KFF Health News received dozens of letters in response to an article last month describing how state budget shortfalls have led to cuts targeting therapies that many families of autistic people call essential. Here is a sampling:

Autism Care: Pros and Cons

I am writing to provide additional context and research for your article on state cuts to the autism therapy known as applied behavior analysis, or ABA (“It’s the ‘Gold Standard’ in Autism Care. Why Are States Reining It In?” Dec. 23).

While the piece focused on caps or cuts in service hours being a harmful thing, there have been recent studies showing that increased hours of therapy do not lead to better outcomes for autistic children. While different families certainly have different needs that should be addressed individually with clinicians, and while some children may struggle with reduced intervention hours, it’s important to note that dire predictions about families losing hours of services are not borne out by research.

Another important piece of context missing from this article is that ABA is considered a controversial intervention among many in the autism community. While many families have positive experiences, many other families and autistic adults strongly criticize ABA and have described widespread abuse and trauma from it. Newer research is beginning to provide empirical confirmation for these reports of trauma from ABA.

An article about ABA that leaves out this controversy is not a complete picture. At a time when autism is on the national stage and autistic people are routinely dehumanized by our leaders in government, it is critical to think about how coverage about autism is framed and whose voices are centered and included.

In stories about ABA, I believe it is crucial to include autistic voices (such as people who identify as ABA survivors, and autistic parents of autistic children, who are more likely to avoid, quit, or criticize ABA). It is responsible reporting to ask why ABA is widely criticized by so many who have experienced the intervention, and why this criticism is unique to ABA and not seen with other autism interventions, such as speech therapy and occupational therapy. Additionally, it’s essential to investigate the ABA industry’s response to these critiques. (Has the industry collected data or conducted research on what aspects of its past or current interventions have caused harm? Has it changed training or certification requirements for interventionists to address any “bad apples” among therapists? Has the industry engaged with abuse survivors or autistic-led organizations in making changes to practices and policies? Have safeguards been created and required in behavior plans? Have policies and ethical guidelines been updated to address critiques from autistic adults?)

Ethics and safeguards, as well as current research, surrounding an intervention for vulnerable children are a critical part of any article about whether taxpayer money is being used responsibly for a controversial autism intervention.

— Kim-Loi Mergenthaler, Burlington, Vermont

I work with Behaven Kids, a locally owned ABA therapy provider serving families in Omaha, Nebraska. Thank you for your recent article highlighting the impact of Medicaid ABA rate cuts on Nebraska families and providers.

As a local provider, we wanted to offer additional context. Overutilization was cited in the article as a primary driver of rate reductions; much of that overuse in Nebraska was associated with large, out-of-state companies operating with limited long-term investment in the local workforce. Many of these organizations had access to external funding or staffing pipelines, allowing them to absorb the cuts or exit the state altogether.

In contrast, Nebraska-based providers rely almost entirely on local clinicians and local funding streams. The rapid implementation of the rate cuts, with only weeks for providers to adjust, has placed a disproportionate strain on organizations rooted in Nebraska that are committed to long-term care for families here. In some cases, families experienced service disruptions or lost continuity of care as larger providers scaled back or withdrew.

We believe there is an important distinction to be explored between ethical, needs-based service delivery and the practices that contributed to overutilization concerns. A more targeted policy approach, such as improved provider vetting or more rigorous authorization standards, could better protect families while preserving access to high-quality local care.

If not policymakers, then better to inform families and pediatricians. Many people continue to work with out-of-state providers without understanding the ethical use issues or that their services could be at risk due to the ever-changing market and noncommittal companies.

— Whitney Reinmiller, Omaha, Nebraska

Why are states reining in the “gold standard” in autism care? Well, frankly, it’s not the gold standard.

As I wrote in one of my online publications, nations are spending billions on developmental disability interventions that too often lack fidelity, effectiveness, or accessibility. Meanwhile, hundreds of children and youth remain on long waitlists, many in rural areas receive no services, and families with the highest-needs children often go without support.

Decades of research shows that the most effective and cost-efficient interventions occur when care is:

• Delivered in natural environments and daily routines.
• Inclusive of parents and natural caregivers.
• Provided with fidelity to evidence-based practices.

We must restructure the system to financially incentivize contextualized, parent-coached interventions and expand telehealth options. Doing so will increase capacity, improve outcomes, and reduce long-term costs to Medicaid, schools, and corrections.

— CR “Pete” Petersen, Hagerman, Idaho

I serve as the chief clinical officer for one of the largest providers of ABA therapy in the country. In that role, I regularly engage with state Medicaid agencies and managed-care organizations across several states on issues related to access, quality, and cost of autism services.

What I am increasingly seeing is states relying on blunt instruments to control spending, primarily rate reductions and increasingly restrictive utilization management. While these approaches may generate short-term savings on paper, they often create unintended and counterproductive consequences. They do not differentiate between clinical complexity, risk, or progress, and they disproportionately impact providers serving higher-need populations.

In practice, this leads to workforce instability, reduced access to care, longer waitlists, and greater reliance on crisis services and emergency systems. Families experience disruption and uncertainty, and states ultimately absorb higher downstream costs when care becomes less effective or less available.

There is a more sustainable path forward. Instead of focusing narrowly on rate cuts or hour reductions, states can move toward models that incentivize outcomes and appropriate reductions in intensity and length of care over time. This requires standardized, risk-adjusted measures of progress, clear and defensible discharge criteria tied to functional outcomes, and payment structures that reward timely, durable improvement rather than volume alone.

Outcome-aligned approaches create better incentives for providers, greater transparency for families, and more predictable, responsible spending for states. The goal should not be simply to reduce utilization, but to reduce dependency through effective care.

— Timothy Yeager, Fresno, California

The Broader Risks of Body Sculpting

Kudos on an excellent, very important article (“The Body Shops: After Outpatient Cosmetic Surgery, They Wound Up in the Hospital or Alone at a Recovery House,” Dec. 23).

In addition to infections/sepsis and medication overdose, a person may die from fat embolus, in which a piece of fat tissue gains access to a blood vessel and is carried to the heart and lungs. As a pathologist, I’ve seen it (a young woman in her 20s).

People considering body sculpting should also be aware that fat tissue is less well-vascularized than, say, skin or muscle, and therefore is more susceptible to necrosis or infection.

— Gloria Kohut, Grand Rapids, Michigan

ACA Consumers Feel the Pain

The Government Accountability Office’s recent report on fraud in the ACA marketplace should be a wake-up call (“Plan-Switching, Sign-Up Impersonations: Obamacare Enrollment Fraud Persists,” Dec. 10). For those of us working directly with consumers, it merely confirms what we have been reporting to the Centers for Medicare & Medicaid Services for years — with little response.

It must also be acknowledged that Obamacare is broken. Premiums have risen sharply, plan options have narrowed, and affordability remains fragile for millions. Reform is clearly necessary, and reasonable people can debate how best to fix the system.

But consumers should not be punished for these failures — nor forced to absorb higher costs driven in part by CMS’ failure to enforce its own rules. Left unchecked, fraud distorts legitimate enrollment figures, inflates associated program costs, and obscures the true financial performance of the marketplace. The cost of that deception is not borne by fraudsters but ultimately paid by everyday Americans just trying to keep coverage.

We have submitted extensive, evidence-backed complaints on behalf of affected consumers documenting broker-driven fraud across the ACA marketplace. These reports include call recordings, enrollment data, agent National Producer Numbers, timelines, and consumer statements. They identify specific brokers, agencies, dates, and methods of abuse. Yet to our knowledge, CMS has not taken decisive enforcement action against even the most egregious offenders across multiple enrollment cycles. In most cases, CMS has not requested additional documentation at all.

The misconduct is neither isolated nor subtle. We have documented unauthorized agent-of-record changes, fabricated special enrollment periods, and impersonation — brokers posing as consumers to override existing coverage. Often fraudsters abuse the Enhanced Direct Enrollment links, including those powered by platforms such as HealthSherpa, where enrollment pathways are misused to obscure consumer intent, override trusted agents, or facilitate unauthorized enrollments. In some cases, recordings capture consumers explicitly stating they do not want to change plans, only to be enrolled anyway.

Consumers pay the price. Many discover that their coverage has been altered without consent, that their doctors are suddenly out-of-network, or that their premiums have increased. Others lose coverage altogether when fraudulent enrollments collapse under verification reviews. Meanwhile, the brokers responsible often continue operating under new agency names, repeating the same tactics.

The GAO report confirms that ACA broker fraud is systemic. Systems fail when oversight is weak and enforcement is optional. CMS’ inaction has sent a clear message: Documented fraud carries little risk with significant financial gain. Predictably, abuse has expanded.

We can debate.

— Jason Fine, Fort Lauderdale, Florida

A Different Kind of Nursing Home Nightmare

Unfortunately, we learned the hard way that long-term care facilities (nursing homes) saw an opportunity pre-covid to hire a couple of physical therapists and transition a room into a “rehabilitation center” and suddenly become certified LTC/rehab centers (“Broken Rehab: They Need a Ventilator To Stay Alive. Getting One Can Be a Nightmare,” Dec. 2). They could advertise as such to doctors and area hospitals, and they took in a new population of patients. Upon discharge from a hospital, many patients benefit from going to an inpatient rehab facility for a couple of weeks to perhaps a month. Insurance companies decide how long they will pay.

Before the covid pandemic, the LTC facilities had separate wings and rooms just for rehabilitation patients, and they were worked with every day, except weekends, by physical therapists. But then came covid, and the overall attendance of rehab patients went down, so many nursing homes had to close the rehab wings.

But the LTCs still needed the extra revenue, so they just put the rehab patients in with the regular nursing home patients. You can imagine where that went, for not only the patients but the staff. Everyone was a “nursing home patient,” and they were treated as such, especially by the staff.

If you’re a nurse who is used to caring for LTC patients, there’s nothing that is ever “in a hurry.” You schedule activities in with the other time or two you see each LTC patient. Oftentimes, rehab patients are a whole different patient with different, more frequent needs and more frequent medications.

You see the case managers that most hospitals employ to keep the assembly line moving, getting patients in one door and then out the exit door as fast as possible. You have to remember, insurance companies are only going to pay for that hospital patient to be cared for in the hospital for so long. Then the case managers swoop in, have a talk with the attending doctor and everyone (except the patient and family), and agree on a discharge date.

Now comes the list. This is a list that the hospital and the LTC/rehab centers agree on. The family and patient are told nothing about one facility over another. You just better have a facility picked out by the discharge date, or the case managers will do it for you.

So your loved one who needs only physical therapy is off to be most likely mixed in with the regular long-term care patients. And you had better be there every day to watch for your loved one. Twice out of three LTC/rehab visits my wife had, I stepped in and fought with the head of the facility to call the ambulance, because my wife was going downhill, medically, and they didn’t notice it because they weren’t used to noticing when non-LTC patients develop other medical problems, because often the case managers insist on discharging a rehab patient too soon, before they are stable. You need to find a facility that takes care of only rehabilitation patients and is licensed as such.

— Stephen Cripe, Monticello, Indiana

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How To Excise Politics From Health Care

More than a decade after the Affordable Care Act took effect, we’re still trapped in a confusing and costly health care maze (“Readers Take Congress to Task and Offer Their Own Health Policy Fixes,” Nov. 12). The ACA expanded coverage and protected people with preexisting conditions, but it also layered subsidies, narrow networks, and rising premiums on top of an already fragmented system. Millions still face deductibles so high that “coverage” often means financial anxiety instead of security.

The problem isn’t our doctors or hospitals — it’s the structure. America spends nearly twice as much per person on health care as other developed countries, yet our life expectancy is shorter and our outcomes worse. We’ve allowed a tangle of private insurers, billing rules, and monopoly pricing to replace coordination with chaos.

We don’t need “socialized medicine.” We need organized medicine that guarantees coverage, controls costs, and cuts red tape. Other nations have done it — efficiently, fairly, and without eliminating private choice.

Here’s what would work (with a little help from my friend ChatGPT):

1. Universal, automatic coverage. Everyone should be enrolled from birth or residency, independent of job or income. Basic care would be guaranteed, while private insurance could supplement it.

2. Rational pricing. Hospitals, doctors, and drugmakers should follow transparent, regulated price schedules — like the all-payer systems used abroad — ending the markups and cost-shifting that drive U.S. prices sky-high.

