Some private schools have shut down because of a rapidly escalating measles outbreak in West Texas. Local health departments are overstretched, pausing other important work as they race to limit the spread of this highly contagious virus.
Since the outbreak emerged three weeks ago, the Texas health department has confirmed 90 cases with 16 hospitalizations, as of Feb. 21. Most of those infected are under age 18. Officials suspect that nine additional measles cases reported in New Mexico, across the border from the epicenter of the Texas outbreak in Gaines, are linked to the Texas outbreak. Ongoing investigations seek to confirm that connection.
Health officials worry they’re missing cases. Undetected infections bode poorly for communities because doctors and health officials can’t contain transmission if they can’t identify who is infected.
“This is the tip of the iceberg,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “I think this is going to get a lot worse before it gets better.”
An unknown number of parents may not be taking sick children to clinics where they could be tested, said Katherine Wells, the public health director in Lubbock, Texas. “If your kids are responding to fever reducers and you’re keeping hydrated, some people may keep them at home,” she said.
Most unvaccinated people will contract measles if they’re exposed to the airborne virus, which can linger for up to two hours indoors. Those infected can spread the disease before they have symptoms. Around 1 in 5 people with measles end up hospitalized, 1 in 10 children develop ear infections that can lead to permanent hearing loss, and about 1 in 1,000 children die from respiratory and neurological conditions.
Gaines has a large Mennonite population, which often shuns vaccinations. “We respect everyone’s right to vaccinate or not get vaccinated,” said Albert Pilkington, CEO of the Seminole Hospital District, in the heart of the county, in an interview with Texas Standard. “That’s just what it means to be an American, right?”
Local health officials have been trying to persuade the parents of unvaccinated children to protect their kids by bringing them to pop-up clinics offering measles vaccines.
“Some people who were on the fence, who thought measles wasn’t something their kids would see, are recalculating and coming forward for vaccination,” Wells said.
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Local health departments are also operating mobile testing units outside schools in an attempt to detect infections before they spread. They’re staffing clinics that can provide treatment prophylactically for infants exposed to the virus, who are too young for vaccination. Local health officials are advising day care centers on how to protect young children and babies, and educating school nurses on how to spot signs of the disease.
“I am putting 75% of my staff on this outbreak,” Wells said. Although Lubbock isn’t at the center of the outbreak, people infected have sought treatment there. “If someone infected was in the [emergency room], we need to identify everyone who was in that ER within two hours of that visit, notify them, and find out if they were vaccinated.”
Local health departments in rural areas are notoriously underfunded. Wells said the workload has meant pressing pause on other programs, such as one providing substance abuse education.
Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines, said health officials were following CDC guidelines, as of last year, by advising schools to keep unvaccinated children home for 21 days if they shared a classroom or the cafeteria with someone infected. This means that many parents may need to stay home from work to care for their kids.
“A lot of private schools have closed down because of a high number of sick children,” Holbrooks said.
The burden of measles outbreaks multiplies as the disease spreads. Curbing a 2018 outbreak in Washington state with 72 cases cost about $2.3 million, in addition to $76,000 in medical costs, and an estimated $1 million in economic losses due to illness, quarantines, and caregiving.
Public health researchers expect such outbreaks to become larger and more common because of scores of laws around the U.S. — pending and recently passed — that ultimately lower vaccine rates by allowing parents to exempt their children from vaccine requirements at public schools and some private schools.
Such policies are coupled with misinformation about childhood vaccination now platformed at the highest levels of government. The new director of the Department of Health and Human Services, Robert F. Kennedy Jr., has erroneously blamed vaccines for autism, pointing to discredited theoriesshown to be untrue by more than a dozen scientificstudies.
In Kennedy’s first week on the job, HHS postponed an important meeting of the CDC’s Advisory Committee on Immunization Practices, without saying when it would resume. In addition, the CDC’s letter template to school principals, advising unvaccinated children to remain home from school for 21 days if they’ve been exposed to the measles virus, is no longer on the agency’s website. An old version remains posted on its archive.
As a rule, at least 95% of people need to be vaccinated against measles for a community to be well protected. That threshold is high enough to protect infants too young for the vaccine, people who can’t take the vaccine for medical reasons, and anyone who doesn’t mount a strong, lasting immune response to it. Last school year, the number of kindergartners exempted from a vaccine requirement was higher than ever reported before, according to the Centers for Disease Control and Prevention.
In Gaines, exemptions were far higher than the national average, approaching 20% in 2023-24. Gaines has one of the lowest rates of childhood vaccination in Texas. At a local public school district in the community of Loop, only 46% of kindergarten students have gotten vaccines that protect against measles.
Amid an outbreak that displays the toll of measles in under-vaccinated pockets of America, Texas lawmakers have filed about 25 bills in this year’s legislative session that could limit vaccination further. Lakshaman said the public — the majority of whom believe in the benefits of measles vaccination — should contact their representatives about the danger of such decisions. Her group and others offer resources to get involved.
“We’ve got children winding up in the hospital, and yet lawmakers who’ve got their blinders on,” she said, referring to pending policies that will erode vaccination rates. “It’s just mind-blowing.”
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.
Republicans, who narrowly control Congress, are pushing proposals that could sharply cut funding to the government health insurance program for poor and disabled Americans, as a way to finance President Donald Trump’s agenda for tax cuts and border security.
Democrats, hoping to block the GOP’s plans and preserve Medicaid funding, are rallying support from hospitals, governors, and consumer advocates.
At stake is coverage for roughly 79 million people enrolled in Medicaid and its related Children’s Health Insurance Program. So, too, is the financial health of thousands of hospitals and community health centers — and a huge revenue source to all states.
On Feb. 13, the House Budget Committee voted to seek at least $880 billion in mandatory spending cuts on programs overseen by the House Energy and Commerce Committee. That committee oversees Medicaid, which is expected to bear much of the cuts.
Senate Republicans, working on their own plan, have not proposed similar deep cuts. Sen. Ron Wyden of Oregon, the Finance Committee’s top Democrat, said he expects “an effort to keep the Medicaid cuts hidden behind the curtain, but they’re going to come sooner or later.”
Since Trump took office, Republicans in Washington have discussed making changes to Medicaid, particularly by requiring that enrollees prove they are working. Because most enrollees already work, go to school, or serve as caregivers or have a disability, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
Other GOP ideas that could gain traction toward meeting budget-cutting goals include reducing the federal government’s share of costs for certain enrollees or for the program overall.
Both Trump and House Speaker Mike Johnson say they are only trying to cut what they describe as “waste, fraud, and abuse” in the program, but have yet to offer examples or specifics.
Trump has said he would “love and cherish” Medicaid along with Medicare. During a Fox News interview that aired Feb. 18, Trump repeated his assurance that Medicaid, along with Social Security and Medicare, was not “going to be touched.”
Known as the workhorse of the U.S. health system, Medicaid covers Americans from the beginning of life to the end — paying for 4 in 10 births and care costs for more than 60% of nursing home residents. The program operates as a state-federal partnership, with the federal government paying most of the money and matching state funds regardless of how many people enroll.
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Medicaid, which turns 60 this summer, was created as part of President Lyndon B. Johnson’s “Great Society” strategy to attack poverty along with Medicare, the federal health insurance program for people 65 and older.
In today’s era of extreme partisanship on Capitol Hill, few topics highlight the ideological chasm between the major political parties better than Medicaid.
Unlike Democrats who view Medicaid as a way to ensure health care is affordable and accessible regardless of income, many Republicans in Washington see Medicaid as a broken and wasteful welfare program that’s grown too big and covers millions of adults who don’t deserve the government assistance. Many Republicans in Congress say “able-bodied” adults could get coverage from a job or by purchasing insurance on their own.
