Time is precious for him. Last year, doctors told the 76-year-old former truck driver that a combination of heart failure, lung disease, and liver damage had left him with only six months to live. “That was about 11 months ago,” Vantrease said in a May interview, smiling at having, for the moment, cheated death.

In June 2025, Vantrease began hospice, which focuses on quality of life for terminally ill patients, receiving regular visits from a nurse in his home in Novato, California. Medicare is covering those services for him. His hospice caregivers reminded him of the attention his unit received from medical staff in Vietnam.

“We used to call them guardian angels,” he said, “because they took such great care of you.”

But the Trump administration’s allegations of unchecked hospice fraud in California have tainted the industry’s reputation, prompting concerns that fewer patients will seek the care they need. Health policy researchers and hospice administrators worry that the negative attention on the industry and potential for overly punitive regulations could put California patients and taxpayers on the losing end.

“The fraud situation has done a lot of damage to the reputation of hospices overall and undone a lot of the progress that had been made in destigmatizing hospice,” said Lauren Hunt, an associate professor at the University of California-San Francisco’s Philip R. Lee Institute for Health Policy Studies who focuses on hospice care. “Policymakers should pursue targeted strategies that root out fraud and abuse without overburdening the many providers who are doing the right thing.”

Hospice care is facing sweeping restrictions. The Centers for Medicare & Medicaid Services in May announced a six-month national moratorium on hospice provider enrollment in Medicare and increased oversight in California and several other states with “elevated fraud risk”: Arizona, Georgia, Nevada, Ohio, and Texas.

In a statement, CMS spokesperson Timothy Foster said state inaction on hospice programs rife with fraud drove the need for federal intervention. Foster said CMS believes the crackdown won’t affect patients’ ability to obtain services, with roughly 7,000 hospices still approved nationwide, and that it will help ensure the hospices that remain provide the care “individuals near end of life deserve.”

“Ensuring patient safety and access to quality hospices and other certified healthcare services is paramount to CMS’ work,” Foster said.

Mehmet Oz, the CMS administrator, has said also protects taxpayer money. that even as for-profit hospices have expanded, the industry has saved Medicare money by offsetting other expensive care. A 2023 University of Chicago report commissioned by industry associations estimated that Medicare patients who used hospice over hospitals in 2019 .

California has already been cracking down on the problems, with Democratic Attorney General Rob Bonta deeming hospice fraud an “” last year and asserting that The state has had its own since 2021, with crimes over the years, and implemented to curb fraud this June.

Hunt said she’s heard from California healthcare providers who are reluctant to refer patients to hospice because they’re unsure the patients will receive high-quality care and from patients who don’t know which hospice providers they can trust. California hospice organizations of any state — as of 2022, according to the California state auditor’s office. That same year, CMS nationwide.

Hospice administrators in good standing have already found themselves in the crosshairs: A found that the federal government’s new anti-fraud task force has already suspended licenses for 43 legitimate hospices.

Still, Hunt and other policy researchers welcome the efforts to target unscrupulous operators.

“While most hospices are committed to providing high-quality care, there are serious concerns about a subset that exploit patients and the system for financial gain,” she said.

The hospice industry is uniquely vulnerable to fraud because of insufficient licensing regulations and inadequate oversight, according to industry researchers. And the percentage of the population aging into Medicare is rapidly rising, with spending expected to accelerate in the next 10 years.

Most of the rapid growth in operators has been among for-profit hospices, a state auditor’s report in 2022 noted. In California, about 94% of hospice providers are now for-profit, a shift from 20 years ago, when nonprofits in California and nationally. On average, for-profit operators per patient in pretax profit and $49 more per patient-day than nonprofit hospice operators, according to one study.

Skelly Wingard, CEO of By the Bay Health, a Northern California nonprofit that provides services to Vantrease, acknowledges that fraud is a big problem in the industry. “These organizations that have exploited patients were extremely savvy,” she said.

But Wingard warns against losing sight of the bigger picture.

“Hospice, when done well, is one of the most compassionate and meaningful benefits in healthcare,” she said. “We should be working to protect that, not inadvertently erode confidence in it.”

By the Bay Health has been in business for 50 years and serves around 750 hospice patients in the Bay Area. About 89% of them are covered by Medicare, 3% by California’s Medicaid program, Medi-Cal, and the rest by commercial health plans, Wingard said.

At home in Novato, Vantrease lifts his shirt to show where a catheter was surgically implanted to drain uncomfortable fluid buildup in his abdomen. The hospital trained his wife, Paula Vantrease, a retired career counselor, to connect a suctioning device to the catheter to siphon the excess fluid. A hospice nurse from By the Bay, Blake Knier, helped her master the technique the first few times she tried it at home.

“Paula is the rock in my foundation,” Mark Vantrease said.

Knier orders all of Vantrease’s medications and rejiggers them when necessary to manage his bouts of intense nausea and pain. Every week, Knier checks the surgical incision around the catheter for infection, listens to Vantrease’s lungs, checks his blood pressure, and cleans and dresses the open wounds that sometimes form from burst blisters on his legs, a complication of the fluid buildup and weakened skin.

Knier helps usher hospice patients and their families through critical turning points. He recalled guiding one patient’s daughter through her mother’s loss of appetite.

“It’s OK if your mother isn’t eating vegetables,” he told the patient’s daughter. “Let her eat ice cream, if that’s what she wants.”

California’s emergency regulations against fraud took effect in late June. In addition to tighter prescreening of license applicants, they call for minimum professional qualifications for management, higher nurse-to-patient ratios, stricter rules around physical office space, and other restrictions.

Hunt said the new regulations are a step in the right direction but urged caution.

“The broader impact on the industry should be closely monitored, particularly to ensure that well-intentioned, high-quality providers are not placed under undue strain or forced to close,” she said.

Late one night last year, when Knier wasn’t available, another hospice nurse from By the Bay Health came promptly to the Vantreases’ home in response to an urgent call from Paula.

“I felt like I was about to die,” Mark Vantrease said, explaining he’d just had a premonition that he wouldn’t wake up in the morning. His sons were called to his bedside. The family needed reassurance. So a nurse arrived, examined him, and checked their father’s vitals.

By midnight, he was sleeping.

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Now, the same pain had returned — on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an , which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed . There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are .

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance — But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs — except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient , which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to ³Ô¹Ï²»´òìÈ, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations — or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off — sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

Bill of the Month is a crowdsourced investigation by ³Ô¹Ï²»´òìÈ and 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!

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The federal government is capping the amount graduate students can borrow. The Department of Education says the new rules are designed to help curb student debt and pressure schools to lower tuition. But some loan experts fear those good intentions could leave many at the mercy of private lenders with higher interest rates. Saddling healthcare graduate students with pricier debt burdens can narrow their career choices.

³Ô¹Ï²»´òìÈ correspondent Lauren Sausser joined WAMU’s Health Hub on July 22 to explain how the loan caps could make healthcare provider shortages worse or compromise the diversity of the workforce. Plus, she discusses how some states are pushing back against the new rules.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

The Consumer Product Safety Commission, responsible for tracking and issuing recalls of dangerous products sold in the U.S., began discreetly pressuring hospital executives this year to share personally identifiable health data with a private contractor. But hospital lawyers and other industry experts have questioned the agency’s authority to collect, its ability to safeguard such a swath of sensitive information, and whether it has followed the legal process to overhaul its surveillance system.

After ³Ô¹Ï²»´òìÈ asked the CPSC about the new system, the the program on July 21. Left unmentioned, however, is the alarm it has raised among hospital executives, as well as the nature and extent of the agency’s data demands.

In a stark departure from its product-focused mission, the agency’s goal is to obtain millions of Americans’ medical records from emergency room visits for most injuries, from a broken bone to a childhood vaccine reaction or even a suicide attempt, according to documents and emails obtained by ³Ô¹Ï²»´òìÈ, as well as interviews with five people involved or familiar with the discussions.

A CPSC official also insisted in the emails that the institutions provide all ER patients’ identifiable information — such as names, addresses, diagnoses, and other personal details — to the contractor, Konza Health, for analysis. In correspondence with , Konza representatives described participation as “mandatory” or “required.”

As a condition of viewing the correspondence, ³Ô¹Ï²»´òìÈ agreed not to republish some of the emails it obtained.

The CPSC wants at least 100 hospitals to start sending detailed medical records by the end of this year, according to an .

“The whole thing is troubling,” said Sharona Hoffman, a professor of health law at Case Western Reserve University who noted that giving a private entity access to a sweeping collection of data will introduce risks to patient privacy. “If this company really is collecting identifiable information, that is worrisome for patients.”

The new project was launched amid upheaval at the traditionally independent agency, which is without a governing board since President Donald Trump fired the CPSC’s three Democratic board members. Nearly 1 in 5 career staffers left the CPSC in the first 16 months of the new administration, according to a ³Ô¹Ï²»´òìÈ analysis of federal workforce data.