3. Streamlined administration. We spend five times as much on billing and insurance overhead as our peers. A single set of rules and electronic standards would save billions and free doctors from paperwork.

4. Invest in primary and mental health care. Paying for outcomes instead of volume would improve health and reduce preventable hospitalizations.

5. Protect families from financial ruin. National catastrophic and long-term care coverage would stop medical bills from destroying lives.

These reforms aren’t radical — they’re what nearly every successful country already does. The obstacle isn’t feasibility; it’s politics. Every dollar saved is a dollar someone currently earns, and entrenched lobbyists fight to preserve that status quo.

The ACA was a step forward, but it left us with a patchwork of subsidies, mandates, and unaffordable premiums. America already spends enough to cover everyone. The challenge now is to spend it wisely — through a rational, universal, and efficient system that works for people, not paperwork.

— Luis Albisu, Warrenton, Virginia

Beating Back Mold

There are only three ingredients to mold: spores, cellulose, and water (“A Hidden Health Crisis Following Natural Disasters: Mold Growth in Homes,” Nov. 19). The spores are floating in the air when construction is taking place. No exceptions. Cellulose is in paper and wood. Its most damaging use is in drywall or gypsum board (gyp board). A single drop of water, from a roof leak or plumbing/sewer pipe, is all that’s needed to start the mold process.

The use of drywall after World War II to build housing quickly is a primary culprit. USG and similar manufacturers make an alternative product without paper sheathing that will not react with water. USG calls it “Mold Tough,” and it uses fiberglass mat instead of paper.

As an architect, I have a simple solution: Stop the use of drywall with paper sheathing.

— Marc Brewster, Bastrop, Texas

Help Is Still Wanted

I am writing in response to the article “Help Wanted: California Looked to Them To Close Health Disparities, Then It Backpedaled” (July 28), in which Vanessa G. Sánchez explained the issues regarding health disparities among immigrant populations — such as chronic diseases, a high uninsured rate, and the more dire fact that the community health workers who do their best to support these people are paid very little for a crucial job. They offer assistance and trust to those who may not be as comfortable asking for it or are unaware that it exists because they are not from here.

She also wrote about a path opening up with the professionalization of these community health workers — how certification programs were opening up, and funding was going to increase. But it has been cut because of the budget cuts going on during this Trump administration, and programs have been slashed or abandoned.

I want to thank you for shedding light on this issue. These community health workers serve as the middle stop for health care for so many people who face immigration and language barriers. This is the workforce they appeal to and go to, and that in and of itself is honorable work that needs to be done and should be paid at a higher rate than it currently is. One could even argue it’s as important as a doctor’s visit, because even to go to the doctor, you need insurance. And who helps you with that and then sends you to the doctor? The community health workers, exactly!

I am part of the Hispanic community and care about the health disparities that exist within it, such as diabetes, and am also very aware of the language barrier that exists in the hospital field. Working together, is there a way to reinstate some certifications or training to promote higher wages and improve health for all Hispanics/immigrants?

— Avelino Cortes, San Leandro, California

Where To Draw the Line on ‘Urgent’ Care?

As a pediatric emergency medicine physician who regularly works shifts in a community hospital, I read the article on a short “nonurgent” but expensive ambulance ride for a child with interest and horror (“Bill of the Month: Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000,” Nov. 25). I would not have come close to guessing that an Advanced Life Support, or ALS, ambulance would cost over $9,000. Often, patients’ costs vary based on which ambulance company arrives, their insurance plan, whether they are uninsured, etc. We, at least as doctors, rarely have that information at our disposal.

I try to have parents drive their children to the referral hospital when it is safe and feasible, but this is not always possible. What risk of your child dying would you accept if you went by car? 10%? 1%? 0.1%? 0.01%? Just because no treatment was administered during this ambulance ride does not mean that the ambulance was not needed.

What makes us good at our jobs in medicine is worrying about the worst-case scenarios. Do providers sometimes overreact and send kids by ambulance who don’t need it? Absolutely. But there are also too many cases in which children die or become critically ill because someone didn’t recognize how sick the child was or the risks. If we send you in an ambulance, or admit you to the intensive care unit, because we are worried you are at risk of something like shock or respiratory failure, it doesn’t mean you will definitely need intensive care. But, if you go into shock or stop breathing while in your parents’ car, you are much less likely to survive than if we are watching for it and treat it right away. The same way that when we tell you it is a virus, after doing lots of tests, it doesn’t mean we didn’t need to do those tests. The absence of needing treatment doesn’t mean the admission or testing we recommend was unnecessary.

Perpetuating the impression that it is wasteful treatment just because everything works out well is a luxury you have when you don’t regularly see how quickly kids can go from looking relatively well to critically ill and at risk of dying. Those of us who are good at what we do know when to worry and when not to worry. Please don’t disparage our caution or treatment without even asking for our rationale. Ask this doctor why he said the baby absolutely had to go by ambulance. Maybe he didn’t have a good reason. But maybe he did. Maybe if a similar child had been sent by car and the child had gone into shock, this article would instead be talking about how incompetent he was in missing the risk of sepsis and causing the child’s death by letting the parents drive him to the hospital.

We are doing our best to provide good care in a broken, overloaded system. If we are going to work together to fix it, we all must work to understand one another’s points of view. Thank you for helping us understand these unexpected and incredibly burdensome costs our patients face. Please try to understand that caution may not be us dismissing the burden or cost but knowing the risks.

— Samantha Rosman, Boston

Investing in Your Own Health Care

About 20 years ago, I switched to a high-deductible health plan and a health savings account. It was the best decision I ever made for health care for my family (“Trump’s Idea for Health Accounts Has Been Tried. Millions of Patients Have Ended Up in Debt,” Dec. 9).

Today, after years of contributions (compounded with investment gains), the dividends and gains return a higher amount than our health care withdrawals. We’re also still contributing the max family amount per year.

We’re in the process of retiring now, and we’ll continue to select an HDHP and max out our HSA contributions. Once on Medicare, our premium payments can be made with our HSA account. Also, it’s another form of IRA once we reach age 65. It’s a double-tax-advantage account.

I don’t understand the resistance to switching to an HDHP and an HSA. The more you insure yourself, the more money you save. Long-term, it compounds into serious money. At my workplace, I try to talk as many people as possible into choosing an HDHP. They’re all so thankful years later.

I believe people are just afraid of change — not realizing it can seriously be the best health care decision they ever made.

— Tim Eckel, Toledo, Ohio

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Health Care as a Human Right

If there is anything to take away from my over half a century of professional experience at the crossroads of law, medicine, and health care — including my being brought to Congress to advise lawmakers as the Affordable Care Act was being crafted in 2009-10 — it is that Americans believe health care is a right — and should be affordable — and not a privilege for only those wealthy enough to pay for the right type of coverage. After all, without the ability to acquire, maintain, or regain our health, none of us is much good to ourselves or our families, friends, loved ones, and communities, and certainly not to our employers. It is more costly for any of us to be sick than well.

The concept of health care being a right goes back many, many decades, and the ACA is the most recent incarnation of that belief — despite ongoing political risks. The latest gamble has been the nearly six-week shutdown and only the promise that the Senate will vote within a month to address the ACA’s enhanced subsidies (“Why Democrats Are Casting the Government Shutdown as a Health Care Showdown,” Oct. 6).

It is consequently not hyperbole to say that the ACA was intended as, and still remains, an indisputable lifeline for millions to achieve health. Of course, that goal is in jeopardy, or at a minimum an open question, since the subsidies will either be eliminated by year’s end if the promised vote on the Democrats’ Senate bill fails in that chamber, or, if it passes, never becomes law. Regardless, notices to insureds of huge premium increases without the subsidies have started reaching mailboxes.

From my perch (and without considering the brouhaha over also limiting Medicaid and decreases in Medicare provider funding that became law courtesy of this year’s budget bill), it is incredulous and maddening to suffer through the longest government shutdown in the nation’s history without honest, credible, and earnest negotiation. All this because a present majority of our federal legislative branch, along with a sparse number of Senate Democrats and one independent now breaking with their caucus, believe denying Americans the right to be healthy remains a tool for political leverage.

— Miles Zaremski, Highland Park, Illinois

Surprise Bills While on Medicaid

I just read your article about the family that had wages garnished to pay medical bills even though they were covered by Medicaid (“Workers’ Wages Siphoned To Pay Medical Bills, Despite Consumer Protections,” Oct. 2). I live in Chaffee County, Colorado. The local nonprofit hospital, the Heart of the Rockies Regional Medical Center, billed my family on four separate occasions (from mid-2021 through late 2023) while we were on Medicaid. Outrageous!

Fortunately, I knew that we weren’t supposed to be getting those bills. I called the state Medicaid office every time, and it issued notices regarding illegal billing actions. I have kept copies of all those letters. Just a completely ridiculous situation, and I wonder how many of my neighbors on Medicaid went ahead and paid such illegal bills.

— Melanie Jacobs, Salida, Colorado

A Menace Metastasized

How can you publish the article “‘Cancer Doesn’t Care’: Citizen Lobbyists Unite To Push Past Washington’s Ugly Politics” (Oct. 21) and not:

1) Address that President Donald Trump and the Republicans have cut funding for numerous cancer research-related initiatives in the name of unfair DEI (diversity, equity, and inclusion)?

2) Address that it is Trump and the Republican Party who won’t negotiate on health care benefits?

3) Ask the Republicans (and Democrats) quoted in this piece what they think about the above? Did it not occur to you to ask Mary Catherine Johnson what she thinks of these policies, given her own cancer?

KFF Health News seems unable to call out fascism for what it is and hold people accountable for their votes. Is a simple “Who did you vote for and do you agree with these policies?” too much to ask?

Being scared to call out the Trump administration and its policies is shameful.

— James Martinez, Tucson

The Long Arm of KFF Health News

Your fabulous 2019 scoop on the secret FDA database on medical device adverse events (“Hidden FDA Reports Detail Harm Caused by Scores of Medical Devices,” March 7, 2019) made a great impact. It served as the basis for this follow-up, showing how the data, once public, vastly altered the industry. Huzzah!

— Jeff Bailey, Denver

The Balkanization of Health Funding

Jim Mangia’s proposal to tax Los Angeles County residents for community health center funding is both strategically brilliant and deeply troubling (“Health Centers Face Risks as Government Funding Lapses,” Oct. 3). As a master of public health student designing a similar ballot measure for Nevada, I’m becoming an expert in what I can only describe as managed abandonment.

My thesis examines the expansion of federally qualified health centers in Nevada, a state ranking near the bottom in primary care provider access. After federal grants were frozen in January and with Medicaid facing massive cuts, my academic project became a case study in health care feudalism: Access to primary care now depends on your county’s wealth and political composition.

Here’s the arithmetic that haunts me: Nevada has about 3.2 million residents across 17 counties. Clark County (with a population of 2.3 million people and encompassing Las Vegas) could potentially pass a health tax generating $90 million-$100 million annually. Eureka County has around 1,800 residents. You see the problem.

Mangia, who is president and CEO of St. John’s Community Health, is right that federal and state governments are unreliable. A Clark County ballot measure could keep FQHCs open and patients alive. That’s emergency triage. But let’s be clear about what we’re designing: 3,000 separate county health care systems in which wealthy urban areas provide care and poor rural counties cannot.

I’m helping design Nevada’s version anyway, because people need care today. But I’m documenting what this represents: not innovation, but the devolution of a federal responsibility to local governments least equipped to handle it equitably.

County health taxes are considered harm reduction for health care access, like providing naloxone while fighting addiction’s root causes. They’re necessary. They’re insufficient. And they’re dangerous precisely because they might work well enough in enough places to let Congress off the hook.

My thesis will recommend multitiered advocacy: county ballot measures where feasible, state emergency funding for rural areas that cannot tax themselves adequately, regional compacts for resource-sharing, and relentless federal pressure for restoration of the Community Health Center Fund and for Medicaid expansion.

But here’s what keeps me awake: Every hour I spend designing county ballot measures normalizes the idea that health care funding is a local responsibility. Every successful local tax makes it easier for Congress to justify cutting federal programs.