Nearly all Republicans opposed the 2010 Affordable Care Act, which expanded Medicaid by offering coverage to millions of low-income adults and helped edge the country closer to Democrats’ long-sought goal of all Americans having health coverage. In exchange for expanding Medicaid, the federal government offered states a larger funding match to cover those individuals.
But while most Republican-controlled states accepted the federal expansion dollars — some only after voters approved ballot initiatives in favor of Medicaid expansion — GOP leaders in Congress have remained steadfastly against the program’s growth.
When Republicans last controlled Congress and the White House, the party sought big cuts to Medicaid as part of efforts in 2017 to repeal and replace the ACA. That campaign failed by a razor-thin margin, partly due to concerns from some congressional Republicans over how it would harm Medicaid and the private industry of health plans and hospitals that benefit from it.
Now, a more conservative GOP caucus has again put a bull’s-eye on Medicaid’s budget, which has grown by at least $300 billion in eight years due largely to the covid pandemic and the decision by more states to expand Medicaid. The House budget plan seeks to free up $4.5 trillion to renew Trump’s 2017 tax cuts, which expire at the end of this year.
“Medicaid is increasingly caught in the middle of partisan polarization in Washington,” said Jonathan Oberlander, a health policy professor at the University of North Carolina and the editor of the Journal of Health Politics, Policy and Law. “This is not just resistance to the ACA’s Medicaid expansion; it is a broader change in the politics of Medicaid that puts the program in a more precarious place.”
Medicaid presents a tempting target for Republicans for several reasons beyond its sheer size, Oberlander said. “The first is fiscal arithmetic: They need Medicaid savings to help pay for the costs of extending the 2017 tax cuts,” he said, noting Trump has taken off the table cuts to Medicare, Social Security, and national defense — the other most costly government programs.
The GOP cuts would also help scale back the program, which covered 93 million people at its apex during the covid pandemic, when states were prohibited for three years from terminating coverage for any enrollee. Oberlander said the cuts also would allow Republicans to strike a blow against the ACA, often called Obamacare.
Republicans’ latest revamping effort comes as Medicaid expansion has become entrenched in most states — and their budgets — over the past decade. Without federal expansion dollars, states would struggle to afford coverage for low-income people on the program without raising taxes, cutting benefits, or slashing spending on other programs such as education.
And since Trump’s first-term effort to cut Medicaid, additional red states such as Utah, Oklahoma, Idaho, and Missouri have expanded the program, helping drop the nation’s uninsured rate to a record low in recent years.
Medicaid is popular. About 3 in 4 Americans view the program favorably, according to a January 2025 KFF poll. That’s similar to polling from 2017.
Here are a few strategies the GOP reportedly is considering to reduce the size of Medicaid:
Cutting ACA Medicaid funding. Through Medicaid expansion, the ACA provided financing for the program to cover adults with incomes up to 138% of the federal poverty level, or $21,597 for an individual. The federal government pays 90% of the cost for adults covered through the expansion, which 40 states and Washington, D.C., have adopted. The GOP could lower that funding to the same match rate the federal government pays states for everyone else in the program, which averages about 60%.
Shifting to block or per capita grants. Either of these two proposals could lower federal funding for states to operate Medicaid while giving states more discretion over how to spend the money. Annual block grants would give states a set amount, regardless of the number of enrollees. Per capita grants would pay the states based on the number of enrollees in each state. Currently, the federal government matches a certain percentage of state spending each year with no cap. Limiting the federal funding would hamper Medicaid’s ability to help states during difficult economic times, when demand for coverage rises with falling employment and incomes, while states also have fewer tax dollars to spend.
Adding work requirements. Republicans in Washington are looking to insert work requirements into federal law. During Trump’s first term, his administration allowed several states to condition coverage for adults on whether they were working, unless they met exemptions such as caregiving or going to school. Arkansas became the first to implement the measure, leading to 18,000 people losing coverage there. Federal judges ruled in 2018 that Medicaid law does not allow for work requirements in the program, which stopped efforts by Trump and several states to impose them in his first term. Several states are taking steps to add a requirement, including Ohio and Montana.
Lawrence Jacobs, founder and director of the University of Minnesota’s Center for the Study of Politics and Governance, said Republicans will face challenges within their own ranks to make major Medicaid cuts, noting House members may be hesitant to cut Medicaid if warned it could lead to hospital closures in their district.
America’s Essential Hospitals, a trade group representing safety-net hospitals that treat the disadvantaged, is encouraging its members to reach out to their lawmakers to make sure they know not only the cuts’ potential impact on patients, but also how they could lead to job cuts and service reductions affecting entire communities.
“The level of cuts being discussed would be incredibly damaging and catastrophic for our hospitals,” said Beth Feldpush, the group’s senior vice president of policy and advocacy.
Said Jacobs: “The politics of cutting Medicaid is really quite fraught, and it’s hard to make a prediction about what will happen at this point.”
We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.
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.
The future of the Medicaid health insurance program for those with low incomes is in doubt, as Congress works on a budget plan calling for major cuts while President Donald Trump both promises to support that plan as well as to protect the program.
Meanwhile, thousands of employees at the Department of Health and Human Services were fired over the holiday weekend, while states with abortion bans face off against states with laws protecting doctors who use telemedicine to prescribe abortion pills to residents of the former.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.
Among the takeaways from this week’s episode:
Medicaid cuts of the magnitude the House is considering would decimate the program. And, as the Republican Party has realigned, cutting it would impact their base. Smaller changes around the edges — concepts like work requirements — may be more possible, even though they have not proved effective in past experiments.
Many of the firings at HHS have a particularly random feel. In some cases, whole offices, some of which were put in place to pursue Trump priorities such as artificial intelligence — have been left without any employees because all their employees were “new.” In other cases, highly recruited scientists were let go. What is emerging as a long-term issue from these federal firings is how agencies like the National Institutes of Health will recruit future scientists. Job candidates are highly educated people who can find more lucrative employment in the private sector. The loss of brainpower, combined with diminished federal support for research, will have consequences. Areas such as basic research, which is not a moneymaker, could suffer.
Texas and Louisiana are each seeking to prosecute a New York doctor who prescribes abortion medication via telemedicine. The governor of New York has vowed to protect such doctors under the state’s “shield law.” But the ultimate decision of which state law prevails will likely be made by the Supreme Court.
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.
In January, during a congressional hearing on his way to becoming secretary of the Department of Health and Human Services, Robert F. Kennedy Jr. got basic details wrong about Medicaid — a program he now oversees.
He said that Medicaid is fully funded by the federal government (it’s not) and that many enrollees are unsatisfied with high out-of-pocket costs (enrollees pay limited, if any, out-of-pocket costs).
Medicaid is complex. The $880 billion-a-year state-federal program offers health coverage to millions of disabled and low-income Americans. The program covers different services for different people in different parts of the country — and enrollees may interact with private insurance companies without “Medicaid” in their names, leaving some unaware that they’re on the program at all.
Although President Donald Trump promised to “love and cherish” Medicaid, Republicans in Congress last week announced federal budget proposals that could dramatically curtail the program. As that debate begins, here is what you need to know about Medicaid.
What is Medicaid, and how is it different from Medicare?
Medicaid and Medicare were created by the same legislation — an addition to the Social Security Act — that was signed into law by President Lyndon B. Johnson in 1965.
Medicaid is a government health insurance program for people with low incomes and adults and children with disabilities.
Medicare, by contrast, generally covers those 65 or older.
For older Americans with low incomes, Medicaid covers out-of-pocket costs for Medicare. Such people are commonly called “dual eligibles,” because they qualify for both programs.