The initiative also comes as the Trump administration has sought unprecedented access to millions of Americans’ medical records, with the Office of Personnel Management requesting federal workers’ sensitive health information and Health and Human Services Secretary Robert F. Kennedy Jr. using a private organization to collect more medical records for his studies on vaccines and autism.

Steve Roney, CPSC spokesperson, said in an emailed statement on July 10 that the CPSC is “modernizing” its surveillance system. Asked whether the CPSC will file complaints against hospitals that do not participate, he said only that while the previous system “operated as a voluntary program, the ability of hospitals to opt out limited the sample size and usefulness of the data.”

Roney also acknowledged that the agency had not yet notified the public, as “required by law.”

Federal law requires the agency to provide notice and a public comment period before requesting information from 10 or more entities, a step it has not taken despite plans for 100 hospitals to join the surveillance system. ³Ô¹Ï²»´òìÈ independently confirmed with over a dozen hospitals that they had been approached.

Federal public health authorities that private health data be reported. But CPSC officials have that if hospitals decline to share data with the new surveillance system, they could be subject to strict penalties from a data-sharing regulation known as “information blocking.”

Yet some hospital executives say they are reluctant to share patients’ sensitive data because they’re concerned about a different violation — that of .

AI Takes Over

Dozens of ERs across the country already participate in the CPSC’s voluntary National Electronic Injury Surveillance System, or NEISS, through which trained hospital workers report injuries involving consumer products, almost always stripped of patients’ identifiable information. The system helps the CPSC identify products, such as baby loungers, toys, and household appliances, with a pattern of injuring consumers.

The new injury surveillance program goes much further.

At a toy industry trade event in February, acting CPSC Chairman Peter Feldman said the agency is “investing in AI-enabled workflows that improve the quality and quantity of injury surveillance data, while also building up digital infrastructure to handle a massive new volume of electronic health records.”

Konza Health, a Kansas-based organization that runs the state’s health data exchange, will automatically pull and analyze medical records of all patient visits from ERs nationwide. Konza won a worth up to $15.9 million with the CPSC last fall.

In email correspondence with hospital technology officials, Konza Health President and CEO Laura McCrary also has described ERs’ participation as “required,” stipulating that they share patients’ records with identifying information.

McCrary told ³Ô¹Ï²»´òìÈ by email that the company is not using AI to process the records it receives, saying instead that Konza will use “advanced analytic parsing and filtering capabilities.” Roney, the CPSC spokesperson, did not answer questions about the .

For years, agency officials moving away from human contractors and automating NEISS to save time and money.

But without workers on-site, hospital staffers may no longer receive training to determine what clinical information is important to include for the CPSC. In short, the changes could dilute the quality of the product safety data the agency collects.

“They want to suck in as much data as possible, but I’m not sure how thoughtful they’re being about what is collected and what is actually needed by the agency,” said former CPSC chair Alexander Hoehn-Saric, one of the Democratic appointees Trump fired last year.

Wanted: Injuries From Vaccines and Stingrays

The CPSC’s new data collection appears to contradict its own 214-page , which instructs hospitals not to include identifiable information “such as names, birthdates, or addresses” when reporting cases.

The agency is supposed to receive patients’ identifying information only when needed for follow-up investigations, which happens in fewer than 1% of reported cases, according to the manual.

The CPSC has also historically limited the records it collects to minimize privacy violations in case of a data breach.

The risk is not hypothetical: From 2017 to 2019, the agency improperly released personal health information of around 30,000 people, a disclosure that a top Republican at the time

Konza, however, will receive even more sensitive information on many more people. McCrary said in a statement that Konza will remove patients’ names, addresses, and medical information “not needed by CPSC” before sharing records with the agency.

Leaving a private organization to collect sensitive information introduces risks, including that it could be stolen or used for business purposes, said Hoffman, the Case Western professor.

“Very often, they will use information for marketing because now they’re going to know what conditions people have,” she said.

Roney said that its contract with Konza, which has not been made public, prohibits the organization from selling or marketing the data it collects.

The CPSC’s manual also identifies types of ER visits that should not be reported to the CPSC, which has jurisdiction over only certain consumer products. Excluded injuries are those caused by food, illegal drugs, medical devices, alcohol, or plants, as well as injuries that did not involve consumer products — such as a cut from a rock or broken bones from a fall on the ground — and suicide attempts by adults.

But in a to one hospital and reviewed by ³Ô¹Ï²»´òìÈ, Konza set no such limits on the information it would gather from ER records and said it would hold on to patient health information for at least 30 days.

In an email sent to hospital technology officials, McCrary wrote that Konza would provide the CPSC with records when a patient is treated in the ER for any of more than 10,000 conditions. The expansive list of diagnostic codes Konza provided in the email includes injuries that do not involve consumer products.

Child injuries resulting from “poisoning by” vaccines or contact with stingrays, neither of which is regulated by the CPSC, are included in the list.

A limited number of hospitals once shared deidentified data on all injuries — regardless of product involvement — through the NEISS using the Centers for Disease Control and Prevention’s injury-tracking program. But the CDC halted that data collection, after funding and staffing were cut last year, and has not restarted it.

Pressure on Hospitals

CPSC Chief Data Officer Elizabeth Puchek, who joined the agency late last year after engineering U.S. Citizenship and Immigration Services’ data system, has told hospitals in emails that they must seek an exemption from the program if they decline to share patients’ emergency room records with Konza.

The CPSC’s targeted outreach has included some of the nation’s largest urban and rural health systems, as well as small, publicly owned hospitals.

Staff members at Mary Greeley Medical Center in Ames, Iowa, said that Konza and federal officials told them their participation in the new program was mandatory. The hospital, which has long participated in NEISS, signed a new contract in April to share its ER records with Konza.

Yet the hospital is reevaluating its participation after being notified that the funds it received to participate in NEISS were “no longer available,” spokesperson Steve Sullivan said.

Several hospital executives, lawyers, and others have raised doubts about the CPSC’s claimed authority.

Harborview Medical Center spokesperson Susan Gregg said the Seattle hospital’s emergency room has “voluntarily submitted de-identified data for many years, but we are not obligated to report this information.”

In Boston, Mass General Brigham has declined to participate in the new program, with spokesperson Kelly Mitchell saying that “to protect patient privacy, we are unable to provide these medical records.”

Henry Ford Health in Detroit; St. Luke’s in Boise, Idaho; and Sanford Health based in Sioux Falls, South Dakota — which together handle over a million ER visits a year — are among the health systems that have been approached but not yet entered into an agreement with Konza, according to representatives. Several of the nation’s busiest hospital systems targeted for the program — including the Mayo Clinic in Minnesota, Yale New Haven Hospital in Connecticut, Nationwide Children’s Hospital and the Cleveland Clinic in Ohio, and Baylor Scott & White Health in Texas — declined to answer questions about whether they’re participating.

Hoehn-Saric, the agency’s former chairman, said he was surprised that the CPSC would insist that hospitals provide identifiable records from all emergency room visits.

“This idea that they can simply demand patient information from a hospital and that the hospital would provide it — I really don’t understand the basis for that,” he said.

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“The national security might be something worth paying for,” Sen. Bill Cassidy of Louisiana, chairman of the Senate Health, Education, Labor, and Pensions Committee, said July 22 in an exclusive interview with ³Ô¹Ï²»´òìÈ.

The U.S., which has grappled with drug shortages in recent years, relies primarily on China to produce the active ingredients in many antibiotics, according to in JAMA Health Forum. Domestic facilities have closed or shifted to producing other drugs.

“Do we want China to have that sort of leverage for these drugs to be produced principally, maybe 99%, over there, and we don’t have access to them if tension rises between the two countries?” said Cassidy, who is a physician.

On July 21, Trump said in a that he would give generic drug companies two years to move production back to the U.S., after which he would impose 100% tariffs on imported products, rising to 200% the following year. Generic drugs make up an estimated 90% of all prescriptions filled in the U.S.

Cassidy, who has served in Congress , lost his bid for reelection in May after Trump endorsed a Republican primary challenger, Rep. Julia Letlow.

Last month, more than 16 months after his vote to confirm Robert F. Kennedy Jr. as head of the Department of Health and Human Services, on CBS News’ Face the Nation that the secretary broke promises he made to the senator, including that he would not change the federal recommendations for childhood vaccines.

Asked whether he would summon Kennedy again to discuss those promises, Cassidy said he had asked for him to appear before his committee but had not heard back about whether he would do so. Kennedy in April to discuss the Trump administration’s fiscal 2027 budget request for HHS.

Cassidy told ³Ô¹Ï²»´òìÈ that when he agreed to vote to advance Kennedy’s nomination, he trusted that Kennedy would keep his word about not disparaging vaccines.

