“The sad thing is we’ll never know if he could have been saved that night or not, because we don’t have a higher level of care in this county,” Pierce said as she stood outside the mobile home where she last hugged her brother.

Emergency crews from a neighboring town worked on Stanley Sears for a half hour but couldn’t revive him for the long drive to the closest hospital, records show.

In the tall grass — which would be mowed if Sears were still alive — Pierce swiped through the photos on her phone. She stopped at a picture that showed Sears smiling. Pierce chuckled and then sighed: “Bless him.”

The local hospital had closed a year before Sears’ death, leaving behind a gutted healthcare system. Martin County does not have paramedics on its ambulances, and it can be 20 miles or more to the closest — and often overcrowded — emergency rooms.

The healthcare gaps in Martin County illustrate the finite reach of a $50 billion rural health fund that Republicans crafted to strengthen support for President Donald Trump’s signature tax and spending measure, the One Big Beautiful Bill Act, last year. Though the cash has not been doled out, Republican candidates in competitive midterm elections — including the closely watched battle for the congressional district that encompasses Martin County — are casting the fund as a lifeline that will shore up critical rural health services across America.

The money has been highly anticipated in North Carolina, where most residents live in rural counties. Pierce, a Republican who blames county officials for the hospital closure, said she has faith Trump will help them. “Old man’s doing his job up in there,” she said.

On paper, Martin County — home to about 22,000 people — looks like a top contender to receive at least some of the $213 million that’s been earmarked for North Carolina.

Yet County Manager Drew Batts said it won’t be the answer for his residents.

“The $50 billion is not something that is specifically going to help our situation,” Batts said as he walked into the shuttered hospital in April. “It’s not going to help us get this place reopened.”

Martin County won’t get direct relief from Trump’s rural health fund — because its hospital isn’t open. North Carolina is distributing the money among existing health and social service organizations. Plus, federal regulators on how much can be spent on construction and building renovations.

‘We Can Only Pray’

Martin General Hospital closed abruptly in 2023, surprising employees and shocking patients, who had to be wheeled out on stretchers and transported elsewhere to finish treatment. The closure even stunned local elected leaders, who say the company operating the county-owned hospital, Quorum Health, did not notify them it intended to shut down operations and file for bankruptcy. Quorum spokesperson Lisa Anderson said the company had told county commissioners of the hospital’s ongoing financial challenges.

Politicians have spent the years since trying to reopen the hospital, with county taxpayers pouring an estimated $2.9 million into maintenance, utilities, and other costs in the hopes of resuming operations, Batts said.

The county is now considering spending at least $1.5 million, he said, to create two higher-level paramedic units with quick-response vehicles, specially equipped with electrocardiogram equipment or other “advanced lifesaving support.”

Pierce said she is praying the county can add paramedics and reopen the hospital.

“There’s some answered prayers happening every day,” she said. “So, we can only pray and hope, you know?”

‘They Just Want To Not Die’

With its nine hospitals, the region’s largest health system is ECU Health, connected to East Carolina University. The system has become a de facto safety net for 29 counties. Batts and Brian Floyd, the Greenville-based system’s chief operating officer, have lobbied state and federal lawmakers, walking them through the shuttered hospital and asking for help.

“It’s a real healthcare crisis that has already proven itself to have lost lives that perhaps didn’t have to be lost,” Floyd said. “They just want to not die because there’s nowhere to go when you have an emergency.”

Eleisa Ann Evans drove 2½ hours from a small town near the Outer Banks on a recent evening so her aunt could get care at an ECU Health ER in Greenville. Once there, Evans said, staff told her to leave her 79-year-old aunt in the waiting room and wait outside because of capacity issues.

Evans said she was outraged at the way the staff treated her. She said she had been standing behind her aunt’s wheelchair while inside and “wasn’t using nobody’s chair.”

With Martin General gone, all the surrounding counties are “also in jeopardy,” Floyd said. “No one knows what to do” with that large of a healthcare “desert,” he said.

What healthcare is left in the county includes one urgent care center, run by a private company, and a nonprofit health clinic, operated by Agape Health Services, which accepts patients from five counties and plans to build another primary care clinic to meet demand.

ECU Health signed a letter of intent to reopen Martin General as a rural emergency hospital that would provide outpatient care as well as an ER. Under the terms of the deal, Martin County would pay to refurbish the hospital, and the North Carolina General Assembly would have to give ECU Health $210 million, of which $150 million would pay for the construction of a new inpatient tower at ECU’s Beaufort Hospital.

The health system, through its affiliate , won a portion of North Carolina’s $213 million first-year payout from the rural fund. But the federal money can’t be used to reopen Martin General, Floyd said.

The five-year Rural Health Transformation Program is slated to be delivered in $10 billion annual increments to states, which applied and competed for the money.

North Carolina’s plan creates a that allots money to six large regional leads, including nonprofits such as Access East. Those hubs will distribute money to local entities and coordinate broad initiatives such as improving primary care and fortifying the healthcare workforce, as well as developing “digital solutions,” according to the state’s .