Who is on Medicaid?
More than 79 million people receive services from Medicaid or the closely related Children’s Health Insurance Program. That represents about 20% of the total population of the United States. Most enrollees qualify because of low incomes.
About 40% of all children in the country are covered by Medicaid or CHIP, created in 1997. Both pay for services such as routine checkups, vaccinations, and hospital stays. Medicaid also covers pregnant people before and after they give birth and pays for more than 40% of all births.
Medicaid also covers people with disabilities or complex medical needs and helps them afford services that allow them to live independently in community settings, outside of institutions such as nursing homes and state-run hospitals.
The program serves a diverse cross section of the country. About 40% of people under 65 who use Medicaid are white, 30% are Hispanic, 19% are Black, and 1% are Indigenous people.
Federal Medicaid dollars cannot be used to cover immigrants who are in the U.S. without legal permission, though some states, as well as Washington, D.C., have used their own funds to extend Medicaid coverage to such individuals. California was the first state to do so.
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What are the income qualifications?
Eligibility generally depends on whether a person is low income, and states have different ways of defining that. For a four-adult household without dependent children, the current national median coverage level is $44,367.
The Affordable Care Act, often called Obamacare, which passed in 2010, allowed more people to qualify for Medicaid on the basis of income. This is what is known as “Medicaid expansion.”
The law offered states a sizable incentive to add more people to their programs: The federal government would pitch in more money per enrollee to help cover them.
The intention behind the expansion was to close gaps in health insurance programs for the millions of Americans who don’t get coverage through an employer. Medicaid would cover people with extremely low incomes, and as their incomes rose, they could move to subsidized health plans sold through the Affordable Care Act’s exchanges.
In 2012, the U.S. Supreme Court said the decision of whether to expand the program would be left up to individual states. Today, 40 states and the District of Columbia — led by Democrats and Republicans alike — have opted in.
In the 10 states that haven’t expanded Medicaid to more low-income adults, the median earnings qualification level is $5,947 a year for a single-person household in 2025. Those who make more are not eligible.
Adults in those states who make too much for Medicaid can also make too little to qualify for help buying plans on the Affordable Care Act exchanges, leaving some unable to afford coverage. An estimated 1.5 million fall into this coverage gap.
Where does the money to pay for it come from?
The federal government pays most of the cost of Medicaid by matching a portion of what states spend.
Currently, the federal government matches at least 50% of state spending and offers states more money for some services and enrollees — for instance, for children and pregnant women.
Less wealthy states — determined by considering residents’ per capita incomes — receive a higher match, translating to a higher percentage of federal dollars. In Mississippi, for instance, the federal government picks up 77% of the cost of Medicaid.
States also receive a 90% match from the federal government for enrollees eligible for Medicaid under the ACA’s expansion.
There is no limit on how much states can spend on the program, and hundreds of billions of federal dollars flow into states each year. In 2023, states spent about 15% of their own budgets on Medicaid.
What does that money pay for?
Federal law requires all state Medicaid programs to cover certain services, including emergency medical transportation, X-rays and lab work, family planning, and medication-assisted treatment for people with opioid use disorder. The program also covers many nursing and home health services, though federal law allows those benefits to be clawed back after an enrollee’s death.
Beyond that, states have the flexibility to choose the services their Medicaid programs cover. All states cover prescription drugs, and most cover eyeglasses, some dental care, and physical therapy.
Medicaid covers more mental health and long-term care services than any other type of insurance, public or private.
What is Medicaid called in my state?
Medicaid programs can go by many different names, even within the same state, in part because most states use private insurance companies to run them. This can be confusing for consumers who may not realize they are actually enrolled in Medicaid.
In New York, for instance, Medicaid plans are offered by major companies, such as Anthem Blue Cross Blue Shield and UnitedHealthcare — and some you may not have heard of, such as Amida Care and MetroPlusHealth. In Wisconsin, enrollees may be in BadgerCare Plus; in Connecticut, Husky Health; in Texas, STAR; and in California, Medi-Cal.
How does Medicaid affect hospitals and doctors in my state?
Medicaid generally pays health care providers such as doctors and hospitals less money for services than Medicare or private insurance does. But it can be more money than they’d get caring for people who are uninsured — and without Medicaid, many more Americans would be uninsured.
Like states, providers and hospitals have come to rely on this money and express concerns that even phasing it out over time would require major adjustments.
What’s going to happen to Medicaid?
It’s not clear. Republicans in Washington are again pushing for major changes, which could take the form of cuts to federal funding. That could reduce the number of people who qualify, the services available, or both. A similar push focused on repealing and replacing Obamacare in 2017, during Trump’s first term, was unsuccessful.
Perhaps one of the biggest obstacles to changing Medicaid is its popularity: 77% of Americans — and majorities of Democrats, independents, and Republicans — view the program favorably.
At the heart of it all are key questions about the role of government in people’s health: How big should the U.S. medical insurance safety net be? Who deserves government assistance? And how will enrollees, states, providers, and the health care system at large absorb major changes to Medicaid, even if a rollout were staggered?
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.
In October, Stanford University professor Jay Bhattacharya hosted a conference on the lessons of covid-19 in order “to do better in the next pandemic.” He invited scholars, journalists, and policy wonks who, like him, have criticized the U.S. management of the crisis as overly draconian.
Bhattacharya also invited public health authorities who had considered his alternative approach reckless. None of them showed up.
Now, the “contrarians” are seizing the reins: President Donald Trump has nominated Bhattacharya to lead the National Institutes of Health and Johns Hopkins University surgeon Marty Makary to run the Food and Drug Administration. Yet the polarized disagreements about what worked and what didn’t in the fight against the biggest public health disaster in modern times have yet to be aired in a nonpartisan setting — and it seems unlikely they ever will be.
“The whole covid discussion turned into culture war dialogue, with one side saying, ‘I believe in the economy and liberty,’ and the other saying, ‘I believe in science and saving people’s lives,’” said Philip Zelikow, a scholar and former diplomat based at Stanford’s Hoover Institution.
Frances Lee, a Princeton University political scientist, has a book coming out that calls for a national inquiry to determine the lockdown and mandate approaches that were most effective.
“This is an open question that needs to be confronted,” she said. “Why not look back?”
For now, even with the threat of an H5N1 bird flu pandemic on the horizon, and some other plague waiting in the wings of a bat or goose in a far-flung corner of the world, U.S. public health officials face ebbing public trust as well as a disruptive new health administration led by skeptics of established medicine. On Feb. 7, the Trump administration announced devastating NIH budget cuts, although a judge put them on hold three days later.
Zelikow led the 34-member Covid Crisis Group, funded by four private foundations in 2021, whose work was intended to inform an independent inquiry along the lines of the 9/11 Commission, which Zelikow headed.
The covid group published a book detailing its findings, after Congress and the Biden administration abandoned initiatives to create a commission.
That was a shame, said Jennifer Nuzzo, director of the Pandemic Center at the Brown University School of Public Health, because “while there are some real ideological battles over covid, there’s also lots of stuff that potentially could be fixed related to government efficiency and policy.”
Bhattacharya, Makary, and others in 2023 called for a larger study of the pandemic. It’s not known whether the Trump administration would support one, Lee said.
The new CIA director, John Ratcliffe, however, has reopened the Wuhan lab leak theory, an issue that Republicans have used to try to cast blame on Anthony Fauci, an infectious disease expert and a top covid adviser to both the first Trump and Biden administrations. Sen. Ron Johnson (R-Wis.), the new head of the Senate’s Permanent Subcommittee on Investigations, says he’ll investigate what he described as a cover-up of covid vaccine safety problems.