“If they agree to guardrails and disregard those guardrails, you can judge me,” Cassidy said. “You may decide my judgment wasn’t very good, but I don’t think you can say I acted in bad faith.”

Regardless, Cassidy added, Kennedy was going to exert influence in the administration, and he thought it would be better for Kennedy to be in an official post, where his work would be subject to oversight.

“I’m pretty sure that RFK was going to have the president’s ear whether he was in office or not,” he said.

While Kennedy’s efforts to roll back federal vaccine recommendations are being blocked by courts, this week reported that the number of measles cases confirmed in the U.S. so far in 2026 has exceeded the total for 2025 — making it the highest number of cases in 35 years.

Cassidy, a principal author of the 2020 No Surprises Act targeting surprise medical bills, also said he doesn’t think Congress needs to make modifications to the law in the wake of reports that doctors and other healthcare providers are winning huge payouts under the arbitration system the law created. The No Surprises Act was intended to shield patients from receiving big bills for receiving medical care they didn’t know was outside their health plan’s network.

An analysis by this week found that providers were awarded nearly $15 billion in disputed claims in 2025, more than triple the 2024 figure of $4.08 billion.

“The initial step to make sure that people are getting their best deal is price transparency,” Cassidy said.

The HELP Committee on July 22 overwhelmingly approved advancing the Patients Deserve Price Tags Act, a bipartisan bill that would further expand the requirements that hospitals, insurers, and other healthcare providers make prices public and available to patients and employers. A House committee advanced a similar bill this week, also with bipartisan support, but it remains unclear whether either measure will be approved by the full House and Senate.

The interview — in which Cassidy also discussed his — was part of the “How Would You Fix It?” series featuring Julie Rovner, ³Ô¹Ï²»´òìÈ’ chief Washington correspondent and host of the What the Health? podcast.

An abbreviated version of this interview aired July 23 in Episode 456 of What the Health? From ³Ô¹Ï²»´òìÈ: “A Shrinking Safety Net.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

For the first time in a quarter century, the U.S. no longer meets a main criterion for having eliminated measles as a public health threat. That status hinges on sporadic outbreaks fizzling out within a year. Utah’s outbreak has lasted for longer, since .

Nearly 400 people have been hospitalized with measles in the U.S. this year and last, three people have died, and at least three suffered with .

This month, the Centers for Disease Control and Prevention is set to finalize a comprehensive study of the nation’s measles situation, examining data from January 2025 through June 2026.

“I don’t think we could say with a straight face that there hasn’t been transmission over the past 12 months,” said a CDC scientist with knowledge of the agency’s measles report. (³Ô¹Ï²»´òìÈ agreed not to name the researcher, who is concerned about retaliation.) The researcher said a national committee of measles specialists will review the CDC’s internal report, which then goes to the Pan American Health Organization, a group that evaluates the measles elimination status of countries throughout North, South, and Central America and the Caribbean.

PAHO will make at an annual meeting this fall, but scientists say the writing is on the wall. “The assessment for elimination isn’t until November, but that is a scheduling issue, basically,” said Anne Schuchat, who led the CDC’s immunization and respiratory disease group from 2006 to 2015.

“It’s just so sad, because some people will get brutally ill,” she said of measles’ return. “This is a wake-up call.”

Pediatricians in Utah have been on the front lines as measles and other vaccine-preventable ailments have returned to the U.S. In interviews with ³Ô¹Ï²»´òìÈ, six doctors shared insights on this new era of vaccine hesitancy — and what could be done to turn the situation around.

The conversations have been edited for clarity.

On Unvaccinated Children Hospitalized With Measles Complications

Emilie Morris, a hospital pediatrician in Salt Lake County and Utah County: When children come in, they’re often bent over. We call it tripoding, which is particular to upper respiratory infections and airway swelling. They have a rash — viruses cause rashes all the time — but in this context, the kid is hunched over, mouth open, drooling, crying, maybe not even producing tears, because they’re so dehydrated. Really labored breathing, kind of tugging in their belly, tugging between their ribs. Their eyes look kind of glazed over. It’s like they’re seeing through you.

Nathan Money, a hospital pediatrician in Salt Lake County and Utah County: If the child has a fever or trouble breathing, and they’re unvaccinated, I have to be way more aggressive from a medical standpoint, because they are at higher risk of having life-threatening illnesses. I have to do more blood work, or lumbar punctures to rule out meningitis. I have to do things which are painful, and it’s traumatic for the families.

I tell them, “Because your child doesn’t have vaccines, I have to be more worried about conditions like sepsis or meningitis, so therefore I need to do more workup.” The last thing I want to do is miss something. These are parents who love their children. They always tell me, “Do what you need to do to make sure my child is safe.”

On Treating Unvaccinated Children Hospitalized for Measles

Trahern W. Jones, a pediatric infectious disease specialist based in Salt Lake City: So I’m coming into a room and just hearing the most awful barking cough, just a cough and a high-pitch stridor as the child is trying to breathe. And he’s just coughing so hard it just makes you feel short of breath. He looks like he’s been beaten down for days, but he can’t rest, because the cough keeps him awake.

The parents tell me they’re not anti-vaccine, but in the past, somebody they know had a reaction to a vaccine — or something they thought was a reaction to a vaccine — and so they paused vaccines when the child was a baby. They were planning to catch up later.

In another case, the parent was stunned by how awful it was. I asked them what they knew about measles before their child was sick, and they said the only person who’d ever taught them anything about measles was their grandmother who had taken care of her kids with measles ages ago. That’s something I’ve heard from other parents. It’s such an awful illness. Even the best possible course is going to be one of the worst diseases most children ever go through.

There are multiple facets to it. Physically, the child has been beat down for multiple days by this virus. The parents don’t get to sleep, because they’re nursing their child. Then there’s the emotional component because the parent is regretting not getting the vaccine, not realizing how bad this was, and then feeling deeply ashamed, trying to reconcile with family members who are really upset at them for not getting their child vaccinated.

Morris: One child was from a family that was uninsured because they didn’t feel that they would need to use the medical system. They were faced with the high burden of cost of our healthcare system. The cost was playing into the parents’ decision on whether or not their child should receive necessary medical care. I said something like: “Please don’t go home. Your child needs oxygen. She has pneumonia. We will figure out a way to pay for this, because we acknowledge what we do is expensive.”

On top of that, the parent had several other children in the home who weren’t vaccinated. It was past the period where we could intervene with vaccines to try to prevent infection, so then our recommendation was to quarantine their children at home for 21 days: “Don’t interact with anybody else in your community. Don’t go to the grocery store, even with a mask. Please take this seriously.”

It takes time for parents to understand the level of concern I have, even when their child is physically ill in the hospital requiring ongoing care. It’s pretty indicative of the breakdown of trust between physicians and families. I say, “This is the gravity or severity of your child’s situation and how serious we need to be about protecting other people.”

It’s frustrating. How can I make people understand I have a very genuine concern for their child? And I know they share that concern, but maybe it’s not the same degree of concern, because they don’t understand the illness and how severe it can become.

Money: It’s heartbreaking to see these children struggling to survive when measles could have been easily prevented by a safe mechanism that is readily available and well studied. These are well-meaning parents who love their children, who have gotten bad information from federal leadership or from online sources. The saddest part to me is when I am caring for a child and the parent says, “I didn’t know that this could get so bad.”

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On Conversations With Parents Who Don’t Vaccinate Their Children

Tim Duffy, a pediatrician in Salt Lake County: A lot of families aren’t aggressively anti-vax, but they’re hesitant. Younger parents who grew up in the digital age have done their research — “research” in quotation marks — for months. And they keep getting confirmation of their concerns on social media. They think they’re doing what’s best for their child.

I’ve told families: “You could do nothing I say as a pediatrician. You could sleep your child on their stomach. You could not put them in a car seat or, when they’re older, not use seat belts. You could do nothing I say, and for your individual child, they will probably be OK. But from my standpoint, where I’m taking care of thousands of kids, within a system that takes care of hundreds of thousands of kids, we will have bad outcomes. These children will show up at our facilities, and it’s so sad.”

Pediatrician in southern Utah whom ³Ô¹Ï²»´òìÈ agreed not to name, because of concerns about harassment after being targeted by anti-vaccine activists in the past: A lot of parents are concerned about autism. I’ve told them that I’d be very concerned if there was any evidence that what we’re doing is causing autism. But if vaccines were causing autism, we should see more cases of autism in vaccinated kids compared to unvaccinated kids, and we’re just not seeing that.

I’ve also had families who say they want to be natural, or that they’re concerned about what is in the shots. A frequently asked question is: “Did you vaccinate your children?” I say that knowing what I know, I’m confident giving this to my kids. They’re all vaccinated.

