, including much employer-sponsored coverage.

Schmid said the bill has not gotten “enough traction on the Hill yet.”

Other ways to obtain medication don’t help patients facing copay accumulators either. The president’s , an online platform through which consumers can buy prescription drugs at a discount, requires patients to pay out-of-pocket, and the cost does not count toward their plan’s cost-sharing requirements.

Christopher Krepich, a Centers for Medicare & Medicaid Services spokesperson, said that HHS, along with the departments of Labor and the Treasury, intend to address the issue of whether copay assistance must apply toward health plan cost sharing.

Until then, he wrote, “the Departments do not intend to take any enforcement action against health insurance issuers or group health plans based on their treatment of such manufacturer assistance.”

Outside of government regulation, consumers have few protections or alternatives.

Patients who rely on expensive medications — and who have a choice in their health insurance plan — should research their coverage options and choose wisely so they’re not caught by surprise, Clingham said.

That may mean reading plan benefit explanation packages, contacting their state’s insurance regulator, or calling an insurance company to ask if their plans use copay accumulator programs.

For Gruber, the extra expense means he won’t take a vacation this year. He’s also concerned that the money he was saving for a home will now go to his medication costs instead.

“It’s the first thing I think of when I wake up in the morning,” he said. “If this happens every year, it would be financially devastating.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

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So he didn’t know he had a bill to pay. After he and Tix returned home to Minnesota in April, they got a letter from Wellcare, the insurer that provided his drug plan, saying his coverage had been terminated after three months of unpaid premiums totaling $28.80. Under Medicare’s rules, he can’t enroll in a plan again until the fall, for coverage beginning in 2027.

Pare takes Xarelto, a blood thinner that reduces his risk of strokes, blood clots, and pulmonary embolism. “He could bleed to death without it,” Tix said. A 90-day supply of the drug costs about $1,800 using a coupon from GoodRx, a discount drug website, she said.

Pare is among tens of thousands of Medicare beneficiaries who were on Wellcare’s Value Script drug plan who will likely go without prescription drug coverage for the rest of the year because they didn’t pay premiums for three months.

Next year, thousands more people in 32 states and Washington, D.C., who are enrolled in zero-premium drug plans from Wellcare and other insurance companies may find themselves in the same situation if their premiums go up and they don’t realize it, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of drug plan data. Premiums and other changes for 2027 will be unveiled in September.

Going without medication can be life-threatening, especially for Medicare beneficiaries. take one or more prescription drugs, according to the Centers for Disease Control and Prevention. Almost half live with four or more chronic health conditions that can cause functional or cognitive impairments.

Congress added prescription drug coverage to Medicare in 2003. But the coverage is administered by commercial insurance companies, which compete fiercely with one another for the business of about enrolled in drug plans.

Zero-dollar or very low monthly premiums have helped make Wellcare’s Value Script the bestselling stand-alone prescription drug plan in Medicare, with nearly 6 million customers across the U.S., according to government data. But in 26 states and Washington, D.C., some Value Script members who didn’t have to pay a premium last year were caught off guard by increases in 2026.

After a two-month grace period — which Wellcare extended to three — Medicare drug plans can drop customers who don’t pay their premiums, no matter how small the amount. Some members who lost their coverage in Nevada, for example, owed as little as $8.10 for three months, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of Medicare drug plan data.

Wellcare terminated coverage for about 140,000 Value Script beneficiaries in April, according to a person with knowledge of the matter who was not authorized to speak publicly about it and feared reprisals at work for doing so. About 40,000 of the people who were dropped may be able to enroll in new coverage immediately because they have low incomes and receive financial assistance through a program Medicare calls “.”

Multiple state officials said they had heard the same disenrollment figures, including Nevada’s insurance commissioner, Ned Gaines, who chairs the National Association of Insurance Commissioners’ senior issues task force; Rebecca Gouty, director of the State Health Insurance Assistance Program in West Virginia; and Tim Smolen, director of Washington state’s Statewide Health Insurance Benefits Advisors. The West Virginia and Washington initiatives are part of the federally funded , or SHIP, which provides free, unbiased help navigating Medicare.

Surprise Bills

The Centers for Medicare & Medicaid Services, which oversees Medicare drug plans, declined to provide the number of Value Script members who lost coverage due to unpaid premiums. “The agency does not publicly provide plan-specific disenrollment figures or state-level breakdowns related to the non-payment of premiums,” Christopher Krepich, a spokesperson, said in a written statement to Ñî¹óåú´«Ã½Ò•îl Health News.

Centene Corp., Wellcare’s parent company, also declined to provide disenrollment numbers.

“We recognize how disruptive a loss of coverage can be and are committed to helping members understand their options,” said Sarah Baiocchi, senior vice president for specialty and prescription drug plans at Centene. She acknowledged that “some members in our Value Script plan experienced a premium for the first time, or for the first time in several years.”

Baiocchi said all Value Script members received a CMS-required annual notice of changes in September, before the premium increases took effect.

A sent to members in two states and Washington, D.C., is 21 pages long. The new premium is mentioned on pages 3 and 8, along with changes to out-of-pocket costs and how to find updates on covered drugs and network pharmacies.

The company also informed members about 2026 premium changes through phone calls, text messages, regular mail, or email, Baiocchi said.

People who are dropped are not able to reenroll or join another drug plan until the start of the open enrollment period this fall for coverage beginning Jan. 1, unless they qualify for an exception, Krepich said. And because they will have gone without coverage for at least 63 days, they could be hit with a permanent that increases every year for the rest of their lives.

“Medicare should be doing something about this so that we can go ahead and get coverage now,” said Wayne Bennett, 74, who lives in Durham, North Carolina.

In May, he found out that Wellcare had canceled his Value Script plan because he hadn’t paid his $3.60 monthly premiums. He takes nine prescription drugs to treat his blood pressure, glaucoma, chronic obstructive pulmonary disease, and other health problems. He filled most of his prescriptions — including several at no cost — before he lost coverage. He doesn’t know what he’ll have to pay when his supply runs out.

Gouty, the West Virginia program head, said many Medicare beneficiaries arrange for their monthly drug plan premium to be automatically deducted from their Social Security benefits, and that many likely thought that choice remained in place until they changed it.

“They didn’t realize that when the plan was a zero premium in 2025, that stopped the Social Security premium deduction and they would have had to reelect it for 2026,” Gouty said.

In other words, even if they mistakenly thought the premium was still zero, Medicare beneficiaries would have needed to somehow allow Social Security to make deductions — something the agency doesn’t do — or set up a payment plan through their bank or credit card in case payment was necessary.

“That sounds goofy,” Tix said.

Centene’s Baiocchi blamed the Social Security Administration for the problem: “We believe this was a key driver of non-payment disenrollments and subsequent complaints.”

Spokespeople for the agency referred questions about the matter to CMS.

Krepich said legal requirements for drug plan enrollment and disenrollment limit what CMS can do to help beneficiaries who lose coverage for not paying their premiums.

‘Pretty Upset’

Now that Pare has no prescription drug coverage, his doctor replaced his blood thinner medication with a much less expensive drug that should be just as effective. Pare paid $111 for four other medications that used to be free under his Value Script plan. He hasn’t had to refill four more prescriptions yet and doesn’t know what they will cost, Tix said.

If Wellcare members knew about the premium increases, they could have set up direct billing or an automatic payment plan early this year before the payment grace period ended April 1. But they would have been able to fill prescriptions during the grace period, so if they didn’t see Wellcare’s notices, they likely assumed there was no problem with their coverage.

Bennett, the North Carolina man, said Wellcare used to send him text messages with health tips and reminders when it was time to pick up a prescription. He didn’t know his premium had increased from $0 to $3.60 until it was too late.

“I was pretty upset,” he said, when he called the company. “The premium wasn’t that much, and I was ready to pay it right off the bat. I had my credit card out ready to make the payment.”

The customer service representative wouldn’t let him pay because his coverage had been canceled, Bennett said.

Hoping to restore it, Bennett called , a Durham nonprofit that advises Medicare beneficiaries and is one of more than 2,200 SHIP sites across the country. He was told he must wait until January to restart his drug coverage, said the group’s executive director, Gina Upchurch.

He doesn’t qualify for the “Extra Help” low-income subsidy or meet other CMS criteria for a , which would allow him to change drug plans during the year. CMS typically allows midyear switches for beneficiaries who, for example, move out of their plan’s service area, experience a natural disaster, or get help paying for drugs from a .

Senior PharmAssist was able to help one of its participants join another drug plan after she lost Value Script coverage because she is in North Carolina’s pharmacy assistance program for people with HIV/AIDS and has limited income, Upchurch said.