Bhattacharya declined to respond to questions for this article. Makary did not respond to requests for comment.
Stanford epidemiologist John Ioannidis said his colleague Bhattacharya has an opportunity to advance understanding of the pandemic.
“Until now it has been mostly a war on impressions and media, kind of mobilizing the troops. That’s not really how science should be done,” Ioannidis said. “We need to move forward with some calm reflection, with no retaliation.”
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Mistakes Were Made
In October 2020, Bhattacharya co-authored the “Great Barrington Declaration” with Trump White House support. It called for people to ignore covid and go about their business while protecting the old and vulnerable — without specifics about how.
Bhattacharya and Makary championed the policies of Sweden, which did not impose a harsh lockdown but emerged with a death rate far lower than that of the United States. The Swedes had advantages including lower poverty rates, greater access to health care, and high levels of social trust. For instance, by April 2022, 87% of Swedes ages 12 and over were vaccinated against covid — without mandates. The U.S. figure, for adults over 18, was 76% at the time.
After Bhattacharya’s earlier research was rebuffed by most of the public health establishment, he “curdled into a theological position that the risk wasn’t that severe and the economic costs were so high that we had to roll the dice, or segregate the elderly — which you cannot do,” Zelikow said.
Ten experts interviewed for this article largely agreed that the health establishment lost public trust after bungling the initial handling of the pandemic. Existing pandemic plans were faulty or ignored. Shortages of protective gear and inadequate testing rendered containment of the virus impossible. As time wore on, government scientists failed to emphasize that their recommendations would change as new data came in.
“We totally blew it,” former NIH Director Francis Collins said, in a discussion sponsored by Braver Angels, a group that promotes dialogue among political opponents. Though he blamed disinformation about vaccines for many deaths, he also wished public health officials had said “we don’t know” more often.
Collins said he didn’t pay enough attention to the socioeconomic impact of lockdowns. “You attach infinite value to stopping the disease and saving a life,” he said. “You attach zero value to whether this actually totally disrupts people’s lives, ruins the economy, and has many kids kept out of school in a way that they never quite recover from.”
While Fauci and other public health officials did express worries about collateral damage from mandates, U.S. measures were stricter than in much of the world. That’s left unresolved issues, such as how long schools should have been shuttered, whether mask mandates worked, and whether the public was misled about the efficacy of vaccines.
At the same time, U.S. officials failed to communicate clearly that vaccines prevented most deaths and hospitalizations. An estimated 232,000 unvaccinated Americans died from covid during the first 15 months in which shots were freely available.
Experiences with HIV control taught public health officials not to moralize about behavior, to focus on harm reduction, and to use the least restrictive methods possible, Nuzzo said. Yet politicization led to shaming of people who wouldn’t mask or refused vaccination.
Harm reduction was top of mind for infectious disease doctor Monica Gandhi when she defied lockdown orders by keeping open Ward 86, the clinic she runs for 2,600 HIV patients at Zuckerberg San Francisco General Hospital. Her patients — many poor or homeless — had to be treated in person to keep their HIV in check, she said.
In general, the lockdowns hurt low-income people most, she said. The wealthy “were happy to be shut down, and the poor struggled and struggled.” Gandhi’s two children attended a private school that quickly reopened, she said. Yet she recalled how a medical assistant burst into tears when asked how her family was doing.
“My 8-year-old is at home, on Zoom, all by himself,” the woman told Gandhi. “I have to work and he doesn’t know how to learn that way. There’s no one to give him food.”
Despite strictures, including school closures that were longer than in most European countries, the U.S.’ death rate from covid was the highest in the world, except for Bulgaria, according to an Ioannidis study of countries with reliable data.
Part of the blame lies with the first Trump administration, which “more or less just said, ‘You states manage this crisis,’” Zelikow said. “They went through a lot of somersaults. They did a lot of feckless things and then they basically just gave up,” he said. Pandemic deaths peaked in the four months after the November 2020 election that Trump lost.
Ioannidis, a critic of lockdowns, said the United States was doomed to a bad outcome in any case because of vulnerabilities in the population including poverty, inequality, lack of health care access, poorly protected nursing homes, high rates of obesity, and low levels of trust.
But the disappearance of viral diseases such as respiratory syncytial virus and flu in late 2020 showed how much worse it could have been without lockdowns, said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, who has noted that, while children were the least vulnerable to covid, it killed 1,700 of them by April 2023. More than a million American children had had long covid as of 2022, according to a new Centers for Disease Control and Prevention study.
Consensus Never Arrived
After arising by accidental passage from bats and other animals to humans (or, alternatively, from a Chinese lab accident), the coronavirus was uncannily adept at frustrating containment efforts — and aggravating political tensions. Its ability to infect up to 50% of people asymptomatically, infection outcomes ranging from sniffles to death, waning immunity after infection and vaccination, and the shifting health impact of new variants meant “the deck was stacked against public health,” said biology professor Joshua Weitz of the University of Maryland.
In the end, teams formed along political lines. Conservatives attacked governors for depriving them of liberty, and Trump’s erroneous ramblings about curing the disease with bleach and ultraviolet light inspired intolerance on the left.
“If anyone else was president we would have had a better result,” Gandhi said. “But if Trump said the sky was blue, then goddamn it, the infection disease doctors disagreed.”
The right and left don’t even agree on the correct questions to ask about the pandemic, said Josh Sharfstein, a vice dean of the Bloomberg School of Public Health at Johns Hopkins University.
“Everyone knew that 9/11 was a terrorist attack,” he said. “But what the pandemic was and represents — there’s so much disagreement still.”
“We let children down, we let poor people down,” Ioannidis said in closing remarks at the Stanford conference. “We let our future down.”
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.
When Colleen Henderson’s 3-year-old daughter complained of pain while using the bathroom, doctors brushed it off as a urinary tract infection or constipation, common maladies in the potty-training years.
After being told her health insurance wouldn’t cover an ultrasound, Henderson charged the $6,000 procedure to her credit card. Then came the news: There was a grapefruit-sized tumor in her toddler’s bladder.
That was in 2009. The next five years, Henderson said, became a protracted battle against her insurer, UnitedHealthcare, over paying for the specialists who finally diagnosed and treated her daughter’s rare condition, inflammatory pseudotumor. She appealed uncovered hospital stays, surgeries, and medication to the insurer and state regulators, to no avail. The family racked up more than $1 million in medical debt, she said, because the insurer told her treatments recommended by doctors were unnecessary. The family declared bankruptcy.
“If I had not fought tooth and nail every step of the way, my daughter would be dead,” said Henderson, of Auburn, whose daughter eventually recovered and is now a thriving 20-year-old junior at Oregon State University. “You pay a lot of money to have health insurance, and you hope that your health insurance has your well-being at the forefront, but that’s not happening at all.”
While insurance denials are on the rise, surveys show few Americans appeal them. Unlike in Henderson’s case, various analyses have found that many who escalate complaints to government regulators successfully get denials overturned. Consumer advocates and policymakers say that’s a clear sign insurance companies routinely deny care they shouldn’t. Now a proposal in the California Legislature seeks to penalize insurers who repeatedly make the wrong call.
While the measure, SB 363, would cover only about a third of insured Californians whose health plans are regulated by the state, experts say it could be one of the boldest attempts in the nation to rein in health insurer denials — before and after care is given. And California could become one of only a handful of states that require insurers to disclose denial rates and reasoning, statistics the industry often considers proprietary information.
The measure also seeks to force insurers to be more judicious with denials and would fine them up to $1 million per case if more than half of appeals filed with regulators are overturned in a year.
