It seems simple: Require hospitals and insurers to post their negotiated prices for most health care services and — bingo — competition follows, yielding lower costs for consumers.
But nearly four years after the first Trump administration’s regulations forced hospitals to post massive amounts of pricing information online, the effect on patients’ costs is unclear. And while President Joe Biden added requirements to make pricing information more user-friendly, Donald Trump’s imminent return to the White House has raised questions about what’s next, even though posting prices is an area of rare bipartisan agreement.
The uncertainty of what might happen next led some proponents to lobby Congress to include hospital and insurer price transparency in must-pass legislation before Trump takes office. That would turn both his and Biden’s regulations into law, making them less susceptible to being weakened or repealed by a future administration. But that effort failed.
Employers are using transparency data to try to slow growth of their health care costs, and “the last thing you want to do is start over,” said James Gelfand, president and CEO of the ERISA Industry Committee, which represents large employers who finance their own health plans. His group is among the organizations pressing Congress to act.
“Congress’ failure to act is deeply disappointing, but employers and other advocates will redouble our efforts,” Gelfand said. “This will get done.”
While there are reports that many hospitals are not fully complying, federal regulators have sent thousands of warning letters to hospitals and fined just over a dozen.
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The transparency rules require hospitals to list the prices they accept from all insurers for thousands of items and services, from stitches to delivery room costs to X-rays. For consumers, hospitals must also provide a list of 300 “shoppable” services, including bundled prices accepted for common services such as having a baby or getting a hip replacement. Insurers in July 2022 were similarly required to list their negotiated prices, not only for care at hospitals, but also surgery centers, imaging facilities, laboratories, and doctors’ offices.
It’s a massive and often confusing amount of data that has drawn interest from researchers and commercial outlets like Turquoise Health, which has sought to organize the information to better help ordinary consumers shopping for medical services or employers overseeing workers’ health plans.
The data shows a huge variation in prices, both in what hospitals charge and what insurers pay, for the same services. But the result of making those prices public is so far hard to quantify.
A recent study by Turquoise looked at negotiated rates in the nation’s 10 largest metro areas for a set of common health care services. It found that rates in the top quarter tier — the most expensive category — declined by 6.3% from December 2021 to June 2024, during the time the transparency rules were in place. But negotiated rates for the lowest-cost tier of services rose by 3.4%.
That may indicate hospitals and insurers — who can now see what rivals are charging and paying — have either cut prices or demanded better rates, at least for the costliest services.
Even so, Gerard Anderson, who oversees research into the data as a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the changes Turquoise noted were small and are not reflective of what his team has seen in their own studies.
“So far we have not detected any impact of this data on behavior, of where insurers decide to go or what hospitals do to change prices once they realize what others are charging,” Anderson said.
Some health policy experts think it’s unlikely the incoming Trump administration would reverse its prior commitment to price transparency.
“I don’t see a world where he tanks his own regulations,” said Joe Wisniewski, an associate vice president at Turquoise Health. “There is also so much broad bipartisan support on the Hill.”
But even after the Biden administration made the data more user-friendly, it’s still not very helpful to consumers, Anderson said.
“This data is not telling them the price they will pay. It’s telling them the average price people paid last month or last quarter for a similar type of service,” he said.
More useful, Anderson and other experts say, are requirements in the price transparency rules that demand insurers offer online calculators for hundreds of nonemergency services. The detailed cost estimates must take into account how much patients have paid toward annual deductibles.
For uninsured consumers or others who don’t have access to online calculators, it remains difficult to piece together how much a service might cost from the information hospitals post online. For one thing, not every hospital has posted its negotiated rates.
The Department of Health and Human Services’ inspector general said in November an audit of 100 hospitals found that 63 complied with the price transparency rule, while the rest failed to meet one or more requirements.
The advocacy group Patient Rights Advocate, which looked at a sample of 2,000 hospitals, says that only 21% were fully compliant, although it used broader measures for compliance than the inspector general.
“By keeping their prices hidden, hospitals continue to block American consumers from their right to compare prices and protect themselves from overcharges,” said Cynthia Fisher, founder and chairman of the group, which has called for stricter rules and enforcement.
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Keith Poulsen’s jaw dropped when farmers showed him images on their cellphones at the World Dairy Expo in Wisconsin in October. A livestock veterinarian at the University of Wisconsin, Poulsen had seen sick cows before, with their noses dripping and udders slack.
But the scale of the farmers’ efforts to treat the sick cows stunned him. They showed videos of systems they built to hydrate hundreds of cattle at once. In 14-hour shifts, dairy workers pumped gallons of electrolyte-rich fluids into ailing cows through metal tubes inserted into the esophagus.
“It was like watching a field hospital on an active battlefront treating hundreds of wounded soldiers,” he said.
Nearly a year into the first outbreak of the bird flu among cattle, the virus shows no sign of slowing. The U.S. government failed to eliminate the virus on dairy farms when it was confined to a handful of states, by quickly identifying infected cows and taking measures to keep their infections from spreading. Now at least 845 herds across 16 states have tested positive.
Experts say they have lost faith in the government’s ability to contain the outbreak.
“We are in a terrible situation and going into a worse situation,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “I don’t know if the bird flu will become a pandemic, but if it does, we are screwed.”
To understand how the bird flu got out of hand, KFF Health News interviewed nearly 70 government officials, farmers and farmworkers, and researchers with expertise in virology, pandemics, veterinary medicine, and more.
Together with emails obtained from local health departments through public records requests, this investigation revealed key problems, including a deference to the farm industry, eroded public health budgets, neglect for the safety of agriculture workers, and the sluggish pace of federal interventions.
Case in point: The U.S. Department of Agriculture this month announced a federal order to test milk nationwide. Researchers welcomed the news but said it should have happened months ago — before the virus was so entrenched.
“It’s disheartening to see so many of the same failures that emerged during the covid-19 crisis reemerge,” said Tom Bollyky, director of the Global Health Program at the Council on Foreign Relations.
The runny nose of a dairy cow on a farm with a bird flu outbreak. (This photo was taken by a livestock veterinarian who asked to remain anonymous because of concerns about reputational damage.)
A photograph of a note found in a break room at a dairy farm saying “cows with flu in Pen 56” in Spanish. (This photo was taken by a livestock veterinarian who asked to remain anonymous because of concerns about reputational damage.)
Far more bird flu damage is inevitable, but the extent of it will be left to the Trump administration and Mother Nature. Already, the USDA has funneled more than $1.7 billion into tamping down the bird flu on poultry farms since 2022, which includes reimbursing farmers who’ve had to cull their flocks, and more than $430 million into combating the bird flu on dairy farms. In coming years, the bird flu may cost billions of dollars more in expenses and losses. Dairy industry experts say the virus kills roughly 2 to 5% of infected dairy cows and reduces a herd’s milk production by about 20%.
Worse, the outbreak poses the threat of a pandemic. More than 60 people in the U.S. have been infected, mainly by cows or poultry, but cases could skyrocket if the virus evolves to spread efficiently from person to person. And the recent news of a person critically ill in Louisiana with bird flu shows that the virus can be dangerous.
Just a few mutations could allow the bird flu to spread between people. Because viruses mutate within human and animal bodies, each infection is like a pull of a slot machine lever.
“Even if there’s only a 5% chance of a bird flu pandemic happening, we’re talking about a pandemic that probably looks like 2020 or worse,” said Tom Peacock, a bird flu researcher at the Pirbright Institute in the United Kingdom, referring to covid-19. “The U.S. knows the risk but hasn’t done anything to slow this down,” he added.