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On the Influence of Politics on Vaccine Hesitancy

Jones: Vaccines have become a political football. That wasn’t true 20 years ago. But now it’s used to drive a wedge between groups of people, which is unfortunate. Vaccines are one of the main reasons why we don’t have to worry about losing our kids.

Southern Utah pediatrician: People don’t know who to believe. If politics comes up, I tell parents that my messaging on vaccines is not politically motivated. When parents ask about changes to the vaccine schedule, I’m transparent. [In January, the Department of Health and Human Services reducing the number of vaccines given to children. A few months later, a federal judge blocked those changes.]

I’ve said there was a process for the approval of immunizations through ACIP [the Advisory Committee on Immunization Practices], which is made up of scientists, public health experts, and doctors, and all those people were let go, and a new panel was selected. A couple of individuals changed the recommendation outside of the time-tested, evidence-based process for evaluating vaccines. That raises concerns for me as a doctor. I tell parents that the American Academy of Pediatrics, the American Academy of Family Physicians, and several other professional organizations have issued statements saying that these changes are not based on evidence.

Ellie Brownstein, a pediatrician in Salt Lake County and president-elect of the Utah chapter of the American Academy of Pediatrics: I avoid talking about politics, but what’s being said has added another layer to our work. One family asked me about changes to vaccine recommendations, so instead of just telling them what immunizations are due, I talk with them about why physicians and researchers have followed a different schedule for years, about the reasoning and the science behind it. I explain that I trust these experts over someone without a lot of experience.

Money: People are not vaccinated, because they’ve lost trust in the medical community. They’re placing trust elsewhere. Rebuilding trust is a complicated process, but it comes from consistent messaging at every level, from the pediatrician to local health departments to community leaders, city leadership, district leadership, religious leadership, educational leadership.

We need consistent messaging from state leadership, which has been pretty absent. I want to see commercials on TV about the safety of the MMR [measles, mumps, and rubella] vaccine and the dangers of the measles, sponsored by my state leadership. I’d like to see this on billboards and in schools, in public buildings and grocery stores. I want to go to a sports event and see messages about the measles and the MMR vaccine. Right now, people have to go out of their way to find information from reputable sources.

We also need policy changes to support vaccination. This train is going in the wrong direction, and it can feel like a helpless situation, because we’re just not seeing the public messaging and leadership that’s needed to turn this around.

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Advice on Talking With Parents Who Don’t Vaccinate Their Children

Jones: Approach them with as much compassion as you possibly can. Ask open-ended questions to learn about their experiences that led them to have these concerns. I think it’s really important to not come down on them, citing facts and figures and pointing to guidelines on why they need to get their kids vaccinated. But try to direct their attention to the fact that you’re a real person with your own real experiences and knowledge. I point out to families that I have my own kids, and I would never recommend something for your kids that I wouldn’t do for mine.

Southern Utah pediatrician: I’ve learned that if you come down hard, you’re going to lose people who need care. My number one goal now is to build bridges and maintain a relationship with families, because that’s what’s going to allow me to convince some of them.

I approach people differently depending on where they are. Parents who are very skeptical or anti-vax will say no when I tell them their child is due for immunizations. I’ll say: “Fine. You guys get to choose. You’re the parents. But I’m curious to know what your reasoning is.” Sometimes they’re just like, “It’s something I’ve decided.” They don’t want to have a conversation.

It’s a good day if I can have a conversation with someone who doesn’t want to vaccinate, even if I don’t convince them. I try to help them think through things rather than shoving anything down their throat. When they’re done talking, I’ll ask, “Can I share my perspectives on this?” Some will say yes enthusiastically, and others will say yes because they’re being polite.

A lot of parents aren’t sure what to do, and those are the people I focus most of my time on. I focus our conversation on their specific concerns, and I’m open about specific side effects that different immunizations can have. For example, I’ll tell them that some children get a fever after a vaccine, which is OK. The fever is not harmful, but it can make babies feel crummy as their body is building up antibodies against viruses and bacteria.

Brownstein: I don’t like the idea of excluding unvaccinated kids from my practice. I know some do that. But what that does is it ends any future discussion. I can’t keep talking with parents about vaccines if I kick them out of my practice, and if these parents find like-minded doctors, this situation will get worse.

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On Being on the Front Lines of Measles’ Comeback in the U.S.

Money: I wish that people could see what I see. Everyone else sees what people post on Instagram. Or they think, “Someone I know had measles when they were a kid and they were fine.” But as a hospital-based pediatrician, I see what happens when things go poorly. I see what happens when children with measles aren’t able to breathe on their own, and they’re in a hospital bed with a cannula in their nose, struggling to breathe, an IV in their arm because they can’t drink on their own. And the child is terrified, and the parents are scared that their child might die.

It’s heartbreaking as a pediatrician and as a father to know that the entire situation could have been easily prevented.

Duffy: Even though parents say vaccination is their choice, I still feel personally responsible if something bad happens that’s preventable, because I feel like I didn’t say the right thing, I didn’t ask the right questions. Maybe I let it drop because of the look on a parent’s face.

Morris: Every pediatrician I know cares so deeply about what they do. Sometimes people forget that we are human beings practicing this discipline, and we bring all our concerns for our community into this space. I’m trying to navigate a lot of complex human emotions, like how it feels to hold grief with a family when something bad happens that was preventable — which is the worst situation, because you think, “Could I have done something differently?”

Jones: I think we’ll see more diseases start coming back that we thought we had gotten rid of. I think it’s going to take dramatic changes to actually prevent those outcomes. I’m not necessarily seeing those changes being done by those in power.

I think of that quote from The Lord of the Rings. It’s something like, you don’t get to choose the time that you’re born into, but you get to choose what you’re going to do about it. And if there’s any comfort that I have, it’s in knowing that there are right decisions to make and that I’m going to make them, and I’m going to help others make them, too.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

More than a decade ago, Noon said, she was diagnosed with adult-onset Still’s disease, a rare type of inflammatory arthritis that can cause rashes, debilitating pain, and fevers. The disease upended her life.

She had been living a typical suburban life in Michigan, shuttling her two kids to activities like cheerleading, choir practice, and track. She was active in the PTA. She managed a bank.

She went from that to crawling to the bathroom because she was in so much pain, “just crying all day long” from being so sick.

Noon, who is disabled, said she couldn’t work for eight years — a time marked by hospital stays that stretched for weeks.

“I honestly thought I was going to die,” Noon said.

So it was a shock when Michigan denied her application for Medicaid benefits last year after she lost private insurance. Worse yet, it came down to an IT error, according to an attorney who helped Noon overturn the denial.

“I can’t afford my medical care. I have to have insurance,” said Noon, who has returned to working.

Deloitte, a multibillion-dollar global consulting firm, has operated Michigan’s Medicaid eligibility system under contracts worth roughly $768 million since 2006, according to contracts reviewed by ³Ô¹Ï²»´òìÈ. Nationwide, Deloitte dominates this important slice of government business: At least 25 states have awarded the company contracts to build or run computer systems that control access to safety net benefits such as Medicaid.

Michigan’s system has incorrectly directed people with disabilities into skimpier benefits that cover limited care or has denied coverage completely, a ³Ô¹Ï²»´òìÈ investigation found. Similar problems were at the center of a class-action suit in Tennessee, , and have occurred in Texas, according to interviews and state records.

The ³Ô¹Ï²»´òìÈ investigations are based on statements from state officials, allegations and declarations in court documents, emails obtained through public records requests, state government information provided to Medicaid enrollees and applicants, and interviews with attorneys and patients or their caregivers.

In an emailed statement, Deloitte spokesperson Karen Walsh said it found “no system anomalies causing routine denials of Medicaid for people with disabilities.”

“There are many reasons why someone may no longer be eligible for a benefit they once received or believe they deserve,” Walsh said. “All of the eligibility systems we support are owned by the states and built to their unique specifications. We will continue to work at the direction of our state clients.”

Lynn Sutfin, a spokesperson for Michigan’s Department of Health and Human Services, said it “is not aware of any widespread or systemic issues” within Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits, “related to disability‑based eligibility pathways.” 

Since 2006, Deloitte’s contracts with the state have said the company is responsible for development, implementation, maintenance, operations, and enhancements to the Michigan system.

Computer system problems foreshadow trouble as states prepare to roll out the most significant and complicated changes to their Medicaid programs in years. Those changes, dictated by President Donald Trump’s landmark One Big Beautiful Bill Act, have states rushing to update their Medicaid computer systems.

Nationwide, on Medicaid have a disability, according to KFF.

“When these administrative systems get overloaded, everyone gets impacted,” said Pamela Herd, a University of Michigan professor who researches bureaucratic obstacles to accessing government benefits. “The systems are going to be really, really strained.” 

In Michigan, Noon was eligible for Medicaid through a program that provides coverage to disabled adults who work. But the state’s computer system didn’t register that she is disabled and said she earned too much to qualify, according to documents reviewed by ³Ô¹Ï²»´òìÈ and interviews with Noon and Anastassia Kolosova, a disability rights attorney who helped her.