We’re teaching the next generation of public health professionals to triage federal abandonment. We’re getting good at it. That’s what terrifies me.

When we look back in 10 years at a health care system balkanized by county, where your access depends on local elections and ballot measures, we need to remember: This wasn’t innovation. This was what we did when the federal safety net collapsed. And we knew it was unjust at the time.

— Pragya Thakur, Bartonsville, Pennsylvania

Paying as I Go

I read with interest your article about hospitals arguing with insurance companies over the results of out-of-network status (“Health Care Helpline: So Your Insurance Dropped Your Doctor. Now What?” Oct. 29). One option you didn’t mention was self-pay.

I’m a retired financial adviser who went back to graduate school at age 62. I am in excellent health and see a doctor only for my annual checkups. So I self-insure.

The interesting thing is that self-pay costs are often discounted by 90% or more. I recently needed a procedure that would have cost $25,000 at the hospital vs. $2,500 at a specialist doctor’s office.

— Paula Schoenhoff, Louisville

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A reporter at Just the News shared our article about a man whose organs were nearly harvested while he was still alive:

Disinformed consent is standard operating procedure in the organ donation industry. And much of medicine. "The sisters said hospital staffers told them the movements were involuntary."https://t.co/tDSp4oCNgL

— Greg Piper (@gregpiper) September 13, 2025

— Greg Piper, Washington, D.C.

Too Close a Call With Organ Donation

When I was a third-year med student doing a rotation on the trauma surgery team, we had a patient in the surgical intensive care unit who had arrived 12 hours earlier with bullet holes in his abdomen. We worked to stabilize him all night; the next day, he was still alive. 

The team determined, however, that although his body was alive, he was likely brain-dead and a candidate for organ donations (“A Surgical Team Was About To Harvest This Man’s Organs — Until His Doctor Intervened,” Sept. 12). 

As we prepared for him to become a donor, I noticed he had a bit of movement. Of course, I was the unknowing third-year med student, so my comments were essentially deemed a nuisance, at best, to the team. (I was, by the way, already a globally recognized researcher in a field distant from trauma surgery.)

Nevertheless, after checking on the patient, I told one of the surgeons, “I think he was trying to communicate with us.”

I was told it was just spinal reflex and I didn’t know what I was looking at.

I couldn’t shake the feeling. I was deeply concerned that I knew what I saw, and it seemed like communication. After our rounds, I went back up to the patient’s bedside, stood over him, and simply said, “Are you able to hear me?”

With a tube in his trachea, stopping any air from entering or exiting (required to make sounds with the vocal cords), he attempted to communicate something in response. The poor guy had an endotracheal tube and was on a ventilator, but because he was given a diagnosis of being brain-dead, he was not being provided with appropriate pain meds and was in and out of consciousness — as best as I could tell. 

I asked him again if he could hear me, and again he tried to communicate with the tube in his throat. It was clear he was absolutely not brain-dead.

I ran and got the team. They evaluated him again — after having already spoken in front of both him and his family about harvesting his organs. This time, the surgeon made a more thorough evaluation. It turned out that he was awake and aware. As they looked him over, they realized he didn’t have bullet holes only in his abdomen; he had a bullet hole through the back of his skull, the bullet still lodged in his brain. During the exam, someone had lifted his head to discover a small, round pool of blood underneath. The bullet in his head went entirely unnoticed in the chaos of trying to stabilize his much more severe hemorrhages.

A CT scan showed the bullet clearly, lodged in the middle of his brain. The neurosurgery team did a procedure to reduce the swelling and pressure in his skull, and he sprang back to life.

The young man, surely a victim of gang violence in South Atlanta, began to interact almost normally with his family over the coming days. For his family, it was almost a rebirth of their child. He had heard the entire conversation about harvesting his organs but could do essentially nothing. It turned out his brain death was documented when he was still under anesthesia, masking his conscience and alertness that would eventually return.

Unfortunately, after an elated two or three days, the man ultimately succumbed to his brain injury.

Still, I will never, ever forget how terrible that experience must have been for him, and, honestly, I don’t know what would have happened if some “naive” third-year med student hadn’t pushed to get the considerably busier surgery team to fully recognize what was happening with their patient.

I deeply appreciate your writing, and I hope it is raising significant awareness.

And I say this as someone with an immediate family member on multiple transplant lists: While I want desperately for lists to move faster, it should never happen at the expense of providing the complete and full dignity that every life deserves. 

— Michael J. Mina, Boston

A radiologist in Denver also posted his thoughts about the article on the social platform X:

This is very rare in the world of transplant surgery. But it should be "never", rather than "rare".https://t.co/yJ3BZkLXND

— Paul Hsieh (@PaulHsieh) September 14, 2025

— Paul Hsieh, Denver

Speaking for Kids With Disabilities

I read the article “Parents Fear Losing Disability Protections as Trump Slashes Civil Rights Office” (Sept. 15) with a renewed sense of purpose. Efforts to dismantle the U.S. Department of Education may be imprudent at best, with little or no consideration for the potential that lies within all of us. I know, because I became a recipient of its special education services after flipping over on my three-wheel motorcycle and landing on my head with the bike over me. I was barely 18 years old and not wearing a helmet. I was in a coma for a week and remained in an acute care hospital for a month. I sustained a severe traumatic brain injury — or, to be more precise, a severe cerebral contusion.

I wish the architects of this federal dismantling could know that I received rehabilitation therapy for over a year and received services through a special education program for more than six years before I graduated with a four-year bachelor’s degree from San Diego State University. I continued on to graduate school and earned two master’s degrees from the University of Southern California.

I established a 30-year career — starting as a lobbyist for the National Association of Social Workers in Washington, D.C., before returning to my home state to finish my career as a research scientist for the California Department of Public Health’s Maternal and Child Health Division. I worked there for 16 years before my retirement in 2020.

We — as children with disabilities — have much to offer to society that cannot be foreseen when we are young. I am the product of dedicated care by my therapists and teachers. This is what I believe the current president and elected officials across the country need to understand. We can be productive citizens when given the chance to thrive.

— Brason Lee, Sacramento, California

A Democratic member of Congress weighs in on X:

Disabled kids are facing great challenges in their schools, and the dismantling of the Department of Education will only worsen these struggles. It is vital we support our students of all backgrounds.https://t.co/pN1cAnRXOd

— Grace Meng (@Grace4NY) September 17, 2025

— Grace Meng, Queens borough of New York City

A Hole in ‘Big Loopholes’?

The article “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab” (Sept. 25) by Michelle Andrews had one glaring omission: The hospitals are supported by government funding for charity care, but private practice providers — such as the specialists in emergency medicine, anesthesiology, and radiology who were mentioned — are not. Do you expect those providers to work for free? I think, to be fair to doctors, there should have been a mention of that in the article.

— Roger Broome, Galena, Ohio

A science writer in New York shared her thoughts on X about our coverage of Trump administration policies:

These clinics were already stretched thin before the new guidance. That seems unlikely to change given the major staffing cuts at HRSA, which directs funding to community clinics and other HHS programs. H/t @sjtribble and @HMLLarweh at @KFFHealthNews https://t.co/ngit8sP9X8

— lauren schneider (@laur_insider) August 8, 2025

— Lauren Schneider, New York City

When HRSA Hurts, Nursing Suffers

The Health Resources and Services Administration, or HRSA, is vitally important to building and maintaining the strength of the pipeline of new nurses and other clinicians entering our health care workforce. With a growing health care shortage across the country, it’s incredibly important that HRSA be maintained and strengthened to meet the growing and more complicated health care challenges of tomorrow (“Deep Staff Cuts at a Little-Known Federal Agency Pose Trouble for Droves of Local Health Programs,” Aug. 1).

One of HRSA’s most important responsibilities is managing Nursing Workforce Development Programs under Title VIII of the Public Health Service Act. These grants help fund everything from education to practice, recruitment, and retention, particularly in rural and underserved communities. As both a nurse and nurse educator myself, I’ve seen how, for decades, Title VIII programs have strengthened the pipeline by covering scholarships and education to support registered nurses, advanced practice nurses, and nurse educators.

As the U.S. population rapidly ages and develops increasingly complex health care needs, we must ensure we have a robust workforce equipped to provide high-quality care in every community. Unfortunately, the Bureau of Labor Statistics projects an average shortfall of roughly 190,000 registered nurses each year from 2024 to 2034. Complicating this issue, faculty shortages, limited clinical sites, and capacity constraints forced nursing schools to turn away over 80,000 qualified applications last year alone.

Our country must do more to graduate enough students to close these gaps. Maintaining funding and staffing for HRSA is essential to sustain a robust health care workforce and ensure patients’ access to care nationwide.

Policymakers must protect and fully appropriate HRSA in the 2026 budget and beyond. There are countless passionate, smart, and dedicated learners out there ready to step into the roles of nurse and nurse educator. We must protect HRSA to open pathways for them to get there.

— Patty Knecht, chief nursing officer of Ascend Learning/ATI Nursing Education, Downingtown, Pennsylvania

A Michigan reader expresses his opinion succinctly on social media:

Make America Ill Againhttps://t.co/DPFJtfB0fl

— Paul Hughes-Cromwick (Pooge) (@cromwick) August 1, 2025

— Paul Hughes-Cromwick, Ann Arbor, Michigan

Keeping PACE With Vulnerable Seniors

Elder homelessness is one of the clearest symptoms of our broken senior care system, as highlighted in the recent article “Health Care Groups Aim To Counter Growing ‘National Scandal’ of Elder Homelessness” (Aug. 18). Today, too many seniors are walking a tightrope, threatened to be tipped off balance when financial or medical issues arise.

This risk of homelessness is especially prevalent in rural communities, where older adults often have lower incomes, higher poverty rates, and greater prevalence of chronic illness. And while homelessness nationwide rose by less than 1% from 2020 to 2022, rural areas saw nearly a 6% increase — clear evidence that rural community members are being left behind by our current system.

Thankfully, the Program of All-Inclusive Care for the Elderly, or PACE, is uniquely equipped to address these challenges. Often, rural PACE programs like ours encounter participants struggling to get through the winter without heat, living in homes with leaky roofs, or lacking safe wheelchair access. In these scenarios, we can authorize heating installation, arrange urgent repairs, or build ramps that make it possible for our participants to remain safely at home.

These are just a few of the many examples that demonstrate how far PACE providers can, and do, go to ensure our participants can stay in their homes. And, by addressing these issues early, the program is saving Medicaid dollars.

To reduce housing instability among older adults, policymakers at both the state and federal levels should expand eligibility and ensure that PACE providers have the flexibility to act quickly when warning signs appear. By investing in PACE, we can reduce homelessness and build a stronger model for community-based care in America.

— Craig Worland, interim CEO and COO of One Senior Care, Erie, Pennsylvania

Saw mention of an idea on Facebook a couple of days ago and then read your PACE article about senior housing and felt compelled to share. Please pass along to your PACE colleagues and anyone else who can help make this possible. The idea was/is to convert the many closed malls, shopping centers, and big-box stores across the U.S. into affordable housing. Rather than leave them as empty eyesores, decaying and becoming havens for vermin and worse, rather than trying to find and fund land purchases and building from scratch, just think how many thousands of people could be housed! Some spaces could be reserved for essential services — groceries, drugstores, coffee shops, restaurants, salon/barber shops, laundry/dry cleaners, etc. Recreate nature with a walking path complete with live trees and plants, and paint the ceiling like the Wienermobile, where “the sky is always blue!” The possibilities are endless. Go for it! Thanks for the opportunity to share. I’ll be out here advocating and watching for this to blossom!

— Brenda Peters, Charlotte, North Carolina

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

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Sounding the Alarm for Ambulances

Thank you for shedding much-needed light on the exorbitant costs and lack of reimbursement that have become a harsh reality for many ambulance services across Colorado and the nation (“Insurers Fight State Laws Restricting Surprise Ambulance Bills,” July 9). While it’s vital to protect patients from “surprise” bills — something your coverage highlights — it’s equally important to acknowledge the other side of the equation.

Ambulance providers often receive reimbursements well below the actual cost of delivering care. A recent industry report found that ambulance services are under‑reimbursed by an average of $1,526 per transport, with Medicare alone paying nearly $2,334 less than the cost incurred. These shortfalls are unsustainable and threaten the financial viability of emergency responders.