A further exception allows any Medicare beneficiary to enroll at any time in a drug plan that has earned five stars, the top grade in Medicare’s performance ratings. However, there are no five-star Medicare drug plans available to the general public. Only two insurers offer five-star plans, and only for retirees from certain employers. Their combined enrollment is about 8,700 as of June 1, according to the insurers.

But Upchurch, with more than two decades of Medicare expertise, doesn’t blame beneficiaries for not paying attention or for assuming Wellcare’s messages were bogus. Older adults are particularly vulnerable to identity theft and other scams and are often advised to ignore junk mail and calls from telemarketers.

Since Value Script members such as Bennett continued to get their prescriptions filled during the payment grace period, “why wouldn’t they think this was a scam?” Upchurch asked. “They are constantly bombarded by people selling them something that’s illegitimate or trying to scam them.”

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Now, Democrat Xavier Becerra and Republican Steve Hilton present a stark choice to voters in the race to be the next governor at a moment when public support for the state’s generous safety net is starting to fray.

Both frame the choice as an economic one.

Becerra, former secretary of Health and Human Services under President Joe Biden, has to exclude the poorest immigrants from routine care and push them into expensive emergency rooms . Hilton, a conservative commentator backed by President Donald Trump, has promised to eliminate their coverage and has echoed national Republicans who have to bolster their claims of fraud and abuse in the Medicaid program.

With voters nationwide worried about inflation and the rising cost of living, some Californians might feel less inclined to provide full healthcare coverage to those lacking legal status. What the state does next could have profound implications for its healthcare system and sprawling economy.

Over the past decade, California lawmakers used state dollars to expand Medi-Cal, offering all low-income residents comprehensive coverage regardless of immigration status. But enrollment surpassed initial projections, as did the cost. Medi-Cal coverage of immigrants without legal status costs the state roughly , according to California’s nonpartisan Legislative Analyst’s Office, more than double the initial estimates.

California lawmakers and Democratic Gov. Gavin Newsom, who , have approved major rollbacks of benefits for those residents. They said the state can’t afford ballooning healthcare costs amid massive federal cuts from the GOP tax-and-spending law known as the One Big Beautiful Bill Act; the California Health and Human Services Agency projected up to 3.4 million Medi-Cal enrollees and the state could lose more than $30 billion a year in federal funding under the law, causing major disruptions in the safety net health program.

Medi-Cal’s budget for the 2026-27 fiscal year is $217 billion, and the program serves more than 14 million Californians.

Meanwhile, many legal U.S. residents and citizens have seen their health premium payments skyrocket this year after Congress let enhanced federal Affordable Care Act subsidies expire at the end of December.

As the state grappled with a deficit last year, a majority of likely voters in California said — for the first time in nearly a decade — that they opposed providing health insurance to immigrants without legal status, by the Public Policy Institute of California.

“The state faces major challenges, and healthcare is one of the major expenditures,” said Mark Baldassare, PPIC survey director. “People have become more selective about how they want to see those limited healthcare dollars spent.”

Hilton, running on a platform of affordability and lowering taxes, has seized on the sentiment, casting health coverage for immigrants without legal status as and a to the state’s ability to help citizens.

“Stop taking money from California taxpayers who can barely afford their healthcare to give free healthcare to citizens of other countries who shouldn’t even be here,” Hilton said in a the morning of the June 2 primary.

In campaign stump speeches, to use the savings to for other Californians without detailing how. Hilton did not respond to requests from Ñî¹óåú´«Ã½Ò•îl Health News for comment.

“Their messaging is very, very simple: It’s an us vs. them,” said Roger Salazar, a Democratic political consultant who represents a coalition of healthcare advocates who argue providing coverage to people who can’t afford it strengthens the workforce and, as a result, the economy. “It’s just a question of convincing the average voter that it’s much better economically.”

A son of immigrants, Becerra for decades pushed to in Congress and has made a similar pitch in his campaign for governor. He did not respond to requests for comment.

“Immigrants, whether documented or not, work hard. They pay taxes, and sometimes they get injured on the job or their children get sick,” during a debate in May. “It would be foolish to tell a family that they don’t have access to the pediatrician or the family doc.”

Becerra, who could become California’s first elected Latino governor, when Newsom and legislative leaders decided to for adults without legal status, cut benefits, and impose monthly premiums.

“Stop treating coverage as a budget variable that expands in good years and contracts when revenue dips,” Becerra wrote in May in response to an Orange County Register . He has new, steady revenue to fund basic services, such as by upping taxes on corporations and the wealthiest Californians.

In 2023, California was home to about 2.3 million people without legal status, representing of the state’s labor force, according to the . And live in a family that includes at least one member without legal status, according to the California Department of Education. Healthcare economists say giving people access to preventive healthcare saves taxpayers money in the long run by and relieving pressure on an overburdened system.

That, Baldassare said, wasn’t a hard argument to make during the covid pandemic, when immigrants were and the link between individual well-being and public health .

But Medi-Cal costs to cover roughly 1.4 million immigrants , according to the latest estimates from the Department of Health Care Services. Because only some lawfully present immigrants are eligible for federal Medicaid benefits, states like California must do so exclusively with state funding.

California’s budget experts that maintaining full Medi-Cal coverage for immigrants without seeking additional revenue would destabilize the state’s long-term fiscal outlook.

In a legislative hearing last year, Republican Assembly member Carl DeMaio questioned whether California taxpayers would prioritize the expansions, saying he doubted “illegal immigrant healthcare in the general fund would be at the top of their list.”

After lawmakers approved the spending reductions, support for immigrant health coverage dropped, Baldassare said. Democratic lawmakers and Newsom  several Medi-Cal cuts until July 2027, leaving decisions for the next governor.

David Hayes-Bautista, who has spent his career studying the economic contributions of Latinos and immigrants, said Californians without legal status and tend to work in industries and occupations that . As a result, many resort to Medi-Cal, saddling the state with the healthcare costs instead of employers.

“California, as a state, has the world’s fourth-largest GDP, which is true thanks to Latinos,” said Hayes-Bautista, director of the Center for the Study of Latino Health and Culture at UCLA. Without contributions from Latinos, many without legal status, it drops to eighth place, about the size , he added.

Immigrant advocates hope to have a more vocal champion in Becerra, the favorite to become governor in a state where Democrats outnumber Republicans nearly 2-to-1.

“He will fight, he will push back, he will do all that he can,” said state Sen. María Elena Durazo, a former labor leader who has championed the immigrant healthcare expansions. “That’s the most we could expect.”

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“REMOVE ME FROM YOUR LIST!!!! DO NOT EMAIL OR MAIL ME ANY MORE!

“It is because of your animal based pre-term artificial baby food crap that you peddle to hospital NICU’s that my son is dead from NEC.”

The mother was referring to neonatal intensive care units and necrotizing enterocolitis, an often fatal condition in which intestinal tissue can die and allow infection to spread through the body of an infant born prematurely.

In an internal memo, Mead Johnson cited its “extensive quality and safety checks” and concluded there was “not a reasonable possibility” that the formula caused the baby’s death. “No further investigation is needed. This file can be closed,” the memo said.

And with that decision, the company narrowed the chance that the mother’s anguish could draw attention to any danger the formula might pose to other infants.

The mother’s email and the company’s memo assessing it were used as evidence in the court cases and .

When doctors, hospitals, parents, or others alert manufacturers that babies got sick or died while receiving infant formula, what happens next is left largely to manufacturers such as Abbott Laboratories and Mead Johnson Nutrition, giants of the industry.

Mead Johnson’s handling of the mother’s email showed how that can play out.

Under , if a complaint about an infant formula — such as a report of an adverse event — shows a possible health hazard, the company must investigate.

But it doesn’t always have to inform the government agency that oversees the safety of infant formula.

A company must complete an investigation and notify the Food and Drug Administration within only if it finds “a reasonable possibility of a causal relationship between the consumption of an infant formula and an infant’s death.”

If that happened even once over more than a quarter century, the FDA could find no record of it, according to information obtained through public records requests.

‘Never Reported’

Under the Freedom of Information Act, Ñî¹óåú´«Ã½Ò•îl Health News asked the FDA for all notifications that manufacturers of infant formula sent the agency per the regulatory requirement since Jan. 1, 2020. The agency’s Human Foods Program “did not receive any,” Kimberly Jones, a government information specialist at the FDA, responded in March.

Ñî¹óåú´«Ã½Ò•îl Health News then asked the FDA to go back decades further — to Jan. 1, 2000. “After a diligent search of our files, we did not locate any responsive records,” Jones wrote on May 5.