In 2023, state data show, about 72% of appeals made to the Department of Managed Health Care, which regulates the vast majority of health plans, resulted in an insurer’s initial denial being reversed.
“When you have health insurance, you should have confidence that it’s going to cover your health care needs,” said Sen. Scott Wiener, the San Francisco Democrat who introduced the bill. “They can just delay, deny, obstruct, and, in many cases, avoid having to cover medically necessary care, and it’s unacceptable.”
A spokesperson for the California Association of Health Plans declined to comment, saying the group was still reviewing the bill language. Gov. Gavin Newsom’s spokesperson Elana Ross said his office generally does not comment on pending legislation.
Concerned about spiraling consumer health costs, state lawmakers across the nation have increasingly looked for ways to verify that insurers are paying claims fairly.
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In 2024, 17 states enacted legislation dealing with prior authorization of care by private insurers, according to the National Conference of State Legislatures. Connecticut, which has one of the most robust denial rate disclosure laws, publishes an annual report card detailing the number and percentage of claims each insurer has denied, as well as the share that ends up getting reversed. Oregon published similar information until recently, when state disclosure requirements lapsed.
In California, there’s no way to know how often insurers deny care, which health experts say is especially troubling as mental health care is reaching crisis levels among children and young adults. According to Keith Humphreys, a health policy professor at Stanford University, it’s easier to deny mental health care because a diagnosis of, say, depression can be more subjective than that of a broken limb or cancer.
“We think it’s unacceptable that the state has absolutely no idea how big of a problem this is,” said Lishaun Francis, senior director of behavioral health for the advocacy group Children Now, a sponsor of the bill.
Under Wiener’s proposal, private insurers regulated by the Department of Managed Health Care and the Department of Insurance would be required to submit detailed data about denials and appeals. They would also need to explain those denials and report the outcomes of the appeals.
For appeals that make it to the state’s independent medical review process, known as IMR, insurers whose denials are overturned more than half the time would face staggering penalties. The first case that brings a company above the 50% threshold would trigger a fine of $50,000, with a penalty ranging from $100,000 to $400,000 for a second. Each one after that would cost $1 million.
If passed, the measure would cover roughly 12.8 million Californians on private insurance. It would not apply to patients on Medi-Cal, the state’s Medicaid program, or Medicare, and it would exclude self-insured plans offered by large employers, which are regulated by the U.S. Department of Labor and cover roughly 5.6 million Californians.
The phrase “deny and delay” continues to reverberate across the health care industry after the killing of UnitedHealthcare CEO Brian Thompson. A survey by NORC at the University of Chicago released shortly after the brazen attack revealed that 7 in 10 people said they believed denials for health coverage and profits by health insurance companies bore a great deal or a moderate amount of responsibility for Thompson’s death.
Wiener called Thompson’s killing a “cold-blooded assassination” but said his bill grew out of a narrower proposal that failed last year aimed at improving mental health coverage for children and adults under age 26. But he acknowledged the nation’s reaction to the killing underscores the long-simmering anger many Americans feel about health insurers’ practices and the urgent need for reform.
Humphreys, the Stanford professor, said the U.S. health system creates strong financial incentives for insurers to deny care. And, he added, state and federal penalties are paltry enough to be written off as a cost of doing business.
“The more care they deny, the more money they make,” he said.
Increasingly, large employers are starting to include language in contracts with claim administrators that would penalize them for approving too many or too few claims, said Shawn Gremminger, president of the National Alliance of Healthcare Purchaser Coalitions.
Gremminger represents mostly large employers who fund their own insurance, are federally regulated, and would be excluded from Wiener’s bill. But even for such so-called self-funded plans, it can be nearly impossible to determine denial rates for the insurance companies hired simply to administer claims, he said.
While it could be too late for many families, Sandra Maturino, of Rialto, said she hopes lawmakers tackle insurance denials so other Californians can avoid the saga she endured to get her niece treatment.
She adopted the girl, now 13, after her sister died. Her niece had long struggled with self-harm and violent behavior, but when therapists recommended inpatient psychiatric care, her insurer, Anthem Blue Cross, would cover it for only 30 days.
For more than a year, Maturino said, her niece cycled in and out of facilities and counseling because her insurance wouldn’t cover a long-term stay. Doctors tested a laundry list of prescription drugs and doses. None of it worked.
Anthem declined a request for comment.
Eventually, Maturino got her niece into a residential program in Utah, paid for by the adoption agency, where she was diagnosed with bipolar disorder and has been undergoing treatment for a year.
Maturino said she didn’t have the energy to appeal to Anthem. “I wasn’t going to wait around for the insurance to kill her, or for her to hurt somebody,” Maturino said.
Collection agents for the state of Iowa have sent letters seeking millions of dollars from the estates of at least two people with disabilities who died after spending most of their lives in a state institution.
The amounts represent what Medicaid spent covering the residents’ care when they lived at the Glenwood Resource Center, a state-run facility that closed last summer.
The bills are extraordinary examples of a practice called Medicaid estate recovery. Federal law requires states to try to collect money after some types of Medicaid recipients die. The point is to encourage people to use their own resources before relying on the public program. But some states, including Iowa, are particularly aggressive about the collections, national reports show.
Joy Higgins was stunned by a letter she received a few weeks after her 41-year-old daughter, Kristin, died last May. The letter was written on Iowa Department of Health and Human Services stationery. At the top, in bold letters, it said, “Re: Kristin Higgins.”
“Dear Joy Higgins,” the letter read. “Our sincere condolences to you, as we understand the above person is deceased.”
The letter explained that any money Kristin Higgins left behind would have to be remitted to the state to help repay Medicaid $4,263,148.67. Her family had 30 days to respond.
Joy Higgins, who lives in Council Bluffs, wonders why state debt collectors would send a massive bill to the family of someone like her daughter, who had little income because of a severe developmental disability stemming from a premature birth.
“What are they gaining? That’s my question. Except for kicking someone in the face right after they lost a loved one?” Higgins said.
Kristin Higgins’ only income was a Social Security disability benefit of $1,105 monthly. Most of that went directly to the state institution, where she lived for more than 30 years. Just $50 was set aside monthly as an allowance for personal expenses, according to a state ledger obtained by her family. “They knew exactly how much she had,” her mother said.
When she died, Kristin’s personal account had a balance of $2,239.84. The family put that money toward her funeral, an allowed expense. Nothing was left for the state to take. Higgins said receiving the letter was traumatic even though the family didn’t have to pay the Medicaid bill.
The Higginses have heard about similar attempts to collect from other families, including that of Eric Tomlyn, who died in 2020 at age 29 after spending most of his life at the Glenwood Resource Center.
Shortly after his death, the Tomlyn family received a Medicaid bill of more than $4.2 million. His mother, Susan Tomlyn, was shocked by the letter. “I was like, ‘What? What? Oh my God,’” she recalled.
Shortly after his 2020 death, Eric Tomlyn’s parents, Tim and Susan Tomlyn, received a Medicaid bill for more than $4.2 million. Susan was shocked by the letter. “I was like, ‘What? What? Oh my God,’” she recalled.(Tracy Lovett)
She filled out a form explaining that the small balance in her son’s personal account had gone toward his funeral. “That’s the last I heard of it,” Tomlyn said.
Supporters of estate recovery efforts say the rules encourage people to pay for their own care before applying for Medicaid, which is mainly intended to help those with little money.
Critics of estate recovery programs say they often target families with little to give. Wealthier families tend to have lawyers who can structure estates in ways that avoid Medicaid repayment demands, the critics note.