It’s crucial that ambulance companies have a stronger voice in this conversation. Reimbursement rates aren’t just numbers — they determine whether crews can stay on the road, maintain readiness, and invest in vital mobile health care services. Emergency preparedness relies on stable funding, and when that funding falls short, communities suffer.

By spotlighting the reimbursement crisis, this article helps lay the groundwork for policy solutions. But let’s go a step further: We need to elevate the voice of ambulance agencies themselves, so lawmakers and insurers understand that fair payment isn’t a bonus — it’s essential to keep us safe.

— Patrick Fahey, Weymouth, Massachusetts

A DevOps engineer shared the NPR version of the article on social media:

Families hit hard by surprise ambulance bills-some see debts soar even with insurance. More states are acting, but a national solution may be needed for real protection. https://t.co/Efb6me3Png pic.twitter.com/HRSW5mCdiu

— Michael Bennett (@M1keB_77) July 11, 2025

— Michael Bennett, Denver

‘Congress Is Playing Political Hot Potato With My Health’

I’m 60, self-employed, and living with congestive heart failure. My ejection fraction is dangerously low, and the Affordable Care Act is the reason I can see a doctor, take my medication, and stay alive.

Now Congress is playing political hot potato with my health. If they don’t extend the ACA’s enhanced subsidies by August, my $30 premium could jump to over $800. That’s over 25 times as much. I’m not a hedge fund manager — I’m an independent contractor. Unless I start selling organs (not ideal when your heart’s the issue), I can’t keep up.

I’m too young for Medicare and have no employer plan. I’ve worked, paid taxes, and managed my condition responsibly. So why am I being priced out of care?

If Congress won’t listen, I’m asking you — the press — to help. Tell this story, or one just like it. Millions of Americans are quietly panicking, walking the same tightrope. These policy changes aren’t just math — they’re about human lives.

Because if nothing changes, a lot of us won’t be around to write letters next year.

— Kevin Bahn, Tamarac, Florida

Americans Pay the Price for a Sick Health Care System

I am sure your readers would be interested in how American health care costs compare with those of the European Union and Switzerland (“Bill of the Month: A Texas Boy Needed Protection From Measles. The Vaccine Cost $1,400,” June 30).

In France, the private price for the MMR vaccine is around $13 (in U.S. dollars), provided you have a prescription. Any pharmacy can administer the jab for about the same.

Here in Switzerland, the most expensive country in Europe, this vaccine costs under $40, as a private purchase.

I’ve moved 18 times with family across Western and Eastern Europe and have had expat staff in 35 countries on four continents.

It’s very clear to me now that most national attempts at health care are a costly failure, with few notable exceptions: Germany and, surprisingly, Spain. Then there’s Switzerland, which has among the best health care systems in the world — close to perfect. Basic coverage terms are federally mandated and cost around $430 a month with a $2,500 annual deductible, irrespective of age, after 26. And with a $300 yearly deductible, the premiums are about 40% higher.

Something is very off in the USA. It’s not that complicated.

— Clement Cohen, Geneva, Switzerland

A registered nurse shared his solution for taming Medicaid fraud in a post on X:

“They’ll give you a bone if you stay in the mud.It’s relatively easy to fix the benefit cliff: just phase in a graduated premium for Medicaid based on income above the threshold. If we had political will to do this, it would prompted self-sufficiency.https://t.co/4fxSnmETRd

— Jacob Larsen 🇺🇸 🇩🇰 🇺🇦 (@SLCPaladin) July 22, 2025

— Jacob Larsen, St. George, Utah

Why ‘Start From Scratch’ Vaccine Testing Can Be Dangerous

I anticipate we’ll be hearing more discussion around the use of “inert” placebos — like saline solutions — as the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention approach new vaccine recommendations (“Kennedy’s Vaccine Advisers Sow Doubts as Scientists Protest US Pivot on Shots,” June 27). This type of messaging seems poised to gain traction with the public, despite its ethical implications.

Increasingly, I’m seeing criticism that vaccine development doesn’t rely on inert placebos. This argument is often used to advocate for new clinical trials — even for vaccines already proven effective — and to justify beginning booster development from scratch.

While inert placebos may have been used and were appropriate in early stages of research for vaccines, their use becomes ethically problematic when a safe, effective vaccine already exists. In such cases, withholding protection from participants in a placebo group can put them at real risk, especially during the development of updated or booster doses of vaccines.

I believe it’s critical that organizations like KFF Health News help clarify this issue for the public. KFF is a highly respected, nonpartisan source with powerful communication reach. I’m a subscriber to KFF Health News and appreciate the way your reporting draws in readers with accessible, engaging headlines — and that your articles are available for syndication to other outlets.

Two key points I found buried in an American Academy of Pediatrics article stood out:

• “Many childhood vaccines were tested originally in randomized clinical trials that included placebo or comparison groups. If the vaccine is for a disease that currently has no vaccine, the placebo may be saline or another substance known to be safe. If the vaccine is a potential replacement for an existing, older vaccine, the comparator group may receive the older vaccine that has already been tested rather than an inert placebo.”
• “When a safe, effective vaccine already exists against a disease, giving children in the placebo group no protection against that disease is unethical. Unvaccinated children can contract dangerous illnesses. Parents of children in the placebo group would not know they didn’t get the vaccine and that their child is unprotected.”

That brings up another important question: Who would volunteer for a randomized, double-blind, controlled trial involving an inert placebo for an existing vaccine? People hesitant about vaccines are unlikely to participate, for fear they will receive the vaccine. And those who support vaccination may be reluctant to risk receiving an inert placebo instead of testing the current, older proven version against a new proposed version.

— Alice Henneman, Lincoln, Nebraska

A virologist and podcaster chimed in on the June installment of our “Bill of the Month” series:

A post doctoral fellow at UTMB couldn’t afford the university’s insurance option for his family so he bought a separate plan. It cost him $1400 to get his child the measles vaccine. During an outbreak. Get your vaccines now, before they are not covered. https://t.co/f3wWRouevA

— Heather McSharry, PhD (@PathogenScribe) July 1, 2025

— Heather McSharry, Austin, Texas

A Premium Shell Game?

I read Michelle Andrews’ article today, published in the San Francisco Chronicle (“Have Job-Based Health Coverage at 65? You May Still Want To Sign Up for Medicare,” June 18). Thanks for reporting on this important issue.

You describe as contributing factors: ignorance of the employee, the lack of any requirement that Medicare notify the employee, and the failure of the broker to notify.

Perhaps I missed it, but I believe there’s an important additional factor you didn’t mention: the profit of the commercial insurance carrier. In my experience, folks don’t notice that their primary insurance has changed to Medicare primarily because their employer is still deducting the premium for their commercial group health insurance.

Isn’t it fraud for the insurance carrier to collect premiums for a policy for which the subscriber is visibly no longer eligible by law?

There’s a financial incentive for the commercial carrier not to tell the subscriber that their coverage has ended, and they are now eligible for a Medicare Advantage supplemental policy (with a much lower premium) if they sign up for Medicare: The commercial carrier can collect high premiums, then decline to pay benefits.

You mention that Medicare representatives note they are not required to notify subscribers. Why? Coincidence? More likely, the commercial insurance companies actively lobby against notification.

Also, there’s a financial incentive for hospitals to perform procedures on patients who are 65 or older and still on a commercial plan. Pretty sure the hospital billing office knows quite well they will eventually be able to bill the patient the retail fee, which is typically 10 times as much (or more) than the Medicare-discounted fee.

In my experience, this is not a doctor issue, as the physician rarely pays any attention to insurance details. But it’s very much a billing office issue.

— John S. Smolowe, Menlo Park, California

A reader in Connecticut tweeted his opinion on the risks of cannabis for an aging population:

Normalized cannabis use now will yield a big public health problem later and all the data points in that direction…👇🏼“As Cannabis Users Age, Health Risks Appear To Grow” https://t.co/xNrqqz1k1L via @kffhealthnews

— Brandon M. Macsata 🎗️ (@Purple_Strategy) June 9, 2025

— Brandon M. Macsata, New Haven, Connecticut

Getting Ahead of Known and Unknown Threats

As highlighted in your article “‘MAHA Report’ Calls for Fighting Chronic Disease, but Trump and Kennedy Have Yanked Funding” (July 2), proposals to eliminate the National Center for Chronic Disease Prevention and Health Promotion do not align with efforts to address our country’s chronic disease crisis. These plans also further underscore the importance of strengthening America’s public health infrastructure not only to save lives, but also to ensure taxpayer dollars are used wisely.

For each dollar invested in disease prevention, the Trust for America’s Health estimates, $5.60 in downstream costs can be saved nationwide — and this figure is even higher in some states.

But just as cuts to chronic health research will hamper the federal government’s goals of preventing diabetes, heart disease, and obesity, so too do cuts to broader public health funding streams inhibit state and local health departments’ ability to stop outbreaks of measles, drug overdoses, or hepatitis, among many other preventable conditions.

Investments in public health have saved lives and strengthened our country. Identifying emerging threats quickly — whether they come from infectious diseases, zoonotic illnesses, accidents, or injuries — is vital to mitigating them. Unfortunately, federal cuts to vital public health funding streams and programs make it increasingly difficult for our nation’s leaders to understand the threats facing their communities and make the most informed decisions possible to help their communities.

Across the country, public health departments are scaling back staff and delaying plans to adopt better technology due to funding constraints; therefore, many departments lack the resources to detect and respond to threats in a timely manner. Rural and underserved communities that have fewer resources to sustain or replace federal investment are at greatest risk.

Without continued investment in public health infrastructure — from the federal government as well as state, territorial, local, and tribal governments — the impact of future health risks will be multiples higher on both the national health care system and the resources (including government investment) needed to address whatever may be coming next.

To truly improve public health, our leaders at every level of government should be doubling down on public health systems, both infrastructure and technology, as the foundation and path to keep America healthy.

— Eric Whitworth, CEO of InductiveHealth, Atlanta

The CEO of 4sight Health had this advice, posted on X:

Don't listen to what the regime says. Watch what it does. What this story calls "contradictions" and "inconsistencies" are lies and diversions from its anti-health agenda. The market must pick up the chronic disease prevention torch. https://t.co/SgWYe3KCtp

— David Johnson (@4sighthealth_) July 8, 2025

— David Johnson, Chicago

Preventive Physical Therapy Can Spare You From Injury — And Rehab

Thank you for recently highlighting the critical need for quality physical therapy (“How To Find the Right Medical Rehab Services,” July 15) and providing a comprehensive guide on navigating rehabilitation services after hospitalization. It is also important to note the preventive power physical therapy has before an acute injury strikes.

Physical and occupational therapy services are not just a form of post-accident care but are also proactive, non-pharmaceutical strategies to preserve strength, balance, and independence — especially for our aging population. And research shows that when physical therapy is the first line of treatment for certain conditions like lower back pain — rather than injections or surgery — Medicare Part A/B costs drop by 19% compared with patients choosing injections first and by 75% compared with surgery-first cases.

Moreover, physical therapist-led fall prevention programs have been shown to reduce fall risk, while also cutting emergency room visits, hospitalizations, and opioid use among older adults. These numbers matter deeply in an aging America where 30 million older adults fall each year and the lifetime medical cost of treating falls is over $100 billion annually. And yet, the Medicare system often prioritizes post‑injury treatment over preventive care, delaying access to essential physical therapy until after damage occurs.

In light of our nation’s need for more preventive care, it is time for our Congress to enable easier, earlier access to physical therapy. One way lawmakers can help is by supporting and passing the bipartisan Stopping Addiction and Falls for the Elderly, or SAFE, Act (H.R. 1171). This commonsense legislation would allow Medicare beneficiaries to access no-cost falls risk assessments from the fall prevention experts: physical and occupational therapists.

Incorporating physical therapy into primary and preventive care has the potential to decrease hospital visits, lower health care spending, and preserve our seniors’ independence — goals we all share. It’s time to shift the policy spotlight upstream. Physical therapy has already proved it saves money and improves lives.