Without Medicaid coverage, Noon paid hundreds of dollars out-of-pocket for prescriptions, after scrounging for discount coupons. She takes some of the drugs twice a day.

Without them, “I’m toast,” she said. It was stressful “not knowing if my medicine’s going to be $50 or $500 this month, because it changes constantly.”

Noon said her doctor agreed to fewer visits to avoid medical bills.

“It was kind of a nightmare,” Noon said.

‘I Just Wanted To Give Up’

Medicaid, a safety net health program jointly run by the federal government and states, people with low incomes or disabilities. State governments rely on companies like Deloitte to design and operate computer systems that assess whether people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps.

That technology has a history of errors that deprive eligible people of benefits, earlier ³Ô¹Ï²»´òìÈ investigations have shown. As reported previously, Kenneth Smith, a Deloitte executive who leads its national human services division, said Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.”

“They’re not Deloitte systems,” he said, noting Deloitte is one player among many who together administer Medicaid benefits.

States are under immense pressure to update their eligibility systems on a tight schedule to adhere to requirements in the Republicans’ sweeping 2025 tax and spending law. Companies including Deloitte, Accenture, and Optum are being paid millions in taxpayer funds to make the changes, which are projected to strip Medicaid from roughly 7.5 million people and SNAP from 2.4 million people by 2034.

Many coverage restrictions in the new federal law don’t apply to seniors, children, or people who are disabled, such as Noon. Nonetheless, the law’s demands on state agencies and the computer systems they oversee will disrupt benefits, advocates for Medicaid enrollees and other healthcare experts said in interviews.

The same systems also need to correctly classify why someone is eligible for Medicaid — and therefore which rules and restrictions apply.

The law’s SNAP restrictions began to take effect in 2025, and major Medicaid provisions begin later this year, generally after the midterm elections.

Kolosova is a supervising attorney with Disability Rights Michigan, a legal advocacy organization for people with disabilities. She said she has been unable to get a meeting with Michigan officials to understand the underlying problem that deprived Noon of health coverage.

State records show Deloitte has held contracts for at least 14 years for Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits. In its attempts to secure more business, the company often cites its nationwide footprint in Medicaid operations.

“Deloitte understands Bridges,” and its history in Michigan makes the company “the ideal vendor,” the firm said in its . Given Deloitte’s work on similar systems in 31 other states, , “Michigan benefits from our technical expertise drawn from across the nation.”

But advocates who work with people with disabilities say Michigan’s computer system has failed to recognize when certain adults should receive Medicaid benefits.

Problems aren’t unique to the Great Lakes State. Medicaid beneficiaries who brought a against Tennessee in 2020 said the state’s Deloitte-built system “does not reliably test for eligibility” for several categories of people with disabilities. The firm’s is worth $1.12 billion over a decade.

A federal judge in 2024 , ruling that Tennessee violated federal law and the U.S. Constitution. The lawsuit does not name Deloitte as a defendant.

In Michigan, a from the state’s Office of the Auditor General said government agencies “did not provide effective project administration” and failed to ensure that the state could “independently maintain and operate Bridges” because “the contractor did not transfer knowledge and skills” to state officials, according to the audit.

The auditor’s report said that, as a result, Deloitte’s original contract — valued at roughly $70 million — ballooned by $50 million over the initial cost, a 71% increase. State records show Michigan would go on to add millions more, bumping the cost of Deloitte’s initial contract to $124.1 million.

The audit said maintaining the contract would result “in significant additional costs.”

Sutfin said that “the state is now fully capable of operating and maintaining Bridges independently.”

Deloitte’s in Michigan — worth $197.4 million — is set to expire in 2030.

Noon applied for Medicaid in August, she and Kolosova said. In September, the Michigan Department of Health and Human Services sent a notice denying her coverage, citing incorrect income information and stating she wasn’t disabled, according to Kolosova and state documents reviewed by ³Ô¹Ï²»´òìÈ.

Noon said that when she called the state for help, state workers “didn’t know anything about” the Medicaid program she had applied to, Freedom to Work.

“I can’t tell you how many times I just wanted to give up,” she said.

For some people with disabilities, Medicaid is supposed to count only half their earnings when assessing whether they should receive benefits. That didn’t happen. Kolosova said she thinks Michigan’s eligibility system didn’t identify Noon as disabled, even though the state “already had all the information they needed” to show she was.

By failing to recognize her disability, the state used the wrong income formula and said Noon earned too much to qualify for Medicaid, she added. Deloitte and Michigan declined to respond to a detailed list of questions about Noon’s experience.

Kolosova said Disability Rights Michigan has seen a growing number of calls from people about Freedom to Work benefit denials. “Maybe two or three a month,” she said.

“There’s something wrong with the system if they’re relying on individual caseworkers to catch this,” Kolosova said. “The system needs to work.”

Enrolled in the Wrong Coverage

Noon’s experience isn’t the first time in recent years that people with disabilities have been denied benefits by Deloitte-run eligibility systems.

In Texas in 2023, Lilly Livingston, who has Down syndrome and is now 22, was abruptly cut off from Medicaid benefits, according to Livingston’s mother, Marie. She has undergone numerous surgeries to reconstruct her severely misaligned jaw, which caused sleep apnea and impaired her speech and chewing ability. She relied on an array of Medicaid services, including speech and occupational therapy.

When Livingston lost benefits, she was wrongly enrolled in Healthy Texas Women, a limited program that provides breast and cervical cancer screenings and family planning services.

“Trying to fix that was a nightmare,” Marie Livingston said.

Terry Anstee, an attorney with Disability Rights Texas, intervened.

In a September 2023 email with the subject line “URGENT,” Anstee begged a Texas Medicaid eligibility worker for help.

Some unknown “error” had occurred and stripped Livingston of her benefits, Anstee said in an email he sent to a state Medicaid staffer. “Lilly has had 2 major surgeries, and her recovery is contingent on Medicaid.”

It was clear that Livingston qualified for Medicaid through multiple paths, Anstee said: “It never made any sense.”

Deloitte declined to respond to a detailed list of questions about Livingston’s case. Jennifer Ruffcorn, a spokesperson for Texas Health and Human Services, confirmed that Livingston was erroneously enrolled in Healthy Texas Women. However, Ruffcorn said, Livingston did not experience a lapse in Medicaid coverage in 2023.

Anstee disputed the state’s characterization: “A glance in the system by a Texas HHS press officer or other staff 3 years after the fact may not tell the full story or show the issues that Ms. Livingston endured in August and September 2023. Ms. Livingston experienced lapses in coverage.”

The problem Livingston encountered in Texas was also reported in Michigan.

In 2024, mental health services advocates in Michigan raised red flags about a similar error: People with disabilities were being enrolled in a limited Medicaid program covering sexual health and family planning services. Plan First covers only services and treatment for sexually transmitted infections. It doesn’t provide the comprehensive coverage that people with disabilities require.

But some enrollees were “being automatically enrolled in Plan First,” Malcolm Kletke, a lobbyist representing the Community Mental Health Association of Michigan and other mental health providers, wrote to a Michigan health official, according to emails obtained by ³Ô¹Ï²»´òìÈ through a public records request.

These enrollees had “long received Medicaid due to their disability,” and getting enrolled in the wrong plan meant losing access to “services essential to their recovery and quality of life,” Kletke wrote in September 2024 to Amy Epkey, a senior deputy director of the Michigan Department of Health and Human Services.

In fact, the state’s own records show that Medicaid enrollment for those with disabilities did decline.

Over roughly four years, enrollment in the Medicaid category that includes people with disabilities , according to the Michigan House Fiscal Agency, which provides nonpartisan analysis to lawmakers. The drop was unusual given people generally leave the program because of death or having recovered from a temporary disability, and it’s unlikely those numbers would balloon, said Robert Sheehan, who was the mental health association’s CEO at the time.

Sutfin said the state examined the decline in enrollment and found “several contributing factors, including post‑covid renewal patterns, changes in beneficiary circumstances and movement to other coverage categories.”

After inquiries from ³Ô¹Ï²»´òìÈ, the Michigan health department acknowledged in April that it had made changes to “address concerns raised by advocates.”

Michigan’s computer system now prevents approval of Plan First benefits until all other coverage options are evaluated, Sutfin told ³Ô¹Ï²»´òìÈ. Sutfin said the changes were implemented but “not to correct system errors.”

Sutfin said the state submitted a change request to Deloitte to address this problem. The fix was implemented in January 2025.

Until presented with Kletke’s email, the state had denied there were problems related to Plan First.

Even after the state addressed that issue, other problems persisted.

Noon’s coverage denial notice arrived in September. She fought with the state for months to reverse its decision, “paying cash for all of the medicines through these appeals over and over and over again.”