Like Higgins, Tomlyn thought her Medicaid recovery bill came from state officials because it was printed on letterhead from the Iowa Department of Health and Human Services. The people who signed the letters identified themselves as being from the “Estate Recovery Program.” But the people who produce such letters work for private contractors hired to collect Medicaid debts, according to Alex Murphy, a spokesperson for the state agency. Their contract requires them to use state stationery.
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Murphy said in an email to KFF Health News that such letters are sent after every death of an Iowa Medicaid recipient who was at least 55 years old or who lived in a long-term care facility. He said the letters “request information from family members regarding the deceased person’s assets and expenses,” and the letters note that repayments are expected only from the person’s estate.
Iowa’s Medicaid collections are handled by Sumo Group, a Des Moines company. Its director, Ben Chatman, declined to answer questions, including why the company sent bills to families of people with disabilities who lived most of their lives in state institutions. “I don’t do media relations,” Chatman said.
Sumo Group is a subcontractor of a national company, Gainwell Technologies, which has handled Medicaid collections for several states. In Iowa, the company is paid 11% of whatever it can collect from the estates of Medicaid participants. A spokesperson for Gainwell declined to comment.
Iowa’s Medicaid estate recovery program brought in $40.2 million in the fiscal year that ended last June, up nearly 14% from two years earlier, state records show. That total represents a sliver of the state’s total Medicaid budget, which is expected to hit $9 billion this year.
Nearly two-thirds of Iowa estate recovery cases wound up being closed with no collection of money last fiscal year, according to the state. In cases in which money was recouped, the average amount paid was about $10,000.
Thirty-five Iowa families were granted hardship waivers, which the state allows if an heir’s health or life would be endangered because payment of the Medicaid bill would deprive them of food, clothing, shelter, or medical care. Officials denied an additional 20 requests for hardship waivers.
A 2021 report to Congress estimated states collected more than $700 million annually from Medicaid participants’ estates. That money is shared with the federal government, which helps finance Medicaid. Some states claw back much less than others. Hawaii, for example, collected just $31,000 in 2019, the latest year analyzed in the federal report. Iowa, with about twice as many residents as Hawaii, raked back more than $26 million that year.
Americans aren’t subject to such clawbacks for using any other federal health program, including Medicare, which covers older people of all income levels.
The national group Justice in Aging has helped lead opposition to Medicaid estate recovery programs. Eric Carlson, a California attorney for the group, said the issue usually comes into play after the death of a person who had nursing home care covered by Medicaid. Recovery demands often force survivors to sell homes that are their families’ main form of wealth, he said.
Carlson said he hadn’t previously heard of Medicaid estate recovery bills topping $4 million, like the ones sent to survivors of the two Iowans with disabilities.
He wondered why debt collectors would pursue such cases, which are unlikely to yield any money but could cause anxiety for families. “Of course, if you open up a piece of mail that says you owe millions of dollars, you’re going to think the worst,” he said.
Carlson said he would advise anyone who receives such a letter to respond to it with documentation showing that their loved one’s estate can’t repay a Medicaid debt. “It’s never a good idea to ignore it,” he said. Failure to respond to the bill could lead to continued collection efforts, which could threaten a family member’s finances or property, he said.
Some states have reined in their Medicaid clawback efforts. For example, Massachusetts legislators last year voted to drastically limit their program. This was the second time Massachusetts reduced its Medicaid estate recovery effort, which once was one of the most aggressive in the U.S.
Critics in Congress have also tried to limit the practice.
Rep. Jan Schakowsky (D-Ill.) has twice introduced bills to eliminate the federal requirement that states claw back Medicaid spending from recipients’ estates. Last year’s bill gained 47 Democratic co-sponsors, but it received no support from the Republicans controlling the chamber, and there was no similar bill in the Senate. She plans to try again this year, even though her party remains in the minority.
Schakowsky said in an interview that she’d never heard of Medicaid estate recovery demands reaching millions of dollars, as the Iowa families faced. But demands for hundreds of thousands of dollars are common. For many families, “that’s still impossible” to meet, she said.
Schakowsky hopes that members of Congress from both parties will agree to curtail the program once they realize how much angst it causes their constituents and how relatively little money it returns to the government. “The whole program is ridiculous,” she said.
Her quest could become even tougher if the Trump administration moves ahead with proposals to trim Medicaid spending.
The office of Sen. Chuck Grassley, who is the senior member of Iowa’s all-Republican congressional delegation and has taken leading roles in many health policy debates, declined to comment on the issue.
The Iowa Department of Health and Human Services said it notifies families about the estate recovery process when they apply for Medicaid. Joy Higgins said she doesn’t recall seeing such a notice.
The institution where Kristin Higgins spent most of her life was closed last year after federal officials investigated complaints of poor medical care. But Joy Higgins said her daughter was treated well there overall. “If I had millions in the bank, I’d give it to the state,” she said. “I would. It was worth it.”
Has your family been sent bills for repayment of Medicaid expenses after the death of a loved one who was covered by the program? Click here to tell KFF Health News your story.
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.
McMINNVILLE, Tenn. — Each month, Michelle Shaw went to a pain clinic to get the shots that made her back feel worse — so she could get the pills that made her back feel better.
Shaw, 56, who has been dependent on opioid painkillers since she injured her back in a fall a decade ago, said in both an interview with KFF Health News and in sworn courtroom testimony that the Tennessee clinic would write the prescriptions only if she first agreed to receive three or four “very painful” injections of another medicine along her spine.
The clinic claimed the injections were steroids that would relieve her pain, Shaw said, but with each shot her agony would grow. Shaw said she eventually tried to decline the shots, then the clinic issued an ultimatum: Take the injections or get her painkillers somewhere else.
“I had nowhere else to go at the time,” Shaw testified, according to a federal court transcript. “I was stuck.”
Shaw was among thousands of patients of Pain MD, a multistate pain management company that was once among the nation’s most prolific users of what it referred to as “tendon origin injections,” which normally inject a single dose of steroids to relieve stiff or painful joints. As many doctors were scaling back their use of prescription painkillers due to the opioid crisis, Pain MD paired opioids with monthly injections into patients’ backs, claiming the shots could ease pain and potentially lessen reliance on painkillers, according to federal court documents.
Michelle Shaw, a former patient of Pain MD in Tennessee, testified in federal court that the pain clinics threatened to discharge her as a patient, which would have cut off her painkiller prescriptions and likely sent her into withdrawal, if she did not agree to monthly injections in her back, making her pain worse. Shaw was a key witness in the trial of Pain MD president Michael Kestner, who was convicted of 13 felonies related to health care fraud in October. Shaw was photographed at her Tennessee home on Jan. 14.(Brett Kelman/KFF Health News)
Now, years later, Pain MD’s injections have been proved in court to be part of a decade-long fraud scheme that made millions by capitalizing on patients’ dependence on opioids. The Department of Justice has successfully argued at trial that Pain MD’s “unnecessary and expensive injections” were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead.
Four Pain MD employees have pleaded guilty or been convicted of health care fraud, including company president Michael Kestner, who was found guilty of 13 felonies at an October trial in Nashville, Tennessee. According to a transcript from Kestner’s trial that became public in December, witnesses testified that the company documented giving patients about 700,000 total injections over about eight years and said some patients got as many as 24 shots at once.
“The defendant, Michael Kestner, found out about an injection that could be billed a lot and paid well,” said federal prosecutor James V. Hayes as the trial began, according to the transcript. “And they turned some patients into human pin cushions.”
The Department of Justice declined to comment for this article. Kestner’s attorneys either declined to comment or did not respond to requests for an interview. At trial, Kestner’s attorneys argued that he was a well-intentioned businessman who wanted to run pain clinics that offered more than just pills. He is scheduled to be sentenced on April 21 in a federal court in Nashville.