— Nikesh Patel, executive director of the Alliance for Physical Therapy Quality and Innovation (APTQI), Sugar Land, Texas

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

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A podcast producer and director emeritus of WOUB Public Media zeroed in on our article about restless doctors, sharing his thoughts on X:

This must be Trump and Kennedy's idiotic plan to make American Healthy Again…https://t.co/jABfhALnXI

— Tom Hodson (@thodson) May 29, 2025

— Tom Hodson, Athens, Ohio

Oh, Canada Welcomes American Doctors!

The article “American Doctors Are Moving to Canada To Escape the Trump Administration” (May 30) presents us Canadians with welcome news. In every part of Canada, in every province, there are not enough doctors. In our city of Victoria, for instance, many people do not have a family doctor because so many doctors have retired; those who are left are unable to take new patients because their lists are full. Walk-in clinics are overbooked, the emergency rooms at the hospitals all have overfull waiting rooms and doctors and nurses are doing 12-hour or longer shifts. We need doctors and will welcome American doctors here with wide-open arms.

There are many aspects of Canada’s health system that could help lure American doctors to join us. The mortality rate for infants and mothers in the USA is worse than in Cuba. Ours is much better. We do not have a director of national health preaching against the use of vaccination. Our national record for health care during the covid pandemic emergency was second to none. Our women’s clinics are not plagued by political ideology. Our society has always been more open than that of the USA to immigrants and others of all races.

Doctors who agree to work for the armed forces receive special benefits. The experience is known to be valuable and rewarding.

I would also recommend Quebec as a great place to live and work. This would present a valuable opportunity for doctors and their families to learn French. France has a wonderful health service and would be a great place for family members to study and work. Germany is also a great place for medicine and health care. An added plus, besides learning the German language, is that the medical schools and universities, once they accept students, including foreigners, do not charge tuition. No post-graduation debt in Germany. That has proved to be a great policy for Germany. It attracts brainy students from all over the world and ensures the continuing high level of the German health system.

American doctors, Canada is an excellent option for escaping from the threat of autocracy. It can be a very positive step to leave the USA after realizing that the world is open to you and your family. Canada fits Americans comfortably. As our Prime Minister Mark Carney told President Donald Trump in his Oval Office, “Canada will never, never, never be your 51st state.” So, American doctors, pack your luggage, come on over and join us. We will welcome you very warmly and help you in every way we can!

— Philip Maxwell, Victoria, British Columbia

A Seattle reader delivered a diagnosis on X:

So I guess this article and the Dr. Interviewed are far left progressive. The US is better off without them.https://t.co/N7e3UZrb6A

— Daniel Arroyo (@danielarrmaga) May 29, 2025

— Daniel Arroyo, Seattle

Tellin’ It Like It Is, Baby

The article “The New Old Age: Honey, Sweetie, Dearie: The Perils of Elderspeak” (May 9), hit home for me.

Several years ago, my health plan referred me to an ophthalmologist’s practice. After one appointment, the woman who was supposed to schedule me for my next one called me “Sweetie.” I don’t remember what I said, but I took umbrage and walked out.

There were other problems (the doctor who examined me didn’t introduce himself, for one thing). I went home and wrote a complaint letter to my health plan. They gave me another referral and reported the practice to Medicare.

I only wish I had read this article a month ago. I had a biopsy in a hospital last month, and one of the nurses spoke to me as if I were a 2-year-old. I would have been prepared to deal with this then.

— Sue Kamm, Los Angeles

The director of the Pitt Band at the University of Pittsburgh threw down the gauntlet on X:

Any who addresses me with "Elderspeak" will be dealt with harshly. You've been warned.https://t.co/iaHAfVlCqN

— Harry Bloomberg (@pittbandphoto) May 3, 2025

— Harry Bloomberg, Pittsburgh

Don’t Gamble With Children’s Lives

Concerning Health and Human Services Secretary Robert F. Kennedy Jr.’s recommendation that healthy children needn’t receive the covid vaccine (“Trump’s Team Cited Safety in Limiting Covid Shots. Patients, Health Advocates See More Risk,” May 23), have pre-vaccine complications such as multisystem inflammatory syndrome in children been forgotten? A western Michigan child lost both hands and both feet to MIS-C and will go through life with prostheses. Please remind people of these serious complications which, though infrequent, cannot be reversed. Not vaccinating is playing Russian roulette with your child!

— Gloria Kohut, Grand Rapids, Michigan

An upbraiding on X came from a reader Down Under:

This decision – apparently made without any expert consultation – will have international ramifications, especially among the vaccine sceptical. https://t.co/hOaOuWBX3T

— Lesley Russell Wolpe (@LRussellWolpe) May 27, 2025

— Lesley Russell Wolpe, Sydney, Australia

Core to California’s Prosperity: The Fruits of Immigrant Labor

I found your article to be incomplete when it comes to offering the perspective of undocumented immigrants (“After Promising Universal Health Care, California Governor Must Reconsider Immigrant Coverage,” May 13). According to the Institute on Taxation and Economic Policy, undocumented immigrants contribute $8.5 billion to the California economy. It is disingenuous to present the cost of medical expansion to undocumented immigrants as a type of handout, when it is widely known that undocumented immigrants work without any prospect of receiving the benefits of their work in social programs. The fact that Gov. Gavin Newsom made the effort to expand benefits to undocumented workers was the right thing to do, and we should work toward rearranging funding to continue the expansion and not retrench during a time when unidentified people are apprehending undocumented workers on their way to work and more than ever face the possibility of suffering human rights abuses. If you, as a news organization, don’t do them justice by inserting their contributions into the discussion, then you are being complacent to their dehumanization.

I grew up in Oxnard, California, and my entire life was surrounded by the fruits of farmworkers’ labor, many of whom were undocumented. If you drive up and down Rice Road at 5 a.m. every day, you will see hard-working people who, during the wintertime, have to stay during the night to warm up the crops. That type of love and dedication to their work — not for their benefit, but for their families and the state of California — should be recognized. I invite your readers to look for “Fresh Fruit, Broken Bodies” by Seth Holmes to start understanding the physical toll that working in the fields takes on young immigrants, even when they arrive as healthy bodies. Still, after years of working in the fields, they face a multitude of health problems and overall physical deterioration. They give their bodies in exchange for an American dream that may or may not materialize.

Undocumented farmworkers fill just one essential sector of the American labor economy that does not stop even during fires or pandemics, so please do better in highlighting the humanity of folks who are more than just the work they produce. It is essential to state that if it weren’t for their cheap labor, the Golden State would not be so golden. Look at Florida, where the criminalization of undocumented workers is leading to labor shortages now intended to be filled by children.

Health care is a minimum that can be provided for undocumented workers, not because of any other reason than health care is a human right, and undocumented workers pay their fair share in unclaimed social benefits. Health care for all!

— Jennifer Diana Figueroa, Oxnard, California

A sociologist who directs social policy at the Niskanen Center, a nonpartisan think tank, weighed in on X:

No matter what advocates told themselves and policymakers, it was never politically sustainable:“It’s making people look at the health care that they can’t afford and ask, ‘Why the hell are we giving it for free to people who are here illegally?’” https://t.co/uOUIqhJJKJ

— Josh McCabe (@JoshuaTMcCabe) May 14, 2025

— Josh McCabe, Lowell, Massachusetts

Improving a Prisoner’s Life Sentence

I was very impressed with “Prisons Routinely Ignore Guidelines on Dying Inmates’ End-of-Life Choices” (May 15), authored by Renuka Rayasam. I have visited prison twice: once to San Quentin as a member of the Berkeley YMCA wrestling team in 1963.

Then, in 1999, I was privileged to be appointed to a new American Hospital Association committee, the Circle of Life Awards Committee, which was created to recognize the most outstanding and innovative hospice and palliative care programs in the country. Among the many applicants in the first year was the Louisiana State Penitentiary Hospice, and it was selected as one of five finalists for a site visit in 2000. I indicated my interest in being a member of the site visit team. This prison, commonly known as Angola, is the nation’s largest maximum-security facility, and we were told prisoners sentenced to life will die there because there was no parole in Louisiana for such a sentence. We were also informed that there was a long waiting list of inmates wanting to be hospice volunteers because the program was so highly valued.

My most distinct memory of our visit was a conversation with a volunteer who said he had just come from bathing and feeding a terminally ill inmate who said, “I love you.” The volunteer was visibly emotional when noting he had never heard these words before, not from his father whom he never met nor even his mother. These comments clearly demonstrated the beneficiaries of the program were not just the patients; they were also the volunteers.

— Paul B. Hofmann, Moraga, California

On X, another reader from Australia dove into a discussion about fluoridation of drinking water in response to our coverage:

https://t.co/Um9QawAqKDRFK making tooth decay great again

— Dan Jago (@dj1au) March 28, 2025

— Dan Jago, Melbourne, Australia

How Fluoride May Hijack Thyroid Health

Stories about fluoride seem not to mention the chemical’s impact on thyroid health (“With Few Dentists and Fluoride Under Siege, Rural America Risks New Surge of Tooth Decay,” March 27). This seems an oversight because it’s estimated that 10%-20% of the population will have thyroid issues in their lifetimes.

When I was an unmedicated hypothyroid person — not taking any supplemental thyroid hormone — I frequently had cavities. After filling the cavity, my dentist would do me the favor of treating my teeth with fluoride. And then followed a period of lassitude so severe I felt my job was at stake, definitely placing me in the “fat and lazy” category, as described by Ozark Mountain Regional Public Water Authority Chairman Andy Anderson in your article. It took me several treatments to make the connection.

I don’t get cavities now and haven’t for about 20 years. I think my now-appropriate dosage of supplemental thyroid plays a role in that.

Studies about thyroid and fluoride vary in their conclusions. Thyroid deficiencies can have widely varied effects on our widely varied population. There may never be widely accepted guidelines. But people should be careful about what they put in their bodies.

— Joy Mullett, Houston

A self-described information technology health care entrepreneur stated his opinion simply while sharing the article on X:

FLOURIDE is poison!https://t.co/Oaw0p1JG4N Daily Health Policy Report&utm_medium=email&_hsenc=p2ANqtz–TOtkdDDnhvAyd8nDZIAFejJobpsKBnLP5smKnlslyZjSC6tT9BHFfvtjE8tnngMhNn7huZCl4MKi1CdAi0QtZkvWmew&_hsmi=353879828&utm_content=353879828&utm_source=hs_email

— Earl Winter (@EarlWinter8) March 27, 2025

— Earl Winter, Nashville, Tennessee

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

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Trump Team’s Rhetoric Doesn’t Match Actions

The recent KFF Health News article “Beyond Ivy League, RFK Jr.’s NIH Slashed Science Funding Across States That Backed Trump” (April 17) struck a nerve. The rapid succession of suspended National Institutes of Health grants that swept the country shortly after President Donald Trump’s election have left us struggling to understand why such vital research — the bedrock of our ability to support the public’s health — would be treated as unnecessary or, worse, harmful.

People often think research, per se, doesn’t directly affect them. But research forms the basis for what we know will best work to treat, prevent, and manage illness, from chronic diseases such as diabetes, hypertension, and HIV, to mental health disorders. In addition to basic and applied research, NIH grants provide services directly to individuals and families, and they build community-based systems of care for its residents. We all benefit.

One area where federally funded research and programs have been especially impactful is in addressing the substance use crisis in America. With relatively modest investments, addiction science has led to enormous personal, societal, and economic benefits. Accomplishments include the treatments we use to break the cycle of addiction for millions of people, strategies for communities to support families with substance-related problems, prevention programs that divert youth away from substance use, and policies that reduce crime, suicide, overdose, and substance-related conditions like hepatitis and liver disease. Although we’re not done yet by any measure, these accomplishments have produced considerable returns on investment in personal and economic terms that are now at risk.

Out of a high level of concern, a group of career scientists formed the Addiction Science Defense Network to protect addiction research and evidence-based practice from actions by this administration. The number of researchers, practitioners, people with lived experience, and national organizations expressing their support for ASDN’s mission is growing into the hundreds. The Trump administration touts its commitment to reducing addiction, but its action don’t match the rhetoric. By curtailing research and funding for science-based solutions, we are practically assuring that the problem will continue to worsen over time. And, as underscored in Rae Ellen Bichell and Rachana Pradhan’s article, given that rates of drug overdose are highest in red states, predictions are that Trump supporters may suffer most of all.