Beyond the bird flu, the federal government’s handling of the outbreak reveals cracks in the U.S. health security system that would allow other risky new pathogens to take root, too. “This virus may not be the one that takes off,” said Maria Van Kerkhove, director of the emerging diseases group at the World Health Organization. “But this is a real fire exercise right now, and it demonstrates what needs to be improved.”
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A Slow Start
It may have been a grackle, a goose, or some other wild bird that infected a cow in northern Texas. In February, the state’s dairy farmers took note when cows stopped making milk. They worked alongside veterinarians to figure out why. In less than two months, veterinary researchers identified the highly pathogenic H5N1 bird flu virus as the culprit.
Long listed among pathogens with pandemic potential, the bird flu’s unprecedented spread among cows marked a worrying shift. It had evolved to thrive in animals that are more like people biologically than birds.
After the USDA announced the dairy outbreak on March 25, control shifted from farmers, veterinarians, and local officials to state and federal agencies. Collaboration disintegrated almost immediately.
Farmers worried the government might block their milk sales or even demand sick cows be killed, like poultry are, said Kay Russo, a livestock veterinarian in Fort Collins, Colorado.
Instead, Russo and other veterinarians said, they were dismayed by inaction. The USDA didn’t respond to their urgent requests to support studies on dairy farms — and for money and confidentiality policies to protect farmers from financial loss if they agreed to test animals.
The USDA announced that it would conduct studies itself. But researchers grew anxious as weeks passed without results. “Probably the biggest mistake from the USDA was not involving the boots-on-the-ground veterinarians,” Russo said.
Will Clement, a USDA senior adviser for communications, said in an email: “Since first learning of H5N1 in dairy cattle in late March 2024, USDA has worked swiftly and diligently to assess the prevalence of the virus in U.S. dairy herds.” The agency provided research funds to state and national animal health labs beginning in April, he added.
A researcher draws blood from a farmworker to analyze it for signs of a previous, undetected bird flu infection.(Thang Nguyen/UTMB)
The USDA didn’t require lactating cows to be tested before interstate travel until April 29. By then, the outbreak had spread to eight other states. Farmers often move cattle across great distances, for calving in one place, raising in warm, dry climates, and milking in cooler ones. Analyses of the virus’s genes implied that it spread between cows rather than repeatedly jumping from birds into herds.
Milking equipment was a likely source of infection, and there were hints of other possibilities, such as through the air as cows coughed or in droplets on objects, like work boots. But not enough data had been collected to know how exactly it was happening. Many farmers declined to test their herds, despite an announcement of funds to compensate them for lost milk production.
“There is a fear within the dairy farmer community that if they become officially listed as an affected farm, they may lose their milk market,” said Jamie Jonker, chief science officer at the National Milk Producers Federation, an organization that represents dairy farmers. To his knowledge, he added, this hasn’t happened.
Speculation filled knowledge gaps. Zach Riley, head of the Colorado Livestock Association, said wild birds may be spreading the virus to herds across the country, despite scientific data suggesting otherwise. Riley said farmers were considering whether to install “floppy inflatable men you see outside of car dealerships” to ward off the birds.
Advisories from agriculture departments to farmers were somewhat speculative, too. Officials recommended biosecurity measures such as disinfecting equipment and limiting visitors. As the virus kept spreading throughout the summer, USDA senior official Eric Deeble said at a press briefing, “The response is adequate.”
The USDA, the Centers for Disease Control and Prevention, and the Food and Drug Administration presented a united front at these briefings, calling it a “One Health” approach. In reality, agriculture agencies took the lead.
This was explicit in an email from a local health department in Colorado to the county’s commissioners. “The State is treating this primarily as an agriculture issue (rightly so) and the public health part is secondary,” wrote Jason Chessher, public health director in Weld County, Colorado. The state’s leading agriculture county, Weld’s livestock and poultry industry produces about $1.9 billion in sales each year.
Patchy Surveillance
In July, the bird flu spread from dairies in Colorado to poultry farms. To contain it, two poultry operations employed about 650 temporary workers — Spanish-speaking immigrants as young as 15 — to cull flocks. Inside hot barns, they caught infected birds, gassed them with carbon dioxide, and disposed of the carcasses. Many did the hazardous job without goggles, face masks, and gloves.
By the time Colorado’s health department asked if workers felt sick, five women and four men had been infected. They all had red, swollen eyes — conjunctivitis — and several had such symptoms as fevers, body aches, and nausea.
State health departments posted online notices offering farms protective gear, but dairy workers in several states told KFF Health News that they had none. They also said they hadn’t been asked to get tested.
Studies in Colorado, Michigan, and Texas would later show that bird flu cases had gone under the radar. In one analysis, eight dairy workers who hadn’t been tested — 7% of those studied — had antibodies against the virus, a sign that they had been infected.
Missed cases made it impossible to determine how the virus jumped into people and whether it was growing more infectious or dangerous. “I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, an executive director at the international organization the Coalition for Epidemic Preparedness Innovations, who served as assistant secretary for preparedness and response in the Obama administration.
Citing “insufficient data,” the British government raised its assessment of the risk posed by the U.S. dairy outbreak in July from three to four on a six-tier scale.
Virologists around the world said they were flabbergasted by how poorly the United States was tracking the situation. “You are surrounded by highly pathogenic viruses in the wild and in farm animals,” said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands. “If three months from now we are at the start of the pandemic, it is nobody’s surprise.”
Although the bird flu is not yet spreading swiftly between people, a shift in that direction could cause immense suffering. The CDC has repeatedly described the cases among farmworkers this year as mild — they weren’t hospitalized. But that doesn’t mean symptoms are a breeze, or that the virus can’t cause worse.
“It does not look pleasant,” wrote Sean Roberts, an emergency services specialist at the Tulare County, California, health department in an email to colleagues in May. He described photographs of an infected dairy worker in another state: “Apparently, the conjunctivitis that this is causing is not a mild one, but rather ruptured blood vessels and bleeding conjunctiva.”
Over the past 30 years, half of around 900 people diagnosed with bird flu around the world have died. Even if the case fatality rate is much lower for this strain of the bird flu, covid showed how devastating a 1% death rate can be when a virus spreads easily.
Like other cases around the world, the person now hospitalized with the bird flu in Louisiana appears to have gotten the virus directly from birds. After the case was announced, the CDC released a statement saying, “A sporadic case of severe H5N1 bird flu illness in a person is not unexpected.”
‘The Cows Are More Valuable Than Us‘
Local health officials were trying hard to track infections, according to hundreds of emails from county health departments in five states. But their efforts were stymied. Even if farmers reported infected herds to the USDA and agriculture agencies told health departments where the infected cows were, health officials had to rely on farm owners for access.
“The agriculture community has dictated the rules of engagement from the start,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That was a big mistake.”
Some farmers told health officials not to visit and declined to monitor their employees for signs of sickness. Sending workers to clinics for testing could leave them shorthanded when cattle needed care. “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too,” said an email from the Weld, Colorado, health department.
“We know of 386 persons exposed – but we know this is far from the total,” said an email from a public health specialist to officials at Tulare’s health department recounting a call with state health officials. “Employers do not want to run this through worker’s compensation. Workers are hesitant to get tested due to cost,” she wrote.
An email obtained through a Freedom of Information Act request to the public health department in Weld County, Colorado, illustrates that some workers on farms with bird flu outbreaks weren’t monitored for signs of infection. (Screenshot by KFF Health News)
Jennifer Morse, medical director of the Mid-Michigan District Health Department, said local health officials have been hesitant to apply pressure after the backlash many faced at the peak of covid. Describing the 19 rural counties she serves as “very minimal-government-minded,” she said, “if you try to work against them, it will not go well.”