According to the transcript of Kestner’s trial, Shaw and three other former patients testified that Pain MD’s injections did not ease their pain and sometimes made it worse. The patients said they tolerated the shots only so Pain MD wouldn’t cut off their prescriptions, without which they might have spiraled into withdrawal.
“They told me that if I didn’t take the shots — because I said they didn’t help — I would not get my medication,” testified Patricia McNeil, a former patient in Tennessee, according to the trial transcript. “I took the shots to get my medication.”
In her interview with KFF Health News, Shaw said that often she would arrive at the Pain MD clinic walking with a cane but would leave in a wheelchair because the injections left her in too much pain to walk.
“That was the pain clinic that was supposed to be helping me,” Shaw said in her interview. “I would come home crying. It just felt like they were using me.”
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‘Not Actually Injections Into Tendons at All’
Pain MD, which sometimes operated under the name Mid-South Pain Management, ran as many as 20 clinics in Tennessee, Virginia, and North Carolina throughout much of the 2010s. Some clinics averaged more than 12 injections per patient each month, and at least two patients each received more than 500 shots in total, according to federal court documents.
All those injections added up. According to Medicare data filed in federal court, Pain MD and Mid-South Pain Management billed Medicare for more than 290,000 “tendon origin injections” from January 2010 to May 2018, which is about seven times that of any other Medicare biller in the U.S. over the same period.
Tens of thousands of additional injections were billed to Medicaid and Tricare during those same years, according to federal court documents. Pain MD billed these government programs for about $111 per injection and collected more than $5 million from the government for the shots, according to the court documents.
More injections were billed to private insurance too. Christy Wallace, an audit manager for BlueCross BlueShield of Tennessee, testified that Pain MD billed the insurance company about $40 million for more than 380,000 injections from January 2010 to March 2013. BlueCross paid out about $7 million before it cut off Pain MD, Wallace said.
These kinds of enormous billing allegations are not uncommon in health care fraud cases, in which fraudsters sometimes find a legitimate treatment that insurance will pay for and then overuse it to the point of absurdity, said Don Cochran, a former U.S. attorney for the Middle District of Tennessee.
Tennessee alone has seen fraud allegations for unnecessary billing of urine testing, skin creams, and other injections in just the past decade. Federal authorities have also investigated an alleged fraud scheme involving a Tennessee company and hundreds of thousands of catheters billed to Medicare, according to The Washington Post, citing anonymous sources.
Cochran said the Pain MD case felt especially “nefarious” because it used opioids to make patients play along.
“A scheme where you get Medicare or Medicaid money to provide a medically unnecessary treatment is always going to be out there,” Cochran said. “The opioid piece just gives you a universe of compliant people who are not going to question what you are doing.”
“It was only opioids that made those folks come back,” he said.
The allegations against Pain MD became public in 2018 when Cochran and the Department of Justice filed a civil lawsuit against the company, Kestner, and several associated clinics, alleging that Pain MD defrauded taxpayers and government insurance programs by billing for “tendon origin injections” that were “not actually injections into tendons at all.”
Kestner, Pain MD, and several associated clinics have each denied all allegations in that lawsuit, which is ongoing.
Scott Kreiner, an expert on spine care and pain medicine who testified at Kestner’s criminal trial, said that true tendon origin injections (or TOIs) typically are used to treat inflamed joints, like the condition known as “tennis elbow,” by injecting steroids or platelet-rich plasma into a tendon. Kreiner said most patients need only one shot at a time, according to the transcript.
But Pain MD made repeated injections into patients’ backs that contained only lidocaine or Marcaine, which are anesthetic medications that cause numbness for mere hours, Kreiner testified. Pain MD also used needles that were often too short to reach back tendons, Kreiner said, and there was no imaging technology used to aim the needle anyway. Kreiner said he didn’t find any injections in Pain MD’s records that appeared medically necessary, and even if they had been, no one could need so many.
“I simply cannot fathom a scenario where the sheer quantity of TOIs that I observed in the patient records would ever be medically necessary,” Kreiner said, according to the trial transcript. “This is not even a close call.”
Jonathan White, a physician assistant who administered injections at Pain MD and trained other employees to do so, then later testified against Kestner as part of a plea deal, said at trial that he believed Pain MD’s injection technique was based on a “cadaveric investigation.”
According to the trial transcript, White said that while working at Pain MD he realized he could find no medical research that supported performing tendon origin injections on patients’ backs instead of their joints. When he asked if Pain MD had any such research, White said, an employee responded with a two-paragraph letter from a Tennessee anatomy professor — not a medical doctor — that said it was possible to reach the region of back tendons in a cadaver by injecting “within two fingerbreadths” of the spine. This process was “exactly the procedure” that was taught at Pain MD, White said.
During his own testimony, Kreiner said it was “potentially dangerous” to inject a patient as described in the letter, which should not have been used to justify medical care.
“This was done on a dead person,” Kreiner said, according to the trial transcript. “So the letter says nothing about how effective the treatment is.”
Michelle Shaw and her fiancé, Thomas Truss, said in interviews that Pain MD clinics required patients to agree to multiple injections near their spines each month or be discharged. Shaw begrudgingly accepted the shots so she would not lose access to her painkiller prescriptions, but Truss said he refused the injections and was “kicked out.” Shaw was a key witness in the trial of Pain MD president Michael Kestner, who was convicted of 13 felonies related to health care fraud in October. Shaw and Truss were photographed at their Tennessee home on Jan. 14.(Brett Kelman/KFF Health News)
At the time, Pain MD defended the injections and its practice of discharging patients who declined the shots. When a former patient publicly accused the company of treating his back “like a dartboard,” Pain MD filed a defamation lawsuit, then dropped the suit about a month later.
“These are interventional clinics, so that’s what they offer,” Jay Bowen, a then-attorney for Pain MD, told The Tennessean newspaper in 2019. “If you don’t want to consider acupuncture, don’t go to an acupuncture clinic. If you don’t want to buy shoes, don’t go to a shoe store.”
Kestner’s trial told another story. According to the trial transcript, eight former Pain MD medical providers testified that the driving force behind Pain MD’s injections was Kestner himself, who is not a medical professional and yet regularly pressured employees to give more shots.
One nurse practitioner testified that she received emails “every single workday” pushing for more injections. Others said Kestner openly ranked employees by their injection rates, and implied that those who ranked low might be fired.
“He told me that if I had to feed my family based on my productivity, that they would starve,” testified Amanda Fryer, a nurse practitioner who was not charged with any crime.
Brian Richey, a former Pain MD nurse practitioner who at times led the company’s injection rankings, and has since taken a plea deal that required him to testify in court, said at the trial that he “performed so many injections” that his hand became chronically inflamed and required surgery.
“‘Over injecting killed my hand,’” Richey said on the witness stand, reading a text message he sent to another Pain MD employee in 2017, according to the trial transcript. “‘I was in so much pain Injecting people that didnt want it but took it to stay a patient.’”
“Why would they want to stay there?” a prosecutor asked.
“To keep getting their narcotics,” Richey responded, according to the trial transcript.
Throughout the trial, defense attorney Peter Strianse argued that Pain MD’s focus on injections was a result of Kestner’s “obsession” with ensuring that the company “would never be called a pill mill.”
Strianse said that Kestner “stayed up at night worrying” about patients coming to clinics only to get opioid prescriptions, so he pushed his employees to administer injections, too.
“Employers motivating employees is not a crime,” Strianse said at closing arguments, according to the court transcript. “We get pushed every day to perform. It’s not fraud; it’s a fact of life.”