— Diana Fishbein, Nova Institute for Health scholar, ASDN Coordinating Committee member, and University of North Carolina senior scientist, Chapel Hill, North Carolina

Staying Afloat Amid Federal Funding Cuts

Your article “Moms in Crisis, Jobs Lost: The Human Cost of Trump’s Addiction Funding Cuts” (April 25) mentioned that the Niyyah Recovery Initiative may be affected by losing federal funding. But it has been provided a state grant not associated with federal money in the sum of $200,000 a year through 2027. Presumptive speculation on how its services would be affected should have been disclosed.

— John Smythe, Fort Lauderdale, Florida

[Editor’s note: A bill to provide Niyyah Recovery Initiative a one-time $200,000 appropriation was introduced in the Minnesota Legislature in April 2025. As of May 12, it had not received a hearing or vote, meaning the payment had not been made.]

Count the Blessings of Direct Primary Care

While I am almost always a fan of the work that KFF Health News and NPR publish, particularly together, the article “In Rural Massachusetts, Patients and Physicians Weigh Trade-Offs of Concierge Medicine” (April 16) contained a mischaracterization that was pretty disappointing.

The author suggests, and a photo caption states, that “direct primary care is similar to concierge medicine but does not accept insurance.” While it’s true DPC patients and concierge patients both pay membership fees, they couldn’t be more different. The membership fee for concierge practices just gets you in the door — patients still pay copays/coinsurance or, in some cases, full out-of-network price, for every service. With direct primary care, your monthly cost — typically (I’ll hedge, though I haven’t seen any exceptions) — includes unlimited visits, in-house procedures and tests, and telemedicine appointments. Many even offer the ability to text-message your doctor when you need medical advice on a more urgent basis.

I’m not affiliated with the DPC industry in any way, I’m just a former patient. DPC changed my life. I felt for the first time as an adult (I am 33) as if I had actual, genuine health care. Not worrying about the drudgery of fee-for-service meant I didn’t hesitate to get, say, tested for flu and covid-19 when I had a respiratory illness, have skin issues looked at, or finally get care for long-standing issues. The fact that I had a high-deductible health plan only rarely mattered. For $100 a month, it was an absolute steal, and I was a cheerleader for everyone in my area who could afford it. At least a few folks who were uninsured or severely underinsured got health care thanks to that practice, which unfortunately is no longer serving primary care.

DPC has its thorns. Certainly, not everyone can afford a monthly fee. Access can be limited by capped patient loads. But, on the whole, DPC is a blessing for many people, and it’s simply unfair to paint it with the same brush as concierge medicine. I hope to see better from KFF Health News and its partners in the future.

— James Joyce, Opelika, Alabama

I got fed up with the feeling of being on a medical hamster wheel and switched to a concierge doctor. I feel like a patient instead of a name on a chart.

— Nailyard (@nailyard.bsky.social) 2025-04-16T16:34:19.766Z

— Ian Carter, Hillsboro, Oregon

Some Medical Debt Is Clearly Fraud

Be aware that false unpaid medical bills are sold to collection companies in bulk along with legitimate paid charges (“Diagnosis: Debt: Blockbuster Deal Will Wipe Out $30 Billion in Medical Debt. Even Backers Say It’s Not Enough,” April 7).

I went through cancer treatment in 2023. I paid all my legitimate charges after my Medicare Advantage plan paid. I paid regularly and on time. But I made sure I received my explanation of benefits (EOB) from my insurance company before I paid any additional fees. Those EOB statements list legal charges and billing.

In February 2024, I received new statements from SSM Healthcare for the infusion center, doctors, and hospital. These statements were for charges that were a year old and listed as paid in full in 2023. The SSM system sold some of that fake debt to a collection agency. I sent that collection company proof of payment and the paid-in-full statements that were still in the MyChart billing system.

Patients who go through chemotherapy, surgeries, and treatments for severe disabling conditions often also have cognitive deficits afterward. These cognitive problems may be short-term, but they can be extreme. False medical billing and fraudulent charges are often purposely used in these situations to take advantage of patients’ cognitive deficits. The medical systems utilize the false debt scam to sell it to collection companies to make a profit on essentially nonexistent debt. This system defrauds patients and the debt collection industry.

The elderly and disabled patients end up paying the legitimate debt and the fraudulent debt. The “unpaid” medical debt is bundled in such a way as to be impossible to identify as fraudulent or legitimate. Disadvantaged individuals aren’t capable of managing the documentation to prove their debt was paid, and the collection companies frighten and bully those individuals.

How much of the debt written off by Undue Medical Debt was legitimate? No one will ever know. But there’s a much larger issue than the simple belief that people don’t pay medical bills. Organizational fraud is likely responsible for a large percentage of the debt that companies like Undue purchase and utilize for profit.

— Diana Rickles, Ballwin, Missouri

Blockbuster Deal Will Wipe Out $30 Billion in Medical Debt. Even Backers Say It’s Not Enough. — yes, it's not enough, but it's something https://t.co/0G06f8DoHh via @kffhealthnews

— Ellen Andrews (@cthealthnotes) April 7, 2025

— Ellen Andrews, Hamden, Connecticut

Don’t Hesitate To Sound the Alarm

I am a regular watcher of “CBS Mornings” and always appreciated Dr. Céline Gounder’s reports during the covid-19 pandemic. But I found her report March 28 on CBS much too meek in the face of a devastating effort on the part of Robert F. Kennedy Jr. to slash the Department of Health and Human Services workforce by 25%.

This is catastrophic for disease prevention and future medical science — as well as the flight of talent from the U.S. to other countries. Dr. Gounder mentioned people from Yale leaving for Toronto. But Dr. Gounder should have been more assertive and sounded a greater alarm than just saying the impact of these cuts “remains to be seen.” For heaven’s sake! These cuts are catastrophic — not only for America’s health, but for the 20,000 talented people who have been shown the door. Dr. Gounder: You need to be more assertive and alert Americans that this is a tragedy.

— Uldis Kruze, El Cerrito, California

Today in NIMBY Land: Neighbors are now stopping hospitals in SIX different states from opening up psychiatric centers for children amidst a psychiatric bed shortage. Ugh. Great story from @EricLBerger @KFFHealthNews: pic.twitter.com/5XrHy2Zqjt

— Lawson Mansell (@lawsonhmansell) April 23, 2025

— Lawson Mansell, Washington, D.C.

We Must Prioritize Children’s Mental Health

As a concerned member of our mental health support community, I write to highlight an urgent issue that too often goes unnoticed: the mental health of our children (“More Psych Hospital Beds Are Needed for Kids, but Neighbors Say Not Here,” April 11). With rising rates of anxiety, depression, suicide, and behavioral challenges among youth, it is imperative that we take collective action to prioritize mental well-being just as seriously as we do physical health.

Children today face a unique set of stressors — from academic pressure and social media to family instability and global uncertainty. These factors can significantly affect their emotional development and overall well-being. Yet, despite the growing need, access to qualified mental health professionals, school counselors, and community support services remains limited or unaffordable for many families. Not all hospitals are equipped for mental health cases, and the number of psychiatric beds available is often little to none. A child in mental health crisis should not have to wait days or weeks to find treatments. Parents shouldn’t have to watch their child struggle and not have their concerns taken seriously. If a child goes into a hospital with a broken bone, it is immediately treated; the parents aren’t given numbers for places to call in hopes that they can be seen in a few days.

We must advocate for policies that ensure mental health screenings in schools, expand funding for youth-focused services, and promote training for educators to identify early signs of distress. Hospitals and mental health facilities need to be prepared and equipped to take in patients, not turn them away. Children should never be unable to receive treatment because of a lack of a bed. Our children should be our priority, not an afterthought of what a care facility will do to the neighborhood. No child should suffer in silence due to a lack of resources or awareness.

Investing in children’s mental health is not just compassionate — it’s smart. Healthy, supported children are more likely to succeed academically and socially and, ultimately, become well-adjusted adults. Let’s ensure that every child has access to the help they need.

— Jennifer Groseclose, Leeton, Missouri

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

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What’s Up With Our Wheat?

Great article (“How the FDA Opens the Door to Risky Chemicals in America’s Food Supply,” March 10). Another topic that needs more research is the fact that the FDA allows glysophate to be sprayed on wheat for human consumption to kill it off before harvest. It is then harvested seven days later and processed for food. In beans and corn, it is applied months before the food portion is developed, so it’s not as big of a concern. The question would be: How much residual glyphosate is still in the wheat when harvested? Does the FDA know, or care? What are the health ramifications?

— Irving Geary, St. Croix Falls, Wisconsin

A small farm in North Carolina’s Forsyth County that shuns herbicides, pesticides, and chemical fertilizers shared the article on the social platform X:

What reasonable (not corrupt) person thinks it’s a good idea to let food companies determine whether their ingredients & additives are safe. Companies don't have to tell the FDA about those decisions, and they don't have to list all ingredients on labels. https://t.co/ndRTNXDKmD

— Amber Lake Farm(stead) 🕊️ (@AmberLakeFarm) March 13, 2025

— Amber Lake Farm, Lewisville, North Carolina

CT Scans, Done Safely, Are Worth the Radiation Risk

Together with our colleagues, we read with great interest your recent article “Some CT Scans Deliver Too Much Radiation, Researchers Say. Regulators Want To Know More” (March 12). We share the crucial concern of patient safety, a mandate that has driven and can further drive technological innovation in imaging. But we note that there is an even more important mandate that should concern us all: imaging benefit.

We believe that the article overemphasized the risk associated with medical radiation exposure, and that such a fear-inducing approach to radiation protection is harmful to patients. We agree that extra care should be exercised when prescribing a diagnostic imaging study, especially in vulnerable groups, like pediatric and pregnant patients. However, once an exam is deemed medically necessary, its benefit is already judged to outweigh any potential risk. With the justification of the exam settled, the main challenge is how to perform the exam as best as possible for the medical need at hand. In that task, prioritizing radiation dose reduction over other considerations can potentially be detrimental to the patient. Radiation safety is a priority but only together with the quality of the diagnostic information for the clinical need.

We recently published a study in Nature Communications Medicine on a population of 1 million digital twins simulating the U.S. population, and we found that the clinical benefit associated with a radiological procedure largely outweighs the radiation risk, by at least a factor of 4. The finding, that the benefit of detecting a problem is worth the small potential risk of radiation, is contrary to common belief. This study shows that putting so much emphasis on radiation safety to the tune of avoiding exams or reducing dose to make the exam “safe” would make the overall procedure less safe by negatively impacting patients’ path of care. Exaggerated dose reductions can harm patients. That is not safe!

Diagnostic imaging exams are prescribed with the specific purpose of finding information that’s essential in improving patient’s life, and to diagnose or rule out pathologies. As health care professionals, it is our duty to offer the best care to patients, and to achieve the best diagnostic performance while exposing patients to the lowest risk possible. Excellence does not arise from spreading irrational fears. Excellence can be attained only with the careful assessment and balance of risks and benefits. And the successes of modern medicine are the irrefutable proof of the irreplaceable diagnostic imaging benefits.

— Francesco Ria and Ehsan Samei, Duke University Health System, Durham, North Carolina

A reader who manages a website predicting the collapse of the American health care system commented on X:

It’s careless work. This is more sobering proof of the huge management knowledge gap that’s ruining US healthcare from within. Medical errors are the same carelessness that is killing more than 400K patients each year, harming millions, and costing about $80 billion annually.

— Francis Anthony Toto (@francisatoto) March 12, 2025

— Francis Anthony Toto, San Diego

I’d Take Mushrooms Over Pills Any Day

Your article “The Colorado Psychedelic Mushroom Experiment Has Arrived” (March 24) states: “Psychedelic mushrooms and their psychoactive compound psilocybin have the potential to treat people with depression and anxiety, including those unresponsive to other medications or therapy.”

In my experience, they work for a couple of months after just one use, and they do not have the lasting side effects of prescription drugs, which rarely work as intended for depression or anxiety. I wish I had been given the option of microdosing mushrooms instead.

I’ve never met an antidepressant that worked for me and didn’t require multiple other medications to offset the side effects of the first pill, and it took two weeks or more to start working. Then, another 30 days or more are required to stop the ill effects, and you figure out that the side effects are far worse than any benefit.

You can’t just stop taking the pills, or you risk psychosis. Been there, done that. The type of craziness these pills unleashed on me and my family was due to my having to stop them abruptly, leaving scars on our entire family. Following the doctor’s advice to start antidepressants is the biggest regret of my life.

— Lori Muir, Helena, Alabama

I could become a psychedelic healer. Vermont is not good for my head. https://t.co/ee3q3pw1eQ

— Cassandra Carbee (@blackeyedcat69) March 20, 2025

— Cassandra Carbee, Wells River, Vermont

What’s in a Name?

What does KFF stand for? Is it Kaiser Family Foundation? Something different? I just want to understand what KFF stands for. Thank you.

— Margaret Chinn, Alameda, California

Editor’s note: Years ago, the organization was known as the Kaiser Family Foundation, but since it’s not part of Kaiser Permanente, nor a foundation, and doesn’t make grants, it’s clearer to simply say KFF, which is how many people already know and refer to it. KFF is a unique health policy information organization that brings together policy research, polling, journalism, and public information campaigns. KFF Health News is one of its core programs. You can read more about the organization’s history here.

Three Timely Levers for Addressing Disparities in Cancer Care

Over the past decade, the United States has witnessed a revolution in the development and approval of cancer-fighting drugs. From 2017 to 2021, the FDA approved an average of more than 50 new cancer drugs each year — an increase of about 40% from the previous five years. FDA approvals for cancer treatments are expected to accelerate as artificial intelligence further speeds up drug discoveries and trials.

While this rise in treatments is promising, disparities in access to cancer care are widening.

As foreign-born cancer doctors from low-income countries who have practiced in both urban and rural areas in the U.S. for nearly three decades and are particularly sensitive to equity issues, we call on the U.S. medical ecosystem to work toward eliminating disparities in access.

These new drugs provide hope for the 2 million Americans diagnosed with cancer each year and their loved ones. Thanks to the dedicated and brilliant researchers, pharmaceutical companies, and funders — including nonprofits and government — for identifying and rigorously testing these novel drug discoveries.

Given the rapid increase in FDA-approved drugs, we must now work toward ensuring that these breakthrough treatments improve outcomes for all patients. This is not a given. Especially in the U.S., which suffers from great disparities in access to quality cancer care and outcomes.

Rural, low-income, and minority patients typically experience cancer at a higher rate, receive a diagnosis at a later stage, and face geographic and financial barriers to accessing cutting-edge, quality care.

At the moment, the most powerful three levers for addressing these unconscionable disparities lie in Washington, D.C., not your doctor’s office.

First, it is critical for the Trump administration to expand, not roll back the Affordable Care Act, also known as Obamacare, which has played a crucial role in reducing disparities by expanding Medicaid in rural and poor communities and ensuring coverage for preventive services. If the ACA is trimmed or eliminated, we can expect cancer disparities to grow quickly and dramatically.

Second, Congress must act quickly to permanently extend the coverage of telehealth and telerehab services, which can help patients in rural areas access equitable, convenient cancer care and support cancer survivorship. Medicare coverage for telehealth, which was extended during the pandemic, was set to expire this month.

Third, counterintuitively, the exponential rate of innovation in the cancer drug development sector is itself a threat to equity. The American Society of Clinical Oncology has warned, “Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients.”

That’s because new treatments are more quickly integrated into standard care regimens in large cancer centers in urban areas — accessed by higher-income patients. The government needs to prioritize addressing the systemic knowledge gaps and economic factors that drive these disparities and initiate preventive and corrective measures.

We know this will take time to untangle. But our leaders in Washington, D.C., can protect the ACA, support telehealth and telerehab, and lead the way toward reimagining the health system that delivers lifesaving care for us all.

— Binay Shah, a Seattle-based hematologist-oncologist and the co-founder of the nonprofit Binaytara, and Manish Kohli, a professor of oncology at Huntsman Cancer Institute

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

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A chronic-pain patient advocate, who has been featured previously in KFF Health News coverage, spoke out on the social platform X about our “Payback: Tracking the Opioid Settlement Cash” project:

Oh, look an entire investigation, of course partly by shatterproof, looking at where the settlement funds are going, and where they should go. Not one mention of pain patients as forgotten victims. Because we’ve actually been erased from the entire thing. https://t.co/LsHFs9tFwu

— Bev Schechtman🇮🇱 (@ibdgirl76) December 17, 2024

— Bev Schechtman, Clayton, North Carolina

Rooting Out the Root Cause of the Opioid Crisis

I read with interest your detailed coverage of how states are spending billions of funds from the opioid crisis (“Payback: Tracking Opioid Cash: How Are States Spending Opioid Settlement Cash? We Built a Database of Answers,” Dec. 16). The bigger story is health advocates and policymakers need to march upstream if we are to beat the “illness industry” players in illicit drug-making, distribution, and sales on our streets.

What should not be overlooked by those interested in solving this public health crisis (legislators, health department officials, and law enforcement and court system leaders) is that such downstream efforts, even when supported by unimaginable funding, does little to prevent those pushing our citizens into the quicksand of individual, family, and community destruction and death. Certainly, such mitigating and treatment programs and services are needed, but little attention is given to rooting out the root cause of the opioid/fentanyl epidemic.

It is easy and popular to damn the corporation, but it takes courage, real work, and much risk to confront Mexico’s drug cartels, Mexico’s government officials, the Chinese Communist Party, and any of their ostensible “leaders.” Furthermore, it is embarrassing to have to confront our own public officials, from the president on down, to stop aiding and abetting this carnage!

If no serious action is taken to work on upstream causes of our opioid crisis, no amount of lifeguarding and posting of warning signs will prevent bodies from struggling in this rip current of drug addiction. The silence and omission of any action from those who have taken the oath to defend and protect the public is creating a moral hazard for all citizens. Consequently, many more people will die, with nary a word against who is pushing them to such destruction.

— Stephen Gambescia, Philadelphia

A retired assistant surgeon general and epidemiologist weighed in on X about an article on the nation’s shortage of primary care providers:

Misdiagnosis. Young people choosing not to become primary care physicians after leaving med school will not be fixed by free tuition for the highest paid profession in America. Fix govt incentives about graduate medical education & reimbursementhttps://t.co/tPgeFVrzql

— Dr. Ali Khan (@DrAliSKhan) January 14, 2025

— Ali Khan, Omaha, Nebraska

Osteopaths Have Big Hand in Filling Primary Care Needs

I appreciate Felice J. Freyer’s insightful Jan. 13 article, “Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline?” As an osteopathic physician and medical educator, I can confidently answer this question with a resounding “Yes!” Osteopathic medical schools have long been at the forefront of this issue by emphasizing core principles of primary care as they train future physicians, a mission embedded in our philosophy since 1874.

Osteopathic medicine is founded on four key tenets that emphasize the interconnected nature of the body, mind, and spirit and the importance of whole-person care. These tenets have guided many of this country’s nearly 150,000 DOs (doctors of osteopathic medicine) into primary care roles. More than half of DOs enter residencies in the primary care specialties of family medicine, internal medicine, and pediatrics.

As mentioned in the article, “Many medical students start out expressing interest in primary care. Then they end up at schools based in academic medical centers, where students become enthralled by complex cases in hospitals, while witnessing little primary care.” This is a major part of the problem. Most Americans, more than 80%, will never be treated in a large academic medical center. Osteopathic medical schools have flipped the script.

Osteopathic medical schools, as well as some newer MD-granting schools, employ a community-based distributed education model, training students in settings such as rural clinics, community health centers, and physician offices where they will encounter underserved populations benefiting from primary care treatment. Training in underserved areas makes medical students almost three times as likely to stay in those areas to practice, and four times as likely to practice primary care in those locations.

I thank Freyer for shining a spotlight on the essential role of primary care and the contributions of osteopathic medicine. The osteopathic medical education community remains committed to working to ensure that underserved communities receive the care they deserve, and that primary care continues to thrive as the backbone of our health care system.

— Robert A. Cain, CEO and president of the American Association of Colleges of Osteopathic Medicine, Bethesda, Maryland

A family doctor and teacher shared the article on X:

The answer is that they can, but they won't try. Financial and public good incentives for schools are not there. Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline? https://t.co/REsfJtfmmh via @kffhealthnews

— John Frey (@jjfrey3MD) January 14, 2025

— John Frey, Grayslake, Illinois

On Immunity for Vaccine Makers

When discussing vaccination in general (“Childhood Vaccination Rates, a Rare Health Bright Spot in Struggling States, Are Slipping,” Jan. 16), please address the federal legislation surrounding this topic.

According to 42 U.S. Code § 300aa–22, vaccine producers have immunity in civil court. It reads: “No vaccine manufacturer shall be liable in a civil action for damages arising from a vaccine-related injury or death associated with the administration of a vaccine after October 1, 1988, solely due to the manufacturer’s failure to provide direct warnings to the injured party (or the injured party’s legal representative) of the potential dangers resulting from the administration of the vaccine manufactured by the manufacturer.”

And there is only one federal National Vaccine Injury Compensation Program, also known as “vaccine court,” to hear all vaccine-related injury cases involving children. And its case backlog is at least a decade long.

In everything else, when a product or service causes harm, there is accountability through the process of civil suits. What other manufacturer of a product has such legal immunity?

The issue with this is there is no true measure to create accountability with vaccine products. And vaccine makers aren’t required to display ingredient labels. So, we may be injecting our children with unknown substances, from a manufacturer who has no judicial accountability if harm results from the use of the product.

Now, what parent wants to subject their child to this? This is a big deterrent to parents vaccinating their children. Emotional appeal will not dissuade parents, but correcting this legal fallacy will.

— Alesia Wright, Tulsa, Oklahoma

An Indiana dad expressed his opinion on X:

Indiana's childhood vaccination rates have dropped significantly since the pandemic too.Some people are just going to have to learn the hard way, apparently. Sad that the only way that happens, however, is by gambling with their kid's health.https://t.co/S9UgXAlAc6

— Steve Garbacz (@Steve_Garbacz) January 14, 2025

— Steve Garbacz, Fort Wayne, Indiana

As a retired primary care physician, I was often frustrated that my management of complex medical conditions was reimbursed at lower rates due to a required treatment code (“Perspective: Removing a Splinter? Treating a Wart? If a Doctor Does It, It Can Be Billed as Surgery,” Dec. 13). Blaming the physician for the discrepancy is inappropriate. The Centers for Medicare & Medicaid Services has strict regulations on billing. We are mandated to code per the regulations. We cannot give “discounts” for procedures. To do so would be problematic in the bizarre catch-22 world of Medicare billing. We are mandated to report our services accurately using only the codes available. To do otherwise is considered fraud by Medicare. When a physician is accused of fraud, he/she is presumed guilty and pays significant financial penalties until innocence is proven. Even a murderer or thief has more rights in the judicial system.

Medicare determines the lowest reimbursement rate; the other carriers pay a higher rate based on that rate. If an individual physician accepts Medicare, he/she must accept that rate. Only a non-participating physician (not accepting Medicare) can offer a lower rate. The exception is if the service is provided at no cost. Should the patient demand the service be provided free?

I’m reminded of the plumber charging $100 to replace a washer: 10 cents for the washer and $99.90 to know how to replace it.

— Robert Sullivan, Adairsville, Georgia

On X, a New England surgeon summed up his views:

We have lost “caring” – "How Everything Became Surgery" from The Washington Post. Read on @Doximity https://t.co/msHja8wsg5

— Rafael Grossmann, MD, MSHS, FACS 🇻🇪🇺🇸 (@ZGJR) December 20, 2024

— Rafael Grossmann, Bangor, Maine

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

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‘Solo Agers,’ Join the Crowd!

Enjoyed your panel discussion (Watch: ‘Going It Alone’ — A Conversation About Growing Old in America, Dec. 12). I am 85, retired at 55. Traveled (birding) in 65 countries. In 2010, I created the First Friday Ideas Salon. We just had our 171st gathering, via Zoom. I curate each gathering. Last month, we hosted a conservator and a scientist from the Getty Museum. The month before: a Caltech professor on robotics. I have had many professors, a Nobel Prize winner, MacArthur Foundation “genius grant” recipients, a presidential candidate, etc.

Recently, I became interested in the issue of how retirees whose professions defined their persona can, after age 80, as a “senior senior,” continue to be a person of substantiality. I created the Glorious Age of Aging to look at this issue over six hourlong meetings over three months. The focus was on “action steps.”

So, for me, as a “solo ager,” the key has been to take action. That said, I worry about the time when my body does not keep up with my mind. Actually, I would say my body has declined and my ability to take care of things required in my life. So, I have prepared food delivered. I hire people to help with my beloved succulent garden and with other chores — so far, young people in my neighborhood. I live in Los Angeles with famously poor public transportation. I use Uber as well as drive. So I wonder if I will be able to continue to find services that will support my living alone. And the real worry is the process of dying — not death — I do not worry about that. Recently, I have decided that I need to create an “intentional community,” which will be there when I need it. I am just beginning to think about how to do this.

— Edna R.S. Alvarez, Los Angeles

A social services agency that has been delivering meals to homebound seniors in all five of New York City’s boroughs for 43 years weighed in on X:

“It’s hard to be by myself so much of the time. It’s lonely." It's vital to understand how isolation increases the risk of health problems for older adults: https://t.co/uQDBysqmQW

— Citymeals on Wheels (@Citymeals) December 14, 2024

— Citymeals on Wheels, New York City

Keeping Pace With Solo Agers

As Judith Graham makes clear (“Going it Alone: Homebound Seniors Living Alone Often Slip Through Health System’s Cracks,” Dec. 2), more Americans are living on their own as they age, relying on a patchwork of health care services to get by.

That’s why the Program of All-Inclusive Care for the Elderly (PACE) is so critical to this conversation. PACE helps older Americans — 91% of whom are 65 or older and have chronic health conditions — stay safe and healthy in their own homes.

The program offers at-home assistance with daily tasks, like dressing, bathing, and eating, and transportation to the PACE day center, where participants can socialize and receive medical care. Unlike other settings, the PACE program coordinates all aspects of a participant’s care, from scheduling medical appointments to providing meals and nutritional advice.

PACE physicians and nurse practitioners’ comprehensive approach to care benefits those who are homebound and may not otherwise have an in-home caregiver to rely on. PACE is also a particularly promising option for those with dementia, as the program allows older adults to receive memory care in the comfort and familiarity of their homes.

It’s also more affordable than many alternative care options. States have reported that PACE costs taxpayers 13% less than the cost of other Medicaid services, all without copays, deductibles, or out-of-pocket expenses for participants.

The program has been quietly transforming our nation’s senior care system, but it remains underutilized. Only a fraction of older Americans are currently eligible for the program, but its benefits can extend far beyond this group. It’s critical for lawmakers to advance policies that expand access to PACE services so that we can set more older Americans up for success as they age at home.

— Jerry Wilborn, chief medical officer of One Senior Care, Erie, Pennsylvania

Gone But Not Forgotten

In February 2023, I came across an article by Tony Leys about the closing of Iowa’s Glenwood Resource Center, which left me reflecting deeply on both the residents who still lived there and those who had passed away and are now buried at the institution. Among them is my great-grandmother, Margarita Hedlund. As I read, I couldn’t help but think about the many people like her, who spent more of their lives at Glenwood than they ever did with their families, and who now rest in the cemetery there.

Nearly two years later, I read another article by Mr. Leys expressing concern for the over 1,300 residents buried in the Glenwood Cemetery and who will take responsibility for maintaining their graves (“After Institutions for People With Disabilities Close, Graves Are at Risk of Being Forgotten,” Nov. 21). The thought of my great-grandmother’s grave and the graves of so many others being neglected is deeply troubling.

Margarita Petterson was born in Sweden in 1866. She came to America as a young child and married Erik Hedlund, also from Sweden. They had five children together, but Erik passed away in 1900, just months before their youngest child was born. My great-grandmother lived with her oldest daughter, but in 1912, for reasons unknown to me, she was sent to Glenwood. She remained there until her death in 1949. Although I knew she had lived at Glenwood, I was never told why, and when I reached out to the institution for information, I received only a brief record. It stated she had a moderate intellectual disability (IQ between 35-49) and died of cirrhosis of the liver. The only other detail I learned was that her son had decided to have her buried in the cemetery there.

I can’t help but feel sadness and frustration that she was buried so far from her husband, who passed away nearly half a century earlier. There are likely many more families with similar stories — of loved ones abandoned or forgotten in a place like Glenwood, with little more than a name and a grave marker to honor them.

Reading about the fate of Glenwood’s residents and the ongoing concern about the cemetery maintenance only deepens my desire to know more about my great-grandmother’s life and her time there. When it’s your own family member, the need for answers is personal. I hope others who may be in the same situation find ways to learn more about their relatives’ lives at Glenwood and that we, as a community, remember and care for those who were forgotten too long.

— Marlys Adkins, Clare, Iowa

Disability Scoop, a 16-year-old news site that offers daily coverage of autism, intellectual disability, cerebral palsy, Down syndrome and other issues vital to the developmental disability community, shared the article on LinkedIn.

ER Care Goes Beyond Doctors

This is an excellent story to remind people to think ahead and utilize urgent care facilities (“Bill of the Month: A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445,” Nov. 27). But why is this family’s bill surprising? I find it reasonable. There was the all-important initial screening by trained personnel — a child may be more ill than the parent appreciates. The medical history was obtained, temperature and other vitals taken, and swabs for the noted tests. That’s all time and effort that could have been spent on another patient. That’s supposed to be free? Surely you’re not implying that ER staff other than the doctors are worthless.

I remember the ’50s, when our local hospital’s ER staff was “on call.” No charge then if you left before you were seen.

— Gloria Kohut, Grand Rapids, Michigan

An emergency physician in Ontario chimed in on X:

A Toddler (in Canada) Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $0. If the swab was positive they'd get a phone call by a doctor again costing $0. https://t.co/NPaPUWASTq via @kffhealthnews pic.twitter.com/qkVuZZFFr0

— Raghu Venugopal MD (@raghu_venugopal) December 12, 2024

— Raghu Venugopal, Toronto

Watch Your Language

It is too bad that an inflammatory article was written like the one titled “How Measles, Whooping Cough, and Worse Could Roar Back on RFK Jr.’s Watch” (Dec. 6). “Could” is just a speculative word and may be associated with fear-mongering. Your bias seems clear. It’s difficult to find unbiased health-related articles nowadays. I request that you write an article concerning RFK Jr. that is not biased — that is not from Big Pharma’s viewpoint. You aren’t aware that the Centers for Disease Control and Prevention, FDA, and other government agencies are industry-captured?

— Wayne Carpenter, Omak, Washington

An infectious disease specialist and senior scholar at the Johns Hopkins Center for Health Security had this to say on X:

“Vaccine development requires millions of dollars. Unless there is prospect of profit, commercial companies are not going to do it.” — why would companies even invest in vaccines if there reward is demonization https://t.co/F6jAv5cdhe

— Amesh Adalja (@AmeshAA) December 9, 2024

— Amesh Adalja, Pittsburgh

Gathering Intel on Plant-Based Diets

I just wanted to say how much I appreciated your roundup of news about prioritizing plant-based proteins (“Morning Briefing: Eat More Plant-Based Foods, According To Dietary Guidelines Advisory Panel,” Dec. 11). The idea that our food choices can come from a place of ethical consumption seems so removed from much of the world today. So many people have questions and concerns about becoming plant-based — is it healthy? What will my friends and family think? etc. But what your newsletter clearly shows is it’s not about what leaving animal products off one’s plate takes away but instead how much trying a plant-based meal gives to the individuals, the animals, and the environment.

Thank you for inspiring change without creating fear. Our future depends on more coverage like this.

— Sara Crane, Toronto

A Slice of Real Life

I really enjoyed your article “Perspective: Removing a Splinter? Treating a Wart? If a Doctor Does It, It Can Be Billed as Surgery” (Dec. 13). The exact thing happened to our family, and I thought we were an anomaly. My daughter got a 1-centimeter cut above her eye after falling out of bed. I took her to MUSC Children’s Health After Hours Care in Mount Pleasant, South Carolina (basically a doctor’s office that is open late). It’s not an ER or urgent care. When we arrived, the receptionist said, “We don’t do stitches here.” I checked in my daughter anyway since the receptionist said the doctor might be able to apply glue to help keep the cut closed. The doctor cleaned the cut with sterile saline, applied glue, and placed a few Steri-Strips. We were billed for “minor surgery” despite no scalpel, no stitches, no lidocaine. I looked up the ICD-10 code, and sure enough “application of tissue adhesive” is a “minor surgery” code. Our out-of-pocket was around $830 with UnitedHealthcare. I still have all the bills. “Liquid bandage” and Steri-Strips can be purchased at Walgreens.

I’ve never emailed the writer of an article, but this got me fired up! Thanks for bringing this to light.

— Cailin Lutz, Charleston, South Carolina

Continuing the surgical thread on X was a professor of medicine and pharmacy at the University of Pittsburgh:

I'm glad this is being looked at: Removing a Splinter? Treating a Wart? If a Doctor Does It, It Can Be Billed as Surgery https://t.co/YVUR9B8BkO via @kffhealthnews

— Bernie Good (@CBGood23) December 13, 2024

— Bernie Good, Pittsburgh

As a retired primary care physician, I was often frustrated that my management of complex medical conditions was reimbursed at lower rates than the illustrated splinter, or other “surgical treatments” as mentioned in Elisabeth Rosenthal’s article. However, blaming the physician for this discrepancy is inappropriate. The Centers for Medicare & Medicaid Services has strict regulations on billing. We are mandated to code per the regulations. We cannot give “discounts” for these procedures. To do so would be problematic in the bizarre catch-22 world of Medicare billing.

We are mandated to report our services accurately using only the codes available. To do otherwise is considered fraud by Medicare. When a physician is accused of fraud, he/she is presumed guilty and pays significant financial penalties until innocence is proven. Even a murderer and thief have more rights in the judicial system.

Medicare determines the lowest reimbursement rate; the other carriers pay a higher rate based on that rate. If an individual physician accepts Medicare, he/she must accept that rate. Only a non-participating physician (not accepting Medicare) can offer a lower rate. The exception is if the service is provided at no cost. Should the patient demand the service be provided free?

I’m reminded of the plumber charging $100 to replace a washer: 10 cents for the washer and $99.90 to know how to replace it.

— Robert Sullivan, Adairsville, Georgia

No Free Pass for Drug Ads

After reading this article by Elisabeth Rosenthal, “Perspective: With TV Drug Ads, What You See Is Not Necessarily What You Get” (Sept. 9), I wanted to share an opinion about the federal court’s decision to deem price disclosure on pharmaceutical advertisements a violation of the First Amendment. Commercial advertising has less protection under the First Amendment than individual speech. According to the Central Hudson Test, commercial speech, at baseline, must concern a lawful activity and not be false, deceptive, or misleading. Even if the speech meets all these criteria, the government can intervene if there is “substantial” government interest. If there is further regulation from the government on commercial advertising, it must be no more extensive than necessary to serve the government’s interest. Essentially, if there is intervention, it must be warranted, and the regulation must be reasonable when compared to the restriction (U.S. Constitution, Amendment 1.7.6.2).

In the case of pharmaceutical ads, especially those that promote oncology medications, they do not meet the baseline qualifications to be considered “not false, deceptive, or misleading.” It has been shown that pharmaceutical ads can rely on emotional response over rational appeal (Main, et al., 2004). If the ad is going to target an emotional response of a vulnerable population, then what is being sold must be accurate. If they are going to sell a chemotherapy that may not be the best option (but possibly have the most adverse side effects), then there is a government responsibility to protect this population and to be more discerning when determining what is truthful. Furthermore, even if the ads met the basic qualifications, they could still be regulated further due to the government interest in both public health and health care cost. Requiring that the drug cost be shown on pharmaceutical ads is appropriate federal intervention that I believe is more than reasonable when compared to the restriction.

— Molly Hilliard, New York City

A national drug safety advocate and public speaker tweeted on X:

Did you know drug companies spend over $1B a month on drug ads in recent years? Last year, the top 3 advertising spenders on TV were drug companies.I have spent my entire career in advertising and Big Pharma is keeping our industry afloat. https://t.co/0cTHTAOSAt

— Kim Witczak 💜 (@woodymatters) September 9, 2024

— Kim Witczak, Minneapolis

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

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