Rural health departments are also stretched thin. Organizations that specialize in outreach to farmworkers offered to assist health officials early in the outbreak, but months passed without contracts or funding. During the first years of covid, lagging government funds for outreach to farmworkers and other historically marginalized groups led to a disproportionate toll of the disease among people of color.
Kevin Griffis, director of communications at the CDC, said the agency worked with the National Center for Farmworker Health throughout the summer “to reach every farmworker impacted by H5N1.” But Bethany Boggess Alcauter, the center’s director of public health programs, said it didn’t receive a CDC grant for bird flu outreach until October, to the tune of $4 million. Before then, she said, the group had very limited funds for the task. “We are certainly not reaching ‘every farmworker,’” she added.
Farmworker advocates also pressed the CDC for money to offset workers’ financial concerns about testing, including paying for medical care, sick leave, and the risk of being fired. This amounted to an offer of $75 each. “Outreach is clearly not a huge priority,” Boggess said. “I hear over and over from workers, ‘The cows are more valuable than us.’”
The USDA has so far put more than $2.1 billion into reimbursing poultry and dairy farmers for losses due to the bird flu and other measures to control the spread on farms. Federal agencies have also put $292 million into developing and stockpiling bird flu vaccines for animals and people. In a controversial decision, the CDC has advised against offering the ones on hand to farmworkers.
“If you want to keep this from becoming a human pandemic, you focus on protecting farmworkers, since that’s the most likely way that this will enter the human population,” said Peg Seminario, an occupational health researcher in Bethesda, Maryland. “The fact that this isn’t happening drives me crazy.”
Nirav Shah, principal deputy director of the CDC, said the agency aims to keep workers safe. “Widespread awareness does take time,” he said. “And that’s the work we’re committed to doing.”
As Trump comes into office in January, farmworkers may be even less protected. Trump’s pledge of mass deportations will have repercussions, said Tania Pacheco-Werner, director of the Central Valley Health Policy Institute in California, whether they happen or not.
Many dairy and poultry workers are living in the U.S. without authorization or on temporary visas linked to their employers. Such precarity made people less willing to see doctors about covid symptoms or complain about unsafe working conditions in 2020. Pacheco-Werner said, “Mass deportation is an astronomical challenge for public health.”
Not ‘Immaculate Conception’
A switch flipped in September among experts who study pandemics as national security threats. A patient in Missouri had the bird flu, and no one knew why. “Evidence points to this being a one-off case,” Shah said at a briefing with journalists. About a month later, the agency revealed it was not.
Antibody tests found that a person who lived with the patient had been infected, too. The CDC didn’t know how the two had gotten the virus, and the possibility of human transmission couldn’t be ruled out.
Nonetheless, at an October briefing, Shah said the public risk remained low and the USDA’s Deeble said he was optimistic that the dairy outbreak could be eliminated.
Experts were perturbed by such confident statements in the face of uncertainty, especially as California’s outbreak spiked and a child was mysteriously infected by the same strain of virus found on dairy farms.
“This wasn’t just immaculate conception,” said Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “It came from somewhere and we don’t know where, but that hasn’t triggered any kind of reset in approach — just the same kind of complacency and low energy.”
Sam Scarpino, a disease surveillance specialist in the Boston area, wondered how many other mysterious infections had gone undetected. Surveillance outside of farms was even patchier than on them, and bird flu tests are hard to get.
Although pandemic experts had identified the CDC’s singular hold on testing for new viruses as a key explanation for why America was hit so hard by covid in 2020, the system remained the same. All bird flu tests must go through the CDC, even though commercial and academic diagnostic laboratories have inquired about running tests themselves since April. The CDC and FDA should have tried to help them along months ago, said Ali Khan, a former top CDC official who now leads the University of Nebraska Medical Center College of Public Health.
As winter sets in, the bird flu becomes harder to spot because patient symptoms may be mistaken for the seasonal flu. Flu season also raises a risk that the two flu viruses could swap genes if they infect a person simultaneously. That could form a hybrid bird flu that spreads swiftly through coughs and sneezes.
A sluggish response to emerging outbreaks may simply be a new, unfortunate norm for America, said Bollyky, at the Council on Foreign Relations. If so, the nation has gotten lucky that the bird flu still can’t spread easily between people. Controlling the virus will be much harder and costlier than it would have been when the outbreak was small. But it’s possible.
MICHAEL MITCHELL/BROWN UNIVERSITY PANDEMIC CENTER
Agriculture officials could start testing every silo of bulk milk, in every state, monthly, said Poulsen, the livestock veterinarian. “Not one and done,” he added. If they detect the virus, they’d need to determine the affected farm in time to stop sick cows from spreading infections to the rest of the herd — or at least to other farms. Cows can spread the bird flu before they’re sick, he said, so speed is crucial.
Curtailing the virus on farms is the best way to prevent human infections, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, but human surveillance must be stepped up, too. Every clinic serving communities where farmworkers live should have easy access to bird flu tests — and be encouraged to use them. Funds for farmworker outreach must be boosted. And, she added, the CDC should change its position and offer farmworkers bird flu vaccines to protect them and ward off the chance of a hybrid bird flu that spreads quickly.
The rising number of cases not linked to farms signals a need for more testing in general. When patients are positive on a general flu test — a common diagnostic that indicates human, swine, or bird flu — clinics should probe more deeply, Nuzzo said.
The alternative is a wait-and-see approach in which the nation responds only after enormous damage to lives or businesses. This tack tends to rely on mass vaccination. But an effort analogous to Trump’s Operation Warp Speed is not assured, and neither is rollout like that for the first covid shots, given a rise in vaccine skepticism among Republican lawmakers.
Change may instead need to start from the bottom up — on dairy farms, still the most common source of human infections, said Poulsen. He noticed a shift in attitudes among farmers at the Dairy Expo: “They’re starting to say, ‘How do I save my dairy for the next generation?’ They recognize how severe this is, and that it’s not just going away.”
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Enjoyed your panel discussion (Watch: ‘Going It Alone’ — A Conversation About Growing Old in America, Dec. 12). I am 85, retired at 55. Traveled (birding) in 65 countries. In 2010, I created the First Friday Ideas Salon. We just had our 171st gathering, via Zoom. I curate each gathering. Last month, we hosted a conservator and a scientist from the Getty museum. The month before: a Cal Tech professor on robotics. I have had many professors, a Nobel Prize winner, MacArthur Foundation “genius grant” recipients, a presidential candidate, etc.
Recently, I became interested in the issue of how retirees whose professions defined their persona can, after age 80, as a “senior senior,” continue to be a person of substantiality. I created the Glorious Age of Aging to look at this issue over six hourlong meetings over three months. The focus was on “action steps.”
So, for me, as a solo ager, the key has been to take action. That said, I worry about the time when my body does not keep up with my mind. Actually, I would say my body has declined and my ability to take care of things required in my life. So, I have prepared food delivered. I hire people to help with my beloved succulent garden and with other chores — so far, young people in my neighborhood. I live in Los Angeles with famously poor public transportation. I use Uber as well as drive. So I wonder if I will be able to continue to find services that will support my living alone. And the real worry is the process of dying — not death — I do not worry about that. Recently, I have decided that I need to create an “intentional community,” which will be there when I need it. I am just beginning to think about how to do this.