It was only in January that she was approved.

“I literally cried,” Noon said. “It was a really big deal.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

In February, Hawai‘i’s parole board granted the now-52-year-old compassionate release, which allows prisoners to receive early probation to seek .

But without a long-term care facility willing to accept him, Alameda has not been able to leave.

As of June, at least three other prisoners granted release to tend to their medical needs were living indefinitely in the infirmary after long-term care facilities were unwilling to accept them, primarily because of their criminal backgrounds, the state parole authority said.

“This is a challenge across the country,” said Molly Crane, an attorney for FAMM, which advocates for .

Every state allows for prisoners, though HawaiÊ»i is the only one without a specific law, relying instead on an internal policy. The prisoners who typically qualify for compassionate release can’t care for themselves or have terminal illnesses and may need an assisted living center, a nursing home, or hospice.

But many long-term care facilities nationwide decline to take such prisoners, leaving them incarcerated for months — or years — after they were granted release.

In , a study found that rejections from nursing homes soared after they were told that a patient was coming from prison. , prisoners with extensive medical needs stayed an average of 200 days after being granted parole, because of denials from long-term care centers. And in , prisoners granted parole sued the state when they couldn’t get placed in nursing homes.

President Donald Trump’s signature One Big Beautiful Bill Act further strains long-term care providers’ ability to take people from incarceration. Prisoners don’t qualify for Medicaid, so parolees after they’re granted the release. The law, enacted last summer, reduces the window in which facilities can get reimbursed from three months to before they apply. That means facilities risk not getting paid for new Medicaid patients whose applications are not submitted within the reduced timeframe.

The Centers for Medicare & Medicaid Services “encourages providers and beneficiaries to prioritize timely application submission to maximize coverage,” CMS spokesperson Timothy Foster said.

‘Risk Is Just Too High’

Most nursing homes nationwide already have a waiting list for new residents, according to a by the American Health Care Association and the National Center for Assisted Living. Those waitlists are another hurdle to getting prisoners placed, said Bob Merce, a former attorney who advocates for prisoners’ compassionate release.

“We tell the nursing homes that most of the people who we are talking about cannot hurt somebody,” Merce said.

Some of the prisoners staying at the Halawa infirmary in June couldn’t walk or dress themselves. One man couldn’t recall what his illness was. Another with brain cancer couldn’t coherently respond to questions.

Sean Sanada, the OÊ»ahu Region CEO with the HawaiÊ»i Health Systems Corp., oversees the region’s two state-funded long-term care facilities, Leahi Hospital and Maluhia. Sanada said that the health system has reviewed dozens of compassionate release referrals but has never accepted any of them.

Sanada said the facilities don’t discriminate based on where the resident comes from. His main concerns, he said, were his staff’s safety and the lack of resources to adequately care for the patient.

“The risk is just too high in most of those instances,” Sanada said.

Violent incidents in long-term care facilities have been well documented. A observing 14 assisted living facilities found that in just one month, 15% of residents experienced resident-to-resident aggression.

When long-term care facilities refuse to accept prisoners who have been granted compassionate release, it leaves state taxpayers footing a larger bill. The annual cost to incarcerate an individual in Hawai‘i with complex needs is up to eight times the $112,505 average of housing one person in prison, according to FAMM. In comparison, the average Medicaid reimbursement for a long-term care patient at a Hawaiʻi Health Systems Corp. facility is about .

Four states — Connecticut, Georgia, Massachusetts, and Vermont — contract with nursing facilities to take prisoners who are granted compassionate release, according to FAMM.

The iCare Health Network’s MissionCare Health, which operates nursing homes for people coming out of prison, secured contracts in three of those states. David Skoczulek, iCare’s vice president of business development and communication, estimated that its rates are $100 to $350 a day more per patient than the average nursing home rates in the states where they operate.

In Hawaiʻi, the correctional department determines recommendations to send to the parole board, which decides whether to grant the release. Prisoners who are granted the early probation can be released to family members who commit to caring for them or to a long-term care facility.

Corey Reincke, head of the HawaiÊ»i Paroling Authority, said that in his 24-year career he couldn’t recall getting anyone placed into a long-term care facility without family intervening, for instance by contacting facilities themselves.

“Parole has to find a facility that can meet their medical needs and is also willing to take them,” Reincke said. “That’s where we’re hitting the roadblocks.”

For one parolee, Reincke called more than 100 care homes, he said, but they all declined to accept the patient, over safety concerns. According to a 2024 state report, while HawaiÊ»i’s long-term care facilities use about workforce strains make it difficult to maintain even those levels.

HawaiÊ»i Prisoners’ Refuge: Family

Last year, 69-year-old Paul Kupihea died at a hospital five days after the state granted him compassionate release to his family. He died before he could get on a flight to his home island.

In July 2025, Lahela Kruse, the mother of Kupihea’s child, received a call from a Honolulu hospital informing her that his condition had become severe. By then he had been diagnosed with an incurable form of cancer and had been in and out of the hospital while still in custody.

Kruse and their daughter flew to Oʻahu to see him and were shocked when they saw how sick he was. Their daughter agreed to take him into her home in Hilo, on Hawaiʻi Island, despite not having a relationship with him for most of her life.

“She knew he was sick,” Kruse said. “I told her that, but she didn’t know the severity of it. I didn’t truly know.”

Her daughter’s willingness to take him prompted his compassionate release. But Kruse said the notification about Kupihea’s illness came too late.

FAMM’s Crane has been working on expanding compassionate release laws in states to allow for more prisoners to qualify and strengthen transparency in the process. HawaiÊ»i lawmakers have tried for years to pass bills on compassionate release, but none has succeeded.

Crane said without a law that outlines a formal process and who qualifies, even family support isn’t enough. Prisoners can still face life-threatening delays, she said.

“The absence of a compassionate release statute means that people who need compassionate release languish and even die in prison,” Crane said.

In Alameda’s cell, two beds stood about 3 feet apart, with a seatless metal toilet in the corner and a window looking out on a concrete wall. The smell of bleach permeated the room. Alameda said he hoped to see his daughter soon. She recently turned 5.

“I made some mistakes in my life,” said Alameda, who has been incarcerated since 2024 for drug possession, driving a stolen vehicle, and jumping bail. “I tried when my daughter was born, but I know I’ll change, because she needs me out of here.”

Merce, the former attorney, is still trying to find a place for Alameda, who committed no violent crimes. Merce became aware of prisoners’ struggles through his work as a trial lawyer. He said he has helped about 15 prisoners leave HawaiÊ»i correctional facilities for medical treatment.

He said he’s seen cases in which people have waited years to get out.

“The ones that stick with me, though,” Merce said, “are the ones that I never found placements for.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Overnight, a nurse aide walked into their room and saw blood splattered on the floor, walls, and ceiling, according to a grand jury transcript. Cecchetto’s face “looked twisted and smashed,” the aide testified. A Banning city police officer testified that Timaloa, 77, told him that he had punched Cecchetto twice.

“He just kept saying that Attilio was being too loud: ‘He talks too much,’” the officer said.

Cecchetto died two days later from blunt force facial trauma.

“You get placed in a facility like this to be taken care of, not to be murdered,” one of his sons, Gino Cecchetto, said in an interview. “This was completely preventable at many different points.”

Timaloa pleaded not guilty to assault. The charges were later upgraded to murder, and a judge ordered a mental health evaluation. The judge will rule as early as August on whether Timaloa is competent to stand trial.

PACS Group, the nursing home chain that owns Sunrise, denied negligence. “We strive to provide quality care to everyone we serve, and our hearts continue to go out to the Cecchetto family for their loss,” PACS spokesman Brooks Stevenson said in an email.

In nursing homes primarily occupied by impoverished people as well as posh assisted living facilities that cost upward of $10,000 a month, agitated residents have shoved, punched, bit, and kicked others. They have wielded canes, walkers, pens, a plate, a mop stick, a shoe, a belt buckle, and even the footrests of wheelchairs as weapons, federal inspection reports show.

How often these altercations take place nationwide is unknown, but an of 14 assisted living facilities in New York state led by Cornell University researchers estimated 1 in 7 residents experienced aggression within a month, including verbal, physical, or sexual acts. Their of 10 New York state nursing homes estimated 1 in 5 residents experienced an altercation in a month. Researchers have found that these assailants are to have dementia.

The diseases that cause dementia can impair brain circuits involved in impulse control and threat perception, raising the risk of aggressive behavior. Residents with Alzheimer’s disease and other dementias constitute more than living in these settings, many of which include specialized units.

Often, altercations involving a resident with dementia erupt after danger signals are missed or ineffectively addressed, according to a ³Ô¹Ï²»´òìÈ examination of court records, police reports, and state and federal inspection reports.

Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show. The federal records do not include assisted living facilities, which are regulated by states.

In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees, the reports show.

