Meanwhile, patients, their advocates, and clinicians say little has improved.

“It has never been this bad for patients,” said U.S. Rep. Greg Murphy (R-N.C.), a physician who co-chairs the GOP Doctors Caucus.

The overarching intent of the June 2025 pledge was to improve a controversial process called prior authorization, which regularly requires patients or someone on their medical team to seek approval from insurers before proceeding with treatment.

According to AHIP, the health insurance industry trade group, health plans have eliminated 6.5 million prior authorizations for patients — equal to an 11% reduction — since the announcement.

But critics remain skeptical. Sally Nix, a patient advocate who has a chronic disease, described the voluntary pledge as “performative.” And Murphy, who participated in the news conference with Health and Human Services Secretary Robert F. Kennedy Jr. announcing the pledge last year, said it has “no teeth.”

Voluntary insurer pledges rarely make things better for patients, said , a research professor at the Center on Health Insurance Reforms at Georgetown University.

“In the absence of clear rules, policies, standards, and mandates,” she said, insurance companies are “going to do what makes sense for them to do financially.”

The Department of Health and Human Services did not respond to questions for this report. It isn’t clear how, or whether, the Trump administration is holding insurers accountable.

‘Zero Faith’

Prior authorization — sometimes called preauthorization or precertification — has been around for decades. The insurance industry has long argued that the practice, which varies by company, helps control costs, reduces waste and fraud, and prevents potential harm to patients. It’s regularly invoked for a huge swath of services, ranging from low-cost urgent care to expensive cancer treatment.

“Prior authorization is a vital patient safeguard,” said Chris Bond, a spokesperson for AHIP.

The 2024 killing of UnitedHealthcare CEO Brian Thompson sparked a national groundswell of anger about insurance denials, with patients and doctors becoming increasingly vocal about the tactics they say insurance companies use to boost profits at the expense of care.

Prior authorization reform is one of the rare healthcare issues Democrats and Republicans tend to agree on. On July 15, the House Ways and Means Committee unanimously that would force Medicare Advantage plans to provide to the federal government a list of all items and services that are subject to prior authorization, and to report data about denials and grievances, among other requirements.

Last year’s industry pledge was organized as a direct response to public anger, Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said when it was announced. “There’s violence in the streets over these issues,” he said.

“Americans are upset about it,” Oz said, later adding, “I’m looking forward to seeing the results.”

Mike Gartner, founder of Health Access Innovation, an organization that helps patients overturn insurance denials, said he doubts that insurance companies are changing their policies in meaningful ways. The 11% reduction in prior authorization cited by AHIP “hides a lot of nuance,” Gartner said.

Patients who need the costliest services, such as cancer treatment, are still being disproportionately denied access to doctor-recommended care, he said.

AHIP said its data included reductions in prior authorization for medical services, not prescription medicines. The trade group didn’t provide details explaining which services have been dropped from prior authorization or how those reductions differ across individual insurers.

Last year, Oz said the federal government would be “evaluating progress” toward the pledge and “driving accountability,” and he foreshadowed “public dashboards.” But no such dashboards exist, and federal officials did not respond to questions about how they’re holding companies accountable.

Murphy, the North Carolina congressman, said he has “zero faith” in the industry policing itself.

He didn’t believe insurance companies then, he said, “and I don’t believe them now.”

‘At War’ With an Insurer

In February, days after Betsy Adler and Justin Young’s daughter Coco was born with a serious heart defect, the Stillwater, Minnesota, family received paperwork showing they were racking up out-of-network costs.

During Adler’s pregnancy, the family had switched insurers, , which is based in Minnetonka, Minnesota, and one of that initially signed the industry pledge. Adler said she’d checked with her employer’s human resources department and on Medica’s website to make sure her maternal-fetal specialists and hospital were in-network before their new health plan went into effect earlier this year.

But then, the insurance company started processing some claims as out-of-network. By mid-March, the family had accrued more than $4,000 in out-of-network charges, on top of more than $3,000 for in-network bills. And the bills kept coming.

When Adler, a psychotherapist, called to figure out what was going on, she said, an insurance company representative said she hadn’t submitted a referral from her primary care provider beforehand. Attempts to fix the problem went nowhere. At one point, Adler said, Medica required her to visit a clinic she’d never been to before to obtain a referral. But she said a Medica representative told her the referral was never received, because the insurer’s fax machine was down.

“I have a critically ill child,” Adler remembered thinking shortly after Coco was discharged from the cardiovascular intensive care unit. “I can either spend my emotional energy at war with Medica, or I can let it go and just enjoy my time with my daughter.”

Medica spokesperson Greg Bury said he wouldn’t discuss the case, citing patient privacy rules. In an emailed statement, he wrote the company is “committed to working with her to ensure she understands what is covered under her benefits and our responsibilities.”

One of six specific promises all insurers made when they signed the pledge was to honor a 90-day grace period when patients switch insurance plans, starting Jan. 1 of this year. Often called “continuity of care,” this grace period allows patients to temporarily continue receiving services and medications that were authorized under a previous insurer.

But that applies only in some circumstances, Georgetown’s Corlette said. The wording of the pledge suggests that insurance companies aren’t obligated to honor another company’s network parameters. When Adler and Young switched insurers, for example, Medica was not obligated to cover the cost of out-of-network providers as if they were in-network, even though they were in-network under the family’s old plan.

Adler and Young switched insurance companies again when Coco was a month old, to avoid accruing more out-of-network costs.

Denial After Approval

The percentages cited by AHIP don’t tell the whole story, said Nix, the patient advocate. Insurers are “not including the data for the loopholes they create,” she said.

For example, nothing in the pledge prevents insurance companies from retroactively denying payment, even when care is preapproved. “Patients are going to see a lot more retroactive denials,” said Nix, who recently had her insurer process, then later deny, a claim for injections to relieve her nerve pain.

Something similar recently happened to Jocelyn Austin, 49, of Amherst, New York. Over the course of nearly 20 years, she developed an addiction to sleeping and anxiety pills prescribed to her by a doctor. Last year, she spent weeks at an inpatient treatment center for substance abuse. Her insurer, Independent Health, had approved the admission. Austin said she has been substance-free since her discharge.

But the facility sent her a bill for more than $12,000 in December showing her insurer had not paid for the treatment she received, according to documents Austin shared with ºÚÁϳԹÏÍø News. This was in addition to the $10,000 she paid at the beginning of her treatment to satisfy her out-of-network deductible. The approval letters from Independent Health had specified that “authorization is not a guarantee of claim payment.”

Frank Sava, a spokesperson for Independent Health, said a denial was issued and upheld in this case because the services provided “were inconsistent with the care that was authorized” and “the medical record did not sufficiently support what was billed.” He said those findings were reviewed and confirmed by an outside consultant.

An explanation of benefits issued by the insurer last summer indicated the “provider,” not the patient, was responsible for the cost of her treatment. And yet the treatment facility has continued to pressure her for payment, she said.

Austin, who has not paid her outstanding bill, said insurance companies “should be held accountable.”

‘Significant Work Ahead’

Another one of the six commitments insurers made last year was to adopt new technology that would standardize the electronic submission of prior authorization requests. During the news conference announcing the pledge last summer, Chris Klomp, the director of Medicare and a deputy CMS administrator, said more than 50% of prior authorizations are still paper-based and processed by phone or fax machine.

In April, AHIP related to that technology initiative, explaining that participating insurers would adopt the new standards on a rolling basis. Health insurers agreed to implement the pledge’s various commitments by predetermined deadlines, and this initiative is scheduled to be operational by Jan. 1, 2027. But eight insurers that initially signed the pledge last year didn’t sign the technology update when it was announced in April, AHIP told ºÚÁϳԹÏÍø News.

Those insurers are Alignment Health Plan, EmblemHealth, HealthFirst, Independent Health, Medica, MVP Health Care, Point32Health, and SummaCare. Their beneficiaries span the country, from California to New York. None of those eight insurers agreed to interviews for this report, but most sent ºÚÁϳԹÏÍø News emailed statements indicating that they remain committed to prior authorization reform.

AHIP’s approach to continuity of care “would have required the transfer of confidential member health information through a non-standardized process involving third-party participation,” wrote Jerry Slowey, a spokesperson for , which offers Medicare Advantage policies in Arizona, California, Nevada, North Carolina, and Texas. “We do not believe that level of data sharing was contemplated in the original commitment.”

Bury, the spokesperson for Medica, which covers beneficiaries in Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, and Wisconsin, said the company “supports the goal of these standardization efforts.” But the April update “raised a significant technical and operational hurdle that we are not able to commit to at this time,” he said.

Alex Gomez, a spokesperson for EmblemHealth, said in late June the company “will sign onto the commitment” after ºÚÁϳԹÏÍø News posed questions about why it had not endorsed the April update.

“We anticipate more plans will be added over the coming months,” said Bond, the AHIP spokesperson. Health plans are “working continuously to implement their commitments to simplify and improve the experience.” He acknowledged that “there is still significant work ahead.”

The original pledge also included a promise that insurance companies would enhance transparency and use “clear, easy-to-understand explanations” when communicating to patients — something they were already supposed to be doing under the Affordable Care Act.

Yet companies still regularly neglect to explain why care has been denied, and their communications often contain “inconsistent and contradictory information,” said Gartner, of Health Access Innovation. He and Murphy also said they suspect insurance companies are increasingly using artificial intelligence to generate denials.

“They craft the pathways to basically deny things immediately with the hope that people will give up,” Murphy said.

The congressman said he wishes President Donald Trump would sign executive orders addressing some of these issues. “The problem is the insurance industry is the strongest lobby in this town.”

Do you have an experience with prior authorization you’d like to share?  to tell ºÚÁϳԹÏÍø News your story.

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It’s one of the many parts of the 25-bed rural hospital that need updating, former CEO Ron Wiens said.

He said the hospital, an essential service in its namesake town of nearly 800 residents in the state’s sprawling north-central high plains, needs at least $1 million for deferred maintenance, including a failing HVAC system. But the facility has struggled to make payroll each month and can’t afford to make all the fixes, Wiens said.

Built by farmers and ranchers in 1965, Big Sandy Medical Center began with nine beds. Today, a similar community effort — donations and grants to plug financial holes each year — keeps it afloat.

Wiens, who recently left his position at the hospital, said he wishes Big Sandy could get funding from Montana’s share of the $50 billion federal Rural Health Transformation Program to renovate the hospital and direct payments to help secure its future. The state received more than $233 million in its first-year award.

But the hospital may not get the kind of help he sought.

That’s because the five-year program focuses on new, creative ways to improve access to rural health care, not on directly funding services and renovations. And Montana is one of at least 10 states whose leaders say projects launched under the federal program could lead rural hospitals to cut services so they can continue to afford to offer emergency and other essential care.

Congressional Republicans created the fund as a last-minute sweetener to their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset disproportionate fallout anticipated in rural communities from the law, which is expected to slash Medicaid spending .

includes programs to make it easier for rural residents to get medical care and live a healthy lifestyle. For example, it says funding can be used to start community gardens, train paramedics to make home visits, open school-based clinics, or bring mobile clinics to rural areas.

rural Montana hospitals can receive payments for implementing recommendations, “including right-sizing select inpatient services” to match demand. In some cases, it says, right-sizing might mean “downsizing.” The state says hospitals will have input and recommendations will be specific to each facility.

“That’s what has all the hospitals on pins and needles, words like restructuring, reducing inpatient beds. Everybody is going, ‘What is this going to look like?’” Wiens said.

The Montana Department of Public Health and Human Services declined to answer questions about how it will carry out its right-sizing efforts.

A Lifeline of Care

Big Sandy cattle rancher Shane Chauvet doesn’t want any services cut.

He credits Big Sandy Medical Center with saving his life after a flying piece of metal nearly cut off his arm during a windstorm a few years back.

“I looked over, saw it coming, and whack!” Chauvet recalled.

His wife drove him to the hospital, where they frantically pounded on the ER door while Chauvet’s blood pooled on the ground.

Because of the storm, staffers worked on Chauvet with no power and no ability to summon a helicopter. He was then taken by ambulance 80 miles through intense rain and hail to a larger hospital.

Chauvet understands the state’s plan doesn’t call for eliminating emergency care, but he worries that reducing other services would set off a downward spiral for the hospital and his town.

In Oklahoma, realigning clinical services could mean “shutting down service lines,” to the federal program. And in Wyoming, any facility that receives funding must agree to “reduce unprofitable, duplicative or nonessential service lines,” .

Monique McBride, business operations administrator at the Wyoming Department of Health, said the department interprets right-sizing as helping rural hospitals provide essential services — such as emergency departments, ambulance services, and labor and delivery units — while maintaining long-term, financial stability.

“This might involve limiting some elective procedures that could be done at lower cost in higher-volume facilities. The main distinction here is time-sensitive emergencies vs. ‘shoppable’ services,” she said.

A New Lease on Life?

Seven of the 10 states — Nebraska, North Dakota, Tennessee, Kansas, Nevada, South Carolina, and Washington — where rural hospital service cuts are on the table say they’ll help pay for hospitals to convert to Rural Emergency Hospitals. The recently created federal designation requires hospitals to halt inpatient services and offers enhanced payments to help them maintain emergency and outpatient care.

At least 15 additional states wrote that they’ll use the federal funding to right-size, evaluate, or adjust services — which could mean adding or taking away services, or transitioning them to a telehealth or outpatient setting.

Brock Slabach, chief operations officer of the National Rural Health Association, said, “There’s a proper concern from rural hospital administrators that this funding is not going to where it was intended.”

He said cutting services that lose money could backfire in the long run. For example, he said, halting labor and delivery care might drive more people out of small towns, further reducing hospitals’ patient numbers and revenue.

The type of hospital services that states will assess matters, said Tony Shih, a senior adviser at the Commonwealth Fund, a nonprofit focused on making health care more equitable.

“If the end result is that high-margin services are taken away from local hospitals with nothing given back in return, it can be financially harmful,” he said.

Shih noted that states’ plans to add more outpatient care could prove beneficial for patients. It’ll take time to know which states help stabilize rural hospitals, he said.

Rural hospital leaders say they know which changes would keep their facilities open and that states shouldn’t suggest or mandate service cuts and other changes on their behalf.

Josh Hannes, who oversees rural health policy at the Colorado Hospital Association, said “top-down” directives won’t work.

He said the association’s members believe they can find efficiencies and are eager to collaborate. But “a state agency shouldn’t be making those determinations,” he said.

Hannes said members are worried Colorado’s plan to classify rural health facilities as a “hub, spoke, or telehealth node” will compel service reductions. The classification will help determine “which services are sustainable locally and which are best provided regionally or through telehealth,” .

Spokespeople for the Colorado and Oklahoma health departments said no facility will be forced to end services. But Oklahoma spokesperson Rachel Klein said some facilities might choose to do so as part of a broader effort to make sure they’re meeting community needs while remaining financially stable.

“A hospital might shift certain services to a nearby regional provider with higher patient volume and specialized staff while expanding other local services,” such as primary, outpatient, or community-based care, she said.

Wiens and Darrell Messersmith, CEO of Dahl Memorial Hospital in the southeastern Montana town of Ekalaka, said they worry the only way hospitals will get their share of funding is to cut services or become Rural Emergency Hospitals that don’t offer inpatient services.

“I would hate to see things shift toward a pack-and-ship facility,” Messersmith said. “Right now, we function quite well as an inpatient facility.”

Not all Montana health leaders are worried.

Ed Buttrey, president and CEO of the Montana Hospital Association, said he thinks his state’s plan could help rural hospitals become financially sustainable and survive Medicaid cuts. Buttrey is also a Republican state lawmaker.

Chauvet, the Big Sandy rancher, said his perspective on whether remote towns like his should have a hospital is forever changed because of his accident.

“I always would say, ‘Oh, they’re nice to have,’ but now I look at the hospital and say, ‘That’s essential to our community,’” he said.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

But plans to spend those nine-digit awards aren’t all warmly received.

At least one group of Republican state lawmakers appears to have scuttled an initiative preapproved by federal officials. And at least one hospital association persuaded its state health leaders to alter who greenlights spending. Other critics are taking a more cautious approach.

That’s because the Centers for Medicare & Medicaid Services, which manages the five-year Rural Health Transformation Program, says states could lose money if they make major changes to the plans approved in their applications. Changes could also delay states’ ability to get projects rolling in time to show the agency that they’re meeting progress deadlines.

“During the application period, states were advised to only propose initiatives and state policy actions that the state deemed feasible,” said CMS spokesperson Catherine Howden, who noted that the agency will work with states case by case.

The recent pushback reflects “tension” over state plans — which were approved by the federal government — from state lawmakers and health leaders who want more input amid tight deadlines, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics.

Cochran-McClain said many states must pass a bill to allow federal dollars to be spent and added that because the program rolled out so quickly “there’s important work that still needs to be done in some states between the legislatures and the governors.”

State lawmakers want to have a say, she said, in “how the funding is being allocated — how the implementation will go.”

Congressional Republicans created the program as a last-minute sweetener to include in their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is expected to slash Medicaid spending by nearly $1 trillion over a decade.

CMS officials announced first-year funding — ranging from $147 million for New Jersey to $281 million for Texas — on Dec. 29, after scoring applications. Federal officials will begin evaluating progress in late summer and announce 2027 allocations at the end of October.

A chorus of critics say the program won’t make up for harm caused by Medicaid cuts.

The program is “a complete sham,” Sen. Ron Wyden (D-Ore.) said at a rural policy conference in February.

Medicaid, a joint federal-state program for low-income and disabled Americans, serves nearly , and many rural hospitals depend on it to stay afloat.

But the rural health program tilts toward seeding innovative projects and technologies, not shoring up rural hospital finances. States can use only up to 15% of their funding to pay providers for patient care.

That hasn’t stopped some federal officials and lawmakers from framing the program as a rural hospital rescue.

For example, the White House , “President Trump secured $50 billion in funding for rural hospitals.”

Now that applications have been approved, some state Republican lawmakers — who are than Democrats are — and hospital associations are upset that the political rhetoric doesn’t match what they see.

They’re also lobbing criticisms at specific aspects of their states’ plans, including the proposed projects, what’s not included, and the spending approval process.

In Wyoming, lawmakers didn’t just criticize an initiative from their state’s application. They moved to kill it.

State Rep. John Bear, a Republican, said he and other lawmakers declined to fund “BearCare,” a proposed state-sponsored health insurance plan that patients could use only after medical emergencies. But they did approve other aspects of the rural health program.

The Wyoming Department of Health won’t “proceed with BearCare without express legislative authority to do so,” said spokesperson Lindsay Mills.

While Wyoming lawmakers removed an initiative from their state’s rural health plan, a group in Ohio wants to add something.

Ohio Rep. Kellie Deeter and other Republican lawmakers to use the maximum allowed funding for provider payments — 15% — to support 13 independent, rural hospitals.

“We understand that the rural transformation fund is not designed to be given directly to prop up hospitals,” Deeter said. “We just want to capitalize on the mechanism of the fund that can be utilized for that purpose.”

Those hospitals “operate with very, very narrow margins, and it’s just difficult and, frankly, unsustainable,” she added.

Ken Gordon, a press secretary responding for the governor’s office and the state health department, said, “It’s still very early in this process, and many details are being worked out.”

State lawmakers around the country are also trying to ensure the federal program’s dollars benefit rural areas.

In North Dakota, Rep. Bill Tveit, a Republican who lives in a town with about 2,000 residents, that would have required the state to reserve its funding for programs located more than 35 miles from urban areas and small cities.

During a hearing, lawmakers appeared sympathetic to Tveit’s concerns but quickly shot down his idea.

State Sen. Brad Bekkedahl said the North Dakota health department already committed to prioritizing funding for the most pressing rural health needs. He also said he’s concerned any significant changes could cause the state to lose funding because CMS already reviewed and approved the plan.

Meanwhile, Republican lawmakers in Michigan and North Carolina have criticized their states’ definitions of “partially rural” or “rural,” saying that counties that include urban population centers could take money from lower-density counties, according to and .

Lawmakers aren’t the only ones speaking out.

The Colorado Hospital Association to state lawmakers denouncing how the state created its plan and two of its proposed initiatives.

“Not only were Colorado’s rural hospitals’ recommendations disregarded,” president and CEO Jeff Tieman wrote, but the plan includes ideas “they actively oppose and believe will harm the communities they serve.”

The department responded to one of the association’s concerns by adding rural health leaders to the .

Meanwhile, and Nebraska, some health groups are upset that their states’ plans lack specific funding streams for rural hospitals.

Lauren LaPine-Ray, who oversees rural health policy at the Michigan Health & Hospital Association, predicted the state’s rural hospitals will compete with other organizations, such as academic centers and health clinics, for funding. She said about 65% of the group’s rural members have never applied for a state grant before.

“The rural hospitals, the ones that really need the funding the most, will not be well equipped to apply for and pull down these dollars,” LaPine-Ray said.

Jed Hansen, executive director of the Nebraska Rural Health Association, said the federal funding won’t go to “rural hospitals, rural clinics, and rural providers in a meaningful way.”

“Rural Health Transformation will not save a single hospital in our state,” he said. “I don’t think it will save a hospital nationally.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Not one U.S. citizen has applied.

West River Health Services in Hettinger, a town of about 1,000 residents in the southwestern part of the state, has four options, and none is good.

The hospital could fork over $100,000 for the Trump administration’s new H-1B visa fee and hire one of the more than 30 applicants from the Philippines or Nigeria. The fee is the equivalent of what some rural hospitals would pay two lab techs in a year, said Holzkamm, who is West River’s lab manager.

West River could ask the Department of Homeland Security to waive the fee. But it’s unclear how long the waiver process would take and if the government would grant one. The hospital could continue trying to recruit someone inside the U.S. for the job. Or, Holzkamm said, it could leave the position unfilled, adding to the workload of the current “skeleton crew.”

The U.S. health care system depends on foreign-born professionals to fill its ranks of doctors, nurses, technicians, and other health providers, particularly in chronically understaffed facilities in rural America.

But a new presidential proclamation aimed at the tech industry’s use of H-1B visas is making it harder for West River and other rural providers to hire those staffers.

“The health care industry wasn’t even considered. They’re going to be collateral damage, and to such an extreme degree that it was clearly not thought about at all,” said Eram Alam, a Harvard associate professor whose new book examines the history of foreign doctors in the U.S.

Elissa Taub, a Memphis, Tennessee-based attorney who assists hospitals with the H-1B application process, has been hearing concerns from her clients.

“It’s not like there’s a surplus of American physicians or nurses waiting in the wings to fill in those positions,” she said.

Until recently, West River and other employers paid up to $5,000 each time they applied to sponsor an H-1B worker. The visas are reserved for highly skilled foreign workers.

The new $100,000 fee — part of a by President Donald Trump — applies to workers living outside the U.S. but not those who were already in the U.S. on a visa.

West River lab tech Kathrine Abelita is one of nine employees — six technicians and three nurses — at the hospital who are current or former H-1B visa holders. Abelita is from the Philippines and has worked at West River since 2018. She’s now a permanent U.S. resident.

“It’s going to be a big problem for rural health care,” she said of the new fee. She said most younger American workers want to live in urban areas.

Sixteen percent of registered nurses, 14% of physician assistants, and 14% of nurse practitioners and midwives who work in U.S. hospitals are immigrants, according to a . Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to .

The , two , and have asked the administration to give the health care industry exemptions from the new fee. The new cost will disproportionally harm rural communities that already struggle to afford and recruit enough providers, the groups argue.

“A blanket exception for healthcare providers is the simplest path forward,” the National Rural Health Association and National Association of Rural Health Clinics wrote in a joint letter.

The proclamation allows fee exemptions for individuals, workers at specific companies, and those in entire industries when “in the national interest.” says the fee will be waived only in an “extraordinarily rare circumstance.” That includes showing that there is “no American worker” available for the position and that requiring a company to spend $100,000 would “significantly undermine” U.S. interests.

Taub called those standards “exceptionally high.”

Representatives of the NRHA and the American Medical Association, which organized a letter from the medical societies, said they’ve received no response after sending requests to Homeland Security Secretary Kristi Noem in late September and early October. The AHA declined to say whether it had heard back.

Homeland Security officials directed ºÚÁϳԹÏÍø News’ inquiries to the White House, which did not answer questions about individual waiver timelines or the possibility of a categorical exemption for the health care industry.

Instead, White House spokesperson Taylor Rogers sent a statement defending the new fee, saying it will “put American workers first.” Her comments echo Trump’s proclamation, which focuses on accusations that the tech industry is abusing the H-1B program by replacing American workers with lower-paid foreign ones. But the order applies to all trades.

Alam, the Harvard professor, said the U.S.’ reliance on international providers does raise legitimate concerns, such as about how it takes professionals away from lower-income countries facing even greater health concerns and staffing shortages than the U.S.

This decades-long dependency, she said, stems from population booms, medical schools’ historical exclusion of nonwhite men, and the “much, much cheaper” cost of importing providers trained abroad than expanding health education in the U.S.

Internationally trained doctors tend to work in rural and urban areas that are poor and underserved, according to and .

Nearly 1,000 H-1B providers were employed in rural areas this year, the two rural health organizations wrote in their letter to the Trump administration.

J-1 visas, the most common type held by foreign doctors during their residencies and other postgraduate training in the U.S., require them to return to their home country for two years before applying for an H-1B.

But a government program called the Conrad 30 Waiver Program allows up to 1,500 J-1 holders a year to remain in the U.S. and apply for an H-1B in exchange for working for three years in a provider shortage area, which includes many rural communities.

Trump’s proclamation says employers that sponsor H-1B workers already inside the U.S., such as doctors with these waivers, won’t have to pay the six-figure fee, a nuance clarified in guidance released about a month later.

But employers will have to pay the new fee when hiring doctors and others who apply while living outside the U.S.

Alyson Kornele, CEO of West River Health Services, said most of the foreign nurses and lab techs it hires are outside the U.S. when they apply.

Ivan Mitchell, CEO of Great Plains Health in North Platte, Nebraska, said most of his hospital’s H-1B physicians were inside the U.S. on other visas when they applied. But he said physical therapists, nurses, and lab techs typically apply from abroad.

Holzkamm said it took five to eight months to hire H-1B applicants at her lab before the new fee was introduced.

Bobby Mukkamala, a surgeon and the president of the American Medical Association, said Republican and Democratic lawmakers are concerned about the ramifications for rural health care.

They include Senate Majority Leader John Thune, who said he planned to reach out about possible exemptions.

“We want to make it easier, not harder, and less expensive, not more expensive, for people who need the workforce,” the Republican told ºÚÁϳԹÏÍø News in September.

Thune’s office did not respond to questions about whether the senator has heard from the administration regarding potential waivers for health workers.

The Trump administration is facing at least two lawsuits attempting to block the new fee. includes a company that recruits foreign nurses and a union that represents medical graduates. , by the U.S. Chamber of Commerce, mentions concerns about the physician shortage and health systems’ ability to afford the new fee.

Kornele said West River won’t be able to afford a $100,000 fee so it’s doubling down on local recruiting and retention.

But Holzkamm said she hasn’t been successful in finding lab techs from North Dakota colleges, even those who intern at the hospital. She said West River can’t compete with the salaries offered in bigger cities.

“It’s a bad cycle right now. We’re in a lot of trouble,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The Trump administration, which has promised “radical transparency,” that it plans to publish the “project summary” for states that win awards. Following the lead of federal regulators, many states are withholding their complete applications, and some have refused to release any details.

“Let’s be clear,” said Alan Morgan, chief executive of the National Rural Health Association. “The hospital CEOs, the clinic administrators, the community leaders: They’re going to want to know what their states are doing.” The NRHA’s members include struggling rural hospitals and clinics, which would benefit from the Trump administration’s Rural Health Transformation Program.

Morgan said his members are interested in what states propose, which of their ideas are approved or rejected, and their budget narratives, which detail how the money could be spent.

Improving rural health care is an “insanely complicated and difficult task,” Morgan said.

The five-year Rural Health Transformation Program was approved by Congress in a law — the One Big Beautiful Bill Act — that also drastically cuts Medicaid spending, on which rural providers heavily depend. It’s being watched closely because it’s a much-needed influx of funds — with a caveat from the Trump administration that the money be spent on transformational ideas, not just to prop up ailing rural hospitals.

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be distributed through a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Health and Human Services Secretary Robert F. Kennedy Jr. has repeatedly promised to open the government to the American people. His agency has devoted to “radical transparency.”

“We’re working to make this the most transparent HHS in its 70-year history,” in written testimony to lawmakers in September.

Lawrence Gostin, a professor of public health law at Georgetown University, said HHS is “acting in a way that utterly lacks transparency” and that the public has the right to demand “greater openness and clarity.” Without transparency, the public cannot hold HHS accountable, he said.

Centers for Medicare & Medicaid Services spokesperson Catherine Howden said the agency will follow the federal regulations when releasing information about the rural health program.

Grant applications are “not released to the public during the merit review process,” Howden said, adding, “The purpose of this policy is to protect the integrity of evaluations, applicant confidentiality, and the competitive nature of the process.”

Democrats and many health care advocates are concerned politics will affect how much money states get.

“I am very concerned about retaliation,” said Rep. Nikki Budzinski (D-Ill.). Because Democrats control her state’s politics, “our application might not be as seriously considered as other states that have Republican leadership,” she added.

Illinois’ Democratic members of the U.S. House to CMS Administrator Mehmet Oz in November asking for “full and fair consideration” of their state application. Illinois officials have not yet released their state’s proposal to ºÚÁϳԹÏÍø News, which has a pending public records request.

Heather Howard, a professor of the practice at Princeton University, said she is “pleasantly surprised at how transparent the states have been.”

Howard directs the university’s State Health and Value Strategies program, which the rural health fund, and praised most states for publicly posting their project summaries.

“To me, it speaks to the intense interest in this program,” Howard said. Her team, reviewing about two dozen state summaries, found themes including expansion of home-based and mobile services, increased use of technology, and workforce development initiatives like scholarships, signing bonuses, and child care assistance for high-demand positions.

“I think it’s exciting,” Howard said. “What’s great here is the experimentation we’re going to learn from.”

Telerobotics appeared in Georgia’s and Alabama’s applications, she said, including a proposal to use robotic equipment for remote ultrasounds.

Another theme that “warms my heart,” Howard said, was the effort among states to create advisory groups or committees, including in Idaho, where work groups are expected to focus on technology, workforce development, tribal collaboration, and behavioral health.

All 50 states submitted applications to federal regulators by the Nov. 5 deadline and awards will be announced by the end of the year, according to CMS.

As of late November, nearly 40 states had released their project narrative, the main part of the application, which describes proposed initiatives, according to ºÚÁϳԹÏÍø News tracking. More than a dozen states have also released their budget narratives.

Also as of late November, only a handful of states — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina, and Wyoming — had released all parts of the application.

ºÚÁϳԹÏÍø News filed public records requests for states’ complete applications. Some states have refused to release any of their application materials.

Nebraska, for example, rejected a public records request, saying its application materials are “proprietary or commercial information” that “would give advantage to business competitors.”

Kentucky shared its application summary but said the remainder of the application is a “preliminary draft” not subject to release under state laws.

Erika Engle, a spokesperson for Hawaii Gov. Josh Green, said the governor “is committed to transparency” but declined to share any of the state’s proposal.

Hawaii and other states are still processing formal public records requests.

The rural health program is part of the July law projected to reduce federal Medicaid spending in rural areas by 10 years.

Those cuts are expected to affect rural health facilities’ bottom lines, threatening their ability to stay open. A recent Commonwealth Fund report found that rural areas continue to to primary care. But the guidelines for the rural health program say states can use only 15% of their new funding to pay providers for patient care.

Between the Medicaid cuts and funding boost from the new program, “there’s real opportunity for national policy to impact rural, both in the negative and the positive potentially,” said Celli Horstman, a senior research associate at the New York-based policy think tank who co-authored the report.

Among the publicly available rural health transformation proposals, Democratic-leaning states show support, or are willing to adopt, some of the administration’s goals but will lose out on points from eschewing others.

For example, New Mexico said it would introduce legislation requiring students to take the Presidential Fitness Test and physicians to complete continuing education courses on nutrition. But it won’t prevent people from using their Supplemental Nutrition Assistance Program benefits to buy “non-nutritious” foods such as soda and candy.

Many states want to invest in technology, including telehealth, cybersecurity, and remote patient monitoring equipment. Other themes include increasing access to healthy food, improving emergency services, preventing and managing chronic illnesses, and enlisting community health workers and paramedics for home visits.

Specific proposals include:

• Arkansas wants to spend $5 million through its “FAITH” program — Faith-based Access, Interventions, Transportation, & Health — to enlist rural religious institutions to host education and preventive screening events. Congregations could also install walking circuits and fitness equipment.
• Alaska, which historically relied on dogsled teams to bring medication to remote areas, is looking to test the use of “unmanned aerial systems” to speed up pharmacy deliveries to such communities.
• Tennessee wants to increase access to healthy activities by spending money on parks, trails, and farmers markets.
• Maryland wants to start mobile markets and install refrigerators and freezers to improve access to fresh, healthy food that often spoils in rural areas with few grocery stores.

State Sen. Stephen Meredith, a Republican who represents part of western Kentucky, said he still expects rural hospitals to close despite his state’s rural health transformation program.

“I think we’re treating symptoms without curing the disease,” he said after listening to a presentation on Kentucky’s proposal at .

Morgan, whose organization represents rural hospitals likely to close, said the state’s ideas may sound good.

“You can craft a narrative that sounds wonderful,” he said. “But then translating the aspirational goals to a functioning program? That’s difficult.”

ºÚÁϳԹÏÍø News staffers Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith, and Lauren Sausser contributed to this report.

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Watts knew other missileers with similar cancers. But the connection really hit home later that same January day, when the results of a blood test revealed that Watts himself had chronic lymphocytic leukemia, a type of non-Hodgkin lymphoma.

“I don’t know if it was ironic or serendipitous or what the right word is, but there it was,” Watts said.

Within the community of U.S. service members who staff nuclear missile silos scattered across the Northern Rockies and Great Plains, suspicions had long been brewing that their workplaces were unsafe. Just months after Watts was diagnosed in 2022, Lt. Col. Danny Sebeck, a former Air Force missileer who had transferred to the U.S. Space Force, wrote a brief on a potential cancer cluster among people who served at Minuteman III launch control centers on Malmstrom Air Force Base in Montana.

Sebeck identified who served primarily from 1993 to 2011 and had been diagnosed with cancer, including himself. Of those, 11 had non-Hodgkin lymphoma; three had died. The Air Force responded swiftly to Sebeck’s findings, into cancer cases and the environment at three intercontinental ballistic missile bases and a California launch facility. The goal is to complete the research by the end of 2025.

The service has released portions of the studies as they conclude, holding online town halls and briefings to highlight its findings. But while former missileers say they are heartened by the rapid response, they remain concerned that the research, which crosses decades and includes thousands of ICBM personnel and administrative workers, may address too large a population or use statistical analyses that won’t show a connection between their illnesses and their military service.

They need that tie to expedite benefits from the Department of Veterans Affairs.

Historically, the Department of Defense has been slow to recognize potential environmental diseases. Veterans sickened by exposure to Agent Orange in Vietnam, Marines who drank contaminated water at Camp Lejeune, North Carolina, and service members who lived and worked near burn pits in Iraq and Afghanistan fought for years to have their illnesses acknowledged as related to military service.

In the case of the missileers, the Air Force already had studied potential contamination and cancer at Malmstrom in and . That research concluded that launch control centers were “safe and healthy working environments.” But with Sebeck’s presentation and the decision to pursue further investigation, Air Force Global Strike Command — the unit responsible for managing nuclear missile silos and aircraft-based nuclear weapons — said the earlier studies may not have included a large enough sampling of medical records to be comprehensive.

Sebeck, who serves as co-director of the Torchlight Initiative, an advocacy group that supports ICBM personnel and their families, told congressional Democrats that the Defense Department has not accurately tracked exposures to the community, making it difficult for veterans to prove a link and obtain VA health care and disability compensation.

“I had to go to a VA person and pull some papers,” Sebeck said, referring to the government system for recording service members’ environmental risks. “It says that I visited Poland once. It doesn’t mention that I pulled 148 alerts in a launch control center with polychlorinated biphenyls and with this contaminated air and water.”

PCBs — And the Missileers Exposed to Them

PCBs are synthetic chemicals once used in industry, including missile control electrical components such as display screens, keyboards, and circuit breakers. They have been banned for manufacture since 1979, deemed toxic and a likely carcinogen by the Environmental Protection Agency.

The Air Force’s Missile Community Cancer Study compares 14 types of common cancers in the general U.S. population and the missile community and also studies the environments at Malmstrom Air Force Base in Montana, F.E. Warren Air Force Base in Wyoming, Minot Air Force Base in North Dakota, and Vandenberg Space Force Base in California to determine whether they may have contributed to the risk of developing cancer.

The Malmstrom, Warren, and Minot bases together field 400 Minuteman III missiles, the land-based leg of the U.S. nuclear triad, which also includes submarine- and aircraft-launched nuclear weapons. The missiles are housed in silos spread across parts of Montana, North Dakota, Wyoming, Colorado, and Nebraska, staffed around the clock by missileers operating from underground, bunkerlike launch control centers.

So far, the Air Force investigation has found from cancer in the missile community compared with the general population, and it found that the death rates for four types of common cancers — non-Hodgkin lymphoma, lung, colon and rectum, and prostate cancer — were significantly lower in missileers than in the general population.

Non-Hodgkin lymphoma accounted for roughly 5.8% of all cancer deaths among people who worked in launch control centers from January 1979 to December 2020.

Early results, derived from Defense Department medical records, found elevated rates of breast and prostate cancers in the missile community, but a later analysis incorporating additional data did not support those findings. The studies also did not find increased rates of non-Hodgkin lymphoma. Air Force officials noted during a June 4 online town hall, however, that these assessments are based on roughly half the data the service expects to review for its final epidemiological reports and cautioned against drawing conclusions given the limitations.

The final incidence report will include federal and state data, including information from civilian cancer registries, and delve into subgroups and exposures, which may “provide deeper insights into the complex relationship” between serving in the missile community and cancer risk, wrote Air Force Col. Richard Speakman in a September 2024 memo on the initial epidemiology results.

Gen. Thomas Bussiere, commander of Air Force Global Strike Command, said during the June town hall that only the final results will determine whether the missile community’s cancer rates are higher than the general population’s.

Some lawmakers share the concern of missileers about the Air Force study. Following the release of a of Torchlight Initiative data that showed higher rates of non-Hodgkin lymphoma — at younger ages — among Malmstrom missileers, Rep. Don Bacon (R-Neb.) to a defense policy bill calling for the National Academies of Sciences, Engineering, and Medicine to review health and safety conditions in the facilities.

“Let’s make sure that we have some outside experts working with the Air Force studying cancer rates with our ICBM missions,” Bacon posted July 30 on the social platform X. “We want to ensure credibility and that whatever results come out, we’ve done total due diligence.”

Regarding additional studies on the working environments at the installations and a possible relationship between exposures and cancer risk, Speakman, who commands the Air Force School of Aerospace Medicine, said Malmstrom had two types of PCBs that the other two missile wing bases did not.

He added that benzene, found in cigarette smoke, vehicle exhaust, and gasoline fumes, was the largest contributor to cancer risk in reviews of the bases.

The assessment concluded that health risks to missileers is “low, but it’s not zero,” Speakman said. He said it would be appropriate to monitor the health of launch control workers.

Next Steps

Watts, whose story has been highlighted by the Torchlight Initiative, has asked the Defense Department’s inspector general to investigate — the watchdog agency referred his request to Global Strike Command — and is closely watching the Air Force research. He said the bulk of the cancer cases reported to Torchlight occurred in the 2000s, when ICBM personnel still used technology that contained PCBs, burned classified material such as treated paper and plastic coding devices indoors, and possibly were exposed to contaminated water.

“I open the door and there’s guys standing there in pressurized suits with sampling equipment,” Watts recalled. “They said, ‘We’re here to check for contaminated water.’ I look at my crew commander, and we’re standing there in cotton uniforms. I said, ‘Do you see anything wrong with this?’”

Launch control operators no longer burn code tapes indoors and the Air Force has made improvements to air circulation in the centers. Sebeck wants Congress to consider including missileers and others sickened by exposure to base contamination in the PACT Act, landmark legislation that mandates health care and benefits for veterans sickened by burn pits and other pollutants.

“It’s documented that there is a large cancer cluster in Montana, probably also in Wyoming. People act surprised, but all they have to do is go to the oncology office in Denver. I can find my missileer buddies there. We are sitting in the same chairs getting chemotherapy,” Sebeck said.

Air Force Global Strike Command spokesperson Maj. Lauren Linscott said in response to Sebeck’s remarks that the unit understands the impact of cancer on its personnel and is committed to supporting them.

“While current findings are preliminary and no conclusions can yet be drawn, we are dedicated to a rigorous, peer-reviewed, data-driven process to better understand potential health risks because the safety of our airmen is our top priority,” Linscott said.

Bills introduced in the House and Senate would address the situation. In addition to Bacon’s amendment, the Senate version of an annual defense policy bill would require a “deep cleaning” of launch control centers every five years until the sites are decommissioned as a new ICBM, the Sentinel, replaces the Minuteman IIIs.

The Air Force aims to release its final epidemiological report by the end of the year.

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The mobile MRI unit visits Southwest Healthcare Services, the hospital in Bowman, North Dakota, each Wednesday. Without it, the community’s 1,400 residents would have to drive 40 minutes to get to an MRI machine, an expensive piece of medical equipment the hospital couldn’t afford on its own.

Southwest Healthcare Services and 21 other independent, rural North Dakota hospitals are part of the Rough Rider Network, which used its members’ combined patient rolls to negotiate better prices for the mobile imaging truck.

Independent rural hospitals are increasingly joining what are called clinically integrated networks, collaborative groups that allow them to avoid selling out to larger health systems while sharing resources to save money and improve patient care. Many are motivated by the chance to combine their patient rolls for , a growing reimbursement model in which insurers pay providers based on the quality of care they provide and the health outcomes of their patients.

Supporters of the networks are exploring whether funding from the $50 billion Rural Health Transformation Program — part of President Donald Trump’s recent tax and spending bill — can be used to help start or expand such organizations.

For independent, rural hospitals, the networks are an alternative to shutting down or reducing services, or to giving up local autonomy and joining a large hospital system.

“Anything that can help our rural hospitals and add services is awesome,” said Jacobi, who provides speech therapy to children in the local school district.

Since 2010, 153 rural hospitals in the U.S. have shuttered completely or stopped offering inpatient services, the Sheps Center for Health Services Research at the University of North Carolina. A far larger number, 441, merged with or were acquired by hospital systems between 2011 and 2021. That’s commissioned by the Coalition to Strengthen America’s Healthcare, an advocacy group comprising hospitals and health associations.

The Rough Rider Network provides negotiating leverage to its members, which serve about two-thirds of rural North Dakotans, said Dennis Goebel, CEO of the Bowman hospital.

Health care vendors “probably wouldn’t be talking to us if we’re by ourselves,” he said. “They’re not looking for the little, tiny crumbs. They want a big contract, and they’ll give you better pricing.”

Some rural networks share specialists who aren’t needed full time at any one hospital, according to , a nonprofit focused on improving the health care system. Some networks also invest in broadband, housing, and other community development projects that can help people stay healthy and access care.

Hospitals can pool staffers for a network-wide employee health insurance plan, said Nathan White, CEO of Cibolo Health, a company that helps launch and manage networks in rural areas. He said they can also enter shared contracts for telehealth, prescription drug programs, and other services.

White said he started Cibolo Health after a leader from an independent, rural North Dakota hospital asked him about collaborating with similar facilities. The Rough Rider Network launched in late 2023 with assistance from the company and $3.5 million from the North Dakota Legislature.

Since then, Cibolo Health has helped start networks in Minnesota, Nebraska, Montana, and Ohio. Once a sixth one opens in September, Cibolo-affiliated networks will represent more than 120 hospitals, with service areas covering 4.7 million people, White said.

The networks, which are nonprofits owned by the hospitals, pay an annual fee to Cibolo Health, a for-profit company, for management services. White said leaders from 10 other states are considering joining this model.

Similar networks have been around for more than 30 years but became more popular after the passage of the 2010 Affordable Care Act, by the Rand Corp., a research nonprofit.

Rural health care providers are increasingly interested in forming such networks, said Marnell Bradfield, executive director of the Community Care Alliance, a network of hospitals and independent primary care offices that launched in 2015 in rural western Colorado. About once a month, she said, she gets a call from health care leaders exploring similar networks and asking about her experience.

The Rand Corp. wrote in its 2020 paper that it didn’t find any academic studies that examined whether these networks do what its supporters claim — save money and improve patient care.

“In theory, quality should improve with the alignment of health care organizations, but there is no evidence,” the report said. The paper also said such networks could end up increasing prices, something that can occur with traditional mergers and acquisitions.

Bradfield and White said they have the evidence, at least for their organizations.

Community Care Alliance members have reduced their insurance costs while improving patient outcomes, such as reducing their need for inpatient and emergency care, Bradfield said.

White said data from a pilot program between Caret Health, a care coordination company, and SMP Health-St. Kateri, one of Rough Rider’s hospitals, showed the program helped a significant number of patients catch up with preventive care.

Gabby Wilkie, finance director at the St. Kateri hospital, in Rolla near the Canadian border, said Caret Health staff called and texted patients who were behind on annual physicals, cancer screenings, vaccinations, and other visits. She said staffers explained to patients why this preventive care is important for their health before setting up a three-way call with St. Kateri staff to schedule an appointment. White said it took an average of 11 outreach attempts before patients came in for any visits.

“To be honest, we didn’t have the resources to reach out,” Wilkie said.

She said St. Kateri would have spent an estimated $300,000 to do that kind of outreach for 1,000 patients. Meanwhile, she said, the hospital estimates it will earn more than $100,000 when that many patients come in for their preventive care. Cibolo Health and the Rough Rider Network both contribute to the cost of the Caret Health service, which is now rolling out to other network hospitals.

Goebel said joining a network to remain independent is also beneficial for the economy of rural areas, where hospitals are often major employers. He said health systems sometimes cut services and staff at rural hospitals they acquire.

Jacobi is taking medication and doing physical therapy after a doctor examined her MRI results. If that doesn’t work, she may need to make a five-hour round trip to Bismarck to get an ultrasound-guided steroid shot. Jacobi was thankful she could get a diagnosis and treatment advice without having to travel far for the MRI.

“Anytime we can maintain more local control, it’s a good thing for our small towns,” she said.

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There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The , open to all medical students and physicians, and the both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in .

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

He pointed to Vermont, where recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, .

The Society of Emergency Medicine PAs PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told ºÚÁϳԹÏÍø News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

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Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. “It seems like it takes entirely too long,” he said.

Many veterans live hours from VA facilities, or they need health services that aren’t readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.

Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.

Two Republican senators have that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump’s first term.

Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn’t be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.

“My main concern is for veterans, not for the VA,” Sen. Kevin Cramer (R-N.D.) told ºÚÁϳԹÏÍø News. “I don’t believe we have an obligation to sustain the bureaucracy.”

About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.

Cramer that would allow veterans who live within 35 miles of a rural, “critical access” hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.

Cramer, who serves on the Senate Veterans’ Affairs Committee, noted his state has just one VA hospital. It’s in Fargo, on the state’s eastern border, which is more than 400 miles by car from parts of western North Dakota.

Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. “I kept thinking to myself, ‘This doesn’t make any sense at all,’” Cramer said.

Cramer said previous laws, including the , made it easier for veterans to use their benefits to cover care at community hospitals and clinics.

But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.

“We can’t let the VA itself determine whether a veteran is qualified to receive local care,” he said.

U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans’ Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department’s money to support private health care facilities.

The VA provides specialized care that responds to veterans’ needs and experiences, he argues.

“We must prevent funds from being siphoned away from veterans’ hospitals and clinics, or VA will crumble,” Takano said in a statement released by his office. “Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community.”

Some veterans’ advocacy groups have also expressed concerns.

Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn’t want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.

Retzer said it’s true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. “This is a national crisis.”

Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. “We want to ensure that the VA is the primary provider of that care,” he said.

Veterans Affairs Secretary Doug Collins to improve the community care program while maintaining the strength of the department’s hospitals and clinics. The department declined a ºÚÁϳԹÏÍø News request to interview Collins.

Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer’s bill. Lewis is a Navy veteran who uses the VA’s community care option to pay for treatment of a back injury stemming from his military service.

Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. “It’s frustrating.”

Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they’re entitled to receive locally.

“I think a lot of folks just don’t want to fight the system,” he said. “They don’t want to go through the extra hoops, and so they’ll jump in the van, and they’ll ride along.”

Rep. Mike Bost (R-Ill.), chairman of the House Veterans’ Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.

Bost helped gain for Trump’s request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that

Bost also co-sponsored that would spell out requirements for the VA to pay for community care.

Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.

Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency’s mission, including its employment of many veterans. “You just feel like you’re being taken care of by your own,” he said.

He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can’t promptly provide.

The local VA doesn’t offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.

Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.

Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn’t have to jump through so many hoops to obtain convenient care.

“After what they’ve done for us? Please,” she said.

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So she pounced on the opportunity to get him vaccinated after learning that a mobile clinic would be visiting her neighborhood.

“I was definitely concerned about the epidemic and the measles,” Palmier, a member of the Oglala Sioux Tribe, said at the June event. “I wanted to do my part.”

So did her son, Makaito Cuny.

“I’m not going to be scared,” the 5-year-old announced as he walked onto the bus containing the clinic and hopped into an exam chair.

Makaito sat still as a nurse gave him the shot in his arm. “I did it!” he said while smiling at his mother.

The vaccine clinic was hosted by the Great Plains Tribal Leaders’ Health Board, which serves tribes across Iowa, Nebraska, and the Dakotas. It’s one way Native American tribes and organizations are responding to concerns about low measles vaccination rates and patients’ difficulty accessing health care as the disease spreads across the country.

Meghan O’Connell, the board’s chief public health officer, said it is also working with tribes that want to host vaccine clinics.

Elsewhere, tribal health organizations have launched social media campaigns, are making sure health providers are vaccinated, and are reaching out to the parents of unvaccinated children.

This spring, Project ECHO at the University of New Mexico hosted an online video series about measles aimed at health care professionals and organizations that serve Native American communities. The presenters outlined the basics of measles diagnosis and treatment, discussed culturally relevant communication strategies, and shared how tribes are responding to the outbreak.

Participants also strategized about ways to improve vaccination rates, said Harry Brown, a physician and an epidemiologist for the United South and Eastern Tribes, a nonprofit that works with 33 tribes in the Atlantic Coast and Southeast regions.

“It’s a pretty hot topic right now in Indian Country and I think a lot of people are being proactive,” he said.

Measles can survive for up to two hours in the air in a space where an infected person has been, of people who aren’t vaccinated, according to the Centers for Disease Control and Prevention.

The U.S. has had 1,319 confirmed cases of measles this year as of July 23, according to the CDC. It’s the largest outbreak in the U.S. since 1992. Ninety-two percent of the 2025 cases involve unvaccinated patients or people with an unknown vaccination status. Three people had died in the U.S. and 165 had been hospitalized as of July 23.

O’Connell said data on Native Americans’ vaccination rates is imperfect but that it suggests a lower percentage of them have received measles shots than the overall U.S. population.

The limited national data on measles vaccination rates for Native Americans is based on small surveys of people who self-identify as Native American. Some show that Native Americans have measles vaccination rates, while others show .

Data from some states, including and , shows that Native Americans are less likely than white children to be vaccinated on schedule.

The national measles vaccination rate is significantly lower for Native Americans who use the mostly rural Indian Health Service. About 76% of children 16 to 27 months old had gotten the first shot, collected by the agency during recent patient visits at 156 clinics. That’s a 10-percentage-point drop from 10 years ago.

But the IHS data shows that its patients are at least as likely as other children to have received both recommended measles shots by the time they’re 17. O’Connell said it’s unclear if currently unvaccinated patients will continue the trend of eventually getting up to date on their shots or if they will remain unvaccinated.

The immunization rate is probably higher for older children since schools require students to get vaccinated unless they have an exemption, Brown said. He said it’s important that parents get their children vaccinated on time, when they’re young and more at risk of being hospitalized or dying from the disease.

Native Americans may have lower vaccination rates due to the challenges they face in accessing shots and other health care, O’Connell said. Those on rural reservations may be an hour or more from a clinic. Or, like Palmier, they may not have reliable transportation.

Another reason, O’Connell said, is that some Native Americans distrust the Indian Health Service, which is chronically underfunded and understaffed. If the only nearby health care facility is run by the agency, patients may delay or skip care.

O’Connell and Brown said vaccine skepticism and mistrust of the entire health care system are growing in Native American communities, as has occurred elsewhere nationwide.

“Prior to social media, I think our population was pretty trustful of childhood vaccination. And American Indians have a long history of being severely impacted by infectious disease,” he said.

European colonizers’ arrival in the late 1400s , including measles, that of Indigenous people in North and South America by the early 1600s. Native Americans have also had high mortality rates in modern pandemics, including the 1918-20 Spanish flu and covid-19.

The Great Plains Tribal Leaders’ Health Board reacted quickly when measles cases began showing up near its headquarters in South Dakota this year. Nebraska health officials announced in late May that a child had measles in a rural part of the state, close to the Pine Ridge Indian Reservation. Then, four people from the Rapid City area got sick later that month and into the middle of June.

“Our phones really rang off the hook” once that news came out, said Darren Crowe, a vice president at the board’s Oyate Health Center in Rapid City. He said parents wanted to know if their children were up to date on their measles vaccines.

Crowe said the health board ordered extra masks, created a measles command team that meets daily, and called parents when its online database showed their children needed a shot.

Brown praised that approach.

“It takes a concerted outreach effort that goes individual to individual,” he said, adding that his organization helped the Mississippi Band of Choctaw Indians and the Alabama-Coushatta Tribe of Texas with similar efforts.

Brown said reaching specific families can be a challenge in some low-income Native American communities, where many people’s phone numbers frequently change since they use temporary prepaid plans.

Once a health worker reaches a parent, Brown said, they should listen and ask questions before sharing the importance of the vaccine against measles, mumps, and rubella.

“Rather than trying to preach to somebody and beat them over the head with data or whatever to convince them that this is what they need to do, you start out by finding out where they are,” he said. “So, ‘Tell me about your experience with vaccination. Tell me what you know about vaccination.’”

Most people agree to immunize their children when presented with helpful information in a nonjudgmental way, Brown said.

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