— Edna R.S. Alvarez, Los Angeles
A social services agency that has been delivering meals to homebound seniors in all five of New York City’s boroughs for 43 years weighed in on X:
“It’s hard to be by myself so much of the time. It’s lonely.” It’s vital to understand how isolation increases the risk of health problems for older adults: https://t.co/uQDBysqmQW
That’s why the Program of All-Inclusive Care for the Elderly (PACE) is so critical to this conversation. PACE helps older Americans — 91% of whom are 65 or older and have chronic health conditions — stay safe and healthy in their own homes.
The program offers at-home assistance with daily tasks, like dressing, bathing, and eating, and transportation to the PACE day center, where participants can socialize and receive medical care. Unlike other settings, the PACE program coordinates all aspects of a participant’s care, from scheduling medical appointments to providing meals and nutritional advice.
PACE physicians and nurse practitioners’ comprehensive approach to care benefits those who are homebound and may not otherwise have an in-home caregiver to rely on. PACE is also a particularly promising option for those with dementia, as the program allows older adults to receive memory care in the comfort and familiarity of their homes.
It’s also more affordable than many alternative care options. States have reported that PACE costs taxpayers 13% less than the cost of other Medicaid services, all without copays, deductibles, or out-of-pocket expenses for participants.
The program has been quietly transforming our nation’s senior care system, but it remains underutilized. Only a fraction of older Americans are currently eligible for the program, but its benefits can extend far beyond this group. It’s critical for lawmakers to advance policies that expand access to PACE services so that we can set more older Americans up for success as they age at home.
— Jerry Wilborn, chief medical officer of One Senior Care, Erie, Pennsylvania
Gone But Not Forgotten
In February 2023, I came across an article by Tony Leys about the closing of Iowa’s Glenwood Resource Center, which left me reflecting deeply on both the residents who still lived there and those who had passed away and are now buried at the institution. Among them is my great-grandmother, Margarita Hedlund. As I read, I couldn’t help but think about the many people like her, who spent more of their lives at Glenwood than they ever did with their families, and who now rest in the cemetery there.
Nearly two years later, I read another article by Mr. Leys expressing concern for the over 1,300 residents buried in the Glenwood Cemetery and who will take responsibility for maintaining their graves (“After Institutions for People With Disabilities Close, Graves Are at Risk of Being Forgotten,” Nov. 21). The thought of my great-grandmother’s grave and the graves of so many others being neglected is deeply troubling.
Margarita Petterson was born in Sweden in 1866. She came to America as a young child and married Erik Hedlund, also from Sweden. They had five children together, but Erik passed away in 1900, just months before their youngest child was born. My great-grandmother lived with her oldest daughter, but in 1912, for reasons unknown to me, she was sent to Glenwood. She remained there until her death in 1949. Although I knew she had lived at Glenwood, I was never told why, and when I reached out to the institution for information, I received only a brief record. It stated she had a moderate intellectual disability (IQ between 35-49) and died of cirrhosis of the liver. The only other detail I learned was that her son had decided to have her buried in the cemetery there.
Margarita Hedlund with her husband, Erik Hedlund, and daughters Bertha and Emma.
I can’t help but feel sadness and frustration that she was buried so far from her husband, who passed away nearly half a century earlier. There are likely many more families with similar stories — of loved ones abandoned or forgotten in a place like Glenwood, with little more than a name and a grave marker to honor them.
Reading about the fate of Glenwood’s residents and the ongoing concern about the cemetery maintenance only deepens my desire to know more about my great-grandmother’s life and her time there. When it’s your own family member, the need for answers is personal. I hope others who may be in the same situation find ways to learn more about their relatives’ lives at Glenwood and that we, as a community, remember and care for those who were forgotten too long.
— Marlys Adkins, Clare, Iowa
Disability Scoop, a 16-year-old news site that offers daily coverage of autism, intellectual disability, cerebral palsy, Down syndrome and other issues vital to the developmental disability community, shared the article on LinkedIn.
ER Care Goes Beyond Doctors
This is an excellent story to remind people to think ahead and utilize urgent care facilities (“Bill of the Month: A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445,” Nov. 27). But why is this family’s bill surprising? I find it reasonable. There was the all-important initial screening by trained personnel — a child may be more ill than the parent appreciates. The medical history was obtained, temperature and other vitals taken, and swabs for the noted tests. That’s all time and effort that could have been spent on another patient. That’s supposed to be free? Surely you’re not implying that ER staff other than the doctors are worthless.
I remember the ’50s, when our local hospital’s ER staff was “on call.” No charge then if you left before you were seen.
— Gloria Kohut, Grand Rapids, Michigan
An emergency physician in Ontario chimed in on X:
— Raghu Venugopal, Toronto
Watch Your Language
It is too bad that an inflammatory article was written like the one titled “How Measles, Whooping Cough, and Worse Could Roar Back on RFK Jr.’s Watch” (Dec. 6). “Could” is just a speculative word and may be associated with fear-mongering. Your bias seems clear. It’s difficult to find unbiased health-related articles nowadays. I request that you write an article concerning RFK Jr. that is not biased — that is not from Big Pharma’s viewpoint. You aren’t aware that the Centers for Disease Control and Prevention, FDA, and other government agencies are industry-captured?
— Wayne Carpenter, Omak, Washington
An infectious disease specialist and senior scholar at the Johns Hopkins Center for Health Security had this to say on X:
“Vaccine development requires millions of dollars. Unless there is prospect of profit, commercial companies are not going to do it.” — why would companies even invest in vaccines if there reward is demonization https://t.co/F6jAv5cdhe
I just wanted to say how much I appreciated your roundup of news about prioritizing plant-based proteins (“Morning Briefing: Eat More Plant-Based Foods, According To Dietary Guidelines Advisory Panel,” Dec. 11). The idea that our food choices can come from a place of ethical consumption seems so removed from much of the world today. So many people have questions and concerns about becoming plant-based — is it healthy? What will my friends and family think? etc. But what your newsletter clearly shows is it’s not about what leaving animal products off one’s plate takes away but instead how much trying a plant-based meal gives to the individuals, the animals, and the environment.
Thank you for inspiring change without creating fear. Our future depends on more coverage like this.
— Sara Crane, Toronto
A Slice of Real Life
I really enjoyed your article “Perspective: Removing a Splinter? Treating a Wart? If a Doctor Does It, It Can Be Billed as Surgery” (Dec. 13). The exact thing happened to our family, and I thought we were an anomaly. My daughter got a 1-centimeter cut above her eye after falling out of bed. I took her to MUSC Children’s Health After Hours Care in Mount Pleasant, South Carolina (basically a doctor’s office that is open late). It’s not an ER or urgent care. When we arrived, the receptionist said, “We don’t do stitches here.” I checked in my daughter anyway since the receptionist said the doctor might be able to apply glue to help keep the cut closed. The doctor cleaned the cut with sterile saline, applied glue, and placed a few Steri-Strips. We were billed for “minor surgery” despite no scalpel, no stitches, no lidocaine. I looked up the ICD-10 code, and sure enough “application of tissue adhesive” is a “minor surgery” code. Our out-of-pocket was around $830 with UnitedHealthcare. I still have all the bills. “Liquid bandage” and Steri-Strips can be purchased at Walgreens.
I’ve never emailed the writer of an article, but this got me fired up! Thanks for bringing this to light.
— Cailin Lutz, Charleston, South Carolina
Continuing the surgical thread on X was a professor of medicine and pharmacy at the University of Pittsburgh:
— Bernie Good, Pittsburgh
As a retired primary care physician, I was often frustrated that my management of complex medical conditions was reimbursed at lower rates than the illustrated splinter, or other “surgical treatments” as mentioned in Elisabeth Rosenthal’s article. However, blaming the physician for this discrepancy is inappropriate. The Centers for Medicare & Medicaid Services has strict regulations on billing. We are mandated to code per the regulations. We cannot give “discounts” for these procedures. To do so would be problematic in the bizarre catch-22 world of Medicare billing.
We are mandated to report our services accurately using only the codes available. To do otherwise is considered fraud by Medicare. When a physician is accused of fraud, he/she is presumed guilty and pays significant financial penalties until innocence is proven. Even a murderer and thief have more rights in the judicial system.
Medicare determines the lowest reimbursement rate; the other carriers pay a higher rate based on that rate. If an individual physician accepts Medicare, he/she must accept that rate. Only a non-participating physician (not accepting Medicare) can offer a lower rate. The exception is if the service is provided at no cost. Should the patient demand the service be provided free?
I’m reminded of the plumber charging $100 to replace a washer: 10 cents for the washer and $99.90 to know how to replace it.
— Robert Sullivan, Adairsville, Georgia
No Free Pass for Drug Ads
After reading this article by Elisabeth Rosenthal, “Perspective: With TV Drug Ads, What You See Is Not Necessarily What You Get” (Sept. 9), I wanted to share an opinion about the federal court’s decision to deem price disclosure on pharmaceutical advertisements a violation of the First Amendment. Commercial advertising has less protection under the First Amendment than individual speech. According to the Central Hudson Test, commercial speech, at baseline, must concern a lawful activity and not be false, deceptive, or misleading. Even if the speech meets all these criteria, the government can intervene if there is “substantial” government interest. If there is further regulation from the government on commercial advertising, it must be no more extensive than necessary to serve the government’s interest. Essentially, if there is intervention, it must be warranted, and the regulation must be reasonable when compared to the restriction (U.S. Constitution, Amendment 1.7.6.2).
In the case of pharmaceutical ads, especially those that promote oncology medications, they do not meet the baseline qualifications to be considered “not false, deceptive, or misleading.” It has been shown that pharmaceutical ads can rely on emotional response over rational appeal (Main, et al., 2004). If the ad is going to target an emotional response of a vulnerable population, then what is being sold must be accurate. If they are going to sell a chemotherapy that may not be the best option (but possibly have the most adverse side effects), then there is a government responsibility to protect this population and to be more discerning when determining what is truthful. Furthermore, even if the ads met the basic qualifications, they could still be regulated further due to the government interest in both public health and health care cost. Requiring that the drug cost be shown on pharmaceutical ads is appropriate federal intervention that I believe is more than reasonable when compared to the restriction.
— Molly Hilliard, New York City
A national drug safety advocate and public speaker tweeted on X:
Did you know drug companies spend over $1B a month on drug ads in recent years? Last year, the top 3 advertising spenders on TV were drug companies.
I have spent my entire career in advertising and Big Pharma is keeping our industry afloat. https://t.co/0cTHTAOSAt
After weeks of painstaking negotiations, Democrats and Republicans in the House and Senate agreed to a major year-end package of health bills, including new regulations for drug companies and pharmacy benefit managers, and renewals of programs to combat opioid abuse and prepare for the next possible pandemic. But the effort could be all for naught, as President-elect Donald Trump and his government-cutting adviser, Elon Musk, complained it gave Democrats too much of what they wanted and threatened Republicans who might vote for it with challenges in upcoming primary elections.
Meanwhile, Texas Attorney General Ken Paxton sued a doctor in New York for prescribing abortion pills via telemedicine to a patient in Texas, in the first major test of whether “shield laws” — intended to protect doctors in states like New York where abortion remains legal — can protect against other states’ enforcement efforts.
This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Victoria Knight of Axios, and Alice Miranda Ollstein of Politico.
Among the takeaways from this week’s episode:
Congress looked to be on the cusp of passing its government spending bills this week, then Trump spoke out. The package featured robust, bipartisan policies — including things that Trump himself has endorsed, such as reforming the pharmacy benefit manager system. Now, it’s not only those policies, plus key extensions on the Medicare telehealth program, opioids, and more, that Trump has undermined: A government shutdown could also furlough the federal employees helping his team transition ahead of his inauguration next month.
Meanwhile, Robert F. Kennedy Jr. has been making the rounds on Capitol Hill to gain support for his confirmation to lead the Department of Health and Human Services. And many senators seem surprisingly supportive of his bid. Some are leaning on shared goals such as limiting ultraprocessed foods. In general, Republican senators do not seem too concerned about RFK Jr.’s nomination — despite a track record of opposing scientific consensus on vaccines and supporting abortion rights.
New government data shows health care spending is up. The recent fatal shooting of an insurance executive has triggered a backlash against the insurance industry, yet the data shows costs are going up due to higher utilization — not necessarily because of factors within insurers’ control. Bottom line: In a system of constant finger-pointing, insurers have earned ire for questionable coverage decisions and lack of transparency — but they’re not the main, or only, culprits of high costs and access problems.
And, in reproductive health news, the attorney general of Texas is suing a New York doctor for prescribing the abortion pill to a patient in Texas. New York, like other more Democratic states, has a shield law protecting providers, yet this case will be the first test of such a law.
Also this week, Rovner interviews KFF President and CEO Drew Altman about what happened in health policy in 2024 and what to expect in 2025.
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
New enrollments under the Affordable Care Act are on pace to trail last year’s record numbers by as many as a million as the outgoing Biden administration confronts upheavals in the program.
Donald Trump’s election to a second term has cast uncertainty around the future of the health law. In addition, the Biden administration implemented cumbersome policies to reduce fraudulent enrollment and is combating a lawsuit that aims to block immigrants who lack legal residency from buying insurance under the program.
So far, the number of new and returning enrollees using healthcare.gov — the federal marketplace that serves 31 states — is below last year’s. New enrollments were just over 730,000 in early December, compared with 1.5 million at the same time last year.
To give consumers in federal marketplace states more time to enroll, the Centers for Medicare & Medicaid Services extended to Dec. 18 the deadline to sign up for coverage that starts Jan. 1. (The Jan. 15 deadline is for coverage that would begin Feb. 1.)
Also in flux is a rule issued by the Biden administration allowing — for the first time — enrollment in ACA coverage by people brought to the U.S. as children without immigration paperwork, known as “Dreamers.”
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The Biden team was granted a temporary stay on Dec. 16 by the U.S. Court of Appeals for the 8th Circuit regarding a Dec. 9 order by a federal judge in North Dakota. That district court judge had ruled in favor of 19 states that sought to block the Biden administration’s Dreamers directive. Without a stay, the decision in that case, Kansas v. the United States, effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in the 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case have said.
A final decision on the temporary stay was expected any day now. If granted, it could allow Dreamers to continue enrolling while the government’s appeal of the district court ruling is heard, which is unlikely to occur before Trump takes office.
In its court filings, the Biden administration argues that not granting a stay would be very disruptive in the middle of open enrollment, causing the federal government to incur costs in retooling its marketplace to reflect the change, and notifying those who have already enrolled that their plans are canceled.
The original case was filed in August in the U.S. District Court for the District of North Dakota and is being heard by District Judge Daniel Traynor, who was nominated in 2019 by then-President Trump.
Previously, the federal government estimated that about 100,000 uninsured people out of a half-million DACA recipients might sign up for 2025 coverage. In its new filing, the government says 2,700 have enrolled in those states that brought the suit and use the federal marketplace.
The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to citizens and those who are called “lawfully present” immigrants.