The long-term care industry says not every clash can be averted. Presbyterian Homes & Services, a nonprofit Christian chain of senior living facilities, said in a statement: “Caring for individuals living with advanced dementia is complex, and behaviors can change in ways that are difficult to fully predict or prevent, even with clinical interventions in place.”

Eilon Caspi, a and researcher who studies resident-on-resident altercations, said that usually there is a specific unmet need that precedes an altercation. “In the vast majority of incidents,” he said, “there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”

Fertile Battlegrounds

One about Alzheimer’s, the most common dementia disease, holds that as the brain’s networks deteriorate, the balance shifts between the prefrontal cortex, which helps govern judgment and self-control, and limbic regions including the amygdala, which helps process fear and threat responses.

As cognition clouds, people lose the ability to understand what is happening around them and to put distress into words, researchers say. Pain, infection, medication side effects, and other physical and emotional distresses through shouting, intimidating gestures, kicking, pushing, or punching. Long-term care facilities can be triggering environments, with intimate care often delivered by a changing stream of aides whom residents can’t recognize. Amid noise, close quarters, and rigid routines, interactions become flash points.

“You don’t feel safe, because you don’t know these strangers who are coming in and taking off your clothes,” said Al Power, a geriatrician and an advocate for alternative models of care for people with cognitive issues. “These things will be distressing to anybody.”

The Cornell researchers found verbal altercations were the most common type of aggressive interaction but estimated 4% of assisted living residents and 5% of nursing home residents in their studies experienced physical assaults in a month.

Another Cornell study found that Connecticut police were called to nursing homes for more often than allegations of staff abuse, theft, and residents wandering away without supervision combined. A national analysis of survey data from the Centers for Disease Control and Prevention calculated in assisted living facilities engaged in physical aggression or abuse toward other residents or staff members.

Many of the physical aggressions ³Ô¹Ï²»´òìÈ identified in CMS inspection reports were perpetrated by residents with diagnoses of dementia, schizophrenia, or other cognitive disorders. In some physical altercations, both residents were aggressors, while other fights were one-sided. Sometimes the residents were roommates.

Laura Mosqueda, a geriatrician at the University of Southern California’s Keck Medicine in Los Angeles and a senior adviser to the National Center on Elder Abuse, said: “What worries me is that we just end up blaming two people who have either cognitive impairment or severe, uncontrolled mental health issues, when they’re supposed to be in an environment where people are safe.”

‘Only a Matter of Time’

Gladys Lynch, a retired department store accountant, transferred into the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, in September 2025. Her monthly cost was more than $10,000, according to an invoice provided by the family.

One of Lynch’s daughters, Rebecca Norton, installed web cameras in her room and often saw another resident inside. “Every day I looked at it, this woman would be walking into my mom’s room, harassing her, digging through her things, using her bathroom, yelling at her,” Norton said in an interview. She informed Harbor Crossing’s administration, and the facility said it would start locking her mother’s door.

Norton emailed a Harbor Crossing administrator a list of issues with her mother’s care. “My biggest concern,” she wrote, was that her mother’s door was not consistently locked and the webcam showed the woman had again entered, rummaged through the bathroom, and taken a couple of adult diapers.

Unknown to Norton, Harbor aides had raised concerns about the other resident, who like Lynch was new to Harbor Crossing’s memory unit, according to a . Diagnosed with Alzheimer’s, severe dementia with agitation, depression, and anxiety, the woman was confused, had difficulty communicating her needs, and hit aides.

Aides repeatedly reported that the woman had “ongoing aggression, entered other residents’ apartments, invaded others’ personal space, and was difficult to redirect,” the health report said. They said medications had been ineffective and pressed for new ones. The report said one nurse told the woman’s doctor it was “only a matter of time before” she “hurts another resident.”

Captured on Camera

On the last day of September, she entered Lynch’s room and resisted leaving, the state report said. The next morning, she reappeared. Video of the incident was described in the police and state reports and reviewed by ³Ô¹Ï²»´òìÈ. It shows Lynch guided the woman out and appeared to attempt to lock the door, but the woman opened it and returned once more.

The woman declared it was her house, went into Lynch’s bathroom, used the toilet, and then returned to the room Lynch was in. Lynch can be seen repeatedly pressing the alert pendant around her neck to signal nurses for help.

The video shows the woman was almost out of her apartment door when she attempted to touch an object near the door. Lynch put her hands up to block her. The woman slapped at her hands and said, “I’m going to kill you if you don’t quit it.” She pushed Lynch, who fell, her head hitting the floor and blood seeping out.

Aides arrived 13 minutes after she had initially pressed her pendant, the state report said. Lynch suffered a brain hemorrhage and fractures to her eye socket and ribs, according to the state report. She died in the hospital five days later at age 96; the medical examiner’s office declared it a homicide.

Norton said her mother was kind and pleasant and never combative. “My mom deserved better than what they gave her,” she said.

Prosecutors declined to bring charges, according to the police report. The Harbor Crossing was responsible for neglect because it was aware the woman “exhibited violent and aggressive behaviors” and yet had failed to put in place effective interventions. Harbor Crossing has requested the state reconsider its findings.

In June, Suzanne Scheller, the attorney for Lynch’s family, filed a wrongful death lawsuit against Presbyterian Homes, which owns Harbor Crossing.

Presbyterian said in a statement: “We are deeply saddened by the loss of Ms. Lynch, and our thoughts remain with her family and all those impacted.” It declined to comment further on the incident or the lawsuit.

Preventive Tactics

Geriatricians, researchers, and resident advocates say long-term care homes should to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces.

Each resident should have a care plan, and homes should train staff to be alert to a resident’s triggers and intervene quickly, dementia specialists say. Organized activities are essential to keep residents occupied and engaged. Antipsychotics and other psychotropic medications are often prescribed, but they can increase the risk of falls, strokes, and .

An aide can be assigned to watch a particularly challenging resident one-on-one, but many places lack enough staff for protracted, dedicated supervision. Some assisted living facilities will tell a resident’s family they must hire a personal aide, who can cost thousands of dollars extra each month. In extreme situations, facilities might send a resident to an emergency room for evaluation or to a psychiatric hospital, or .

Camille Russell, who served as Kansas’ long-term care ombudsman until 2024, said she observed nurses and aides were often “woefully undertrained” in basic elements of dementia care.

“We’ve gotten too far away from making decisions that are caring decisions,” Russell said. “There has to be a balance, and the balance has gotten too far to the profit side.”

A Debilitating Kick

Many physical altercations between residents result in a scratch or a bruise, but nonfatal scraps can leave permanent damage on deeply frail residents.

Linda Twiddy’s first weeks in a Chesapeake, Virginia, memory care unit in August 2024 were happy, her daughter, Barbara Howerin, said in a May interview. Twiddy, a former church secretary with vascular dementia, sang along with a visiting church choir, decorated pumpkins, and visited a cat cafe. The facility, The Vero at Chesapeake, charged Twiddy a one-time $6,825 move-in fee and monthly charges of $7,475, according to the lease.

Seven weeks after Twiddy started living there, a nurse called Howerin. She told her that her mother had been kicked in an altercation with another resident and was being sent to the hospital.

When Howerin arrived at the hospital, she was shocked by the extent of the injury. “It was like 10 inches long by 6 inches wide, the whole front of her shin,” she said. “The calf was just like dangling down.”

According to an internal facility incident report the family obtained, an aide heard Twiddy scream for help and raced over to see a male resident with dementia trying to hit Twiddy as she sat on the floor in “a pool of blood.” The report said, “Linda was screaming get him away from me, he pushed and kicked me.”

The man had prior episodes of aggression, according to documents Twiddy’s family obtained in a lawsuit they brought against The Vero in Chesapeake Circuit Court. At his previous facility, a progress note from 2023 stated, he was “becoming very aggressive in tone and actions to residents and staff.” He “grabbed another resident by the wrists and pushed her,” according to the note. He was sent to an emergency room for evaluation of agitation, according to a hospital report. It did not make clear whether he was discharged back to the facility or elsewhere.

Agitation Tied to Pain

The male resident’s medical records at The Vero said he was diagnosed with late-onset Alzheimer’s disease, agitation, and anxiety, according to his doctor’s deposition. He had chronic pain in his back and trouble sleeping. He could answer simple yes-or-no questions but had trouble providing more extensive answers and couldn’t communicate that he was in pain, she testified. His behavioral changes usually occurred when he had a urinary tract infection, the doctor said.

When he was agitated, aides could sometimes calm him by turning on the television so he could watch his beloved New England Patriots, one aide testified in a deposition. A former aide said she tried to avoid dealing with him altogether. “If you go up to him and he was agitated, he’d reach out to try to grab you,” she testified. “If he had that cane, he would swing that cane or he would punch at you.”