Prosecutors insisted that this defense rang hollow. During the trial, former employees had testified that most patients’ opioid dosages remained steady or increased while at Pain MD, and that the clinics did not taper off the painkillers no matter how many injections were given.
“Giving them injections does not fix the pill mill problem,” federal prosecutor Katherine Payerle said during closing arguments, according to the trial transcript. “The way to fix being a pill mill is to stop giving the drugs or taper the drugs.”
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.
Sonya Stokes, an emergency room physician in the San Francisco Bay Area, braces herself for a daily deluge of patients sick with coughs, soreness, fevers, vomiting, and other flu-like symptoms.
She’s desperate for information, but the Centers for Disease Control and Prevention, a critical source of urgent analyses of the flu and other public health threats, has gone quiet in the weeks since President Donald Trump took office.
“Without more information, we are blind,” she said.
Flu has been brutal this season. The CDC estimates at least 24 million illnesses, 310,000 hospitalizations, and 13,000 deaths from the flu since the start of October. At the same time, the bird flu outbreak continues to infect cattle and farmworkers. But CDC analyses that would inform people about these situations are delayed, and the CDC has cut off communication with doctors, researchers, and the World Health Organization, say doctors and public health experts.
“CDC right now is not reporting influenza data through the WHO global platforms, FluNet [and] FluID, that they’ve been providing information [on] for many, many years,” Maria Van Kerkhove, interim director of epidemic and pandemic preparedness at the WHO, said at a Feb. 12 press briefing.
“We are communicating with them,” she added, “but we haven’t heard anything back.”
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On his first day in office, President Donald Trump announced the U.S. would withdraw from the WHO.
A critical analysis of the seasonal flu selected for distribution through the CDC’s Health Alert Network has stalled, according to people close to the CDC. They asked not to be identified because of fears of retaliation. The network, abbreviated as HAN, is the CDC’s main method of sharing urgent public health information with health officials, doctors, and, sometimes, the public.
A chart from that analysis, reviewed by KFF Health News, suggests that flu may be at a record high. About 7.7% of patients who visited clinics and hospitals without being admitted had flu-like symptoms in early February, a ratio higher than in four other flu seasons depicted in the graph. That includes 2003-04, when an atypical strain of flu fueled a particularly treacherous season that killed at least 153 children.
Without a complete analysis, however, it’s unclear whether this tidal wave of sickness foreshadows a spike in hospitalizations and deaths that hospitals, pharmacies, and schools must prepare for. Specifically, other data could relay how many of the flu-like illnesses are caused by flu viruses — or which flu strain is infecting people. A deeper report might also reveal whether the flu is more severe or contagious than usual.
“I need to know if we are dealing with a more virulent strain or a coinfection with another virus that is making my patients sicker, and what to look for so that I know if my patients are in danger,” Stokes said. “Delays in data create dangerous situations on the front line.”
Although the CDC’s flu dashboard shows a surge of influenza, it doesn’t include all data needed to interpret the situation. Nor does it offer the tailored advice found in HAN alerts that tells health care workers how to protect patients and the public. In 2023, for example, a report urged clinics to test patients with respiratory symptoms rather than assume cases are the flu, since other viruses were causing similar issues that year.
“This is incredibly disturbing,” said Rachel Hardeman, a member of the Advisory Committee to the Director of the CDC. On Feb. 10, Hardeman and other committee members wrote to acting CDC Director Susan Monarez asking the agency to explain missing data, delayed studies, and potentially severe staff cuts. “The CDC is vital to our nation’s security,” the letter said.
Several studies have also been delayed or remain missing from the CDC’s preeminent scientific publication, the Morbidity and Mortality Weekly Report. Anne Schuchat, a former principal deputy director at the CDC, said she would be concerned if there was political oversight of scientific material: “Suppressing information is potentially confusing, possibly dangerous, and it can backfire.”
CDC spokesperson Melissa Dibble declined to comment on delayed or missing analyses. “It is not unexpected to see flu activity elevated and increasing at this time of the year,” she said.
A draft of one unpublished study, reviewed by KFF Health News, that has been withheld from the MMWR for three weeks describes how a milk hauler and a dairy worker in Michigan may have spread bird flu to their pet cats. The indoor cats became severely sick and died. Although the workers weren’t tested, the study says that one of them had irritated eyes before the cat fell ill — a common bird flu symptom. That person told researchers that the pet “would roll in their work clothes.”
After one cat became sick, the investigation reports, an adolescent in the household developed a cough. But the report says this young person tested negative for the flu, and positive for a cold-causing virus.
Corresponding CDC documents summarizing the cat study and another as-yet unpublished bird flu analysis said the reports were scheduled to be published Jan. 23. These were reviewed by KFF Health News. The briefing on cats advises dairy farmworkers to “remove clothing and footwear, and rinse off any animal biproduct residue before entering the household to protect others in the household, including potentially indoor-only cats.”
The second summary refers to “the most comprehensive” analysis of bird flu virus detected in wastewater in the United States.
Jennifer Nuzzo, director of the Pandemic Center at Brown University, said delays of bird flu reports are upsetting because they’re needed to inform the public about a worsening situation with many unknown elements. Citing “insufficient data” and “high uncertainty,” the United Kingdom raised its assessment of the risk posed by the U.S. outbreak on dairies.
“Missing and delayed data causes uncertainty,” Nuzzo said. “It also potentially makes us react in ways that are counterproductive.”
Another bird flu study slated for January publication showed up in the MMWR on Feb. 13, three weeks after it was expected. It revealed that three cattle veterinarians had been unknowingly infected last year, based on the discovery of antibodies against the bird flu virus in their blood. One of the veterinarians worked in Georgia and South Carolina, states that haven’t reported outbreaks on dairy farms.
The study provides further evidence that the United States is not adequately detecting cases in cows and people. Nuzzo said it also highlights how data can supply reassuring news. Only three of 150 cattle veterinarians had signs of prior infections, suggesting that the virus doesn’t easily spread from the animals into people. More than 40 dairy workers have been infected, but they generally have had more sustained contact with sick cattle and their virus-laden milk than veterinarians.
Instead, recently released reports have been about wildfires in California and Hawaii.
“Interesting but not urgent,” Nuzzo said, considering the acute fire emergencies have ended. The bird flu outbreak, she said, is an ongoing “urgent health threat for which we need up-to-the-minute information to know how to protect people.”
“The American public is at greater risk when we don’t have information on a timely basis,” Schuchat said.
This week, a federal judge ordered the CDC and other health agencies to “restore” datasets and websites that the organization Doctors for America had identified in a lawsuit as having been altered. Further, the judge ordered the agencies to “identify any other resources that DFA members rely on to provide medical care” and restore them by Feb. 14.
In their letter, CDC advisory committee members requested an investigation into missing data and delayed reports. Hardeman, an adviser who is a health policy expert at the University of Minnesota, said the group didn’t know why data and scientific findings were being withheld or removed. Still, she added, “I hold accountable the acting director of the CDC, the head of HHS, and the White House.”
Hardeman said the Trump administration has the power to disband the advisory committee. She said the group expects that to happen but proceeded with its demands regardless.
“We want to safeguard the rigor of the work at the CDC because we care deeply about public health,” she said. “We aren’t here to be silent.”
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.
Nothing sweeps us off our feet like a health policy valentine. Readers showed their love this season, writing poetic lines about surprise medical bills, bird flu, the cost of health care, and more.
Here are some of our favorites, starting with the grand prize winner, whose entry was turned into a cartoon by staff illustrator Oona Zenda.
1st Place
Runner-Up
What to make for my valentine? Maybe a cake on which we can dine! But raw milk and flu-ish eggs won’t do. Perhaps some fluoridated water in lieu?