The FDA’s search results were consistent with court testimony.

John Wallingford, a paid expert witness for Abbott, testified in a Missouri court in October 2024 that Abbott had under any regulation for preterm infant formula.

that he was not referring to adverse events in clinical trials, which are studies used for research and development and are subject to different procedures. Abbott informed the FDA about adverse events that occurred during a clinical trial, .

Christina Valentine testified in a 2024 deposition that she never sent the FDA a report of death from NEC during her seven years as Mead Johnson’s medical director for North America. In the deposition, used in the Whitfield case, she said she never concluded there was a reasonable possibility that an infant’s death from NEC might have been related to a Mead Johnson product.

As medical director for North America, she was responsible for signing off on those determinations, she testified in the Watson trial.

In the deposition, Valentine said she wasn’t sure whether anyone else at the company sent a death report to the FDA.

In late May and mid-June, Mead Johnson spokesperson Jen O’Neill added to the picture.

“Where there is a physician report that includes an opinion that one of our products caused NEC in a preterm infant, we have treated that as a ‘reasonable possibility of a causal relationship,’ and we submitted an adverse event report to the FDA,” she wrote.

“These physician reports were generally made by plaintiffs’ paid experts, with which we disagree,” she wrote.

O’Neill left unclear whether events Mead Johnson reported to the FDA were raised in lawsuits and, if so, whether the company reported them to the FDA before they surfaced in litigation.

Asked repeatedly when Mead Johnson filed the reports, O’Neill didn’t say.

It’s unclear why the FDA found no record of them.

Nor would O’Neill say whether the company submitted one related to the distraught mother’s September 2016 complaint.

That mother’s name wasn’t publicly disclosed in the court record containing her complaint.

“[P]rior to the current litigation, we received very few reports relating to our products and NEC and even fewer for which our investigation uncovered any evidence supporting a reasonable possibility of a causal relationship,” O’Neill wrote.

Industry personnel have reacted to some complaints with circular reasoning, as shown by court records from the Watson, Whitfield, and cases. Company personnel didn’t think their products caused harm, and they didn’t view new cases as evidence of harm, records show.

‘Reprehensible’ Conduct

About 2,300 newborns died of necrotizing enterocolitis in the United States from 2017 through 2023, the equivalent of almost , according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of a for those years. The database doesn’t attempt to explain what caused those babies to develop NEC, and it doesn’t count babies who survived NEC.

A wave of lawsuits has alleged that infant formula made by Abbott or Mead Johnson harmed or killed preterm babies by causing or contributing to cases of NEC. As of late January, 1,760 NEC lawsuits were pending against Abbott, company spokesperson Scott Stoffel said, clarifying a disclosure in a .

This article is based largely on transcripts, deposition videos, and exhibits from three court cases that went to trial in 2024. The lawsuits were filed by parents of babies who suffered or died from NEC.

Abbott and Mead Johnson have denied fault. They, along with various medical authorities including and the , have said that, when nutritional needs can’t be met with human milk, formula is vital.

One of the cases, , led to a against Mead Johnson. , Gill v. Abbott, led to a against Abbott. , Whitfield v. St. Louis Children’s Hospital, et al., led to a jury verdict in favor of Abbott and Mead Johnson, but the judge found errors and misconduct on the part of defense counsel, faulted his own performance, and .

The judge’s ruling in the Whitfield case is on appeal.

On May 5, a Missouri appeals court against Abbott, saying “we find Abbott’s conduct significantly reprehensible.”

“Throughout the trial, the jury heard evidence that Abbott knew its formula posed significant risks to preterm infants weighing under 1500g yet made little effort to mitigate that risk,” the court wrote.

On June 12, an Illinois appeals court against Mead Johnson and sent the case back for a new trial. The trial court risked prejudicing the jury by improperly admitting evidence about Mead Johnson’s finances, including its revenues, profits, and executive compensation, the appeals court said.

In addition, the trial judge gave the jury erroneous instructions, the appeals court ruled. Any negligence on Mead Johnson’s part hinged on a failure to warn, and the company’s duty was not to warn the mother in that case of any danger, as she had claimed, but rather to warn doctors, the appeals court ruled.

In April, after another trial, a jury in Chicago ordered Abbott to pay four plaintiffs a total of $70 million. Abbott is contesting that verdict and the Missouri appeals court’s decision.

In at least four cases, judges have in favor of Abbott — ruling for the company before the lawsuits reached trial.

‘Branding NICU Babies’

Abbott makes Similac products, and Mead Johnson makes the Enfamil line.

The two companies have vied to place their products in neonatal intensive care units, which serve as entry points to hospital contracts and the retail market, Ñî¹óåú´«Ã½Ò•îl Health News reported in a March article based largely on records from court cases.

For instance, a Mead Johnson slide deck for a 2020 national sales meeting — later used in the Whitfield trial — outlined a plan for “Branding NICU Babies.”

The litigation opened a wider window into the business and regulation of infant formula, including adverse event reports.

“Abbott complies with all applicable FDA regulations on adverse event reporting, including by keeping detailed records of every single complaint/adverse event report Abbott receives and investigating NEC complaints,” Stoffel said in November. “FDA routinely conducts audits that include Abbott’s adverse event investigations and reporting as part of its active regulation of infant nutrition.”

Mead Johnson’s O’Neill echoed that.

“Our adverse event reporting complies with all applicable regulatory requirements,” O’Neill said in a November statement to Ñî¹óåú´«Ã½Ò•îl Health News. “The FDA audits Mead Johnson on an annual basis and has never identified any issue about our approach to reporting.”

The reports the company filed with the FDA were submitted through the agency’s regional office in Detroit, she said.

It’s unclear whether the FDA looked in Detroit.

FDA rules require manufacturers to send written confirmations in the Washington area that oversees infant formula and other foods.

Asked if the company sent them to that office, O’Neill did not answer.

Ñî¹óåú´«Ã½Ò•îl Health News requested an interview with Mead Johnson to clarify its statements about how it handled adverse event reports. The company did not grant one.

Plaintiffs have used internal documents from the companies to allege that, in house, people have long recognized a correlation between NEC and the use of preterm formulas made from cow’s milk.

For example, in a 2010 research proposal shown in a deposition used in the Gill case, Abbott scientists wrote that NEC “is the most severe GI complication of prematurity and the use of bovine milk-based fortifiers and formulas are believed to be the primary risk factor.”

A Mead Johnson document used in the Whitfield lawsuit cited “80% necrotizing enterocolitis (NEC) risk reduction when human milk is used in place of formula.”

Abbott that correlation does not equal causation.

“Numerous studies and NEC authorities have made clear that preterm infant formula does not cause NEC; it’s the absence of human milk that increases NEC risk rather than anything harmful in formula,” Abbott spokesperson Stoffel said.

The FDA, the Centers for Disease Control and Prevention, and the National Institutes of Health weighed in with a in October 2024, saying, “There is no conclusive evidence that preterm infant formula causes NEC” and “there is strong evidence that human milk is protective against NEC.”

Mead Johnson’s O’Neill said the scientific consensus is that there is no established causal link between the use of specialized preterm hospital nutrition products and NEC.

O’Neill cited a statement by the saying the causes of NEC “are multifaceted and not completely understood.”

In a legal brief filed with an Illinois appeals court in the Watson case, the company said “the NEC related risks” of a formula for preterm infants “are the subject of medical debate.”

Managing Potential Warnings

Court records from lawsuits shed light on how the manufacturers have managed potential warnings from the field.

Fabrizis Suarez, who was director of medical safety and surveillance at Abbott from 2006 to 2023, said in a January 2024 deposition used in the Gill and Whitfield cases that he knew of no instance in which Abbott notified the FDA that a baby had died of NEC that could have been caused by Abbott’s formula for preterm infants.

There were numerous cases in which healthcare providers told Abbott they believed the formula caused the NEC, but Abbott disagreed every time, Suarez testified.

Abbott tracks and reviews every NEC report it receives and looks for patterns, Suarez testified.

Courtney Colombo, who identified herself in a March 2024 deposition used in the Gill and Whitfield cases as director of postmarketing medical safety and surveillance at Abbott, likewise testified that she knew of no instance in which Abbott reported to any regulatory authority anywhere in the world that one of its preterm infant formulas was possibly related to a death caused by NEC.

Abbott from the FDA, according to testimony from Wallingford, a paid expert witness on regulatory matters who spent 10 years at the FDA. The complaints were in company files FDA inspectors reviewed during annual inspections, he said in the Whitfield case.

Wallingford also testified that inspections are for reporting infant deaths.

Questioning Wallingford in court, plaintiff’s lawyer Kevin Carnie Jr. invoked the cliché about the .

Wallingford declined to comment for this article. Valentine and Colombo did not respond to messages sent via LinkedIn. Valentine and Suarez did not respond to letters mailed to addresses that appeared to be associated with them. A letter to Colombo with signature required, sent to an address apparently associated with her, was returned unopened.

Not Publicly Reported

Adverse event reports can prompt the FDA to take action to protect the public.

For example, in 2011, the parents, caregivers, and healthcare providers not to feed SimplyThick, a thickening gel, to premature infants fitting a particular profile. The product, used to manage swallowing difficulties, might cause NEC, the FDA said.

The FDA first learned about possible problems with SimplyThick from physicians, according to an FDA document that an attorney for Abbott, Sierra Elizabeth, read from during the Whitfield trial.

The stakes for companies and consumers are high.

A finding under the “reasonable possibility” standard could trigger a product recall, said Martin Hahn, a regulatory attorney for Mead Johnson.

The FDA’s handling of adverse event reports for infant formulas — and fortifiers, which are used to nutritionally supplement a mother’s milk when babies are born prematurely — contrasts with its handling of reports about drugs and medical devices.

The FDA posts manufacturers’ adverse event reports on and online in databases available to the public.

But the notifications manufacturers are required to submit about formulas and fortifiers are not publicly reported, said Emily Hilliard, a spokesperson for the Department of Health and Human Services, which includes the FDA.

In addition, the FDA’s reporting requirements for drugs and medical devices are, in key ways, more demanding than those for infant formula.

Device makers not just deaths but also “serious injuries” that the product “may have caused or contributed to.”

Drugmakers are required to report any “” adverse event, “.” That fatal or life-threatening events.

The FDA also maintains a about dietary supplements, foods, and infant formulas, among other products, that includes from consumers and healthcare practitioners.

Ñî¹óåú´«Ã½Ò•îl Health News searched that database and found one death report that mentioned NEC and a formula made for premature or low-birth-weight babies.

The search turned up seven other reports of infant deaths that mentioned NEC and fortifiers designed for premature or low-birth-weight babies. One of those reports, obtained by Ñî¹óåú´«Ã½Ò•îl Health News through the Freedom of Information Act, said three preterm babies at the same hospital had NEC and died within a month of one another in 2024.

The FDA cautions that reports are not verified and do not prove causation.

A former attorney for Abbott now leads the FDA.

Before becoming the FDA’s last year and being named acting head of the agency in May, Kyle Diamantas in the and lawsuits, court records show.

Diamantas “complies with all applicable ethics laws and regulations,” said Hilliard, the HHS spokesperson. “That included a specific recusal related to Abbott Laboratories, which concluded in January 2026.”

“During that period, Mr. Diamantas voluntarily recused himself from all matters involving infant formula to avoid any appearance of partiality,” Hilliard said.

‘No Health Hazard’

Ñî¹óåú´«Ã½Ò•îl Health News asked the FDA a series of questions for this article. The agency left many unanswered.

“Infant formula safety is a top priority of the FDA given the vulnerability of the intended population,” Hilliard said.

Ñî¹óåú´«Ã½Ò•îl Health News asked Abbott and Mead Johnson for data on all infant death reports the companies received and those they forwarded to the FDA. Neither company provided that information.

Court records provide fragmentary data.

Abbott lawyer Elizabeth said in court that, before Wallingford took the stand as an expert witness, the company gave him from 2005 through 2022 that contained the search term “NEC.”

When Wallingford went through the files, he found that mentioned death and NEC, he testified.

If Similac Special Care products for preterm infants were a problem, and if only 1% of adverse events led to a report, “you would expect to see of complaints,” Wallingford testified.

In 2010, a registered dietitian at a Cincinnati hospital notified Abbott that three babies had died of NEC shortly after starting on an Abbott formula. The dietitian thought there might be a correlation, according to an internal Abbott summary of the complaint shown during Colombo’s deposition. The babies, who were about 17 days old, had no complications other than prematurity, the summary said.

After reviewing the complaint, Abbott’s Colombo wrote, as shown in a deposition video, that she found “NO OTHER REPORTS OF DEATH AND NO TRENDS FOR NEC REPORTED BY OTHER FACILITIES ASSOCIATED WITH THIS STOCK CODE.”

“PREVIOUS COMPLAINT HISTORY INDICATES NO HEALTH HAZARD,” she concluded.

As for Mead Johnson, Valentine “testified that NEC was not one of the top adverse event complaints for Enfamil premature formulas of the 68 received between 2015-2019,” O’Neill, the company spokesperson, told Ñî¹óåú´«Ã½Ò•îl Health News.

Valentine — who was Mead Johnson Nutrition’s medical director for North America from 2014 to 2021 and parent company Reckitt’s chief medical officer from 2022 to 2023, according to a LinkedIn profile — signed off on the decision to close the 2016 file on the distraught mother’s complaint, according to an exhibit and her deposition testimony played in the Whitfield trial.

When she signed off, Mead Johnson didn’t know which of its products the complaint involved, Valentine said in the deposition.

Asked about it during the Watson trial in February 2024, Valentine testified that, in light of the mother’s request never to contact her again, it wouldn’t have been appropriate to call her back for more information.

Valentine “testified that she believes that the Mead Johnson complaint team appropriately investigated reports of death from NEC based on the information provided,” Mead Johnson’s O’Neill said.

Valentine also testified that the FDA encourages infant formula companies to send in all adverse event reports and that nothing prevented Mead Johnson from doing so.

As reflected in an email thread used in the Watson case, Valentine reacted skeptically in 2019 when a colleague told her a particular hospital wanted to exit its contract with Mead Johnson.

“They had 3 cases of NEC since they started using our formulas. They had 0 cases when they were with Abbott,” the colleague reported.

Valentine agreed to follow up but added: “Sad but please reassure them we are not seeing this with our formula … so no science basis for sure.”

Share your story with us: Do you have experience with necrotizing enterocolitis (NEC) or infant formula that you’d like to share? We’d like to hear from you. Click here to contact the Ñî¹óåú´«Ã½Ò•îl Health News reporting team.

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Julie Rovner Ñî¹óåú´«Ã½Ò•îl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of Ñî¹óåú´«Ã½Ò•îl Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

The Supreme Court wrapped up its 2025-26 session this week with a spate of decisions, including several affecting health policy. The most significant: an immigration case that could exacerbate a shortage of workers in nursing homes and other long-term care facilities.

Meanwhile, two separate investigations paint in vivid detail how some doctors and hospitals are pocketing huge profits as a result of a federal law intended to shield patients from surprise medical bills.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Lizzy Lawrence of Stat, Alice Miranda Ollstein of Politico, and Amanda Seitz of Ñî¹óåú´«Ã½Ò•îl Health News.

Panelists

Lizzy Lawrence Stat

Alice Miranda Ollstein Politico

Amanda Seitz Ñî¹óåú´«Ã½Ò•îl Health News aseitz@kff.org Read Amanda's stories.

Among the takeaways from this week’s episode:

• The Supreme Court ended its term this week by issuing several decisions with major implications for American health. They included one ruling allowing more leeway for the president to fire members of independent federal agencies, as well as a ruling blocking lawsuits under state laws from those who claim they were harmed by the weedkiller glyphosate. In particular, the court’s decision enabling the president to end temporary protected status for certain immigrants is expected to have serious consequences for the long-term and elder care industries, both of which rely heavily on Haitian migrants and are already experiencing staffing shortages.
• The Department of Health and Human Services reissued the charter for the Advisory Committee on Immunization Practices, upending the precedent that members must have professional expertise in vaccines. The change is expected to allow the panel — which has been tied up in litigation — to move forward with members appointed by HHS Secretary Robert F. Kennedy Jr.
• Sen. Bill Cassidy of Louisiana, the Republican chairman of the Senate’s primary health committee, finally broke his silence about Kennedy’s confirmation promises. The senator, who lost his bid for reelection to a primary challenger endorsed by President Donald Trump, said he believes Kennedy violated the agreements he made to not disrupt vaccine policy in exchange for Cassidy’s vote. Kennedy again denied that charge.

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

Julie Rovner: Modern Healthcare’s “,” by Michael McAuliff.

Alice Miranda Ollstein: Stateline’s “,” by Kelcie Moseley-Morris.

Lizzy Lawrence: The Wall Street Journal’s “,” by Dave Michaels, Sadie Gurman, and Liz Essley Whyte.

Amanda Seitz: ProPublica’s “,” by Sharon Lerner and Anna Maria Barry-Jester.

Also mentioned in this week’s podcast:

• The New York Times’ ,” by Margot Sanger-Katz and Sarah Kliff.
• Stat’s “,” by Tara Bannow.
• The Washington Post’s “,” by Dan Diamond and Isaac Arnsdorf.
• Stat’s “,” by Lizzy Lawrence and Sarah Todd.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News” on , , , , , or wherever you listen to podcasts.

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He had been targeted by a drive-by shooter in Jacksonville, Florida, and hospitalized with two gunshot wounds. During his weeklong hospitalization, he said, a physician assistant changed the course of his life by visiting his hospital bed each day and warning him that Black men with gunshot wounds often end up paralyzed — or worse.

“I used to run the streets, you know, on the wrong sides of the track,” Pinckney said. “He made me promise that I would never come into his ER that way again. That was the last conversation we had, right before I was discharged.”

His goal since then has been to become a physician assistant. Pinckney, who spent most of his career working for New York City’s Department of Sanitation and as an Army Reserve medic, recently took a step toward achieving it. In May, he graduated with departmental honors from Lehman College with a Bachelor of Science degree.

After moving from New York to Prince George’s County, Maryland, he’d planned on applying for physician assistant school this year. But now, he’s worried his dream may be thwarted by new student loan rules.

Starting July 1, the amount of money graduate students will be allowed to borrow from the federal government . The new student loan limits are part of the GOP’s tax-and-spending legislation known as the One Big Beautiful Bill Act, which President Donald Trump signed into law last year.

The caps are intended to curb the cost of higher education and student loan debt, according to the Trump administration.

But critics widely agree the new limits are too low, especially for students allowed to borrow only $20,500 a year in federal loans due to the law’s controversial definition of a “professional degree.” On June 24, a federal judge temporarily blocked the Department of Education from enforcing that definition. Still, for many students, the new caps won’t cover the combined cost of tuition, housing, and living expenses.

This could leave hundreds of thousands of students who borrow money for graduate school each year at the mercy of private lenders with higher interest rates and fewer repayment options.

Some experts and students also worry that the limits will threaten efforts to diversify the healthcare workforce by deterring minorities and people from low-income households from applying to graduate programs. A drop in incoming students could worsen existing rural and primary care shortages, they argue.

Many politicians and loan experts have acknowledged that the cost of higher education needs to be addressed. But the new federal loan limits are “just not going to achieve that goal,” said Todd Pickard, president of the American Academy of Physician Associates, one of several organizations that have sued the Department of Education over the rules.

“It’d be like if you had a hangnail and I cut your whole arm off instead of just taking care of your hangnail,” Pickard said. “The treatment doesn’t match the problem.”

‘A Rock and a Hard Place’

Students working toward what the law describes as “professional degrees” — including trainee doctors, dentists, pharmacists, and chiropractors — will be allowed to borrow up to $200,000 total, and no more than $50,000 a year.

Meanwhile, the median cost of attending a public medical school is nearly $300,000 over four years, while the median cost of a private medical school education exceeds $400,000, according to the Association of American Medical Colleges.

The caps were set even lower for those pursuing other “graduate” degrees, who face a $100,000 borrowing limit for federal loans over the course of their degree programs. The annual limit for this category of students is only $20,500. Students pursuing physical therapy, physician assistant, and nursing degrees were originally included in this group. But according to new guidance issued by the Department of Education on June 29, some of these students will at least temporarily be able to borrow up to the higher limit, .

The Department of Education, which has been sued by clinician trade groups and about two dozen states over the new rules, did not respond to questions for this article.

As the law was written, a physician assistant student who completed their degree within the average two to three years would not have been eligible to borrow the full $100,000. Meanwhile, physician assistants typically start their careers with an average debt of $112,000, meaning some could be forced to finance their education with higher-interest private loans.

“I feel like I’m between a rock and a hard place,” said Olivia Trull, 24, who is scheduled to begin the physician assistant program at Northwest University in Kirkland, Washington, this summer. The 28-month program costs $137,000, with about $62,000 in tuition and fees estimated for the first year, she said. That doesn’t include living expenses.

Before the court order, Trull said she qualified for the maximum annual allotment under the new rules of $20,500 in federal loans during her first year of graduate school. The balance would need to be financed through a private lender.

She anticipated she would need up to $100,000 in private loans to finance her graduate degree and would face loan payments of more than $3,000 a month when she was done.

“I have to actually sit down and have a conversation with myself,” Trull said, to consider “if I want to be drowning in debt for the next 10 years of my life.” One private bank offered her a loan with an interest rate of nearly 14%, she said.

Pinckney, who said he finished his undergraduate degree with about $10,000 in federal student loan debt, said some of his friends who have already applied for private student loans have been quoted interest rates as high as 13%. Meanwhile, interest rates for federal loans for graduate students, which are set annually, are currently about 8-9%. Federal loans also offer more flexible repayment options than private loans typically do.

In May, 25 states and the District of Columbia against the Department of Education over the new rules. The complaint described the law’s “professional degree” definition as “arbitrary and capricious.”

In a separate filed in June, the American Academy of Physician Associates and the PA Education Association alleged that the new rules deny students the loan amounts needed to attend physician assistant schools. They argue that PA students should be able to access the higher loan limits available to students in medical school and other professional degree programs. (While “physician assistant” and “physician associate” typically refer to the same role, the AAPA in 2021 because of “concern that ‘assistant’ does not reflect the important role of PAs in delivering high-quality healthcare to patients.”)

Meanwhile, Trump administration officials have contended the cost of graduate school is too high across the board. Education Secretary Linda McMahon, speaking before a House committee in May about the new limits, said, “It is our overall goal to bring down the cost of college and education.”

Indeed, some experts acknowledge that the new limits may be helpful in bringing down costs. The federal Grad PLUS loan program, established by Congress 20 years ago, did not cap the amount graduate students could borrow in federal loans. That program was eliminated in the One Big Beautiful Bill Act.

“There is considerable evidence that people borrowed more than they really needed to go to school,” said Sandy Baum, a higher education economist and a senior fellow at the Urban Institute.

Already, some graduate programs have lowered tuition prices, Baum said. In May, for example, the it would lower the cost of its MBA programs by tens of thousands of dollars to fall below the new federal lending thresholds.

And yet Baum doesn’t anticipate many other schools will follow suit.

“I don’t think we’re going to see some dramatic decline in prices,” she said. “I think some programs could close down because they can’t manage.”

‘Tears Have Been Shed’

The new lending limits will also disproportionately affect Black students, Baum said, because they have historically borrowed more than white and Hispanic students.

For some students who borrowed money to finance their undergraduate degrees, the new limits will hit especially hard. Under the new rules, they will be subject to a lifetime limit of $257,000 in federal student loans.

“There will be students who can’t enroll,” Baum said.

Andrei Robu, 26, a medical student at the Medical University of South Carolina, leads the Financial Literacy Interest Group on the Charleston campus. He said many of his peers are worried that the lending limits will make the student body less diverse.

He is also concerned that, because the demand for acceptance into medical school is already so high, schools could prioritize entrance for students from wealthy backgrounds and “still fill up their classes.”

“That’s just not what we want in our physician workforce,” said Robu, who isn’t subject to the new rules as a current student. “We want to represent the population of the country at large.”

Jasmine Vasquez, 26, who has been accepted into the physician assistant program at South College in Atlanta, decided to defer her enrollment until 2027, partly to see if her financing options change. She is worried about taking on too much debt from a private bank.

“Tears have been shed multiple times,” said Vasquez, who is due to give birth in September. “It’s nothing that’s within my control.”

Betsy Mayotte, president of the Institute for Student Loan Advisors, expects the new rules will force some graduates into bankruptcy when they can’t afford to repay private loans.

First, though, she expects enrollment numbers to drop and some graduate programs to close because they can’t recruit enough students. Completion rates will also drop, she expects, as students run into federal loan limits partway through their degree programs.

Beyond that, she predicts healthcare graduates will seek jobs in high-paying specialties, exacerbating shortages in rural and underserved communities.

“They’re going to go where they can make the most money,” Mayotte said.

Pinckney said he is “not really sure” what the future holds. He paid for most of his undergraduate education by working while he was in school, but that’s typically not possible for full-time physician assistant students.

He has considered applying to a biomedical science graduate program instead, which he estimated would cost about $30,000 — an amount that’s “a lot more doable,” he said. It would allow him to potentially work in a lab or in pharmaceuticals, he said. It’s still aligned with medicine, he said, but it wouldn’t help him realize his goal of working with patients.

“Maybe this thing will blow over,” he said of the new federal loan limits. In the meantime, he’s holding out hope.

“If I can influence one person’s life, that would be my way of paying him forward for what he did,” he said, referring to the physician assistant who inspired him back in 1999. “It’s very hard to pivot from that dream.”

This <a target="_blank" href="/health-industry/physician-assistant-professional-graduate-degrees-student-loan-limits/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

But after surgery, Bates said, she couldn’t get out of bed or walk to the bathroom without help. She complained of intense pain radiating down her left leg, weakness in her knee, and a numbing sensation below it, according to hospital records. Bates, who worked as an Uber Eats driver, didn’t have the strength to drive a car.

Still, Bates said, the hospital told her it was time to go.

“They didn’t do any further X-rays or CTs or MRIs to figure out why my knee was numb,” she said. “And they were just like, you know, ‘It’ll go away.’”

Doctors said she was medically stable, Bates said, and because she had no health insurance, they could not send her to a rehabilitation hospital or a skilled nursing facility, which can charge thousands of dollars a day for such care.

“They were just like, We need the bed for somebody who has insurance,” she said. “That’s of course, you know, what they say without saying it.”

At least one firearm injury is treated in an American emergency room every . Tens of thousands die from their injuries every year. Many more, like Bates, are left to face long recoveries, steep medical debt, and enduring trauma.

How insurance affects the care of gunshot wound victims has remained shrouded in mystery — until now, due to a new analysis by The Trace and Ñî¹óåú´«Ã½Ò•îl Health News of data that Florida hospitals compile to collect payments from insurance companies and file with the state.

When uninsured patients arrive at hospitals in Florida with gunshot wounds, on average they spend significantly fewer days in the hospital — in some cases half the time — than those with health insurance, according to the data analysis.

Among the most severely injured patients, the uninsured stayed three fewer days in the hospital on average than their counterparts with insurance.

The data was obtained exclusively for this reporting on gun violence hospitalizations in the state, aided by Florida state law.

The newsrooms spent more than a year analyzing the records, which did not identify patients. The data contained patients’ insurance status, their residential ZIP code, their race, and other demographic info. Reporters reviewed academic studies and government documents and interviewed health policy experts, doctors, activists, and victims of gun violence or their relatives.

The results are a first-of-its-kind look at what happens to the insured and the uninsured who are shot and admitted to the hospital for treatment.

Across Florida, the analysis of hospital billing data from 2018 to 2024 obtained from the Florida Agency for Health Care Administration shows:

• Uninsured patients make up a quarter of the more than 20,000 gunshot wound hospitalizations identified, making them the largest single group treated for firearm injuries.
• Uninsured gunshot victims had hospital stays of about six days on average, only three-quarters of the time spent by patients with private insurance and less than half the average stay for patients on traditional Medicaid, the public health insurance program for poor and disabled people.
• The gap in hospital care persisted regardless of hospital size, location, or ownership type, including at facilities that receive taxpayer money with a mandate to treat all patients regardless of their ability to pay.
• Of the gunshot wound patients, nearly half were Black, making the group highly overrepresented. About a quarter of nonwhite patients were uninsured, versus fewer than a fifth of white patients.

The inequality echoes a in U.S. healthcare against Black and Latino patients, groups that and a .

The U.S. has deaths than other wealthy nations, and no group suffers more than Black Americans like Bates. Black people are far to become victims of a firearm homicide than white people, according to the Johns Hopkins Bloomberg School of Public Health.

Patient outreach workers say hospital personnel might perceive gunshot victims as gang members or troublemakers who deserve blame for getting shot. rehab centers refuse to admit gunshot victims more often than other patients, and some medical records from hospitals were littered with racist or insensitive descriptions of patients and their behavior.

The damage can be lasting: Patients who after a traumatic injury have a higher risk of serious complications, including infection, hemorrhage, nerve damage, and death, especially if wounds — and mental health concerns — are left untreated.

, a University of Florida professor and vice chair for research in community health and family medicine, said there’s evidence that financial incentives drive care — for patients and for hospitals.

Regardless of how often the care team is told to follow quality protocols, Mainous said, “ultimately there’s a business aspect to it, whether the physician is thinking about it or not, whether the nurses think about it or not. But somebody is.”

The Florida data findings come at a time when Republican Gov. Ron DeSantis and state lawmakers have pushed to make guns cheaper and more widely available, despite a in the state from 2014 to 2023, and when President Donald Trump’s administration has rolled back legislation from the Joe Biden presidency to curb gun violence and .

allows eligible residents to carry a concealed firearm and to openly carry a firearm without a state-issued license. State law also prevents cities and counties from enacting stricter gun control measures.

In early June, Florida Attorney General James Uthmeier to strike down the state’s three-day waiting period for receiving a purchased gun, arguing it is unconstitutional. Uthmeier’s request is part of a proposed settlement of a lawsuit brought by the National Rifle Association.

Ñî¹óåú´«Ã½Ò•îl Health News and The Trace requested to speak with administrators at nine of Florida’s large hospital systems to ask why the disparities exist. None agreed to an interview.

Sarah Cannon, communications director at Tallahassee Memorial HealthCare, would not agree to an interview or address Bates’ account of her care for gunshot injuries.

“Clinical decisions, including acute medical intervention, readiness for discharge, and post-acute care needs, are guided by the patient’s condition and response to treatment,” she said in an email.

Cannon said the hospital offers support to patients after discharge, including from social workers who coordinate care and access to services including post-acute care placement, home healthcare, and primary care or specialty follow-up.

Bates said she had to coordinate her own care after being released from the hospital. She said nobody called to schedule a follow-up test of her leg’s muscle function, and her medical records show she did not receive one.

“If I had had insurance,” she said, “they would have definitely kept me there for at least another week to work with me on my standing and walking.”

‘It’s a Business’

Some of Florida’s largest hospitals showed huge differences in length of stay for gun injuries, the Ñî¹óåú´«Ã½Ò•îl Health News-Trace analysis showed. In Miami at Jackson Memorial, the average number of days in the hospital for uninsured patients was 6.6; for those with private insurance, it was 10.7; and for those on traditional Medicaid, it was 15.4. Jackson Memorial did not respond to requests for comment.

Tampa General Hospital reported 4.9 days for uninsured patients, 8 days for those with private insurance, and 13.6 days for Medicaid patients. “To suggest that care decisions for trauma-related patients, and in this case, gun shot victims, are influenced by insurance status is not only absurd, it’s inaccurate,” Amanda Bevis, a hospital spokesperson, said in a written statement. “At Tampa General, every patient is treated equally, based on clinical need and urgency, not insurance coverage.”

And at UF Health Jacksonville, it was 7.2 days for the uninsured, 8.5 days for the privately insured, and 13.8 days for patients on traditional Medicaid. UF Health declined to comment.

Broward Health in Fort Lauderdale reported 7.5 days for uninsured patients, 10.5 days for privately insured patients, and 12.2 days for those on traditional Medicaid. “Insurance status does not impact treatment plans for patients,” Jennifer Smith, a Broward Health spokesperson, said in an email. “Our physicians always proceed in the best interest of the patient regardless of reimbursement or what length of stay may be required.”

Memorial Regional Hospital in Hollywood reported 6.7 days for uninsured patients, 8.8 days for privately insured patients, and 9.5 days for those on traditional Medicaid. Tania Ordaz, a hospital spokesperson, said in an email that she disagreed with the findings: “Treatment decisions are based on the patient’s clinical condition and what is necessary to ensure a safe and appropriate transition of care, not on the patient’s insurance status.”

Trauma surgeons and academics said the Florida data aligns with research nationwide on where gun violence occurs and who’s most affected. Some said they fear the differences contribute to long-standing disparities in America’s healthcare system along the lines of race and class.

The Florida hospital data showed gunshot injuries are concentrated in a handful of ZIP codes marked by poverty, disinvestment, redlining, and other injustices stemming from racial discrimination.

“Why would people without insurance be discharged earlier?” Mainous said. “Because they’re in better health? I think we’ve got a lot of data that would suggest that’s not true.”

Once they leave the hospital, people with commercial insurance or traditional Medicaid are more than twice as likely to receive follow-up care from another provider — such as a rehab center or home health service — as uninsured patients.

Those patients are staying longer, in part, because hospital case managers coordinate their transfers to other facilities, which can be time-consuming and take days.

“You have to go through insurance authorization and approval,” said , a trauma surgeon formerly at Jackson Memorial in Miami who now practices in Oregon. He said patients with private insurance might have access to rehab, preventive care, and training for both the patient and their caregiver to “help them transition to a completely new phase of life.”

For patients without insurance, he said, “sometimes our hands are a little bit tied.”

“The hospital is telling us that this patient has to leave the hospital because they’re medically ready,” he said, “and so I guess we’re discharging them to their car or to their tent, and it doesn’t feel right, but I think that would probably explain some of the differences” in length of stay.

, a trauma surgeon at Jackson Memorial, said hospital staff work to ensure that uninsured patients with long recoveries learn to care for wounds and to enlist family help at home.

Valenzuela said the county-owned hospital does not send uninsured patients home to fend for themselves. She goes into neighborhoods and follows up with patients as part of a Miami-Dade County violence intervention program, whose social workers help them access food, employment, and more to heal and feel safe.

“We know that full recovery is beyond just the hospital and even the rehab centers, even the best ones,” Valenzuela said, pointing to housing and navigating the healthcare system as factors.

runs the Miami-Dade program, which connects victims of gun violence with social workers who visit bedside at the hospital and an intensive care unit-trained nurse who visits at home to provide wound care and other services.

Rawlins said young, Black gunshot patients without health insurance are often at a loss when they leave the hospital about how to schedule a follow-up appointment or manage their mental health.

“After they have been shot and they’re getting out of the hospital and they’re still in crisis,” he said, “their concern is more: How am I going to now pay the rent? How am I going to live? Who’s going to take care of me?”

Often, he said, his uninsured clients leave the hospital before they are ready.

“That’s the reality of it: It’s a business,” he said. “It’s like a hotel. You know, checkout time: You got to go. We got to make room for someone, for a next customer.”

How Long Is Long Enough?

Alea Bates said the hospital discharged her with crutches and one prescription: a seven-day supply of the painkiller Percocet.

A family member drove Bates home. She wore a leg brace, with bandages on her back, stomach, hand, forearm, and feet. When she tried to get out of the car, Bates said, her knee gave and she fell.

Surgeons, health policy experts, and researchers say physicians follow evidence-based best practices for treating gunshot wounds and that a shorter hospital stay does not necessarily reflect a lower-level of care.

, an assistant professor of surgery at the University of Pennsylvania who conducts research on violence reduction, offered one explanation.

In published in The Journal of Trauma and Acute Care Surgery, Kaufman and colleagues found that patients who were admitted while uninsured but then enrolled in Medicaid during their hospitalization — and who needed ongoing rehabilitative care after discharge — spent more time in the hospital and had higher costs.

“I have personally been in situations where I felt like I did the best I could for a patient, but they would say, ‘You’re kicking me out,’” she said. “Sometimes, what the doctor is telling you doesn’t match what you are feeling in your body.”

But Kaufman said: “I’m not going to tell you hospitals never discriminate. That would not be realistic. I would say it is more indirect.”

Kaufman said she couldn’t judge whether Bates stayed in the hospital long enough because she was not her doctor. Still, she said, Bates “didn’t get what she needed from our healthcare system.”

Unlike many states, Florida excludes most single adults without children, like Bates, from Medicaid eligibility, making it exceedingly uncommon for a Medicaid patient to have been admitted as an uninsured adult.

Gunshot survivors endure bleeding and oozing flesh wounds and pain, and they experience . “These experiences are common, but they are not talked about,” Kaufman said. “Mental health is part of the recovery process.”

Recovering the ability to walk or use an arm or a leg after a gunshot wound requires rehab and physical therapy that can be out of financial reach for uninsured patients, said , a pediatric surgeon and an associate professor at the University of Maryland who that uninsured patients hospitalized for traumatic injuries have shorter stays than insured patients.

A shorter stay, he said, “suggests that these patients are not getting the same level of care, and that’s going to put them at risk for functional deficits down the road.”

He said it is impossible to arrive at a set number of days that any patient should remain in a hospital. Factors include the severity of their injury, their age, and any other illnesses they have.

“We’re looking for that Goldilocks length of stay,” Englum said, “and unfortunately, it is not perfectly defined for any specific admission, and it’s not perfectly defined for any specific patient.”

‘Oh, Shit. He Shot Me.’

Bates had delivered her last order for the night when she was shot. It was December 2019: As she was walking back to her car, she heard two loud bangs. Just kids playing pranks, she thought to herself. Then she turned toward the sound and saw a gun pointed at her.

“In that split second it registered in my mind, like, ‘Oh, shit. He shot me,’” Bates said. “I had some brief, like, burning, but it wasn’t registering in my brain right away what it was.”

Within seconds, Bates said, the stranger emptied the clip of his handgun into her body, even after she fell to the ground. He shot her seven times — twice in the back and once each in the pelvis, stomach, left forearm, right thumb, and right foot.

Bates screamed. She reached for her cellphone to call 911. She said residents came out of their apartments. Someone took her phone to tell the emergency dispatcher the address. Another person pressed towels on her wounds to slow the bleeding. An ambulance rushed her to Tallahassee Memorial.

Bates said she did not believe race was a factor in the care she received. But she believed that the circumstances surrounding her shooting — that it happened while she was working, and that she did not know the shooter — affected the way doctors and nurses viewed her.

Language in medical records can sometimes signal a bias in clinicians and perpetuate differences in care that patients receive, said , an associate professor at the Boston University School of Public Health who conducts research on exposure to gun violence.

Jay said bias based on patients’ race, income, or insurance status can deny some people necessary treatment once they leave the hospital.

He said his research suggests the healthcare system treats gunshot survivors and motor vehicle accident victims differently based on perceptions of “whether the victim was in no way at fault. They made assumptions when a person was violently shot.”

“The results are consistent with what we hear so much from hospital outreach workers for gunshot victims,” he said. “They say there is substantial bias. There is an assumption that they contributed to their condition with risky behavior.”

The preoperative notes in Bates’ medical records describe her as “a pleasant 39-year-old female who sustained multiple gunshot wounds to her abdomen, pelvis and extremities last night after performing Uber Eats delivery.”

Bates said it mattered to her caregivers what she was doing when she was shot.

“The nurses and doctors, they all talk about that stuff,” she said. “They were like, ‘Oh, my God, you were ambushed. That’s so scary.’

“I was working. Like, I don’t know these people. And the fact that they were teenagers, I think that that is what maybe changed the narrative,” she said. “Because I feel a lot of times people blame you for what happened.

“But when I was asked and I told them what happened and my story and how I got there,” she said, “I think just the shock in people’s eyes of like, ‘Oh, my God. So you really were, like, you know, minding your business.’”

She added: “And it also wasn’t in a sketchy part of town, if I can just say that. I was in a predominantly white complex. So I think that’s what saved me.”

‘Less Than a Human Being’

Bates had received care at the hospital before as an insured patient.

She had lost her job in the legal department of a state agency — along with her insurance — two months before she was shot.

As an uninsured patient, Bates said, “they kind of just dismiss you. It makes you feel like less than a human being.”

She said she felt ignored when she told doctors she didn’t feel safe going home after four days. She said the physical therapist working with her at the hospital had persuaded the facility to let her stay an extra day.

“We would like, as a medical community, I think as a society, to see everybody get the same care,” said Englum, the University of Maryland trauma surgeon. “Regardless of what color their skin is, what insurance status they have — we want them to get appropriate care.”

The reason for racial or ethnic differences in care is hard to tease out, Englum said. Is it that there’s mistrust of the medical system in some Black and Latino communities, leading people to avoid going to rehab because they don’t want to be there? Is it an income issue? Is it that medical providers see some patients and, due to implicit or explicit bias, think, “That’s as good as they’re going to get?”

“Getting that care is what you need to get your full functional outcome back. And if you’re not getting it,” he said, “patients are suffering that didn’t have to.”

At home, Bates said, she depended on family members to help her out of bed, drive her places, even help her feel safe out in public.

“I really didn’t know how to stand or move or walk around,” she said. “I had to figure it out.”

She still fears loud noises, which remind her of being shot. Bates said she and her dog stay indoors on July Fourth and New Year’s Eve.

“The fireworks were going off, and I was paralyzed,” Bates said of her first New Year’s Eve after being shot. “I was literally sitting there crying. My cousin actually came outside and put my noise-canceling headphones on and turned the music on so that I couldn’t hear anymore. That’s the only way that I could move from outside to inside.”

Bates said her follow-up care included getting her stitches removed at an orthopedic clinic that has physicians who work at the hospital and had performed the initial surgery.

During the visit, Bates said, the orthopedic clinic’s staff reminded her of the unpaid balance from her surgery, which was about $1,200 for physician services. She still owed the hospital $52,000 for treatment, according to her medical bills, and an additional $5,300 for the anesthesiologist. Bates was not working at the time.

Bates said a community outpatient clinic provided physical therapy at a reduced cost and that the victim advocate unit at the Tallahassee Police Department helped find her mental health counseling and get her financial aid from Florida’s .

By 2021, Bates developed a cyst on the gunshot wound to her right thumb, which required surgery. But, she said, the clinic would not perform the surgery until she paid her $1,200 balance. She said friends paid the bill so she could have the surgery.

Bates’ knee bothered her. “Even with going through physical therapy,” she said, “it was still like I couldn’t feel it.”

Bates said she now has private health insurance that pays for her mental health therapy. She pays for physical therapy out-of-pocket.

“It’s crazy that in this country somebody else can hurt you,” Bates said, and “you have to pay for what they did to you.”

“So it’s like you’re triple-paying: You’re paying every day mentally, you’re paying with the bills, and you’re paying by them saying, We know that this is not your fault, but we still have to make our money.”

Methodology

The Trace and Ñî¹óåú´«Ã½Ò•îl Health News examined more than 20 million inpatient hospitalizations in Florida from 2018 to 2024, using data obtained from the Florida Agency for Health Care Administration. We identified 20,255 gunshot wound-related visits using the Centers for Disease Control and Prevention’s injury surveillance case definition, which relies on diagnosis codes. We limited the analysis to initial encounters and excluded patients who died in the hospital or left against medical advice. We excluded cases in the top 1% for hospital length of stay (68 days or more) to prevent these outliers from disproportionately influencing results.

Our primary finding compares the average length of stay of uninsured patients with that of privately insured patients. We chose privately insured patients as the reference group because many researchers believe their care on average is long enough to be effective but not longer than medically necessary. Overall, uninsured patients had hospital stays that were about 25% shorter on average than privately insured patients’ and 50% shorter than those of patients on traditional Medicaid. In most cases we also found that, within the same hospital, uninsured patients had shorter stays than privately insured ones.

To assess whether age or injury severity explained the shorter lengths of stay for uninsured patients, we calculated and fit regression models for Florida’s highest-volume gunshot wound hospitals. We found that, in nearly all cases, the gap narrowed slightly but did not disappear.

Ñî¹óåú´«Ã½Ò•îl Health News data editor Holly K. Hacker contributed to this report.

This article was produced in partnership with The Trace, a nonprofit newsroom covering gun violence in America. .

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A professional in-home caregiver lost her coverage for Zepbound. She soon realized getting it back was not straightforward.

“I was like: ‘What am I going to do? Hopefully I can just continue keeping this weight off.’”

— Deborah Finley, 50, of Lodi, California

---

Deborah Finley, 50, of Lodi, California, said her weight started to worry her during the early days of covid. That’s when she noticed a lot of the people who were on ventilators or dying had something in common: obesity.

“It was a scary time,” she said. As a single mom, she was afraid “that I wouldn’t be here for my daughter.”

Finley had been diagnosed with sleep apnea and nonalcoholic fatty liver disease, and she was prediabetic. Her pulmonologist suggested bariatric surgery but couldn’t get Finley’s insurer to cover it.

She exercised and watched what she ate, but she wasn’t losing weight and her mental health suffered.

She remembers telling her doctor: “Look, I’m at 223 pounds. I feel like I’m hitting this wall. I don’t know what else I can do.” That’s when he suggested Zepbound, a GLP-1 drug for obesity.

Finley said she still had to put in a lot of work to get healthy. But the drug helped. Her sleep apnea improved dramatically. She lost weight.

Then her insurance plan stopped covering Zepbound for weight loss at the end of last year. That’s become common because GLP-1 drugs are expensive for health plans and the employers that pay for them.

“They started sending out notices to all the patients,” Finley said. “And they said: ‘Look, we’re pulling this medication. We’re giving you 90 days’ notice to figure out what you want to do.”

From 2025 to 2026, 12 million people were on plans that for Zepbound and 12 million had plans that dropped Wegovy, another GLP-1, according to , a website that helps patients find discounts on prescription drugs.

If you find yourself in this situation, these tips can help. 

1. Read the fine print on coverage.

While many plans don’t cover GLP-1 drugs for weight loss alone, they may make exceptions if you have other conditions.

That was Finley’s situation. She learned that her insurer would cover Zepbound if it was used to treat obstructive sleep apnea, or MASH, a fatty liver disease. GLP-1s are also covered for people with Type 2 diabetes.

You can work with your doctors to screen for qualifying conditions, said , a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health.

Undiagnosed diabetes, he said, is “the most likely scenario that would allow for someone to go from not being qualified to being qualified.”

Since Finley had sleep apnea and testing showing that the drug helped, she learned it could still be covered with a prior authorization — that’s when you have to get approval from your health insurance before it will cover .

Finley said her physician told her a prior authorization was on file, but when she tried to refill her prescription, the pharmacist told her Zepbound was denied.

2. File an appeal — and get some help from your doctor.

Don’t give up if your medication is denied, said , the obesity medicine director for UVA Health, the health system affiliated with the University of Virginia in Charlottesville. Sometimes your insurer will relent on appeal, if you make a good case.

Finley made several frustrating phone calls and eventually went digging through her online medical records.

“I had to do my own investigative work,” she said.

Those records showed that Zepbound was indeed denied. Her doctor had applied for prior authorization, but it did not go through, because her insurer said there was not sufficient data to back up the request. Somehow, her health information, including the sleep apnea testing results, hadn’t made it to the right people.

Finley eventually got her hands on the 17-page report and got a little help from ChatGPT to write an appeal, showing that the drug was necessary for her based on her diagnosis and covered under her policy.

This kind of appeal can be a lot of work. Luckily, many doctors’ offices will help and know how the system works, Alexander said.

“I don’t think that patients should be expected to navigate these waters on their own,” he said.

3. Carefully document your care.

Sometimes you may have to file multiple appeals if the first one is unsuccessful, said , the vice president for advocacy and research at the nonprofit Obesity Action Coalition, which receives financial support from drugmakers including Zepbound maker Eli Lilly and Wegovy producer Novo Nordisk.

Zvenyach also recommends keeping meticulous records. Some plans require something called step therapy, meaning patients have to try and fail on other drugs or treatments before getting covered for the one their doctor wants them to take.

“Keep a history of other meds you’ve taken so you can provide documentation for step therapy requirements,” she said. “Document dates of participation in any nutrition and physical activity program or membership.”

Finley filed an appeal on Feb. 4, and although she expected a hearing within 90 days, it hadn’t been scheduled yet as of mid-June.

She said it’s been stressful because she hasn’t been able to get new injections of Zepbound since mid-January.

4. Look for discounts if you pay out-of-pocket.

The drugmakers that make Zepbound and Wegovy sell the medicines at a discount to people who pay out-of-pocket instead of using insurance. (Try discount sites like TrumpRx or GoodRx.)

Even with discounts, the drugs are not affordable for everyone. If you have a or a flexible spending account, you can use it to pay for them with pretax dollars.

5. If you’re considering compounded GLP-1s online, watch for red flags.

You might have seen ads for affordable off-brand obesity drugs prescribed by online providers. These are compounded products — that is, made by specialized pharmacists instead of a drug company.

Compounded medicines are prepared using the same active ingredient as the brand-name drugs. But they aren’t approved by the Food and Drug Administration.

Look out for . Check the National Association of Boards of Pharmacy’s . Make sure the pharmacy preparing your drug is . If it’s not, it may not be undergoing inspections or complying with other laws.

After stretching out her remaining supply of Zepbound as long as she could, Finley is taking a compounded version of the drug while she continues the insurance appeals process.

6. Be persistent. And remember to breathe.

Being told no by an insurer is maddening. But Alexander said you often have other options.

“If any appeal that we make is unsuccessful, there are other treatments that we can use,” he said — for example drugs like Contrave, or a cheaper combination of generic naltrexone and bupropion.

UVA Health’s Varney, who has consulted for Eli Lilly, said not to give up on trying to get GLP-1s covered. “Take a breath, but go right back to it,” she said, adding that GLP-1s are superior to the older drugs on the market.

Alexander said he thinks obesity drugs will eventually become affordable — cheap even. Statins, which are used to treat high cholesterol, were once expensive and hard to get covered. Now, Alexander notes, they’re generic and often cost just a few bucks.

“I know it’s hard to imagine,” he said. “But there will come a day when we no longer see these access barriers for GLP-1s.”

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