In a court filing, The Vero denied allegations by Twiddy’s family that it should have protected residents from him. The filing said The Vero complied with all standards of care and that any injuries Twiddy sustained “were caused by her own negligence” or acts of others.

In their investigation of the incident, Virginia regulators alleged The Vero had for the health, safety, and well-being of its residents. The inspection report said The Vero pledged to appropriately staff the memory care unit based on the number of residents and to ensure someone completed rounds at least every two hours during sleeping hours.

Twiddy underwent three surgeries at the hospital for her leg, including a skin graft, then spent a month in rehabilitation. “She was never able to walk again,” her son, Doug Twiddy, said in a May interview.

The family moved Linda Twiddy to a different memory care facility where the nursing station had a clear view of all the rooms. She lived there until her death earlier this year.

The lawsuit was settled on confidential terms in early June. Carlton Bennett, the family’s attorney, declined to comment. In an email, Lauren Rogers, a spokesperson for Sinceri Senior Living, which operates The Vero, said the company was pleased the legal case had been resolved but could not comment further, citing confidentiality and patient privacy.

“The Vero at Chesapeake is committed to providing a caring, supportive environment where resident health, safety, and well-being remain our highest priorities,” she said.

A History of Violence

After Attilio Cecchetto was fatally bludgeoned at Sunrise Post Acute, his adult children and their attorney, Jody Moore, discovered disturbing details about Sam Ato Timaloa. He had been imprisoned in 1999 after being convicted of raping an underage girl and sentenced in 2008 to 24 years in prison for attempted murder involving domestic violence, according to Riverside County court records. His public defender declined to comment.

Cecchetto’s sons, Moore, and her colleagues at Moore Hutchins Moore also learned more about the home’s owner, PACS Group, a publicly traded company with more than 300 long-term care facilities. Last year, PACS earned $191 million on revenue of $5.3 billion, according to its .

In the Cecchettos and their father’s widow filed against PACS, they accused the company’s founders, Jason Murray and Mark Hancock, of draining resources from their nursing homes to pay for the chain’s expansion and swell their personal wealth.

The two had earned more than $650 million through stock sales since taking the company public and bought two private luxury jets, according to the lawsuit and securities filings. PACS has also purchased corporate sponsorships for Utah sports teams even though it owns no nursing homes in the state, the lawsuit said.

California regulators fined Sunrise $120,000 for Cecchetto and for not taking Timaloa’s articulated dislike of noise into account when assigning rooms. Medicare issued its own $62,810 fine.

In responding to the Cecchettos’ lawsuit, PACS denied negligence for his death and alleged he “failed to exercise ordinary care on his own behalf for his own safety.” It has sued to overturn the $120,000 state fine, saying it was issued too late and that Sunrise “did what might reasonably be expected of a long-term health care facility licensee acting under similar circumstances” to comply with state rules.

The Cecchettos’ lawsuit asks for a judge to impose robust procedures PACS homes must follow for admissions, staff training, room changes, and the reporting of altercations between residents. The suit asks for a court-appointed monitor to oversee compliance. In its written statement to ³Ô¹Ï²»´òìÈ, PACS said “important context” would come out during the process and declined further comment.

In an interview, Cecchetto’s three sons, Dino, Gino, and Marco Cecchetto, described their father’s life. He spent his childhood on a farm in Italy, growing up under Benito Mussolini. After World War II he moved to Canada, where he learned to tile and lay marble and terrazzo, a decorative flooring material made of chips of stone, glass, or other materials embedded in cement or resin. He relocated to California in the early 1960s, became naturalized, and worked as a tile journeyman and a contractor for decades.

“We don’t want this to happen to somebody again,” Gino Cecchetto said. “With the life he led, he deserved a quiet, dignified death. Instead, he ended his life in pain and fear.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Her team tends to “cringe” anytime they hear about patients having to fill out lots of paperwork, like when applying for Social Security Disability payments, because it can be a difficult, burdensome process.

Thornton tries to support her patients, she said, but understands the limits of her training.

“A lot of times the forms are so complex that I don’t really know what’s the true definition of what this form is asking me,” she said. “We refer them to a disability provider.”

Doctors including Thornton worry they’ll see more of those kinds of requests because of coming changes to Medicaid, the government health insurance program for people with low incomes or disabilities. Starting Jan. 1 in most of the country, some enrollees — mainly adults without dependents — must prove they’re working or performing other qualifying activities 80 hours a month.

issued in June say people can obtain an exemption if they’re “medically frail,” or too sick or disabled to work, which may require them to submit documentation from a medical professional. That standard prompted a lawsuit at the end of June from dozens of mostly Democratic-led states and has Thornton worried it could force her and her staff to assess things like how much a patient can lift or how far they can walk.

“If I’m asked, ‘Is this person medically frail?’ What does that even mean?” Thornton said. “I don’t know, and I’ve been doing this for 25 years.”

Last year’s GOP tax-and-spending law known as the One Big Beautiful Bill Act established the work rule, which will affect an estimated when more states start enforcing it. The mandate is expected to cause a larger increase in the number of people without health insurance than any other part of the law, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.

“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.

The Centers for Medicare & Medicaid Services declined to respond on the record about doctors’ concerns. But the agency confirmed that enrollees may need to get documentation from a clinician to prove they’re too sick to work and said states would make final determinations.

The Trump administration has previously said states should use available data sources — such as medical claims and payment data — before making patients submit proof of medical frailty from a provider.

“Documentation should be relatively easy to provide,” Mehmet Oz, the CMS administrator, said during a June 1 press call.

But deciding whether a patient is too sick to work is a subjective, high-stakes decision, said Chen, who also practices as a hospitalist at Valley Medical Center in Renton, Washington.

“We’re trained to take care of people,” he said. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We’re not trained to make these kinds of work determinations.”

When they apply and every six months after, Medicaid enrollees subject to the rule will have to prove that they’re performing the minimum monthly hours of qualifying activities — or will likely have to prove as frequently that they qualify for an exemption.

If states can’t find sufficient evidence that someone is too sick to work, that person will be able to self-attest to it under penalty of perjury — but only for a short time. States may take someone’s word that they’re medically frail twice in 2027 and only once in 2028.

Last month, 25 mostly Democratic-led states over the final regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.

The standard, they argue, requires state Medicaid agencies to “take on the role of occupational medicine experts” or adds that burden to physicians who are not necessarily trained in occupational medicine.

CMS declined to comment on the litigation.

The Trump administration has crusaded against fraud in government health programs including Medicaid. It recently — including medical professionals — over more than $6.5 billion in alleged fraud schemes.

CMS has said it will keep a close watch on how states administer the work requirements and may take corrective action if states step out of line.

That has doctors concerned about the potential repercussions if they incorrectly assess whether someone is too sick to work, as farfetched as those worries might be, said Rahul Vanjani, a primary care and addiction medicine physician and researcher at Brown University.

“We, using our imaginations, wonder if someone is auditing these forms in the background and if they’re going to reach out to the licensing board.”

The country is short of primary care providers, and it could be hard for people seeking an exemption to find a clinician to help them document that they’re too sick to work, doctors said.

It will be even more challenging for someone without insurance, said Jennifer Wagner, who researches Medicaid eligibility at the left-leaning Center on Budget and Policy Priorities.

“How could an applicant who doesn’t have health coverage get a doctor’s note?” she asked.

The American Medical Association, the nation’s largest professional association of doctors and medical students, lobbied federal officials to change the standard for documenting medical frailty in the days before the final regulations were made public.

In May, the AMA sent to Oz, the CMS administrator, arguing that forcing doctors to attest to their patients’ ability to work wouldn’t just be an administrative headache but would affect the way they interact with those in their care.

In a statement, the association’s president, Willie Underwood III, said the work rule “transforms the clinical encounter into an eligibility gatekeeping process.”

“Patients will likely sense that shift,” he said. “And if they begin to suspect that what they share with their physician could affect their coverage, the conditions for open and honest communication will start to break down.”

Doctors have a fixed amount of time to spend with patients and would rather focus on treating medical conditions than filling out forms, especially ones that put them in a position to “represent the state,” said John Ayanian, an internal medicine physician and researcher at the University of Michigan.

“Their first obligation is to serve the best interest of their patients,” Ayanian said.

Lauren Davis, an attorney with Community Legal Services of Philadelphia, helps clients navigate other public benefit programs, such as the Supplemental Nutrition Assistance Program, which has a similar work rule. Enrollees can get an exemption from it if they’re too sick to work.

She recalled a client with a cognitive condition that affected her memory. The client’s doctor wasn’t comfortable filling out an exemption form without seeing her in person, but she kept forgetting to make an appointment and eventually gave up, said Davis, who worries Medicaid enrollees could face similar barriers to getting exemptions.

“This person is eligible,” Davis said. “The reason that they’re not able to get what they need to show that they’re eligible is because of their medical condition.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .