Six months after a West Virginia man died following a protracted battle with his health insurer over doctor-recommended cancer care, the state’s Republican governor signed a bill intended to curb the harm of insurance denials.

West Virginia’s Public Employees Insurance Agency enrolls nearly 215,000 people — state workers, as well as their spouses and dependents. The new law, which will take effect June 10, will allow plan members who have been approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without the need for another approval from the state-based health plan.

“This legislation is rooted in a simple principle: if a treatment has already been approved, patients should be able to pursue a medically appropriate alternative without being forced to start the process over again — especially when it does not cost more,” Gov. Patrick Morrisey said in a statement after signing the bill into law on March 31.

“This is about common sense, compassion, and trusting patients and their doctors to make the best decisions for their care,” he said.

Delegate Laura Kimble, the Republican from Harrison County who introduced the legislation, told ºÚÁϳԹÏÍø News the measure offers “a rational solution” for patients facing “the most irrational and chaotic time of their lives.”

From Arizona to Rhode Island, at least half of all state legislatures have taken up bills this year related to prior authorization, a process that requires patients or their medical team to seek approval from an insurer before proceeding with care. These state efforts come as patients across the country await relief from prior authorization hurdles, as promised by dozens of major health insurers in a pledge announced by the Trump administration last year.

The West Virginia law was inspired by Eric Tennant, a coal-mining safety instructor from Bridgeport who died on Sept. 17 at age 58. In early 2025, the Public Employees Insurance Agency of a $50,000 noninvasive cancer treatment, called histotripsy, that would have used ultrasound waves to target, and potentially shrink, the largest tumor in his liver. His family didn’t expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life. The insurer said the procedure wasn’t medically necessary and that it was considered “experimental and investigational.”

Becky Tennant, Eric’s widow, told members of a West Virginia House committee in late February that she submitted medical records, expert opinions, and data as part of several attempts to appeal the denial. She also reached out to “almost every one of our state representatives,” asking for help.

Nothing worked, she told lawmakers, until ºÚÁϳԹÏÍø News and NBC News got involved and posed questions to the Public Employees Insurance Agency about Eric’s case. Only then did the insurer reverse its decision and approve histotripsy, Tennant said.

“But by then, the delay had already done its damage,” she said.

Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure. “The insurance company’s decision did not simply delay care. It closed doors,” his wife said.

Had the new law been in effect, Kimble said, Tennant could have undergone histotripsy without preapproval, because it was a less expensive alternative to chemotherapy, which his insurer had already authorized. The bill was passed unanimously by the state legislature in March.

U.S. health insurers argue that most prior authorization requests are quickly, if not instantly, approved. AHIP, the health insurance industry trade group, says prior authorization in preventing potential harm to patients and reducing unnecessary health care costs. But denials and delays tend to affect patients who need expensive, time-sensitive care, .

The practice has come under intense scrutiny in recent years, particularly after the in New York City in late 2024. Americans rank prior authorization as their biggest burden when it comes to getting health care, according to a by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Samantha Knapp, a spokesperson for the West Virginia Department of Administration, would not answer questions about the law’s financial impact on the state. “We prefer to avoid any speculation at this time regarding potential impact or actions,” Knapp said.

In a fiscal note attached to the bill, Jason Haught, the Public Employees Insurance Agency’s chief financial officer, said the law would cost the agency an estimated $13 million annually and “cause member disruption.”

West Virginia isn’t an outlier in targeting prior authorization. By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books, according to a by the National Association of Insurance Commissioners.

Many states have set up “gold carding” programs, which allow physicians with a track record of approvals to bypass prior authorization requirements. Some states establish a maximum number of days insurance companies are allowed to respond to requests, while others prohibit insurance companies from issuing retrospective denials after a service has already been preauthorized. There are also a crop of new state laws seeking to regulate the use of artificial intelligence in prior authorization decision-making.

Meanwhile, prior authorization bills introduced this year across the country, including in Kentucky, Missouri, and New Jersey, have been supported by politicians from both parties.

“Republicans in conservative states see health care as a vulnerability for the midterm elections, and so, unsurprisingly, you’ll see some action on this,” said Robert Hartwig, a clinical associate professor of risk management, insurance, and finance at the University of South Carolina. “They realize that they’re not really going to get much action at the federal level given the degree of gridlock we’ve already seen.”

Last summer, the Trump administration announced a pledge signed by dozens of health insurers vowing to reform prior authorization. The insurers promised to reduce the scope of claims that require preapproval, decrease wait times, and communicate with patients in clear language when denying a request.

Consumers, patient advocates, and medical providers that companies will follow through on their promises.

Becky Tennant is skeptical, too. That’s why she advocated for the West Virginia bill.

“Families should not have to beg, appeal, or go public just to access time-sensitive care,” she told lawmakers. Tennant, who sees the bill’s passage as bittersweet, said she thought her husband would have been proud.

During Eric’s final hospital stay, Tennant recalled, right before he was discharged to home hospice care, she asked him whether he wanted her to keep fighting to change the state agency’s prior authorization process.

“‘Well, you need to at least try to change it,’” she recalled her husband saying. “‘Because it’s not fair.’”

“I told him I would keep trying,” she said, “at least for a while. And so I am keeping that promise to him.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

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

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He was already thinking about delaying it — then his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income, he said. And with a $2,700 deductible, he’d be on the hook for most of the diagnostic exam, a financial hit he said he couldn’t stomach.

“It was going to cost close to $3,000,” said Galvin, who lives in North Kingstown, Rhode Island, and recently retired as director of a durable medical equipment company. “I put it off.”

Galvin said his wife, Nancy, is delaying a costly CT scan for a few years until she too qualifies for Medicare, so it can foot the bill. The federal health program offers coverage for all Americans 65 and older.

People on Affordable Care Act plans nearing retirement age experienced some of the largest price increases following the expiration of enhanced federal subsidies at the end of December. Those with incomes above 400% of the federal poverty level — — had been getting help paying for the plans since the Biden administration expanded the subsidies during the covid-19 pandemic. Adults ages 50 through 64 of those ACA enrollees.

Now, without that federal financial help, some in this age group say they’re wrestling with whether to delay care until they qualify for Medicare. Not only does that put their physical health at risk, said patient advocates, doctors, and health policy researchers, but it potentially just shifts the costs — and could lead to taxpayers’ footing even bigger bills to fix health issues that worsen amid the delays.

“There’s going to be a lot of pent-up demand and unmet need,” said , a health policy consultant who worked in the Obama and Biden administrations. “Medicare is going to have to spend a whole heck of a lot of money covering and dealing with their treatment.”

The Affordable Care Act has been a key source of health care coverage for people 50 through 64. Access to Obamacare plans helped cut the uninsured rate for this age group by half, , a lobbying group that represents older adults. That allowed some people to retire early while keeping coverage. It also has provided a safety net for and those with jobs that don’t offer health insurance.

Last fall, the occurred amid an unsuccessful effort by Democrats to extend the enhanced subsidies. Republicans opposing the extension had said the assistance went to insurers, incentivizing fraud and wasteful coverage.

The issue will continue to have political relevance, especially in this year’s midterm elections, including among older Americans who reliably show up to the polls, said Republican strategist , who runs the Atlas Strategy Group.

“Is affordability going to be an issue? Absolutely,” he said. “Are health care prices going to factor into that? Yes.”

Even before the subsidies expired, the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50, a found.

Middle-aged adults with Obamacare plans acutely feel the pinch of the expired subsidies, because to charge adults in their 60s up to three times as much for premiums as those in their 20s, who generally use fewer medical services.

And many middle-aged adults were already enrolled in the lowest-cost plans available, which leaves them without cheaper options to fall back on, said , a policy analyst with KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“This is very dire for the older marketplace enrollees,” he said.

Someone making a few dollars over 400% of the federal poverty level earns too much to get a subsidy now, and in some states average premium payments were due to for this group. Many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes.

, a primary care physician and health policy researcher at the University of Michigan, said he has regular conversations with older patients who are trying to figure out how to afford their medical care. Some in their early 60s are likely to drop ACA coverage because of rising premiums, he said.

“That’s a gamble,” he added.

Marci Heinbaugh may take that bet. The 63-year-old social services worker, who lives in rural Illinois, said her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum.

She knew she’d be paying more, she said, but wasn’t anticipating that kind of increase. A few months in, she’s not sure if she’ll stick with the plan for the rest of the year. She said she may go uninsured.

“I’m petrified to even think about that,” Heinbaugh said.

People want to buy their own insurance on the marketplace, and many middle-aged adults could afford it with just a little federal financial help, said , senior vice president of public policy at AARP. Those who drop coverage or delay care until they reach age 65 might save money now, but that could be more costly for them — and taxpayers — later.

“There’s significant possibility that the purported savings associated with reducing subsidies as people approach retirement end up turning into higher utilization costs for Medicare,” Weil said.

And Medicare enrollees aren’t insulated from rising costs. In January, for example, standard Medicare from $185 per month to almost $203.

Until Galvin joins Medicare, he said, he expects to burn through a $30,000 retirement account to cover his marketplace plan’s premium payments and deductible.

A found that 1 in 5 adults over 50 had no retirement savings and 3 in 5 were worried they wouldn’t have enough retirement savings to support themselves.

The expiration of these Obamacare subsidies puts additional financial pressure on Americans as they approach retirement, health policy researchers said.

“It’s forcing people to make impossible choices,” said , director of federal health advocacy for the national nonprofit Justice in Aging.

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Lingering pain from a car crash two months ago, on top of an already hardscrabble life, has Angulo worried about her pregnancy. So, she was relieved when a mobile street medicine van from St. John’s Community Health pulled up near her encampment last month.

“Thank God that we have them,” she said.

, which operates 28 clinics, mostly in L.A. County, is part of the nation’s network of nonprofit community clinics that care for the poorest Americans. Around 80% of its 144,000 patients, including Angulo, have Medi-Cal, California’s version of the Medicaid program for people with low incomes or disabilities.

But federal cuts to Medicaid spending under the Republican-passed One Big Beautiful Bill Act, compounded by in Sacramento, could cost St. John’s up to one-third of its $240 million annual revenue, requiring cuts to services that might include street medicine, said Jim Mangia, the president and CEO.

Smaller, more cash-strapped clinics in L.A. County could face harsher consequences, including closure, if the lost funding is not replaced.

That’s why Mangia, along with a coalition of community clinics, health care workers, and advocates, is pushing for a five-year, in the nation’s most populous county to help backfill the projected loss of federal and state dollars. St. John’s has contributed at least $2 million to the campaign so far.

Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said there aren’t a lot of options to save the health care system from disaster.

“Our backs are up against the wall,” she said. “This has the potential to be a game changer. It will be an absolutely significant offset to the losses.”

The L.A. County Board of Supervisors last month for inclusion on the June 2 primary ballot, over the objection of some cities within the county. Their leaders argued the tax would put a strain on consumers and business owners. Most of an in annual revenue generated would be used to protect safety-net health care at community clinics, hospitals, and schools.

Scrambling To Stay Afloat

Nationally, the GOP budget law is expected to cut federal Medicaid spending by over 10 years, and it could lead to an increase of in the number of people left uninsured. The L.A. ballot proposal is among many local and state initiatives nationwide, as clinics, hospitals, health care workers, advocates, and legislators scramble for new money to help offset the spending cuts.

In Michigan, where the federal law is projected to cost the state , Democratic Gov. Gretchen Whitmer’s office has proposed on tobacco, vape products, online gambling, sports betting, and digital advertising, which it projects would raise hundreds of millions of dollars annually.

In Rhode Island, a group of state legislators hopes to ease some of the pain caused by the federal cuts with a that includes a tax on digital ads and a 3% surcharge on taxable incomes above roughly $640,000.

“The goal is not to replace the revenue; it’s to mitigate the damage,” said Democratic state Rep. Brandon Potter, one of the legislators involved.

In Washington, Democratic state Rep. Shaun Scott recently introduced legislation to address the loss of federal dollars with on large companies, applied to employee salaries exceeding $125,000 a year.

In California, the GOP law will slash the to Medi-Cal by an a year, or 25%. Enrollment in Medi-Cal could by 2028 as a result of the federal and state spending cuts, according to an analysis by the UCLA Center for Health Policy Research and the University of California-Berkeley Labor Center.

In July, California will slash Medi-Cal payments that community clinics receive for certain services provided to patients with “unsatisfactory” immigration status by about . Those patients include permanent residents in the country for less than five years, refugees, asylees, and other lawfully present people.

Bracing for a ‘New Reality’?

Advocates and health care experts say finding new revenue is the only way to avoid a crisis in California’s health care system.

“Are we going to let the gaps created by federal policies and state budget cuts leave millions of people uninsured?” said Laurel Lucia, deputy executive director of programs at the UC Berkeley Labor Center. “I think a lot of that question comes down to revenues.”

Some medical professionals say that new revenue is needed in the short term but that the country needs to address its notoriously expensive health care system.

“This new reality is that we have to do our work with less money going into the future,” said Hector Flores, of the Los Angeles County Medical Association. “So, this is an opportunity for us to look at how we can do things better.”

In the meantime, efforts to raise taxes for health care abound.

Voters in Santa Clara County, home to Silicon Valley, last November approved a five-year 0.625% to offset federal Medicaid cuts. A will be on the June ballot in Contra Costa County.

The best-known initiative, and a hotly contested one, is a union-sponsored ballot proposal in California for a on the state’s . Democratic Gov. Gavin Newsom strongly opposes it; Sen. Bernie Sanders (I-Vt.) stumped for it in California recently and has a national version in Congress.

Proponents of the temporary wealth tax say it would raise , which would mostly be used to backfill lost federal and state dollars in Medi-Cal and other safety-net programs. Proponents are trying to collect nearly 875,000 signatures needed to get it on the November ballot.

“We are on the precipice of a collapse of our health care system. So the most fortunate among us pay a modest tax that will hold us over and allow us to figure out a long-term solution,” said Suzanne Jimenez, chief of staff for Service Employees International Union-United Healthcare Workers West, the measure’s chief sponsor. “They would still be incredibly wealthy after that.”

Billionaires Push Back

The plan has stirred considerable controversy, not just in the Golden State but nationwide, and has generated strong and others.

Critics argue the measure could prompt billionaires to leave California, putting a damper on innovation, jobs, and tax receipts. And, some warn, the measure could end up in a legal quagmire, as those deemed liable to pony up challenge it on multiple fronts.

“If this passed, you would expect it to be tied up in court for some time,” said Jared Walczak, a visiting fellow at the California Tax Foundation. “It is fairly plausible that no revenue could come in for a number of years, if there’s ever any revenue at all.”

The prospect of such complications has led some health care advocates to focus instead on local initiatives that could start generating revenue more quickly, such as the proposed sales tax in L.A. County.

That one has critics too, including leaders of multiple cities within the county who to reject a proposal they argued would add to the affordability worries of consumers and put a strain on businesses.

Kathryn Barger, a Republican and the only L.A. County supervisor to oppose putting the measure on the June ballot, said in a statement that the proposed tax would make the county “less affordable for families and less appealing for consumers to shop and businesses to operate.”

But supporters say safety-net health care is already feeling the impact of diminished funding. Last month, for example, L.A. County’s Department of Public Health announced it was due to $50 million in federal, state, and local funding cuts.

Medi-Cal enrollees are worried, too. “We get a lot of calls from panicked patients afraid they’re going to lose their Medi-Cal. Dozens of calls a day, hundreds of calls a week,” said St. John’s Mangia.

“We tell them that we’re working on a solution and hopefully we’ll have that solution come June.”

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“The person said he was an officer of the Department of Criminal Investigations looking into drug trafficking and money laundering,” the woman recalled. He seemed to know a lot about her: the states where she and her late husband had lived; his name and occupation; and her current address in Washington County, Rhode Island.

On her phone, he showed her a convincing badge and a photo ID with his name (“‘Frank’ something”), plus an article describing the supposed investigation. The woman, a 76-year-old retiree, denied any involvement.

“You can hire a very expensive criminal defense attorney, or you can cooperate with me,” Frank told her.

“Now, when you think about it, it doesn’t make any sense,” the woman acknowledged recently. But persuaded by the badge and ID, she agreed to cooperate. Otherwise, “I thought they were going to come and arrest me.”

Frank called each morning to learn where she was going, what she was doing. His team would be watching, he warned. The woman, feeling “petrified,” started looking around as she drove to garden club meetings. Was somebody following her?

It was all a scam.

Because victims’ sense of shame often leaves them reluctant to report such crimes, the extent of elder financial exploitation is hard to calculate. The Federal Trade Commission of $2.4 billion in 2024, largely driven by investment and and impersonations, with total losses much higher.

Americans age 60 and older lose more than $28 billion annually to financial exploitation, .

As those numbers rise, because the population is aging and predators are growing increasingly resourceful, banks and investment firms are becoming the first line of defense.

Frank’s initial target: her account at Fidelity Investments. He instructed her to shift about $250,000 into her checking account, telling the financial adviser at her local office that she and her family intended to buy real estate.

That scheme fizzled when the adviser said Fidelity could not approve the transaction without more information on the property.

So Frank sent her to her local branch of Washington Trust Company to take $70,000 in cash from a home-equity line of credit. “We don’t give out that much in cash,” the teller said, quietly messaging the branch manager, who had known the woman and her husband for years.

The manager ushered the woman into her office to talk, and the scam stopped there, with a call to the local police. The woman’s assets remained intact, but the experience proved so mortifying that she has not told even her family how close she came to losing much of her life savings. The New York Times is withholding her name to spare her embarrassment.

“I felt so stupid,” she said. “I felt like a fool.”

Financial predators targeting older adults represent “a heightened focus for us now,” said Mary Noons, president and chief operating officer of Washington Trust.

A regional community bank, Washington Trust cranked up its efforts last fall to advise older customers and their families about finances, including the dangers of elder fraud and exploitation. It published and distributed a booklet called “Age With Wisdom” and brought in an expert on dementia to speak with staff members.

And it became one of the 1,500 financial institutions to date to use BankSafe, a free AARP video program that trains front-line employees to spot the indicating possible elder exploitation and to intervene. Everyone at the branch where the 76-year-old banked had taken the training.

“Some older customers visit their bank far more frequently than they see their health care providers,” Noons pointed out.

Until recent years, financial institutions placed “more of an emphasis on the autonomy of the client,” said Pamela Teaster, director of the Virginia Tech Center for Gerontology and an elder abuse researcher. Their approach was, “an adult has the capacity to make poor choices, and we’re going to let them make them,” she added.

But changes in government and industry policies and practices have encouraged greater vigilance. Congress passed in 2018, protecting banks and financial firms from liability if they reported suspected exploitation to authorities.

That year, the Financial Industry Regulatory Authority began requiring member firms to ask for a when investors open or update accounts. (The account holder isn’t obliged to provide one, however.) And since 2022, it has on older investors’ transactions if they suspect exploitation is involved.

About half of states have enacted laws that permit financial institutions to deny suspicious transactions or impose holds for specified periods to allow investigations, said Jilenne Gunther, the director of BankSafe.

“It adds friction,” she explained. “With space and time, the criminal gets worried and might move on. And the potential mark has time to stop and think.”

Teaster’s analysis of during a six-month pilot in 82 financial institutions, found that participants were much more likely to report suspected cases and save customers money than a control group was.

Not all of older adults’ losses result from predators, however. They can, on their own, get caught up in investment fads, take on too much debt, or make otherwise unwise decisions, even without criminals pulling the strings or relatives looting their accounts.

Managing finances presents complex cognitive challenges, said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine. “It requires a lot of brain,” he said, including: “Memory, remembering that a bill is due. Executive function, the ability to manage your time. Abstraction, hypothesizing about your future.”

He added, “Financial errors are not infrequently the or a neurocognitive disorder.”

A by the Federal Reserve Bank of New York, for instance, found an increased probability of delinquent payments and deteriorating credit ratings in the five years before a dementia diagnosis. Those errors can reduce seniors’ access to credit and raise their interest rates on loans at the very point when caregiving expenses are likely to soar.

Lachs has called on fellow doctors to recognize what he calls , a syndrome that can affect even older people with normal cognition, especially if they contend with medical illnesses, sensory deficits, or social isolation.

And he remains skeptical about the financial industry’s claims of heightened attention to its oldest customers. “I still see concerning financial transactions executed that should have received far greater scrutiny,” he said.

Training more front-line staff members and increasing emphasis on establishing trusted contacts for older customers would help, Gunther said, because “once the money leaves the account, it’s near impossible to ever retrieve it.” More states could enact laws allowing financial institutions to deny suspicious transactions or impose holds.

Several related bills with bipartisan support are working their way through Congress. The would require the FBI to coordinate efforts to protect seniors. A would at least provide the consolation of excusing scam victims from paying taxes on money they no longer have.

However, new weapons like artificial-intelligence voice cloning — in which the supposed grandson four states away who urgently needs $5,000 in gift cards actually sounds like the victim’s grandson — keep advocates and bankers awake at night.

In the Washington Trust branch where the Rhode Island woman didn’t lose her money, employees just days earlier had stopped a scam similar to the one that had targeted her.

But more recently, nobody spotted any danger signs when an older woman withdrew $9,000 for a kitchen renovation, until it went to a scammer instead of a contractor.

The New Old Age is produced through a partnership with .

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That’s the case in New Orleans, where an investigation by Verite News found high lead levels in about half of the playgrounds on city property and found in most homes that tested their drinking water in a voluntary program.

No level of lead exposure is safe, according to federal environmental officials, but undertaking a comprehensive cleanup can be financially prohibitive. New Orleans is facing a $220 million budget deficit that has led to city employee furloughs and layoffs.

Congress allocated $15 billion over five years to lead pipe replacement under the Bipartisan Infrastructure Law, a Biden-era measure set to expire at the end of this year. In 2024, the Environmental Protection Agency also tightened the standards for lead-contaminated soil for the first time in 30 years and mandated that water systems by late 2037.

But passed by Congress and signed by President Donald Trump in January redirected $125 million of that lead remediation money to wildfire prevention. And since October, the EPA has partially rolled back protections against soil contamination, raising the federal hazard level in urban areas and the threshold for removing contaminated soil.

Tom Neltner, the national director of the nonprofit advocacy group Unleaded Kids, said it was the first time an administration had loosened the limits on lead in soil.

“ We’ve seen the Trump administration say positive things about its commitment to lead but then take actions that undermine that,” Neltner said.

But, he added, progress is still being made in some communities.

EPA press secretary Brigit Hirsch said the changes made under the Trump administration have reduced confusion and uncertainty that could hamper cleanup efforts.

“The Trump EPA’s record on protecting Americans — especially American children — from lead is unmatched,” Hirsch said in an emailed statement. “In just the last year, the Trump EPA backed up its commitment to reducing lead exposure in children with BILLIONS of dollars and historic action.”

She cited a of $3 billion available to pay for water pipe replacement. That money is from the passed during the Biden administration.

Verite News spoke with people in Michigan, Indiana, and Rhode Island to learn how they addressed their lead pollution, with the aim of finding options that could be applied in New Orleans and other cities.

“ We don’t need to do research on lead anymore,” said Tulane University professor Felicia Rabito, an epidemiologist who researches the toxic metal and its sources. “What we need are policies to get the lead out of the environment.”

Benton Harbor, Michigan: Lead Pipes Begone

Benton Harbor, a predominantly Black beach town of about 9,000 people on the southeastern shore of Lake Michigan, spent three years out of compliance with federal drinking water standards. The concentration of lead in the water remained dangerously high until residents and organizations petitioned the EPA in 2021, drawing responses from state and federal officials.

“Nobody should be drinking lead in their water for this long,” said Elin Betanzo, an engineer who provided the petitioning residents with technical support.

That year, federal officials issued an for the Michigan city to bring its water supply into compliance, and the state required Benton Harbor to replace all its lead pipes within 18 months. Gov. Gretchen Whitmer, a Democrat, committed to securing funding in the state budget for the $35 million effort, which included bottled water distribution and paying outstanding water bills for low-income residents. The state, alongside the city, allocated money from its general fund, secured regional water loans, and cobbled together grants from several federal programs to cover the total.

By the end of 2023, city officials had completed the project. Now it’s one of 21 municipalities in Michigan that have replaced all their lead pipes. Benton Harbor had more than 4,500 pipes to replace.

The Trump administration has said it would defend the Biden-era mandate for lead pipe replacement by 2037 against a lawsuit challenging it.

Betanzo recommended that utilities in other cities reduce barriers to line replacement to increase efficiency, as Benton Harbor’s water system did.

City officials saved time after assuming most pipes would be lead. They decided to go street by street, digging up, inspecting, and replacing nearly every pipe. If the pipe wasn’t lead, it wasn’t replaced, but nearly all were, Betanzo said.

Concentrating the mass replacement in one zone at a time made the contracts more cost-effective, Betanzo added. Contractors bid on zones in the city, and multiple contractors worked in different neighborhoods simultaneously. For transparency, progress was published on a public database.

The city also passed a law requiring lead lines be replaced, including those on customers’ side of the water meter. All residents had to allow the contractors onto their property or face disconnection. The residents didn’t pay for the line replacements.

“ The health benefits of lead service line replacement are greatest the sooner you get it done,” Betanzo noted, referencing a she co-authored. “If you do it wrong, you can absolutely increase exposure to lead through a lead service line replacement.”

Completion of full pipe replacement is rare in the U.S., because of the cost, poor service line tracking, the time it takes, and the prioritization of other issues. In New Orleans, the process could require up to $1 billion of investment over 10 years, according to the city’s Sewerage and Water Board.

Indianapolis: Safe Dirt for Kids

It’s not just lead pipes that are problematic. In 2024, a in the academic journal GeoHealth estimated that nearly a quarter of homes in the U.S. have unsafe levels of lead in the soil on their properties.

To that end, Indianapolis has taken some actions that other cities can learn from, said Gabriel Filippelli, a professor at the Indiana University-Indianapolis School of Science who led the study and has researched the risk of lead exposure through soil for years.

The Indy Parks & Recreation department partnered with Filippelli’s team to test a dozen parks relatively close to the contaminated site of a shuttered lead smelter.

Out of all the parks tested, Filippelli’s team found only one hot spot, beneath an old bench from which lead-based paint had flaked off into the surrounding soil.

The parks department followed Filippelli’s suggestion to replace the bench and add concrete and a thick layer of mulch and plants on the ground, so kids wouldn’t be able to play directly in the contaminated dirt.

“It was a relatively low-cost intervention,” he said, estimating it cost a few thousand dollars. The ground wasn’t excavated, and new dirt wasn’t brought in. “If you deal with it by dilution and by capping, remove the source, you’re solving the problem for today and probably many, many years to come.”

The contaminated dirt may need to be removed in some cases and replaced with clean soil, such as after severe, widespread pollution from industrial sources. But Filippelli said such extensive remediation can be impractical and too expensive for cities to undertake on their own.

Where full remediation is cost-prohibitive, Filippelli said, there are more creative solutions, like landscaping, covering the area with new dirt, or mulching. These methods won’t eliminate the lead entirely, but they will significantly reduce exposure risk.

“You can eliminate the hazard at a fraction of the cost,” he said.

Cities could also look to New York City’s , which places uncontaminated soil left over from construction projects in neighborhood-level banks for volunteers to distribute, he said.

Rhode Island: Stopping Lead at the Source

New England, home to some of the nation’s oldest homes, has led the U.S. in mitigating one of the largest ongoing sources of lead contamination: paint.

In 2023, the state legislature in Rhode Island, where most of the homes were built before lead paint was banned in 1978, passed strengthening the state’s ability to enforce tenant protections.

Prior to 2023, the state had long required most landlords to have their property inspected to ensure it met “lead safe” guidelines, said DeeAnn Guo, a community organizer for the . Although no level of lead is considered safe, replacing windows and doors that have lead paint, painting over all interior and exterior walls, and mitigating contaminated soil significantly reduce the risk of exposure.

But for years “there was no incentive to do it,” Guo said, “aside from it being the right thing to do.”

Now, landlords can be fined if they don’t have an active lead certificate on file for homes built before 1978, and the property has to be inspected every two years to remain in compliance. Before the new law, less than 15% of rentals were certified. In late 2025, that had increased to 40%, Guo said.

The state has also seen a steady decline in the in children’s blood.

Guo said it helps that the state has federal funding from the Department of Housing and Urban Development to subsidize its If a homeowner or landlord owns an old house, they can apply for the state to send an inspector. If lead is found, the state will then send a certified contractor to address the problem at little to no cost to the property owner.

Rhode Island prioritizes low-income households and homes with pregnant women or children under 6 years old, because of the heightened health risk. It can also help pay to remediate homes if a child living there has elevated levels of lead in their blood.

States and communities looking to start a successful lead paint abatement program using HUD money should combine strong enforcement, public education, and offers of subsidies, Guo said. It also helps to include community members in the planning process, she said.

Under the Trump administration, however, it might become harder for more communities like New Orleans to receive money for a “lead safe” program. Last year, HUD asked Congress to eliminate new funding for its lead hazards program, stating it would be restored in 2027. But advocates for more lead protections argue that once funding is lost, it is unlikely to be approved again.

“It shows the White House’s hypocrisy, where they talk about lead as being important and then propose eliminating the funds that are essential to cleaning up affordable housing,” said Neltner, the Unleaded Kids director. “This administration talks about the importance of children and then seems to be careless about children’s brains.”

This article was produced in collaboration with . The four-month investigation was supported by a Kozik Environmental Justice Reporting grant funded by the National Press Foundation and the National Press Club Journalism Institute. It was also produced as a project for the USC Annenberg Center for Health Journalism’s National Fellowship fund and Dennis A. Hunt Fund for Health Journalism.

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“I was kind of a mess,” recalled Abrams, 69. Trying to cope, “I was eating myself into oblivion.” As her weight hit 270 pounds and her blood pressure, cholesterol, and blood glucose levels climbed, “I knew I was in trouble health-wise.”

What came to mind? “Oh, oh, oh, Ozempic!” — the from television commercials that promoted the GLP-1 medication for diabetes. The ads also pointed out that patients who took it lost weight.

Abrams remembered the commercials as “joyful” and sometimes found herself humming the jingle. They depicted Ozempic-takers cooking omelets, repairing bikes, playing pickleball — “doing everyday activities, but with verve,” she said. “These people were enjoying the hell out of life.”

So, just as such ads often urge, even though she had never been diagnosed with diabetes, she asked her doctor if Ozempic was right for her.

Small wonder Abrams recalled those ads. Novo Nordisk, which manufactures Ozempic, spent an estimated $180 million in direct-to-consumer advertising in 2022 and $189 million in 2023, according to MediaRadar, which monitors advertising.

By last year, the sum — including radio and TV commercials, billboards, and print and digital ads — had reached an estimated $201 million, and total spending on direct-to-consumer advertising of prescription drugs topped $9 billion, by MediaRadar’s calculations.

Novo Nordisk declined to address those numbers.

Should it be legal to market drugs directly to potential patients? This controversy, which has simmered for decades, has begun receiving renewed attention from both the Trump administration and legislators.

The question has particular relevance for older adults, who contend with more medical problems than younger people and are more apt to take prescription drugs. “Part of aging is developing health conditions and becoming a target of drug advertising,” said Steven Woloshin, who studies health communication and decision-making at the Dartmouth Institute.

The debate over direct-to-consumer ads dates to 1997, when the FDA loosened restrictions and allowed prescription drug ads on television as long as they included a rapid-fire summary of major risks and provided a source for further information.

“That really opened the door,” said Abby Alpert, a health economist at the Wharton School of the University of Pennsylvania.

The introduction of Medicare Part D, in 2006, brought “a huge expansion in prescription drug coverage and, as a result, a big increase in pharmaceutical advertising,” Alpert added. A study she co-wrote in 2023 found that pharmaceutical ads in areas with a high proportion of residents 65 and older.

and have shown that ads influence prescription rates. Patients are more apt to make appointments and request drugs, either by brand name or by category, and doctors often comply. may ensue.

But does that benefit consumers? Most developed countries take a hard pass. Only New Zealand and, despite the decadelong , the United States allow direct-to-consumer prescription drug advertising.

Public health advocates argue that such ads encourage the use and overuse of expensive new medications, even when existing, cheaper drugs work as effectively. (Drug companies don’t bother advertising once patents expire and generic drugs become available.)

In a 2023 study in JAMA Network Open, for instance, researchers analyzed the “” of the drugs most advertised on television, based on the assessments of independent European and Canadian organizations that negotiate prices for approved drugs.

Nearly three-quarters of the top-advertised medications didn’t perform markedly better than older ones, the analysis found.

“Often, really good drugs sell themselves,” said Aaron Kesselheim, senior author of the study and director of the Program on Regulation, Therapeutics, and Law at Harvard University.

“Drugs without added therapeutic value need to be pushed, and that’s what direct-to-consumer advertising does,” he said.

Opponents of a ban on such advertising say it benefits consumers. “It provides information and education to patients, makes them aware of available treatments and leads them to seek care,” Alpert said. That is “especially important for underdiagnosed conditions,” like depression.

Moreover, she wrote in a recent , direct-to-consumer ads lead to increased use not only of brand-name drugs but also of non-advertised substitutes, including generics.

The Trump administration entered this debate last September, with calling for a return to the pre-1997 policy severely restricting direct-to-consumer drug advertising.

That position has repeatedly been urged by Health and Human Services Secretary Robert F. Kennedy Jr., who has charged that “pharmaceutical ads hooked this country on prescription drugs.”

At the same time, the FDA said it was issuing about deceptive drug ads and sending “thousands” of warnings to pharmaceutical companies to remove misleading ads. Marty Makary, the FDA commissioner, in an essay in The New York Times.

“There’s a lot of chatter,” Woloshin said of those actions. “I don’t know that we’ll see anything concrete.”

This month, however, the that the agency had found its TV spot for a new oral version of Wegovy false and misleading. Novo Nordisk said in an email that it was “in the process of responding to the FDA” to address the concerns.

Meanwhile, Democratic and independent senators who rarely align with the Trump administration also have introduced legislation to ban or limit direct-to-consumer pharmaceutical ads.

Last February, independent Sen. Angus King of Maine and two other sponsors prohibiting direct-to-consumer ads for the first three years after a drug gains FDA approval.

King said in an email that the act would better inform consumers “by making sure newly approved drugs aren’t allowed to immediately flood the market with ads before we fully understand their impact on the general public.”

Then, in June, he and independent Sen. Bernie Sanders of Vermont proposed entirely. That might prove difficult, Woloshin said, given the Supreme Court’s Citizens United ruling .

Moreover, direct-to-consumer ads represent only part of the industry’s promotional efforts. Pharmaceutical firms actually spend than to consumers.

Although television still accounts for most consumer spending, because it’s expensive, Kesselheim pointed to “the mostly unregulated expansion of direct-to-consumer ads onto the web” as a particular concern. Drug sales themselves are bypassing doctors’ practices by moving online.

Woloshin said that “disease awareness campaigns” — for everything from shingles to restless legs — don’t mention any particular drug but are “often marketing dressed up as education.”

He advocates more effective educational campaigns, he said, “to help consumers become more savvy and skeptical and able to recognize reliable versus unreliable information.”

For example, Woloshin and Lisa Schwartz, a late colleague, designed and tested a simple “,” similar to the nutritional labeling on packaged foods, that summarizes and quantifies the benefits and harms of medications.

For now, consumers have to try to educate themselves about the drugs they see ballyhooed on TV.

Abrams read a lot about Ozempic. Her doctor agreed that trying it made sense.

Abrams was referred to an endocrinologist, who decided that her blood glucose was high enough to warrant treatment. Three years later and 90 pounds lighter, she feels able to scramble after her 2-year-old grandson, enjoys Zumba classes, and no longer needs blood pressure or cholesterol drugs.

So Abrams is unsure, she said, how to feel about a possible ban on direct-to-consumer drug ads.

“If I hadn’t asked my new doctor about it, would she have suggested Ozempic?” Abrams wondered. “Or would I still weigh 270 pounds?”

The New Old Age is produced through a partnership with .

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Regulating artificial intelligence, especially its use by health insurers, is becoming a politically divisive topic, and it’s scrambling traditional partisan lines.

Boosters, led by Trump, are not only pushing its integration into government, as in in prior authorization, but also trying to stop others from building curbs and guardrails. A December seeks to preempt most state efforts to govern AI, describing “a race with adversaries for supremacy” in a new “technological revolution.”

“To win, United States AI companies must be free to innovate without cumbersome regulation,” Trump’s order said. “But excessive State regulation thwarts this imperative.”

Across the nation, states are in revolt. At least four — Arizona, Maryland, Nebraska, and Texas — enacted legislation last year reining in the use of AI in health insurance. Two others, Illinois and California, enacted bills the year before.

Legislators in Rhode Island plan to try again this year after a bill requiring regulators to collect data on technology use failed to clear both chambers last year. A bill in North Carolina requiring insurers not to use AI as the sole basis of a coverage decision attracted significant interest from Republican legislators last year.

DeSantis, a former GOP presidential candidate, has rolled out an “AI Bill of Rights,” include restrictions on its use in processing insurance claims and a requirement allowing a state regulatory body to inspect algorithms.

“We have a responsibility to ensure that new technologies develop in ways that are moral and ethical, in ways that reinforce our American values, not in ways that erode them,” DeSantis said during his State of the State address in January.

Ripe for Regulation

Polling shows Americans are skeptical of AI. A from Fox News found 63% of voters describe themselves as “very” or “extremely” concerned about artificial intelligence, including majorities across the political spectrum. Nearly two-thirds of Democrats and just over 3 in 5 Republicans said they had qualms about AI.

Health insurers’ tactics to hold down costs also trouble the public; from KFF found widespread discontent over issues like prior authorization. (KFF is a health information nonprofit that includes ºÚÁϳԹÏÍø News.) Reporting and in recent years has highlighted the use of algorithms to rapidly deny insurance claims or prior authorization requests, apparently with little review by a doctor.

Last month, the House Ways and Means Committee hauled in executives from Cigna, UnitedHealth Group, and other major health insurers to address concerns about affordability. When pressed, the executives either denied or avoided talking about using the most advanced technology to reject authorization requests or toss out claims.

AI is “never used for a denial,” Cigna CEO David Cordani told lawmakers. Like others in the health insurance industry, the company is being sued for its methods of denying claims, as spotlighted by ProPublica. Cigna spokesperson Justine Sessions said the company’s claims-denial process “is not powered by AI.”

Indeed, companies are at pains to frame AI as a loyal servant. Optum, part of health giant UnitedHealth Group, announced Feb. 4 that it was rolling out tech-powered prior authorization, with plenty of mentions of speedier approvals.

“We’re transforming the prior authorization process to address the friction it causes,” John Kontor, a senior vice president at Optum,

Still, Alex Bores, a computer scientist and New York Assembly member prominent in the state’s legislative debate over AI, which culminated in a comprehensive bill governing the technology, said AI is a natural field to regulate.

“So many people already find the answers that they’re getting from their insurance companies to be inscrutable,” said Bores, a Democrat who is running for Congress. “Adding in a layer that cannot by its nature explain itself doesn’t seem like it’ll be helpful there.”

At least some people in medicine — doctors, for example — are cheering legislators and regulators on. The American Medical Association “supports state regulations seeking greater accountability and transparency from commercial health insurers that use AI and machine learning tools to review prior authorization requests,” said John Whyte, the organization’s CEO.

Whyte said insurers already use AI and “doctors still face delayed patient care, opaque insurer decisions, inconsistent authorization rules, and crushing administrative work.”

Insurers Push Back

With legislation approved or pending in at least nine states, it’s unclear how much of an effect the state laws will have, said University of Minnesota law professor Daniel Schwarcz. States can’t regulate “self-insured” plans, which are used by many employers; only the federal government has that power.

But there are deeper issues, Schwarcz said: Most of the state legislation he’s seen would require a human to sign off on any decision proposed by AI but doesn’t specify what that means.

The laws don’t offer a clear framework for understanding how much review is enough, and over time humans tend to become a little lazy and simply sign off on any suggestions by a computer, he said.

Still, insurers view the spate of bills as a problem. “Broadly speaking, regulatory burden is real,” said Dan Jones, senior vice president for federal affairs at the Alliance of Community Health Plans, a trade group for some nonprofit health insurers. If insurers spend more time working through a patchwork of state and federal laws, he continued, that means “less time that can be spent and invested into what we’re intended to be doing, which is focusing on making sure that patients are getting the right access to care.”

Linda Ujifusa, a Democratic state senator in Rhode Island, said insurers came out last year against the bill she sponsored to restrict AI use in coverage denials. It passed in one chamber, though not the other.

“There’s tremendous opposition” to anything that regulates , she said, and “tremendous opposition” to identifying intermediaries such as private insurers or pharmacy benefit managers “as a problem.”

In a , AHIP, an insurer trade group, advocated for “balanced policies that promote innovation while protecting patients.”

“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden and costs to improve the focus on patient care,” Chris Bond, an AHIP spokesperson, told ºÚÁϳԹÏÍø News. And, he continued, they need a “consistent, national approach anchored in a comprehensive federal AI policy framework.”

Seeking Balance

In California, Newsom has signed some laws regulating AI, including one requiring health insurers to ensure their algorithms are fairly and equitably applied. But the Democratic governor has vetoed others with a broader approach, such as a bill including more mandates about how the technology must work and requirements to disclose its use to regulators, clinicians, and patients upon request.

Chris Micheli, a Sacramento-based lobbyist, said the governor likely wants to ensure the state budget — consistently powered by outsize stock market gains, especially from tech companies — stays flush. That necessitates balance.

Newsom is trying to “ensure that financial spigot continues, and at the same time ensure that there are some protections for California consumers,” he said. He added insurers believe they’re subject to a welter of regulations already.

The Trump administration seems persuaded. The president’s recent executive order proposed to sue and restrict certain federal funding for any state that enacts what it characterized as “excessive” state regulation — with some exceptions, including for policies that protect children.

That order is possibly unconstitutional, said Carmel Shachar, a health policy scholar at Harvard Law School. The source of preemption authority is generally Congress, she said, and federal lawmakers twice took up, but ultimately declined to pass, a provision barring states from regulating AI.

“Based on our previous understanding of federalism and the balance of powers between Congress and the executive, a challenge here would be very likely to succeed,” Shachar said.

Some lawmakers view Trump’s order skeptically at best, noting the administration has been removing guardrails, and preventing others from erecting them, to an extreme degree.

“There isn’t really a question of, should it be federal or should it be state right now?” Bores said. “The question is, should it be state or not at all?”

Do you have an experience navigating prior authorization to get medical treatment that you’d like to share with us for our reporting? .

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“If we didn’t have health issues, I’d just go back to where I was in my 40s and not have health insurance,” she said, “but we’re not in that position now.”

Freeman and her husband, , are freelancers who work in storytelling and podcasting.

In October, Lawrence, 52, got very sick, very fast.

“I knew I was in trouble,” he said. “I went into the emergency room, and I walked over to the desk, and I said, ‘Hi, I’ve gained 25 pounds in five days and I’m having trouble breathing and my chest hurts.’ And they stopped blinking.”

Doctors diagnosed him with kidney disease, and he was hospitalized for four days.

Now Lawrence has to take medication with an without insurance of $760 a month.

In January, the cost of the couple’s current “silver” plan rose nearly 75%, to $801 a month.

To bring in extra cash, Freeman has picked up a part-time bartending gig.

Millions of who have ACA health plans are facing soaring premium payments in 2026, without help from the enhanced subsidies that Congress failed to renew. Some are contemplating big life changes to deal with new rates that kicked in on Jan. 1.

It often falls to women to figure out a family’s insurance puzzle.

Women generally than men, in part because of their need for reproductive services, according to , a professor at Brown University’s School of Public Health.

Women also tend to be the for the family, she said, especially for the children.

“There’s a disproportionate role that women play in families around what we think of as the mental load,” said Tobin-Tyler, and that includes “making decisions around health insurance.”

Before the holidays, a few forms of relief for the premium hikes, but nothing has materialized, and significant deadlines have already passed.

Going Uninsured?

As the clock ticked down on 2025, B. agonized over her family’s insurance options. She was looking for a full-time job with benefits, because the premium prices she was seeing for 2026 ACA plans were alarming.

In the meantime, she decided, she and her husband would drop coverage and insure only the kids. But it would be risky.

“My husband works with major tools all day,” she said, “so it feels like rolling the dice.”

NPR and ºÚÁϳԹÏÍø News are identifying B. by her middle initial because she believes her insurance needs could affect her ongoing search for a job with health benefits.

The family lives in Providence, Rhode Island. Her husband is a self-employed woodworker, and she worked full-time as a nonprofit manager before she lost her job last spring.

After she lost her job, she turned to the ACA marketplace. The family’s cost them nearly $2,000 a month in premiums.

It was a lot, and they dug into retirement savings to pay for it while B. kept looking for a new position.

Because Congress failed to extend enhanced subsidies for ACA plans, despite ongoing political battles and a lengthy government shutdown over the issue, B.’s family plan would have cost even more in 2026 — almost $3,000 a month.

“I don’t have an additional $900 lying around in my family budget to pay for this,” she said.

B. had already pulled $12,000 out of retirement funds to pay her family’s 2025 rates.

Unless she finds a new job soon, the family’s projected income for 2026 will be less than . That means the children qualify for free coverage through Medicaid.

So B. decided to buy a plan on the ACA marketplace for herself and her husband, paying premiums of $1,200 a month.

“The bottom line is none of this is affordable,” she said, “so we’re going to be dipping into savings to pay for this.”

Postponing a Wedding

The prospect of soaring insurance premiums put a pause on Nicole Benisch’s plans to get married.

Benisch, 45, owns a holistic wellness business in Providence. She paid $108 a month for a zero-deductible “silver” plan on Rhode Island’s insurance exchange.

But the cost in 2026 more than doubled, to $220 a month.

She and her fiance had planned to marry on Dec. 19, her late mother’s birthday. “And then,” she said, “we realized how drastically that was going to change the cost of my premium.”

As a married couple, their combined income would exceed 400% of the federal poverty level and make Benisch ineligible for financial help. Her current plan’s monthly premium payments would triple, costing her more than $700 a month.

Benisch considered a less expensive “bronze” plan, but it wouldn’t cover vocal therapy, which she needs to treat , a condition that can make her voice strain or give out.

If they get married, there’s another option: Switch to her fiance’s health plan in Massachusetts. But that would mean losing all her Rhode Island doctors, who would be out-of-network.

“We have some tough decisions to make,” she said, “and none of the options are really great for us.”

This article is from a partnership with .

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Health officials are recommending diet and exercise as alternatives to heavily advertised weight loss drugs like Wegovy and Zepbound, advice experts say is unrealistic.

“Of course he tried eating well and everything, but now with the medications, it’s better — a 100% change,” said Wilmer Cardenas of Santa Clara, who said his husband lost about 100 pounds over about two years using GLP-1s covered by Medi-Cal, California’s version of Medicaid.

California joined several other states in restricting an option they say is no longer affordable as they confront soaring pharmaceutical costs and steep Medicaid cuts under the Trump administration, among . Despite negotiated price reductions announced in November that would make the drugs available at a “dramatically lower cost to taxpayers” and enable Medicaid to cover them, states are going ahead with the cuts, which providers say may undermine patients’ health.

“It will be quite negative for our patients” because data shows people typically regain weight after stopping the drugs, said , medical director of the University of California-San Francisco Weight Management Program.

While California, , , and stopped covering adult GLP-1 prescriptions for obesity on Jan. 1, they continue to cover the drugs for other health issues, such as Type 2 diabetes, cardiovascular disease, and chronic kidney disease.

, , and Wisconsin are planning or considering restrictions, according to KFF’s .

That reverses a trend that saw 16 states covering the medications for obesity as of Oct. 1. Interest in providing the coverage “appears to be waning,” the survey found, likely due to the drugs’ cost and other state budget pressures. North Carolina pulled back GLP-1 coverage in October, but reinstated it in December, bowing to court orders despite a lingering budget shortfall.

Catherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its affiliated Obesity Association, said it’s not clear how states will adjust to the White House plan to lower the cost of several of the most popular GLP-1s through TrumpRx, an online portal for discounted prescription drugs. The price of Wegovy, for example, will be $350 per month for consumers, versus the current list price of nearly $1,350, and Medicare and Medicaid programs will pay $245, according to the plan.

“Many states are facing budgetary challenges, such as deficits, and are working to address the impacts of the changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available for the Administration’s agreements, we will see how state Medicaid responds.”

The Department of Health and Human Services referred questions to the White House, which did not respond to requests for comment on states’ termination of Medicaid coverage for the weight loss drugs.

California projected its costs to cover GLP-1s for weight loss would have more than quadrupled over four years to if it didn’t end Medi-Cal coverage for that use. Medi-Cal has covered weight loss drugs since 2006, but use of GLP-1s soared only in recent years. By 2024, more than 645,000 prescriptions were covered by Medi-Cal across all uses of the medications. The California Department of Health Care Services could not readily provide a breakdown of whether the drugs were for weight loss or other conditions.

When asked whether the state would reconsider its plans in light of the announced price cuts, Department of Finance spokesperson H.D. Palmer said it had no plans to do so. California’s cut is written into .

California officials would not say how much it could save under the TrumpRx plan, citing federal and state restrictions on disclosing rebate information.

Health providers don’t expect the Trump administration’s negotiated price cuts to make much difference to consumers, because pharmaceutical companies already offer some discounts.

“The out-of-pocket costs will still be very cost-prohibitive for most, especially individuals with Medicaid insurance,” Thiara said.

is among the other states that ended their coverage Jan. 1. Officials with the New Hampshire Department of Health and Human Services did not respond to requests for comment.

About 1 in 8 adults are now taking a GLP-1 drug for obesity, disease, or both, up 6 percentage points from May 2024, according to released in November. Over half of users said their GLP-1s were difficult to afford, and many who had stopped the treatment cited the cost.

Public and private payers have been trying to wean patients off to save costs. California health officials said Medi-Cal members and their health care providers “other treatment options that can support weight loss, such as diet changes, increased activity or exercise, and counseling.” That echoes advice from the New Hampshire Medicaid program.

California Department of Health Care Services spokesperson Tessa Outhyse said in an email that the official advice to try those other approaches now “is not meant to dismiss any past efforts, but to encourage Medi-Cal members to take a renewed, proactive, and medically supported approach with their healthcare provider that may appropriately include these additional options.”

But that may be unrealistic, said , founding director of the Center for Clinical Nutrition at Keck School of Medicine of the University of Southern California.

“We definitely want patients to do their part with the diet and exercise, but unfortunately, and from a practical standpoint, that itself frequently is not enough,” Hong said, adding that usually by the time patients see doctors they have already failed at achieving results through those means.

Hong understands why Medicaid programs, as well as private providers, want to cut back on covering the drugs, which can cost per patient per year. However, they can produce twice the weight loss as the medications typically used previously, he said.

A school of medical thought supports patients’ gradually ending their use, but Hong said obesity is generally considered a chronic condition that requires indefinite treatment.

“Once they reach their target weight, a lot of people will try to see whether or not they can wean off,” Hong said. “We do see a lot of patients — when they try to get off, unfortunately, then the weight comes back.”

Medi-Cal members under age 21 for purposes including weight loss, California officials said, citing a federal requirement.

Medi-Cal members are able to keep their GLP-1 coverage if they can demonstrate it is medically necessary for purposes other than weight loss, the department said. Members who are denied coverage can seek a hearing, the department said in to members.

Members will still be able to pay for the prescriptions and may be able to use various discounts to lower costs. Another option is new pills to treat obesity, which will be cheaper than their injectable counterparts. The a pill version of Wegovy on Dec. 22, which will likely run $149 per month for the lowest dosage, and similar weight loss pills are expected to be available in the first half of the year.

While Cardenas said his husband, Jeffer Jimenez, 37, uses GLP-1s primarily for weight loss, Jimenez’s prescription is for his diabetes, so the couple hoped to continue receiving coverage through Medi-Cal.

“He tried a thousand medications, pills, natural teas, exercise program, but it doesn’t work like the injections,” Cardenas said. “You need both.”

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The ambulances frequently travel back and forth to in Asheville, the largest and most central hospital in the region. Trips can take more than two hours, according to Mark Snelson, director of , the local emergency medical service.

“When we get busy and all three of them are gone, we have no ambulances in our county,” he said.

Snelson and others in Madison County aren’t seeking more ambulances. They want a hospital closer than Mission. And the state agrees. In 2022, North Carolina Department of Health and Human Services officials said Madison and three other mountain counties needed 67 more acute care hospital beds. The state raised that to 93 beds in 2024, then to 222 by Oct. 15.

But the only indication of a new hospital thus far is a 25-acre field of graded dirt with a sign planted beside the highway reading “FUTURE HOME OF AdventHealth Weaverville.”

For the past three years, Mission Hospital’s owner has contested Florida-headquartered ’s attempt to build the hospital on land bought for $7.5 million in rural Weaverville, just minutes south of Madison County. It was , an event that would have defied the of rural hospital closures.

The irony is that the very law that calls for the new hospital — the state’s certificate of need, or CON, law — has been used to prevent further construction. Such laws are intended to cap unfettered health care expansion by allowing new hospitals and expansions only when a state can document a need for them. But the legal process has tied up the proposed Weaverville hospital in court, just as other such laws have done with projects in ; ; and .

All states had certificate of need laws until 1987, when the federal government repealed a mandate requiring them. Today, North Carolina is one of with the laws still on the books. Twelve others have repealed them or let them expire, and some, and , have significantly weakened theirs amid concerns they limit health care access and boost costs. President Donald Trump’s Federal Trade Commission and Department of Justice are among those questioning the need for the laws.

In North Carolina, too, opposition to the state’s certificate of need law has surfaced in both the General Assembly, where a has been dormant since April, and more prominently in the state Superior Court.

But some , health care economists, and certificate of need lawyers argue that, though the laws create bureaucracy that can delay projects, that’s not justification to do away with them.

The principle behind certificates of need is to hold at bay what is unnecessary expansion and price inflation brought on by a free market, which makes health care more expensive for everyone.

“If the principle is worth preserving, don’t abandon the principle,” said , a health care attorney with the Benesch law firm and former counsel for . “Improve the process to allow the principle to flourish.”

Who Should Fill the Need?

Mission Health is the largest health care network and the largest employer in the Tar Heel State’s share of the Appalachians. Nashville-based bought the century-old, nonprofit, six-hospital system for $1.5 billion in 2019, converting it to a for-profit operation that serves an 18-county region. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund ºÚÁϳԹÏÍø News’ coverage.)

Though AdventHealth already owns one hospital in the North Carolina mountains about a 30-minute drive from the Weaverville site, its bid to build a new one represents a threat to HCA’s stronghold. Mission argues it is best positioned to meet the needs the state says exist in the Madison County region.

“Not all acute care beds are the same,” Mission Health spokesperson Nancy Lindell said. “Instead of adding more beds at facilities that are unable to provide the complex medical and surgical care needed, the region would be better served by expanding bed capacity at Mission Hospital.”

An eastern North Carolina eye surgeon’s against the state’s health agency and top state officials alleged the state’s certificate of need law “has nothing to do with protecting the health or safety of real patients.” The ophthalmologist, Jay Singleton, has argued the law prevented him from performing surgeries at his own center because the state didn’t see a need to duplicate services already provided at the local hospital, where he was obligated to operate.

In early November, Republican state Treasurer Brad Briner, the , and several academics who study such laws nationally filed amicus briefs supporting Singleton’s case and urging a judge to reject the state’s attempt to dismiss it.

“I’ve characterized CON law as a permission slip to compete,” said , a George Mason University economics and law professor who co-authored the brief. “It’s as if, when a McDonald’s wanted to open up a shop next to Burger King, they have to go to the state regulator to ask if that’s OK.”

Stratmann argued that, instead of , more competition would give hospitals and providers greater leverage in negotiating with insurance companies.

That view aligns with a stance the federal government has held for almost 40 years. With varying degrees of fervor under Democratic and Republican leadership, the Federal Trade Commission and Department of Justice have argued that the laws are anticompetitive and bad for consumers. The Justice Department did not respond to questions about its current position, and the FTC declined to comment on the record.

“CON laws create barriers to entry and expansion, limit consumer choice, and stifle innovation,” the Federal Trade Commission wrote in an April letter to Rhode Island Gov. Dan McKee, a Democrat, as the state’s legislature considered, but ultimately abandoned, amendments to its certificate of need law. “For these reasons, the Agencies have consistently suggested that states repeal or retrench their CON laws.”

‘It’s Personal’

In a to Trump and congressional leaders, Senate Democrats named five North Carolina hospitals on a list of rural hospitals in danger of closing if the president’s then-pending spending and tax-cut legislation, called the One Big Beautiful Bill, became law, citing research from the .

Two of the five North Carolina hospitals on that list, and , are part of the Mission Health system. Both had three consecutive years of negative profit margins, like hundreds of others on the list. Lindell, the Mission Health spokesperson, said HCA is committed to keeping those two facilities open.

Even so, Madison County Health Department Director Tammy Cody said the needs in the region remain and the certificate of need appeals process has slowed down getting help.

“This isn’t theoretical — it’s personal,” she said. “Every delay means a mother in labor risks a longer ride, an elder with chest pain waits longer for help, or a worker injured on the job faces unnecessary complications.”

AdventHealth spokesperson Victoria Dunkle said the hospital system supports the state’s law partly because it “protects rural access to health care and ensures the community has a voice in the process.” The legal process has kept families waiting, she said, but AdventHealth plans to move forward with the Weaverville hospital “as soon as possible.”

Snelson, the ambulance service director, voiced a question many in the region have asked since the hope of a new rural hospital surfaced.

“Why is it a bad thing for another hospital to come in here to take some of the stress off of Mission?” he asked. “Within a day of it opening, it’s going to be full.”

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Six months after a West Virginia man died following a protracted battle with his health insurer over doctor-recommended cancer care, the state’s Republican governor signed a bill intended to curb the harm of insurance denials.

West Virginia’s Public Employees Insurance Agency enrolls nearly 215,000 people — state workers, as well as their spouses and dependents. The new law, which will take effect June 10, will allow plan members who have been approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without the need for another approval from the state-based health plan.

“This legislation is rooted in a simple principle: if a treatment has already been approved, patients should be able to pursue a medically appropriate alternative without being forced to start the process over again — especially when it does not cost more,” Gov. Patrick Morrisey said in a statement after signing the bill into law on March 31.

“This is about common sense, compassion, and trusting patients and their doctors to make the best decisions for their care,” he said.

Delegate Laura Kimble, the Republican from Harrison County who introduced the legislation, told ºÚÁϳԹÏÍø News the measure offers “a rational solution” for patients facing “the most irrational and chaotic time of their lives.”

From Arizona to Rhode Island, at least half of all state legislatures have taken up bills this year related to prior authorization, a process that requires patients or their medical team to seek approval from an insurer before proceeding with care. These state efforts come as patients across the country await relief from prior authorization hurdles, as promised by dozens of major health insurers in a pledge announced by the Trump administration last year.

The West Virginia law was inspired by Eric Tennant, a coal-mining safety instructor from Bridgeport who died on Sept. 17 at age 58. In early 2025, the Public Employees Insurance Agency of a $50,000 noninvasive cancer treatment, called histotripsy, that would have used ultrasound waves to target, and potentially shrink, the largest tumor in his liver. His family didn’t expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life. The insurer said the procedure wasn’t medically necessary and that it was considered “experimental and investigational.”

Becky Tennant, Eric’s widow, told members of a West Virginia House committee in late February that she submitted medical records, expert opinions, and data as part of several attempts to appeal the denial. She also reached out to “almost every one of our state representatives,” asking for help.

Nothing worked, she told lawmakers, until ºÚÁϳԹÏÍø News and NBC News got involved and posed questions to the Public Employees Insurance Agency about Eric’s case. Only then did the insurer reverse its decision and approve histotripsy, Tennant said.

“But by then, the delay had already done its damage,” she said.

Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure. “The insurance company’s decision did not simply delay care. It closed doors,” his wife said.

Had the new law been in effect, Kimble said, Tennant could have undergone histotripsy without preapproval, because it was a less expensive alternative to chemotherapy, which his insurer had already authorized. The bill was passed unanimously by the state legislature in March.

U.S. health insurers argue that most prior authorization requests are quickly, if not instantly, approved. AHIP, the health insurance industry trade group, says prior authorization in preventing potential harm to patients and reducing unnecessary health care costs. But denials and delays tend to affect patients who need expensive, time-sensitive care, .

The practice has come under intense scrutiny in recent years, particularly after the in New York City in late 2024. Americans rank prior authorization as their biggest burden when it comes to getting health care, according to a by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Samantha Knapp, a spokesperson for the West Virginia Department of Administration, would not answer questions about the law’s financial impact on the state. “We prefer to avoid any speculation at this time regarding potential impact or actions,” Knapp said.

In a fiscal note attached to the bill, Jason Haught, the Public Employees Insurance Agency’s chief financial officer, said the law would cost the agency an estimated $13 million annually and “cause member disruption.”

West Virginia isn’t an outlier in targeting prior authorization. By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books, according to a by the National Association of Insurance Commissioners.

Many states have set up “gold carding” programs, which allow physicians with a track record of approvals to bypass prior authorization requirements. Some states establish a maximum number of days insurance companies are allowed to respond to requests, while others prohibit insurance companies from issuing retrospective denials after a service has already been preauthorized. There are also a crop of new state laws seeking to regulate the use of artificial intelligence in prior authorization decision-making.

Meanwhile, prior authorization bills introduced this year across the country, including in Kentucky, Missouri, and New Jersey, have been supported by politicians from both parties.

“Republicans in conservative states see health care as a vulnerability for the midterm elections, and so, unsurprisingly, you’ll see some action on this,” said Robert Hartwig, a clinical associate professor of risk management, insurance, and finance at the University of South Carolina. “They realize that they’re not really going to get much action at the federal level given the degree of gridlock we’ve already seen.”

Last summer, the Trump administration announced a pledge signed by dozens of health insurers vowing to reform prior authorization. The insurers promised to reduce the scope of claims that require preapproval, decrease wait times, and communicate with patients in clear language when denying a request.

Consumers, patient advocates, and medical providers that companies will follow through on their promises.

Becky Tennant is skeptical, too. That’s why she advocated for the West Virginia bill.

“Families should not have to beg, appeal, or go public just to access time-sensitive care,” she told lawmakers. Tennant, who sees the bill’s passage as bittersweet, said she thought her husband would have been proud.

During Eric’s final hospital stay, Tennant recalled, right before he was discharged to home hospice care, she asked him whether he wanted her to keep fighting to change the state agency’s prior authorization process.

“‘Well, you need to at least try to change it,’” she recalled her husband saying. “‘Because it’s not fair.’”

“I told him I would keep trying,” she said, “at least for a while. And so I am keeping that promise to him.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

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

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He was already thinking about delaying it — then his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income, he said. And with a $2,700 deductible, he’d be on the hook for most of the diagnostic exam, a financial hit he said he couldn’t stomach.

“It was going to cost close to $3,000,” said Galvin, who lives in North Kingstown, Rhode Island, and recently retired as director of a durable medical equipment company. “I put it off.”

Galvin said his wife, Nancy, is delaying a costly CT scan for a few years until she too qualifies for Medicare, so it can foot the bill. The federal health program offers coverage for all Americans 65 and older.

People on Affordable Care Act plans nearing retirement age experienced some of the largest price increases following the expiration of enhanced federal subsidies at the end of December. Those with incomes above 400% of the federal poverty level — — had been getting help paying for the plans since the Biden administration expanded the subsidies during the covid-19 pandemic. Adults ages 50 through 64 of those ACA enrollees.

Now, without that federal financial help, some in this age group say they’re wrestling with whether to delay care until they qualify for Medicare. Not only does that put their physical health at risk, said patient advocates, doctors, and health policy researchers, but it potentially just shifts the costs — and could lead to taxpayers’ footing even bigger bills to fix health issues that worsen amid the delays.

“There’s going to be a lot of pent-up demand and unmet need,” said , a health policy consultant who worked in the Obama and Biden administrations. “Medicare is going to have to spend a whole heck of a lot of money covering and dealing with their treatment.”

The Affordable Care Act has been a key source of health care coverage for people 50 through 64. Access to Obamacare plans helped cut the uninsured rate for this age group by half, , a lobbying group that represents older adults. That allowed some people to retire early while keeping coverage. It also has provided a safety net for and those with jobs that don’t offer health insurance.

Last fall, the occurred amid an unsuccessful effort by Democrats to extend the enhanced subsidies. Republicans opposing the extension had said the assistance went to insurers, incentivizing fraud and wasteful coverage.

The issue will continue to have political relevance, especially in this year’s midterm elections, including among older Americans who reliably show up to the polls, said Republican strategist , who runs the Atlas Strategy Group.

“Is affordability going to be an issue? Absolutely,” he said. “Are health care prices going to factor into that? Yes.”

Even before the subsidies expired, the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50, a found.

Middle-aged adults with Obamacare plans acutely feel the pinch of the expired subsidies, because to charge adults in their 60s up to three times as much for premiums as those in their 20s, who generally use fewer medical services.

And many middle-aged adults were already enrolled in the lowest-cost plans available, which leaves them without cheaper options to fall back on, said , a policy analyst with KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“This is very dire for the older marketplace enrollees,” he said.

Someone making a few dollars over 400% of the federal poverty level earns too much to get a subsidy now, and in some states average premium payments were due to for this group. Many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes.

, a primary care physician and health policy researcher at the University of Michigan, said he has regular conversations with older patients who are trying to figure out how to afford their medical care. Some in their early 60s are likely to drop ACA coverage because of rising premiums, he said.

“That’s a gamble,” he added.

Marci Heinbaugh may take that bet. The 63-year-old social services worker, who lives in rural Illinois, said her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum.

She knew she’d be paying more, she said, but wasn’t anticipating that kind of increase. A few months in, she’s not sure if she’ll stick with the plan for the rest of the year. She said she may go uninsured.

“I’m petrified to even think about that,” Heinbaugh said.

People want to buy their own insurance on the marketplace, and many middle-aged adults could afford it with just a little federal financial help, said , senior vice president of public policy at AARP. Those who drop coverage or delay care until they reach age 65 might save money now, but that could be more costly for them — and taxpayers — later.

“There’s significant possibility that the purported savings associated with reducing subsidies as people approach retirement end up turning into higher utilization costs for Medicare,” Weil said.

And Medicare enrollees aren’t insulated from rising costs. In January, for example, standard Medicare from $185 per month to almost $203.

Until Galvin joins Medicare, he said, he expects to burn through a $30,000 retirement account to cover his marketplace plan’s premium payments and deductible.

A found that 1 in 5 adults over 50 had no retirement savings and 3 in 5 were worried they wouldn’t have enough retirement savings to support themselves.

The expiration of these Obamacare subsidies puts additional financial pressure on Americans as they approach retirement, health policy researchers said.

“It’s forcing people to make impossible choices,” said , director of federal health advocacy for the national nonprofit Justice in Aging.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact ºÚÁϳԹÏÍø News and share your story.

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Lingering pain from a car crash two months ago, on top of an already hardscrabble life, has Angulo worried about her pregnancy. So, she was relieved when a mobile street medicine van from St. John’s Community Health pulled up near her encampment last month.

“Thank God that we have them,” she said.

, which operates 28 clinics, mostly in L.A. County, is part of the nation’s network of nonprofit community clinics that care for the poorest Americans. Around 80% of its 144,000 patients, including Angulo, have Medi-Cal, California’s version of the Medicaid program for people with low incomes or disabilities.

But federal cuts to Medicaid spending under the Republican-passed One Big Beautiful Bill Act, compounded by in Sacramento, could cost St. John’s up to one-third of its $240 million annual revenue, requiring cuts to services that might include street medicine, said Jim Mangia, the president and CEO.

Smaller, more cash-strapped clinics in L.A. County could face harsher consequences, including closure, if the lost funding is not replaced.

That’s why Mangia, along with a coalition of community clinics, health care workers, and advocates, is pushing for a five-year, in the nation’s most populous county to help backfill the projected loss of federal and state dollars. St. John’s has contributed at least $2 million to the campaign so far.

Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said there aren’t a lot of options to save the health care system from disaster.

“Our backs are up against the wall,” she said. “This has the potential to be a game changer. It will be an absolutely significant offset to the losses.”

The L.A. County Board of Supervisors last month for inclusion on the June 2 primary ballot, over the objection of some cities within the county. Their leaders argued the tax would put a strain on consumers and business owners. Most of an in annual revenue generated would be used to protect safety-net health care at community clinics, hospitals, and schools.

Scrambling To Stay Afloat

Nationally, the GOP budget law is expected to cut federal Medicaid spending by over 10 years, and it could lead to an increase of in the number of people left uninsured. The L.A. ballot proposal is among many local and state initiatives nationwide, as clinics, hospitals, health care workers, advocates, and legislators scramble for new money to help offset the spending cuts.

In Michigan, where the federal law is projected to cost the state , Democratic Gov. Gretchen Whitmer’s office has proposed on tobacco, vape products, online gambling, sports betting, and digital advertising, which it projects would raise hundreds of millions of dollars annually.

In Rhode Island, a group of state legislators hopes to ease some of the pain caused by the federal cuts with a that includes a tax on digital ads and a 3% surcharge on taxable incomes above roughly $640,000.

“The goal is not to replace the revenue; it’s to mitigate the damage,” said Democratic state Rep. Brandon Potter, one of the legislators involved.

In Washington, Democratic state Rep. Shaun Scott recently introduced legislation to address the loss of federal dollars with on large companies, applied to employee salaries exceeding $125,000 a year.

In California, the GOP law will slash the to Medi-Cal by an a year, or 25%. Enrollment in Medi-Cal could by 2028 as a result of the federal and state spending cuts, according to an analysis by the UCLA Center for Health Policy Research and the University of California-Berkeley Labor Center.

In July, California will slash Medi-Cal payments that community clinics receive for certain services provided to patients with “unsatisfactory” immigration status by about . Those patients include permanent residents in the country for less than five years, refugees, asylees, and other lawfully present people.

Bracing for a ‘New Reality’?

Advocates and health care experts say finding new revenue is the only way to avoid a crisis in California’s health care system.

“Are we going to let the gaps created by federal policies and state budget cuts leave millions of people uninsured?” said Laurel Lucia, deputy executive director of programs at the UC Berkeley Labor Center. “I think a lot of that question comes down to revenues.”

Some medical professionals say that new revenue is needed in the short term but that the country needs to address its notoriously expensive health care system.

“This new reality is that we have to do our work with less money going into the future,” said Hector Flores, of the Los Angeles County Medical Association. “So, this is an opportunity for us to look at how we can do things better.”

In the meantime, efforts to raise taxes for health care abound.

Voters in Santa Clara County, home to Silicon Valley, last November approved a five-year 0.625% to offset federal Medicaid cuts. A will be on the June ballot in Contra Costa County.

The best-known initiative, and a hotly contested one, is a union-sponsored ballot proposal in California for a on the state’s . Democratic Gov. Gavin Newsom strongly opposes it; Sen. Bernie Sanders (I-Vt.) stumped for it in California recently and has a national version in Congress.

Proponents of the temporary wealth tax say it would raise , which would mostly be used to backfill lost federal and state dollars in Medi-Cal and other safety-net programs. Proponents are trying to collect nearly 875,000 signatures needed to get it on the November ballot.

“We are on the precipice of a collapse of our health care system. So the most fortunate among us pay a modest tax that will hold us over and allow us to figure out a long-term solution,” said Suzanne Jimenez, chief of staff for Service Employees International Union-United Healthcare Workers West, the measure’s chief sponsor. “They would still be incredibly wealthy after that.”

Billionaires Push Back

The plan has stirred considerable controversy, not just in the Golden State but nationwide, and has generated strong and others.

Critics argue the measure could prompt billionaires to leave California, putting a damper on innovation, jobs, and tax receipts. And, some warn, the measure could end up in a legal quagmire, as those deemed liable to pony up challenge it on multiple fronts.

“If this passed, you would expect it to be tied up in court for some time,” said Jared Walczak, a visiting fellow at the California Tax Foundation. “It is fairly plausible that no revenue could come in for a number of years, if there’s ever any revenue at all.”

The prospect of such complications has led some health care advocates to focus instead on local initiatives that could start generating revenue more quickly, such as the proposed sales tax in L.A. County.

That one has critics too, including leaders of multiple cities within the county who to reject a proposal they argued would add to the affordability worries of consumers and put a strain on businesses.

Kathryn Barger, a Republican and the only L.A. County supervisor to oppose putting the measure on the June ballot, said in a statement that the proposed tax would make the county “less affordable for families and less appealing for consumers to shop and businesses to operate.”

But supporters say safety-net health care is already feeling the impact of diminished funding. Last month, for example, L.A. County’s Department of Public Health announced it was due to $50 million in federal, state, and local funding cuts.

Medi-Cal enrollees are worried, too. “We get a lot of calls from panicked patients afraid they’re going to lose their Medi-Cal. Dozens of calls a day, hundreds of calls a week,” said St. John’s Mangia.

“We tell them that we’re working on a solution and hopefully we’ll have that solution come June.”

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“The person said he was an officer of the Department of Criminal Investigations looking into drug trafficking and money laundering,” the woman recalled. He seemed to know a lot about her: the states where she and her late husband had lived; his name and occupation; and her current address in Washington County, Rhode Island.

On her phone, he showed her a convincing badge and a photo ID with his name (“‘Frank’ something”), plus an article describing the supposed investigation. The woman, a 76-year-old retiree, denied any involvement.

“You can hire a very expensive criminal defense attorney, or you can cooperate with me,” Frank told her.

“Now, when you think about it, it doesn’t make any sense,” the woman acknowledged recently. But persuaded by the badge and ID, she agreed to cooperate. Otherwise, “I thought they were going to come and arrest me.”

Frank called each morning to learn where she was going, what she was doing. His team would be watching, he warned. The woman, feeling “petrified,” started looking around as she drove to garden club meetings. Was somebody following her?

It was all a scam.

Because victims’ sense of shame often leaves them reluctant to report such crimes, the extent of elder financial exploitation is hard to calculate. The Federal Trade Commission of $2.4 billion in 2024, largely driven by investment and and impersonations, with total losses much higher.

Americans age 60 and older lose more than $28 billion annually to financial exploitation, .

As those numbers rise, because the population is aging and predators are growing increasingly resourceful, banks and investment firms are becoming the first line of defense.

Frank’s initial target: her account at Fidelity Investments. He instructed her to shift about $250,000 into her checking account, telling the financial adviser at her local office that she and her family intended to buy real estate.

That scheme fizzled when the adviser said Fidelity could not approve the transaction without more information on the property.

So Frank sent her to her local branch of Washington Trust Company to take $70,000 in cash from a home-equity line of credit. “We don’t give out that much in cash,” the teller said, quietly messaging the branch manager, who had known the woman and her husband for years.

The manager ushered the woman into her office to talk, and the scam stopped there, with a call to the local police. The woman’s assets remained intact, but the experience proved so mortifying that she has not told even her family how close she came to losing much of her life savings. The New York Times is withholding her name to spare her embarrassment.

“I felt so stupid,” she said. “I felt like a fool.”

Financial predators targeting older adults represent “a heightened focus for us now,” said Mary Noons, president and chief operating officer of Washington Trust.

A regional community bank, Washington Trust cranked up its efforts last fall to advise older customers and their families about finances, including the dangers of elder fraud and exploitation. It published and distributed a booklet called “Age With Wisdom” and brought in an expert on dementia to speak with staff members.

And it became one of the 1,500 financial institutions to date to use BankSafe, a free AARP video program that trains front-line employees to spot the indicating possible elder exploitation and to intervene. Everyone at the branch where the 76-year-old banked had taken the training.

“Some older customers visit their bank far more frequently than they see their health care providers,” Noons pointed out.

Until recent years, financial institutions placed “more of an emphasis on the autonomy of the client,” said Pamela Teaster, director of the Virginia Tech Center for Gerontology and an elder abuse researcher. Their approach was, “an adult has the capacity to make poor choices, and we’re going to let them make them,” she added.

But changes in government and industry policies and practices have encouraged greater vigilance. Congress passed in 2018, protecting banks and financial firms from liability if they reported suspected exploitation to authorities.

That year, the Financial Industry Regulatory Authority began requiring member firms to ask for a when investors open or update accounts. (The account holder isn’t obliged to provide one, however.) And since 2022, it has on older investors’ transactions if they suspect exploitation is involved.

About half of states have enacted laws that permit financial institutions to deny suspicious transactions or impose holds for specified periods to allow investigations, said Jilenne Gunther, the director of BankSafe.

“It adds friction,” she explained. “With space and time, the criminal gets worried and might move on. And the potential mark has time to stop and think.”

Teaster’s analysis of during a six-month pilot in 82 financial institutions, found that participants were much more likely to report suspected cases and save customers money than a control group was.

Not all of older adults’ losses result from predators, however. They can, on their own, get caught up in investment fads, take on too much debt, or make otherwise unwise decisions, even without criminals pulling the strings or relatives looting their accounts.

Managing finances presents complex cognitive challenges, said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine. “It requires a lot of brain,” he said, including: “Memory, remembering that a bill is due. Executive function, the ability to manage your time. Abstraction, hypothesizing about your future.”

He added, “Financial errors are not infrequently the or a neurocognitive disorder.”

A by the Federal Reserve Bank of New York, for instance, found an increased probability of delinquent payments and deteriorating credit ratings in the five years before a dementia diagnosis. Those errors can reduce seniors’ access to credit and raise their interest rates on loans at the very point when caregiving expenses are likely to soar.

Lachs has called on fellow doctors to recognize what he calls , a syndrome that can affect even older people with normal cognition, especially if they contend with medical illnesses, sensory deficits, or social isolation.

And he remains skeptical about the financial industry’s claims of heightened attention to its oldest customers. “I still see concerning financial transactions executed that should have received far greater scrutiny,” he said.

Training more front-line staff members and increasing emphasis on establishing trusted contacts for older customers would help, Gunther said, because “once the money leaves the account, it’s near impossible to ever retrieve it.” More states could enact laws allowing financial institutions to deny suspicious transactions or impose holds.

Several related bills with bipartisan support are working their way through Congress. The would require the FBI to coordinate efforts to protect seniors. A would at least provide the consolation of excusing scam victims from paying taxes on money they no longer have.

However, new weapons like artificial-intelligence voice cloning — in which the supposed grandson four states away who urgently needs $5,000 in gift cards actually sounds like the victim’s grandson — keep advocates and bankers awake at night.

In the Washington Trust branch where the Rhode Island woman didn’t lose her money, employees just days earlier had stopped a scam similar to the one that had targeted her.

But more recently, nobody spotted any danger signs when an older woman withdrew $9,000 for a kitchen renovation, until it went to a scammer instead of a contractor.

The New Old Age is produced through a partnership with .

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That’s the case in New Orleans, where an investigation by Verite News found high lead levels in about half of the playgrounds on city property and found in most homes that tested their drinking water in a voluntary program.

No level of lead exposure is safe, according to federal environmental officials, but undertaking a comprehensive cleanup can be financially prohibitive. New Orleans is facing a $220 million budget deficit that has led to city employee furloughs and layoffs.

Congress allocated $15 billion over five years to lead pipe replacement under the Bipartisan Infrastructure Law, a Biden-era measure set to expire at the end of this year. In 2024, the Environmental Protection Agency also tightened the standards for lead-contaminated soil for the first time in 30 years and mandated that water systems by late 2037.

But passed by Congress and signed by President Donald Trump in January redirected $125 million of that lead remediation money to wildfire prevention. And since October, the EPA has partially rolled back protections against soil contamination, raising the federal hazard level in urban areas and the threshold for removing contaminated soil.

Tom Neltner, the national director of the nonprofit advocacy group Unleaded Kids, said it was the first time an administration had loosened the limits on lead in soil.

“ We’ve seen the Trump administration say positive things about its commitment to lead but then take actions that undermine that,” Neltner said.

But, he added, progress is still being made in some communities.

EPA press secretary Brigit Hirsch said the changes made under the Trump administration have reduced confusion and uncertainty that could hamper cleanup efforts.

“The Trump EPA’s record on protecting Americans — especially American children — from lead is unmatched,” Hirsch said in an emailed statement. “In just the last year, the Trump EPA backed up its commitment to reducing lead exposure in children with BILLIONS of dollars and historic action.”

She cited a of $3 billion available to pay for water pipe replacement. That money is from the passed during the Biden administration.

Verite News spoke with people in Michigan, Indiana, and Rhode Island to learn how they addressed their lead pollution, with the aim of finding options that could be applied in New Orleans and other cities.

“ We don’t need to do research on lead anymore,” said Tulane University professor Felicia Rabito, an epidemiologist who researches the toxic metal and its sources. “What we need are policies to get the lead out of the environment.”

Benton Harbor, Michigan: Lead Pipes Begone

Benton Harbor, a predominantly Black beach town of about 9,000 people on the southeastern shore of Lake Michigan, spent three years out of compliance with federal drinking water standards. The concentration of lead in the water remained dangerously high until residents and organizations petitioned the EPA in 2021, drawing responses from state and federal officials.

“Nobody should be drinking lead in their water for this long,” said Elin Betanzo, an engineer who provided the petitioning residents with technical support.

That year, federal officials issued an for the Michigan city to bring its water supply into compliance, and the state required Benton Harbor to replace all its lead pipes within 18 months. Gov. Gretchen Whitmer, a Democrat, committed to securing funding in the state budget for the $35 million effort, which included bottled water distribution and paying outstanding water bills for low-income residents. The state, alongside the city, allocated money from its general fund, secured regional water loans, and cobbled together grants from several federal programs to cover the total.

By the end of 2023, city officials had completed the project. Now it’s one of 21 municipalities in Michigan that have replaced all their lead pipes. Benton Harbor had more than 4,500 pipes to replace.

The Trump administration has said it would defend the Biden-era mandate for lead pipe replacement by 2037 against a lawsuit challenging it.

Betanzo recommended that utilities in other cities reduce barriers to line replacement to increase efficiency, as Benton Harbor’s water system did.

City officials saved time after assuming most pipes would be lead. They decided to go street by street, digging up, inspecting, and replacing nearly every pipe. If the pipe wasn’t lead, it wasn’t replaced, but nearly all were, Betanzo said.

Concentrating the mass replacement in one zone at a time made the contracts more cost-effective, Betanzo added. Contractors bid on zones in the city, and multiple contractors worked in different neighborhoods simultaneously. For transparency, progress was published on a public database.

The city also passed a law requiring lead lines be replaced, including those on customers’ side of the water meter. All residents had to allow the contractors onto their property or face disconnection. The residents didn’t pay for the line replacements.

“ The health benefits of lead service line replacement are greatest the sooner you get it done,” Betanzo noted, referencing a she co-authored. “If you do it wrong, you can absolutely increase exposure to lead through a lead service line replacement.”

Completion of full pipe replacement is rare in the U.S., because of the cost, poor service line tracking, the time it takes, and the prioritization of other issues. In New Orleans, the process could require up to $1 billion of investment over 10 years, according to the city’s Sewerage and Water Board.

Indianapolis: Safe Dirt for Kids

It’s not just lead pipes that are problematic. In 2024, a in the academic journal GeoHealth estimated that nearly a quarter of homes in the U.S. have unsafe levels of lead in the soil on their properties.

To that end, Indianapolis has taken some actions that other cities can learn from, said Gabriel Filippelli, a professor at the Indiana University-Indianapolis School of Science who led the study and has researched the risk of lead exposure through soil for years.

The Indy Parks & Recreation department partnered with Filippelli’s team to test a dozen parks relatively close to the contaminated site of a shuttered lead smelter.

Out of all the parks tested, Filippelli’s team found only one hot spot, beneath an old bench from which lead-based paint had flaked off into the surrounding soil.

The parks department followed Filippelli’s suggestion to replace the bench and add concrete and a thick layer of mulch and plants on the ground, so kids wouldn’t be able to play directly in the contaminated dirt.

“It was a relatively low-cost intervention,” he said, estimating it cost a few thousand dollars. The ground wasn’t excavated, and new dirt wasn’t brought in. “If you deal with it by dilution and by capping, remove the source, you’re solving the problem for today and probably many, many years to come.”

The contaminated dirt may need to be removed in some cases and replaced with clean soil, such as after severe, widespread pollution from industrial sources. But Filippelli said such extensive remediation can be impractical and too expensive for cities to undertake on their own.

Where full remediation is cost-prohibitive, Filippelli said, there are more creative solutions, like landscaping, covering the area with new dirt, or mulching. These methods won’t eliminate the lead entirely, but they will significantly reduce exposure risk.

“You can eliminate the hazard at a fraction of the cost,” he said.

Cities could also look to New York City’s , which places uncontaminated soil left over from construction projects in neighborhood-level banks for volunteers to distribute, he said.

Rhode Island: Stopping Lead at the Source

New England, home to some of the nation’s oldest homes, has led the U.S. in mitigating one of the largest ongoing sources of lead contamination: paint.

In 2023, the state legislature in Rhode Island, where most of the homes were built before lead paint was banned in 1978, passed strengthening the state’s ability to enforce tenant protections.

Prior to 2023, the state had long required most landlords to have their property inspected to ensure it met “lead safe” guidelines, said DeeAnn Guo, a community organizer for the . Although no level of lead is considered safe, replacing windows and doors that have lead paint, painting over all interior and exterior walls, and mitigating contaminated soil significantly reduce the risk of exposure.

But for years “there was no incentive to do it,” Guo said, “aside from it being the right thing to do.”

Now, landlords can be fined if they don’t have an active lead certificate on file for homes built before 1978, and the property has to be inspected every two years to remain in compliance. Before the new law, less than 15% of rentals were certified. In late 2025, that had increased to 40%, Guo said.

The state has also seen a steady decline in the in children’s blood.

Guo said it helps that the state has federal funding from the Department of Housing and Urban Development to subsidize its If a homeowner or landlord owns an old house, they can apply for the state to send an inspector. If lead is found, the state will then send a certified contractor to address the problem at little to no cost to the property owner.

Rhode Island prioritizes low-income households and homes with pregnant women or children under 6 years old, because of the heightened health risk. It can also help pay to remediate homes if a child living there has elevated levels of lead in their blood.

States and communities looking to start a successful lead paint abatement program using HUD money should combine strong enforcement, public education, and offers of subsidies, Guo said. It also helps to include community members in the planning process, she said.

Under the Trump administration, however, it might become harder for more communities like New Orleans to receive money for a “lead safe” program. Last year, HUD asked Congress to eliminate new funding for its lead hazards program, stating it would be restored in 2027. But advocates for more lead protections argue that once funding is lost, it is unlikely to be approved again.

“It shows the White House’s hypocrisy, where they talk about lead as being important and then propose eliminating the funds that are essential to cleaning up affordable housing,” said Neltner, the Unleaded Kids director. “This administration talks about the importance of children and then seems to be careless about children’s brains.”

This article was produced in collaboration with . The four-month investigation was supported by a Kozik Environmental Justice Reporting grant funded by the National Press Foundation and the National Press Club Journalism Institute. It was also produced as a project for the USC Annenberg Center for Health Journalism’s National Fellowship fund and Dennis A. Hunt Fund for Health Journalism.

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“I was kind of a mess,” recalled Abrams, 69. Trying to cope, “I was eating myself into oblivion.” As her weight hit 270 pounds and her blood pressure, cholesterol, and blood glucose levels climbed, “I knew I was in trouble health-wise.”

What came to mind? “Oh, oh, oh, Ozempic!” — the from television commercials that promoted the GLP-1 medication for diabetes. The ads also pointed out that patients who took it lost weight.

Abrams remembered the commercials as “joyful” and sometimes found herself humming the jingle. They depicted Ozempic-takers cooking omelets, repairing bikes, playing pickleball — “doing everyday activities, but with verve,” she said. “These people were enjoying the hell out of life.”

So, just as such ads often urge, even though she had never been diagnosed with diabetes, she asked her doctor if Ozempic was right for her.

Small wonder Abrams recalled those ads. Novo Nordisk, which manufactures Ozempic, spent an estimated $180 million in direct-to-consumer advertising in 2022 and $189 million in 2023, according to MediaRadar, which monitors advertising.

By last year, the sum — including radio and TV commercials, billboards, and print and digital ads — had reached an estimated $201 million, and total spending on direct-to-consumer advertising of prescription drugs topped $9 billion, by MediaRadar’s calculations.

Novo Nordisk declined to address those numbers.

Should it be legal to market drugs directly to potential patients? This controversy, which has simmered for decades, has begun receiving renewed attention from both the Trump administration and legislators.

The question has particular relevance for older adults, who contend with more medical problems than younger people and are more apt to take prescription drugs. “Part of aging is developing health conditions and becoming a target of drug advertising,” said Steven Woloshin, who studies health communication and decision-making at the Dartmouth Institute.

The debate over direct-to-consumer ads dates to 1997, when the FDA loosened restrictions and allowed prescription drug ads on television as long as they included a rapid-fire summary of major risks and provided a source for further information.

“That really opened the door,” said Abby Alpert, a health economist at the Wharton School of the University of Pennsylvania.

The introduction of Medicare Part D, in 2006, brought “a huge expansion in prescription drug coverage and, as a result, a big increase in pharmaceutical advertising,” Alpert added. A study she co-wrote in 2023 found that pharmaceutical ads in areas with a high proportion of residents 65 and older.

and have shown that ads influence prescription rates. Patients are more apt to make appointments and request drugs, either by brand name or by category, and doctors often comply. may ensue.

But does that benefit consumers? Most developed countries take a hard pass. Only New Zealand and, despite the decadelong , the United States allow direct-to-consumer prescription drug advertising.

Public health advocates argue that such ads encourage the use and overuse of expensive new medications, even when existing, cheaper drugs work as effectively. (Drug companies don’t bother advertising once patents expire and generic drugs become available.)

In a 2023 study in JAMA Network Open, for instance, researchers analyzed the “” of the drugs most advertised on television, based on the assessments of independent European and Canadian organizations that negotiate prices for approved drugs.

Nearly three-quarters of the top-advertised medications didn’t perform markedly better than older ones, the analysis found.

“Often, really good drugs sell themselves,” said Aaron Kesselheim, senior author of the study and director of the Program on Regulation, Therapeutics, and Law at Harvard University.

“Drugs without added therapeutic value need to be pushed, and that’s what direct-to-consumer advertising does,” he said.

Opponents of a ban on such advertising say it benefits consumers. “It provides information and education to patients, makes them aware of available treatments and leads them to seek care,” Alpert said. That is “especially important for underdiagnosed conditions,” like depression.

Moreover, she wrote in a recent , direct-to-consumer ads lead to increased use not only of brand-name drugs but also of non-advertised substitutes, including generics.

The Trump administration entered this debate last September, with calling for a return to the pre-1997 policy severely restricting direct-to-consumer drug advertising.

That position has repeatedly been urged by Health and Human Services Secretary Robert F. Kennedy Jr., who has charged that “pharmaceutical ads hooked this country on prescription drugs.”

At the same time, the FDA said it was issuing about deceptive drug ads and sending “thousands” of warnings to pharmaceutical companies to remove misleading ads. Marty Makary, the FDA commissioner, in an essay in The New York Times.

“There’s a lot of chatter,” Woloshin said of those actions. “I don’t know that we’ll see anything concrete.”

This month, however, the that the agency had found its TV spot for a new oral version of Wegovy false and misleading. Novo Nordisk said in an email that it was “in the process of responding to the FDA” to address the concerns.

Meanwhile, Democratic and independent senators who rarely align with the Trump administration also have introduced legislation to ban or limit direct-to-consumer pharmaceutical ads.

Last February, independent Sen. Angus King of Maine and two other sponsors prohibiting direct-to-consumer ads for the first three years after a drug gains FDA approval.

King said in an email that the act would better inform consumers “by making sure newly approved drugs aren’t allowed to immediately flood the market with ads before we fully understand their impact on the general public.”

Then, in June, he and independent Sen. Bernie Sanders of Vermont proposed entirely. That might prove difficult, Woloshin said, given the Supreme Court’s Citizens United ruling .

Moreover, direct-to-consumer ads represent only part of the industry’s promotional efforts. Pharmaceutical firms actually spend than to consumers.

Although television still accounts for most consumer spending, because it’s expensive, Kesselheim pointed to “the mostly unregulated expansion of direct-to-consumer ads onto the web” as a particular concern. Drug sales themselves are bypassing doctors’ practices by moving online.

Woloshin said that “disease awareness campaigns” — for everything from shingles to restless legs — don’t mention any particular drug but are “often marketing dressed up as education.”

He advocates more effective educational campaigns, he said, “to help consumers become more savvy and skeptical and able to recognize reliable versus unreliable information.”

For example, Woloshin and Lisa Schwartz, a late colleague, designed and tested a simple “,” similar to the nutritional labeling on packaged foods, that summarizes and quantifies the benefits and harms of medications.

For now, consumers have to try to educate themselves about the drugs they see ballyhooed on TV.

Abrams read a lot about Ozempic. Her doctor agreed that trying it made sense.

Abrams was referred to an endocrinologist, who decided that her blood glucose was high enough to warrant treatment. Three years later and 90 pounds lighter, she feels able to scramble after her 2-year-old grandson, enjoys Zumba classes, and no longer needs blood pressure or cholesterol drugs.

So Abrams is unsure, she said, how to feel about a possible ban on direct-to-consumer drug ads.

“If I hadn’t asked my new doctor about it, would she have suggested Ozempic?” Abrams wondered. “Or would I still weigh 270 pounds?”

The New Old Age is produced through a partnership with .

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Regulating artificial intelligence, especially its use by health insurers, is becoming a politically divisive topic, and it’s scrambling traditional partisan lines.

Boosters, led by Trump, are not only pushing its integration into government, as in in prior authorization, but also trying to stop others from building curbs and guardrails. A December seeks to preempt most state efforts to govern AI, describing “a race with adversaries for supremacy” in a new “technological revolution.”

“To win, United States AI companies must be free to innovate without cumbersome regulation,” Trump’s order said. “But excessive State regulation thwarts this imperative.”

Across the nation, states are in revolt. At least four — Arizona, Maryland, Nebraska, and Texas — enacted legislation last year reining in the use of AI in health insurance. Two others, Illinois and California, enacted bills the year before.

Legislators in Rhode Island plan to try again this year after a bill requiring regulators to collect data on technology use failed to clear both chambers last year. A bill in North Carolina requiring insurers not to use AI as the sole basis of a coverage decision attracted significant interest from Republican legislators last year.

DeSantis, a former GOP presidential candidate, has rolled out an “AI Bill of Rights,” include restrictions on its use in processing insurance claims and a requirement allowing a state regulatory body to inspect algorithms.

“We have a responsibility to ensure that new technologies develop in ways that are moral and ethical, in ways that reinforce our American values, not in ways that erode them,” DeSantis said during his State of the State address in January.

Ripe for Regulation

Polling shows Americans are skeptical of AI. A from Fox News found 63% of voters describe themselves as “very” or “extremely” concerned about artificial intelligence, including majorities across the political spectrum. Nearly two-thirds of Democrats and just over 3 in 5 Republicans said they had qualms about AI.

Health insurers’ tactics to hold down costs also trouble the public; from KFF found widespread discontent over issues like prior authorization. (KFF is a health information nonprofit that includes ºÚÁϳԹÏÍø News.) Reporting and in recent years has highlighted the use of algorithms to rapidly deny insurance claims or prior authorization requests, apparently with little review by a doctor.

Last month, the House Ways and Means Committee hauled in executives from Cigna, UnitedHealth Group, and other major health insurers to address concerns about affordability. When pressed, the executives either denied or avoided talking about using the most advanced technology to reject authorization requests or toss out claims.

AI is “never used for a denial,” Cigna CEO David Cordani told lawmakers. Like others in the health insurance industry, the company is being sued for its methods of denying claims, as spotlighted by ProPublica. Cigna spokesperson Justine Sessions said the company’s claims-denial process “is not powered by AI.”

Indeed, companies are at pains to frame AI as a loyal servant. Optum, part of health giant UnitedHealth Group, announced Feb. 4 that it was rolling out tech-powered prior authorization, with plenty of mentions of speedier approvals.

“We’re transforming the prior authorization process to address the friction it causes,” John Kontor, a senior vice president at Optum,

Still, Alex Bores, a computer scientist and New York Assembly member prominent in the state’s legislative debate over AI, which culminated in a comprehensive bill governing the technology, said AI is a natural field to regulate.

“So many people already find the answers that they’re getting from their insurance companies to be inscrutable,” said Bores, a Democrat who is running for Congress. “Adding in a layer that cannot by its nature explain itself doesn’t seem like it’ll be helpful there.”

At least some people in medicine — doctors, for example — are cheering legislators and regulators on. The American Medical Association “supports state regulations seeking greater accountability and transparency from commercial health insurers that use AI and machine learning tools to review prior authorization requests,” said John Whyte, the organization’s CEO.

Whyte said insurers already use AI and “doctors still face delayed patient care, opaque insurer decisions, inconsistent authorization rules, and crushing administrative work.”

Insurers Push Back

With legislation approved or pending in at least nine states, it’s unclear how much of an effect the state laws will have, said University of Minnesota law professor Daniel Schwarcz. States can’t regulate “self-insured” plans, which are used by many employers; only the federal government has that power.

But there are deeper issues, Schwarcz said: Most of the state legislation he’s seen would require a human to sign off on any decision proposed by AI but doesn’t specify what that means.

The laws don’t offer a clear framework for understanding how much review is enough, and over time humans tend to become a little lazy and simply sign off on any suggestions by a computer, he said.

Still, insurers view the spate of bills as a problem. “Broadly speaking, regulatory burden is real,” said Dan Jones, senior vice president for federal affairs at the Alliance of Community Health Plans, a trade group for some nonprofit health insurers. If insurers spend more time working through a patchwork of state and federal laws, he continued, that means “less time that can be spent and invested into what we’re intended to be doing, which is focusing on making sure that patients are getting the right access to care.”

Linda Ujifusa, a Democratic state senator in Rhode Island, said insurers came out last year against the bill she sponsored to restrict AI use in coverage denials. It passed in one chamber, though not the other.

“There’s tremendous opposition” to anything that regulates , she said, and “tremendous opposition” to identifying intermediaries such as private insurers or pharmacy benefit managers “as a problem.”

In a , AHIP, an insurer trade group, advocated for “balanced policies that promote innovation while protecting patients.”

“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden and costs to improve the focus on patient care,” Chris Bond, an AHIP spokesperson, told ºÚÁϳԹÏÍø News. And, he continued, they need a “consistent, national approach anchored in a comprehensive federal AI policy framework.”

Seeking Balance

In California, Newsom has signed some laws regulating AI, including one requiring health insurers to ensure their algorithms are fairly and equitably applied. But the Democratic governor has vetoed others with a broader approach, such as a bill including more mandates about how the technology must work and requirements to disclose its use to regulators, clinicians, and patients upon request.

Chris Micheli, a Sacramento-based lobbyist, said the governor likely wants to ensure the state budget — consistently powered by outsize stock market gains, especially from tech companies — stays flush. That necessitates balance.

Newsom is trying to “ensure that financial spigot continues, and at the same time ensure that there are some protections for California consumers,” he said. He added insurers believe they’re subject to a welter of regulations already.

The Trump administration seems persuaded. The president’s recent executive order proposed to sue and restrict certain federal funding for any state that enacts what it characterized as “excessive” state regulation — with some exceptions, including for policies that protect children.

That order is possibly unconstitutional, said Carmel Shachar, a health policy scholar at Harvard Law School. The source of preemption authority is generally Congress, she said, and federal lawmakers twice took up, but ultimately declined to pass, a provision barring states from regulating AI.

“Based on our previous understanding of federalism and the balance of powers between Congress and the executive, a challenge here would be very likely to succeed,” Shachar said.

Some lawmakers view Trump’s order skeptically at best, noting the administration has been removing guardrails, and preventing others from erecting them, to an extreme degree.

“There isn’t really a question of, should it be federal or should it be state right now?” Bores said. “The question is, should it be state or not at all?”

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“If we didn’t have health issues, I’d just go back to where I was in my 40s and not have health insurance,” she said, “but we’re not in that position now.”

Freeman and her husband, , are freelancers who work in storytelling and podcasting.

In October, Lawrence, 52, got very sick, very fast.

“I knew I was in trouble,” he said. “I went into the emergency room, and I walked over to the desk, and I said, ‘Hi, I’ve gained 25 pounds in five days and I’m having trouble breathing and my chest hurts.’ And they stopped blinking.”

Doctors diagnosed him with kidney disease, and he was hospitalized for four days.

Now Lawrence has to take medication with an without insurance of $760 a month.

In January, the cost of the couple’s current “silver” plan rose nearly 75%, to $801 a month.

To bring in extra cash, Freeman has picked up a part-time bartending gig.

Millions of who have ACA health plans are facing soaring premium payments in 2026, without help from the enhanced subsidies that Congress failed to renew. Some are contemplating big life changes to deal with new rates that kicked in on Jan. 1.

It often falls to women to figure out a family’s insurance puzzle.

Women generally than men, in part because of their need for reproductive services, according to , a professor at Brown University’s School of Public Health.

Women also tend to be the for the family, she said, especially for the children.

“There’s a disproportionate role that women play in families around what we think of as the mental load,” said Tobin-Tyler, and that includes “making decisions around health insurance.”

Before the holidays, a few forms of relief for the premium hikes, but nothing has materialized, and significant deadlines have already passed.

Going Uninsured?

As the clock ticked down on 2025, B. agonized over her family’s insurance options. She was looking for a full-time job with benefits, because the premium prices she was seeing for 2026 ACA plans were alarming.

In the meantime, she decided, she and her husband would drop coverage and insure only the kids. But it would be risky.

“My husband works with major tools all day,” she said, “so it feels like rolling the dice.”

NPR and ºÚÁϳԹÏÍø News are identifying B. by her middle initial because she believes her insurance needs could affect her ongoing search for a job with health benefits.

The family lives in Providence, Rhode Island. Her husband is a self-employed woodworker, and she worked full-time as a nonprofit manager before she lost her job last spring.

After she lost her job, she turned to the ACA marketplace. The family’s cost them nearly $2,000 a month in premiums.

It was a lot, and they dug into retirement savings to pay for it while B. kept looking for a new position.

Because Congress failed to extend enhanced subsidies for ACA plans, despite ongoing political battles and a lengthy government shutdown over the issue, B.’s family plan would have cost even more in 2026 — almost $3,000 a month.

“I don’t have an additional $900 lying around in my family budget to pay for this,” she said.

B. had already pulled $12,000 out of retirement funds to pay her family’s 2025 rates.

Unless she finds a new job soon, the family’s projected income for 2026 will be less than . That means the children qualify for free coverage through Medicaid.

So B. decided to buy a plan on the ACA marketplace for herself and her husband, paying premiums of $1,200 a month.

“The bottom line is none of this is affordable,” she said, “so we’re going to be dipping into savings to pay for this.”

Postponing a Wedding

The prospect of soaring insurance premiums put a pause on Nicole Benisch’s plans to get married.

Benisch, 45, owns a holistic wellness business in Providence. She paid $108 a month for a zero-deductible “silver” plan on Rhode Island’s insurance exchange.

But the cost in 2026 more than doubled, to $220 a month.

She and her fiance had planned to marry on Dec. 19, her late mother’s birthday. “And then,” she said, “we realized how drastically that was going to change the cost of my premium.”

As a married couple, their combined income would exceed 400% of the federal poverty level and make Benisch ineligible for financial help. Her current plan’s monthly premium payments would triple, costing her more than $700 a month.

Benisch considered a less expensive “bronze” plan, but it wouldn’t cover vocal therapy, which she needs to treat , a condition that can make her voice strain or give out.

If they get married, there’s another option: Switch to her fiance’s health plan in Massachusetts. But that would mean losing all her Rhode Island doctors, who would be out-of-network.

“We have some tough decisions to make,” she said, “and none of the options are really great for us.”

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Health officials are recommending diet and exercise as alternatives to heavily advertised weight loss drugs like Wegovy and Zepbound, advice experts say is unrealistic.

“Of course he tried eating well and everything, but now with the medications, it’s better — a 100% change,” said Wilmer Cardenas of Santa Clara, who said his husband lost about 100 pounds over about two years using GLP-1s covered by Medi-Cal, California’s version of Medicaid.

California joined several other states in restricting an option they say is no longer affordable as they confront soaring pharmaceutical costs and steep Medicaid cuts under the Trump administration, among . Despite negotiated price reductions announced in November that would make the drugs available at a “dramatically lower cost to taxpayers” and enable Medicaid to cover them, states are going ahead with the cuts, which providers say may undermine patients’ health.

“It will be quite negative for our patients” because data shows people typically regain weight after stopping the drugs, said , medical director of the University of California-San Francisco Weight Management Program.

While California, , , and stopped covering adult GLP-1 prescriptions for obesity on Jan. 1, they continue to cover the drugs for other health issues, such as Type 2 diabetes, cardiovascular disease, and chronic kidney disease.

, , and Wisconsin are planning or considering restrictions, according to KFF’s .

That reverses a trend that saw 16 states covering the medications for obesity as of Oct. 1. Interest in providing the coverage “appears to be waning,” the survey found, likely due to the drugs’ cost and other state budget pressures. North Carolina pulled back GLP-1 coverage in October, but reinstated it in December, bowing to court orders despite a lingering budget shortfall.

Catherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its affiliated Obesity Association, said it’s not clear how states will adjust to the White House plan to lower the cost of several of the most popular GLP-1s through TrumpRx, an online portal for discounted prescription drugs. The price of Wegovy, for example, will be $350 per month for consumers, versus the current list price of nearly $1,350, and Medicare and Medicaid programs will pay $245, according to the plan.

“Many states are facing budgetary challenges, such as deficits, and are working to address the impacts of the changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available for the Administration’s agreements, we will see how state Medicaid responds.”

The Department of Health and Human Services referred questions to the White House, which did not respond to requests for comment on states’ termination of Medicaid coverage for the weight loss drugs.

California projected its costs to cover GLP-1s for weight loss would have more than quadrupled over four years to if it didn’t end Medi-Cal coverage for that use. Medi-Cal has covered weight loss drugs since 2006, but use of GLP-1s soared only in recent years. By 2024, more than 645,000 prescriptions were covered by Medi-Cal across all uses of the medications. The California Department of Health Care Services could not readily provide a breakdown of whether the drugs were for weight loss or other conditions.

When asked whether the state would reconsider its plans in light of the announced price cuts, Department of Finance spokesperson H.D. Palmer said it had no plans to do so. California’s cut is written into .

California officials would not say how much it could save under the TrumpRx plan, citing federal and state restrictions on disclosing rebate information.

Health providers don’t expect the Trump administration’s negotiated price cuts to make much difference to consumers, because pharmaceutical companies already offer some discounts.

“The out-of-pocket costs will still be very cost-prohibitive for most, especially individuals with Medicaid insurance,” Thiara said.

is among the other states that ended their coverage Jan. 1. Officials with the New Hampshire Department of Health and Human Services did not respond to requests for comment.

About 1 in 8 adults are now taking a GLP-1 drug for obesity, disease, or both, up 6 percentage points from May 2024, according to released in November. Over half of users said their GLP-1s were difficult to afford, and many who had stopped the treatment cited the cost.

Public and private payers have been trying to wean patients off to save costs. California health officials said Medi-Cal members and their health care providers “other treatment options that can support weight loss, such as diet changes, increased activity or exercise, and counseling.” That echoes advice from the New Hampshire Medicaid program.

California Department of Health Care Services spokesperson Tessa Outhyse said in an email that the official advice to try those other approaches now “is not meant to dismiss any past efforts, but to encourage Medi-Cal members to take a renewed, proactive, and medically supported approach with their healthcare provider that may appropriately include these additional options.”

But that may be unrealistic, said , founding director of the Center for Clinical Nutrition at Keck School of Medicine of the University of Southern California.

“We definitely want patients to do their part with the diet and exercise, but unfortunately, and from a practical standpoint, that itself frequently is not enough,” Hong said, adding that usually by the time patients see doctors they have already failed at achieving results through those means.

Hong understands why Medicaid programs, as well as private providers, want to cut back on covering the drugs, which can cost per patient per year. However, they can produce twice the weight loss as the medications typically used previously, he said.

A school of medical thought supports patients’ gradually ending their use, but Hong said obesity is generally considered a chronic condition that requires indefinite treatment.

“Once they reach their target weight, a lot of people will try to see whether or not they can wean off,” Hong said. “We do see a lot of patients — when they try to get off, unfortunately, then the weight comes back.”

Medi-Cal members under age 21 for purposes including weight loss, California officials said, citing a federal requirement.

Medi-Cal members are able to keep their GLP-1 coverage if they can demonstrate it is medically necessary for purposes other than weight loss, the department said. Members who are denied coverage can seek a hearing, the department said in to members.

Members will still be able to pay for the prescriptions and may be able to use various discounts to lower costs. Another option is new pills to treat obesity, which will be cheaper than their injectable counterparts. The a pill version of Wegovy on Dec. 22, which will likely run $149 per month for the lowest dosage, and similar weight loss pills are expected to be available in the first half of the year.

While Cardenas said his husband, Jeffer Jimenez, 37, uses GLP-1s primarily for weight loss, Jimenez’s prescription is for his diabetes, so the couple hoped to continue receiving coverage through Medi-Cal.

“He tried a thousand medications, pills, natural teas, exercise program, but it doesn’t work like the injections,” Cardenas said. “You need both.”

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The ambulances frequently travel back and forth to in Asheville, the largest and most central hospital in the region. Trips can take more than two hours, according to Mark Snelson, director of , the local emergency medical service.

“When we get busy and all three of them are gone, we have no ambulances in our county,” he said.

Snelson and others in Madison County aren’t seeking more ambulances. They want a hospital closer than Mission. And the state agrees. In 2022, North Carolina Department of Health and Human Services officials said Madison and three other mountain counties needed 67 more acute care hospital beds. The state raised that to 93 beds in 2024, then to 222 by Oct. 15.

But the only indication of a new hospital thus far is a 25-acre field of graded dirt with a sign planted beside the highway reading “FUTURE HOME OF AdventHealth Weaverville.”

For the past three years, Mission Hospital’s owner has contested Florida-headquartered ’s attempt to build the hospital on land bought for $7.5 million in rural Weaverville, just minutes south of Madison County. It was , an event that would have defied the of rural hospital closures.

The irony is that the very law that calls for the new hospital — the state’s certificate of need, or CON, law — has been used to prevent further construction. Such laws are intended to cap unfettered health care expansion by allowing new hospitals and expansions only when a state can document a need for them. But the legal process has tied up the proposed Weaverville hospital in court, just as other such laws have done with projects in ; ; and .

All states had certificate of need laws until 1987, when the federal government repealed a mandate requiring them. Today, North Carolina is one of with the laws still on the books. Twelve others have repealed them or let them expire, and some, and , have significantly weakened theirs amid concerns they limit health care access and boost costs. President Donald Trump’s Federal Trade Commission and Department of Justice are among those questioning the need for the laws.

In North Carolina, too, opposition to the state’s certificate of need law has surfaced in both the General Assembly, where a has been dormant since April, and more prominently in the state Superior Court.

But some , health care economists, and certificate of need lawyers argue that, though the laws create bureaucracy that can delay projects, that’s not justification to do away with them.

The principle behind certificates of need is to hold at bay what is unnecessary expansion and price inflation brought on by a free market, which makes health care more expensive for everyone.

“If the principle is worth preserving, don’t abandon the principle,” said , a health care attorney with the Benesch law firm and former counsel for . “Improve the process to allow the principle to flourish.”

Who Should Fill the Need?

Mission Health is the largest health care network and the largest employer in the Tar Heel State’s share of the Appalachians. Nashville-based bought the century-old, nonprofit, six-hospital system for $1.5 billion in 2019, converting it to a for-profit operation that serves an 18-county region. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund ºÚÁϳԹÏÍø News’ coverage.)

Though AdventHealth already owns one hospital in the North Carolina mountains about a 30-minute drive from the Weaverville site, its bid to build a new one represents a threat to HCA’s stronghold. Mission argues it is best positioned to meet the needs the state says exist in the Madison County region.

“Not all acute care beds are the same,” Mission Health spokesperson Nancy Lindell said. “Instead of adding more beds at facilities that are unable to provide the complex medical and surgical care needed, the region would be better served by expanding bed capacity at Mission Hospital.”

An eastern North Carolina eye surgeon’s against the state’s health agency and top state officials alleged the state’s certificate of need law “has nothing to do with protecting the health or safety of real patients.” The ophthalmologist, Jay Singleton, has argued the law prevented him from performing surgeries at his own center because the state didn’t see a need to duplicate services already provided at the local hospital, where he was obligated to operate.

In early November, Republican state Treasurer Brad Briner, the , and several academics who study such laws nationally filed amicus briefs supporting Singleton’s case and urging a judge to reject the state’s attempt to dismiss it.

“I’ve characterized CON law as a permission slip to compete,” said , a George Mason University economics and law professor who co-authored the brief. “It’s as if, when a McDonald’s wanted to open up a shop next to Burger King, they have to go to the state regulator to ask if that’s OK.”

Stratmann argued that, instead of , more competition would give hospitals and providers greater leverage in negotiating with insurance companies.

That view aligns with a stance the federal government has held for almost 40 years. With varying degrees of fervor under Democratic and Republican leadership, the Federal Trade Commission and Department of Justice have argued that the laws are anticompetitive and bad for consumers. The Justice Department did not respond to questions about its current position, and the FTC declined to comment on the record.

“CON laws create barriers to entry and expansion, limit consumer choice, and stifle innovation,” the Federal Trade Commission wrote in an April letter to Rhode Island Gov. Dan McKee, a Democrat, as the state’s legislature considered, but ultimately abandoned, amendments to its certificate of need law. “For these reasons, the Agencies have consistently suggested that states repeal or retrench their CON laws.”

‘It’s Personal’

In a to Trump and congressional leaders, Senate Democrats named five North Carolina hospitals on a list of rural hospitals in danger of closing if the president’s then-pending spending and tax-cut legislation, called the One Big Beautiful Bill, became law, citing research from the .

Two of the five North Carolina hospitals on that list, and , are part of the Mission Health system. Both had three consecutive years of negative profit margins, like hundreds of others on the list. Lindell, the Mission Health spokesperson, said HCA is committed to keeping those two facilities open.

Even so, Madison County Health Department Director Tammy Cody said the needs in the region remain and the certificate of need appeals process has slowed down getting help.

“This isn’t theoretical — it’s personal,” she said. “Every delay means a mother in labor risks a longer ride, an elder with chest pain waits longer for help, or a worker injured on the job faces unnecessary complications.”

AdventHealth spokesperson Victoria Dunkle said the hospital system supports the state’s law partly because it “protects rural access to health care and ensures the community has a voice in the process.” The legal process has kept families waiting, she said, but AdventHealth plans to move forward with the Weaverville hospital “as soon as possible.”

Snelson, the ambulance service director, voiced a question many in the region have asked since the hope of a new rural hospital surfaced.

“Why is it a bad thing for another hospital to come in here to take some of the stress off of Mission?” he asked. “Within a day of it opening, it’s going to be full.”

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