The federal lawyers argue that North Dakota has not proved it would be harmed by the rule, so it has no standing to bring the case. North Dakota argued that it incurs costs for approximately 130 DACA recipients who live in its state, and that it would not have those expenses if they were barred from enrolling in the ACA and thus decided to leave the country. An exodus is unlikely, the federal government argued. The legal brief also questioned North Dakota’s calculation that it incurs costs of $585 to issue driver’s licenses to the DACA recipients and about $14,000 annually to educate at least one DACA member or dependent.
All the states challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The plaintiff states are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.
Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise could be the cause and tried to ignore it. But he became increasingly worried when the bleeding continued for weeks.
The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.
“I work out a lot,” he said. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, let’s get you in.’”
Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.
Then the bill came.
The Medical Procedure
Colonoscopies are performed in the United States more than 15 million times a year. Rates of colorectal cancer are on the rise, particularly among younger people.
The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.
It typically takes less than one hour, with another hour spent taking the patient’s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
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According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.
The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.
The Final Bill
The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving a patient share of $4,047. (It wasn’t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.
The Billing Problem: Colonoscopies That Find Polyps Cost More
Contos was shocked and angry when he received his itemized bill. “I said, ‘I don’t understand this.’ Then I started to research the cost.”
He asked the hospital what it charges for a diagnostic colonoscopy and was told he’d been sent a cost estimate through his online patient portal prior to the procedure.
The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.
One big reason was revealed in an explanation of benefits (EOB) statement from Contos’ insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist — $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy,” while the second was listed as “colonoscopy w/lesion removal.” Aetna’s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 — $1,638 less.
Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.
After examining Contos’ bill, Littenberg said it’s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.
“How do you explain that in sensible terms that anyone could understand?” Littenberg said.
Even with that reduction, Littenberg said, he thought Contos’ total out-of-pocket cost of $4,047 was “a lot, though not rare for large academic centers.”
Contos paid a fee up front, then made another payment after his procedure. He was shocked and angry when he got his itemized bill showing he still owed more.(Taylor Glascock for KFF Heath News)
Contos’ insurance documents show Aetna’s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer’s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.
In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn’t actually being billed for two procedures, which Contos found bewildering.
“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.
The Resolution
In an email, Contos told the billing department that its charge was “ridiculously high.” A representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and “non-negotiable” — and that his account would be turned over to a collections agency.
CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were “paid accurately” by Aetna, declining further comment. (CVS Health owns Aetna.)
Northwestern did not respond to multiple requests for comment.
Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system’s high pricing.
He said he’s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.
The Takeaway
To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.
To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital’s price website and an insurer’s cost-estimator website, both required by federal price transparency rules.
Patients also can look up a good-faith estimate of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or claims data from insurers.
Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems — regardless of the number found.
It all should be easier for patients, Xiao said: “You shouldn’t have to be a medical billing expert to know what you’re going to pay.”
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Las nuevas inscripciones bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) parecen ser hasta un millón menos que el número récord del año pasado, especialmente por problemas con el programa que enfrenta la saliente administración Biden.
La reelección de Donald Trump para un segundo mandato ha generado incertidumbre sobre el futuro de la ley de salud. Además, el gobierno implementó normas complejas para reducir las inscripciones fraudulentas y está combatiendo una demanda que busca evitar que un grupo de inmigrantes sin residencia legal adquieran cobertura en los mercados de seguros de salud.
Hasta ahora, el número de nuevos inscritos y reinscritos que utilizan cuidadodesalud.gov, el sitio del mercado federal que usan 31 estados, está por debajo del año pasado. A principios de diciembre, las nuevas inscripciones apenas superaban las 730,000, en comparación con 1.5 millones en el mismo período de 2023.
Para dar más tiempo a los consumidores de los estados del mercado federal para inscribirse, los Centros de Servicios de Medicare y Medicaid (CMS) extendieron hasta el 18 de diciembre el plazo para adquirir cobertura que comienza el 1 de enero. (El plazo del 15 de enero es para la que comenzaría el 1 de febrero).
También está en juego una regla emitida por la administración Biden que permite, por primera vez, que los Dreamers, las personas traídas al país de niños sin papeles, puedan inscribirse en los mercados y obtener subsidios.
El 9 de diciembre, un juez federal de Dakota del Norte falló a favor de 19 estados que buscaban bloquear esta directiva de la administración Biden.
El 16, el equipo de Biden obtuvo una suspensión temporal, pero el destino de esta opción todavía está por verse.
De prevalecer, la decisión en este caso, Kansas vs Estados Unidos, efectivamente prohíbiría a quienes han calificado para el programa de Acción Diferida para los Llegados en la Infancia (DACA) inscribirse o recibir subsidios para los planes de ACA en los 19 estados. Según los abogados que siguen el caso, no parece afectar la inscripción o la cobertura en otros estados.
Se espera una decisión final sobre la suspensión temporal en cualquier momento. Si se concede, podría permitir que los Dreamers sigan inscribiéndose mientras se escucha la apelación del gobierno a la decisión del tribunal de distrito, lo cual es poco probable que ocurra antes de que Trump asuma el cargo.
En sus documentos judiciales, la administración Biden argumenta que no conceder una suspensión sería muy disruptivo en medio del período de inscripción abierta, lo que causaría que el gobierno federal incurra en costos para reajustar su mercado para reflejar el cambio y notificar a aquellos que ya se han inscrito que sus planes han sido cancelados.
El caso original fue presentado en agosto en el Tribunal de Distrito de los Estados Unidos para el Distrito de Dakota del Norte y está siendo escuchado por el juez de distrito Daniel Traynor, nominado en 2019 por el entonces presidente Trump.
Previamente, el gobierno federal estimó que alrededor de 100,000 personas sin seguro de un total de medio millón de beneficiarios de DACA podrían inscribirse para tener cobertura de 2025. En su nuevo escrito, el gobierno dice que 2,700 se han inscrito en los estados que presentaron la demanda y que usan el mercado federal.
La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados “legalmente presentes” para los propósitos de inscribirse en planes bajo ACA, los cuales están abiertos a ciudadanos y aquellos denominados inmigrantes “legalmente presentes”.
Los abogados federales argumentan que Dakota del Norte no ha demostrado que sería perjudicado por la regla, por lo que no tiene legitimidad para presentar el caso. El estado argumentó que incurre en costos para aproximadamente 130 beneficiarios de DACA que viven allí, y que no tendría esos gastos si se les prohibiera inscribirse en ACA y, por lo tanto, decidieran abandonar el país.
Por su parte, el gobierno federal argumentó que un éxodo es poco probable. El escrito legal también cuestionó el cálculo de Dakota del Norte de que incurre en costos de $585 para emitir licencias de conducir a los beneficiarios de DACA y alrededor de $14,000 anuales para educar al menos a un miembro o dependiente de DACA.
Todos los estados que impugnan esta regla argumentan que causará cargas administrativas y económicas a medida que más individuos se inscriban, y que alentará a más personas a permanecer en Estados Unidos sin documentos.
Los estados demandantes son: Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Dakota del Norte, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.
Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo.
Newswise — HOUSTON ― The University of Texas MD Anderson Cancer Center’s Research Highlights showcases the latest breakthroughs in cancer care, research and prevention. These advances are made possible through seamless collaboration between MD Anderson’s world-leading clinicians and scientists, bringing discoveries from the lab to the clinic and back.
Smoking cessation medications are safe and effective for people with depression Individuals with major depressive disorder (MDD) are more likely to smoke, leading to higher risks of nicotine addiction and early death from tobacco-related illnesses. To identify the best treatments for quitting, researchers led by George Kypriotakis, Ph.D., and Paul Cinciripini, Ph.D., evaluated the safety and efficacy of three smoking cessation monotherapies previously approved by the Food and Drug Administration – varenicline, bupropion and nicotine patches – on 6,553 participants with current or past MDD. There were no differences in risk of neuro-psychiatric adverse events based on medication among all participants. According to the study, varenicline plus counseling had greater efficacy – continuous abstinence during the nine to 12-week period – and may be the best treatment for individuals with past or current MDD. Participants with current MDD also had reduced anxiety and depression while trying to quit. The study highlights the safety and efficacy of these medications for MDD and emphasizes the continued need for more research to address both untreated depression and nicotine addiction to improve outcomes. Learn more in The American Journal of Psychiatry.
Definitive radiotherapy demonstrates effectiveness in metastatic thyroid cancers Definitive radiotherapy (dRT), intended for long-term disease control, is an effective option for several solid tumors that are oligometastatic, meaning they have limited metastatic lesions, or oligoprogressive, meaning few metastases are progressing. However, the benefit of dRT for metastatic thyroid cancers is largely unknown. Researchers led by Matthew Ning, M.D., examined the use of targeted dRT using stereotactic body radiotherapy (SBRT) in 119 patients with oligometastatic/oligoprogressive thyroid cancer. Treatment with dRT showed a 91% local control rate for treated sites at three years and was associated with significant delays in the need for systemic therapy, the current standard of care. Only 2.5% of patients experienced grade 3 toxicities, with no higher-grade events. The median time to systemic therapy escalation, which can bring significant adverse effects and impact quality of life, was more than four years. While further studies are needed, this study highlights the potential of dRT in controlling oligometastatic and oligoprogressive thyroid cancers. Learn more in the Journal of the National Comprehensive Cancer Network.
Targeting signaling pathway may overcome treatment resistance in pancreatic cancer Many patients with late-stage pancreatic cancer develop resistance to various treatments including first-line chemotherapy, highlighting a need to identify and understand the mechanisms of resistance. To provide insights, researchers led by Yohei Saito, Ph.D., Yi Xiao, Ph.D., and Dihua Yu, M.D., Ph.D., examined single-cell transcriptomic data from models of pancreatic cancer and clinical pathological information from patients with pancreatic cancer. They discovered a novel signaling circuit – Yap1 in cancer cells and Cox2 in fibroblasts of tumor microenvironment – that is activated during chemotherapy and helps these cancer cells survive. Co-targeting Yap1 in cancer cells and Cox2 in fibroblasts effectively overcame chemotherapy resistance and significantly extended survival in preclinical models. Interestingly, clinical analyses revealed that patients with pancreatic cancer who received statins, which inhibit Yap1, and aspirin, which targets Cox2, had prolonged survival during chemotherapy. These findings further highlight the therapeutic potential of co-targeting this signaling circuit to overcome resistance and improve patient outcomes. Learn more in Cell Discovery.
ctDNA in appendix cancer reveals new insights for prognosis and treatment Appendiceal adenocarcinoma (AA), a rare type of appendix cancer, can be challenging to detect. While it is often treated with surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), better tools are needed to guide patient selection, monitoring and treatment decisions. Researchers led by Michael White, M.D., and John Paul Shen, M.D., analyzed circulating tumor DNA (ctDNA) in AA and identified a unique mutational profile, with TP53 mutations being the most common. They detected ctDNA less frequently in metastatic AA and at lower levels than in colorectal cancer, suggesting that AA sheds less DNA into the bloodstream. Detectable ctDNA was associated with lower survival rates, highlighting ctDNA’s potential as a valuable tool for identifying AA patients with poorer prognoses. This approach could enhance patient selection and monitoring in AA care. Learn more in Clinical Cancer Research.
TP53 aberrations affect treatment response and survival in myeloid leukemias TP53 genetic alterations are associated with poor outcomes in myeloid leukemias, but their exact impact on treatment response and survival, considering newer treatment options and allogeneic hematopoietic stem cell transplantation (HSCT), warrants further evaluation. In a new retrospective study, researchers led by Jayastu Senapati, M.D., D.M., Sanam Loghavi, M.D., and Naval Daver, M.D., analyzed 413 newly diagnosed patients with myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) with TP53 mutations. They characterized the relationship between patient outcomes and multiple variables, such as age, disease state, TP53 mutation burden, and therapy received. The study found improved survival outcomes in those with AML and a low-risk TP53 aberration and all patients treated with an HSCT. The overall response rate was 62% and 53% in patients with MDS and AML, respectively. Patients with AML also had higher overall response rates and composite complete response rates when treated with venetoclax, although this did not translate to higher rates of allogeneic HSCT or survival. The comprehensive analysis highlights the importance of knowing a patient’s burden of TP53 aberrations to predict outcomes and determine better therapeutic strategies. Learn more in Haematologica.
Colorado’s new voter-approved gun initiative has a target unlike those of previous measures meant to reduce gun violence. The tax on guns and ammunition is meant to generate revenue to support cash-strapped victim services, and it’s an open question whether it will affect firearms sales.
The 6.5% tax on manufacturers and sellers — including pawnbrokers — of guns, gun parts, and ammunition will generate an estimated $39 million a year. The money is aimed primarily at crime victim services, including groups that help victims of domestic violence. Some of it is earmarked for behavioral and mental health for veterans and youth, and a sliver will support school security.
Firearm deaths have been rising in Colorado since at least 2006, growing more quickly than the state’s population, and with a notable bump in homicides early in the covid pandemic, which prompted a national gun-buying spree. The tax could have public health effects beyond generating money for social services, researchers said. But they don’t know for sure because only one other state, California, has a gun-and-ammo tax — an 11% tax that has been in effect only since July.
Emmy Betz directs the Firearm Injury Prevention Initiative at the University of Colorado School of Medicine and wonders if the tax will change consumer behavior. “The question is whether that will change gun sales or not,” she said.
A federal tax has been levied on gun manufacturers for more than a century — currently at 10% for pistols/revolvers and 11% for other kinds of firearms, plus cartridges and shells.
Colorado state Rep. and Majority Leader Monica Duran, a Democrat, co-sponsored the new law, scheduled to take effect in April. Voters approved it in November as Proposition KK. The connection between firearms and domestic violence is stark: Nationally, every month an average of 57 women are killed by an intimate partner using a gun. Researchers have also found that 59% of mass shootings between 2014 and 2019 in the United States were related to domestic violence.
Support groups for victims of domestic violence and other crimes receive funding through the 1984 federal Victims of Crime Act. Those dollars mostly come from fines and penalties from convicted federal criminals and fluctuate annually depending on what cases the Department of Justice pursues. Federal prosecutions and fines have dropped, so the state’s pot of money has shrunk from nearly $57 million in 2018, when Duran was first elected, to about $14 million in 2024 — a 76% drop.
But the need for victim support services has grown, said Duran, who is a gun owner and a survivor of domestic violence who used such services to escape homelessness.
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Colorado’s new tax is what economists call a “Pigouvian” tax, which seeks to compensate financially for the societal toll or damage a product causes. For example, people who drive cars pay a tax on gas, which goes toward repairing roads.
“It’s not because you’re a bad driver that we’re taxing gasoline. It’s because we need this money to be able to improve our infrastructure in ways that allow people to continue to use that product,” said Rosanna Smart, an economist who co-directs the Rand Gun Policy in America initiative.
She said Colorado’s gun tax is similar: It supports the social infrastructure that’s required in a society with firearms.
In 2022, the U.S. Supreme Court ruled that people can carry a gun outside their homes for self-defense. Smart said the decision made it harder to pass laws restricting gun possession and highlighted the importance of historical precedent. Both the California and Colorado tax laws cite taxes passed by eight states and then-independent Hawaii between 1844 and 1926.
The actual effect of the Colorado and California laws won’t be known for some time. But should other states pursue similar policies, researchers think focusing taxes on specific weapons or places might be more effective at reducing harm, rather than simply generating revenue.
Smart, for example, found that if the goal is to reduce harm, a more optimal design would be to follow the lead of alcohol policies and have varying tax levels based on an item’s likelihood to cause harm.
Adam Rosenberg, a doctoral candidate in economics at Stanford University, found doing so at the national level, by rejiggering the federal tax to be 13.3% on handguns and nothing on long guns, would prevent deaths while holding industry profits steady.
The Colorado tax applies to firearms dealers, manufacturers, and ammunition vendors that make at least $20,000 a year (excluding sales to law enforcement or active-duty military). Neither state officials nor lawmakers nor industry groups could confirm what fraction of firearm businesses that represents. According to data from the Bureau of Alcohol, Tobacco, Firearms and Explosives, about 2,200 firearms dealers or pawnbrokers and manufacturers of ammunition/firearms operate in the state. Ammunition sellers aren’t tallied in that figure.
Some firearms businesses worry the tax will drive people across state lines to purchase guns.
“We’ve already got people saying, ‘Well, we can run over to Utah or Wyoming instead,’” said Frank Sadvar of Northwest Outfitters, a gun store and pawn shop in Craig. The city is a 40-minute drive to Wyoming and 1½ hours to Utah.
“The way it was worded on the ballots, it looked really good,” he said. But Sadvar suspects the revenue will fall short of the $39 million estimated because supporters didn’t factor in sales lost to other states.
In Cortez, which is a half-hour drive from New Mexico, Jesse Fine said he’s heard people say they’d rather drive there to buy a gun than pay the tax in Colorado — even though they’d face a seven-day waiting period there.
Fine, who manages Goods for the Woods, an outdoor gear shop carrying a range of firearms and hunting equipment, said he believes the tax discriminates against gun owners who are exercising their civil rights.
“It makes it hard for a mom-and-pop shop to stay in play,” he said. “We’re going to take the biggest hit because we’re not a big corporation.”
Victim services organizations said they will be in a tight spot financially until the new tax’s revenue starts to fully flow in 2026.
Courtney Sutton, public policy director of the Colorado Organization for Victim Assistance, said most victim service agencies in the state, many of which are members of COVA, “heavily, heavily rely on” the federal funds that have been ballooning up and down.
“We did get $6 million from the state budget, but that’s not very much across 215 programs,” she said, referencing the state’s four victim services coalitions.
The new tax is estimated to bring in $30 million a year to such groups.
Rocky Mountain Victim Law Center executive director Emily Tofte Nestaval said she hopes the new tax revenue will help the center restart a program for people sorting out protection orders, housing issues, and name changes, among other things. Nestaval said that, for now, crime victims in Colorado are on their own.
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
Among the biggest-grossing films in America in February 2002 were a war drama about American troops in Somalia (“Black Hawk Down”), an Arnold Schwarzenegger action movie (“Collateral Damage”), and a future Oscar winner about a brilliant mathematician struggling with schizophrenia (“A Beautiful Mind”).
But none of these films topped the box office that month. That title went to “John Q.,” a movie about health insurance.
Or, more precisely, a story about a desperate father — played by Denzel Washington — who takes a hospital emergency room hostage at gunpoint when his HMO refuses to cover a heart transplant for his young son.
John Q.’s violent quest for justice was, of course, fictional. And even in the film, no one ends up dead.
Tragically, that wasn’t the case on the streets of New York City on Dec. 4 when a gunman fatally shot Brian Thompson, CEO of health insurance giant UnitedHealthcare.
But there was nothing new about the anger at health insurers that Thompson’s shooting unleashed online — and which suspect Luigi Mangione expressed in a document he allegedly wrote.
In fact, eruptions of public rage have shadowed the American health care system for decades.
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In the late 1990s and early 2000s, as “John Q.” was hitting movie screens, Americans were revolting against HMOs, whose practice of denying care to plan members to pad their bottom lines made them public enemy No. 1.
Just a few years later, health insurers stoked new ire for rescinding coverage after people were diagnosed with expensive illnesses like cancer. More recently, insurers’ widening use of cumbersome prior authorization procedures that slow patients’ access to care has provoked yet another round of fury.
The cycle of outrage periodically turns on others in the health care industry as well. Exorbitant bills and aggressive collection tactics, such as garnishing patients’ wages, are sapping public trust in hospitals and other medical providers.
And drug companies — perennial poster children for greed and profiteering — have enraged Americans since at least the 1950s, when new “wonder drugs” like steroids were fueling a growing industry.
When Sen. Estes Kefauver, a Tennessee Democrat who had led an investigation of the Mafia, convened hearings in 1959 to probe high prescription prices, his committee received mountains of mail from Americans who reported being fleeced by drugmakers. One retired rail worker told of having to spend more than a third of his retirement income on medicines for himself and his wife.
All this public outcry has occasionally sparked change. President Barack Obama and congressional Democrats leveraged anger at spiking insurance premiums in California to get the Affordable Care Act over the finish line in 2010, a landmark achievement that expanded health coverage to millions of Americans.
But more often, cycles of rage have been so much sound and fury, producing only modest reforms. In some cases, public anger has yielded more headaches for patients.
The HMO backlash in the late 1990s and early 2000s, for example, prompted employers — from whom about half of Americans get their health coverage — to embrace high-deductible health plans. Many employers saw these plans as a way to hold down costs if they couldn’t limit patients’ choice of medical providers through HMOs. These deductibles, which can reach thousands of dollars a year, are driving tens of millions of Americans into debt.
To many on the left who have long argued for a single-payer, government-run health system, the obstacle to more meaningful relief has been the political power of the same industries — health insurers, drug companies, hospitals — that fuel patient anger.
These industries have indeed proven adept at resisting change that threatened their bottom lines. They’ve also benefited from a paradox in how Americans think about their health care.
Patients may get angry. They may even lose faith in the system. This year, public views of health care quality fell to the lowest point since Gallup began asking about it in 2001, with 44% of Americans rating quality as excellent or good, down from a high of 62%.
Yet more than 70% said their own health care is excellent or good.
There is much debate about what accounts for this paradox. Are Americans just grateful to have the health protections they do? Are they satisfied because most don’t have to use the health care system on a regular basis? Do they simply like their doctor, in the way that voters routinely say they like their own member of Congress but hate Washington politicians? Or do they worry that no matter how frustrating the current system can be, any change risks making the situation worse?
The answer is probably a bit of all of this. Together, such sentiments represent a major challenge for those who hope the current wave of anger at health insurers will drive big improvements.
Could that change? Maybe. These are volatile and unpredictable political times. And the pressure of big medical bills is real. Medical debt, in particular, is exacting a fearsome toll on millions of Americans, KFF Health News’ reporting has shown.
But to drive change, advocates looking to harness public anger at the health care industry probably need to rethink their favored solutions. Old ideas like “Medicare for All,” long cherished on the left, or a deregulated health care market, long championed by the right, haven’t swayed Americans so far, no matter how angry they’ve been.
I don’t know when we’ll see meaningful alternatives. One thing that’s almost certainly on the way: Hollywood’s spin on the death of a health insurance executive gunned down in Midtown Manhattan.
This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