An Election Issue

The lack of emergency care in the region has emerged as a top talking point in a close U.S. House race between Rep. Don Davis, a Democrat who represented the district when Martin General closed and is seeking his third term, and Republican Laurie Buckhout.

The rural health fund was added at the last minute in 2025 to win votes for the One Big Beautiful Bill Act, which is expected to reduce federal Medicaid spending by more than $900 billion over a decade — cuts that are projected to hit rural hospitals and clinics especially hard. Rural health executives say the fund won’t come close to offsetting those losses.

Matt Mercer, a spokesperson for the North Carolina Republican Party, called the rural fund a “once in-a-generation opportunity” for the state.

But U.S. Sen. Thom Tillis, who was one of three Republican senators to vote against the bill — and who announced shortly before the final vote that he planned to retire from Congress — warned of devastating consequences ahead for healthcare in his state.

Buckhout, who declined an interview, plans to attack Davis — a vulnerable incumbent whose district was recently redrawn to favor GOP candidates — for voting against the bill.

“Martin County lost its hospital on his watch, and he still opposed the funding meant to help communities like it,” Buckhout campaign spokesperson Stephen Gallagher said in a statement to ºÚÁϳԹÏÍø News. The campaign did not respond to additional queries about her plans for healthcare access, if elected.

Davis, who signed from lawmakers in support of North Carolina’s rural health fund application, said the money “is essentially putting a band-aid on a much, much broader situation that needs dire help.” He has that would increase Medicaid reimbursements for rural hospitals, though it has not moved forward.

During recent testimony on Capitol Hill in Washington, ECU Health CEO Michael Waldrum said his system expects to lose a billion dollars over the next 10 years from the looming Medicaid cuts.

Overnight Waits for Emergency Care

The region’s emergency rooms offer a stark glimpse of a healthcare system in crisis.

Martin General’s ER treated annually before it closed, according to state data. A sign still hangs in the staff break room showing that 23 patients were seen in the ER the day it closed.

ECU Health, which owns all but one of the rural hospitals around Martin General, reported a 132% increase in its daily ER visits since the hospital’s closure. The company’s nearly 1,000-bed hospital in Greenville, about 40 minutes from Williamston, is the state’s only Level 1 trauma center east of Raleigh.

The Greenville hospital’s median patient ER wait and treatment time was nearly 4½ hours, according to the most . That’s longer than 96% of thousands of hospitals reporting nationwide. The wait times “don’t reflect poor care,” ECU Health spokesperson Brian Wudkwych said in an emailed statement. He said the system’s ERs treat nearly 300,000 patients annually.

While the system has seen an increase in Martin County patients, the wait times primarily stem from shortages of inpatient and behavioral health beds, Wudkwych said.

Floyd, the ECU Health chief operating officer, said many rural patients who arrive at the system’s ERs have multiple chronic conditions that require longer visits. Often doctors start treating one problem and then find the patient’s “blood sugar is out of control, your hypertension is far out of control,” he said.

ECU staff encourage people who are not too sick to skip Greenville and, instead, seek care at one of the system’s community hospitals, which aren’t as busy, Floyd said.

A security officer guarded the Greenville emergency department’s doors on two nights in April. The “capacity notice” sign near the entrance meant family members of patients had to wait in cars or on benches outside.

“We’ve only been here six hours,” Tonya Miles said after bringing her mother for a potential blood clot in her leg. The family had left the day before after waiting for two hours, because her mom “wasn’t prepared” for such a delay in treatment, Miles said.

On another evening, Olivia Lewis said she had brought her mother two nights previously and left without care after their wait stretched from 10:30 p.m. to 7 a.m.

“She tore off her hospital bracelet and said: ‘I’m out. I’m done,’” she said. Now, they were back.

On a recent Friday in Martin County, Vannessa Little was sitting at a McDonald’s with her kids just down the street from the closed hospital. Little pointed to one of her girls and wondered how her care would have been different if the hospital had been open.

Her daughter, then 6, suffered severe burns over 30% of her body in 2024, and the journey to treatment was “just crazy,” Little said. An ambulance arrived at her Williamston home from neighboring Bertie County to transport them to ECU’s Greenville ER.

“That was a long time,” Little said of the 30-mile drive. The girl was ultimately airlifted more than 100 miles to Chapel Hill. Little said she hadn’t heard of Trump’s rural health investment. “The only changes that people are making is they’re taking away everything.”

She voted against Trump in 2024 and said she didn’t think she would vote this year.

“It’s a waste of my time.”

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7B Care Clinic has been operating in Sandpoint since 2001 and was previously called Life Choices Pregnancy Center and Sandpoint Crisis Pregnancy Center. It is of a nationwide network of Christian evangelical centers called Care Net. 7B, one of about 1,200 pregnancy centers affiliated with Care Net, offers pregnancy tests, limited ultrasounds, parenting and life skills classes, community support groups, and other free resources, such as children’s clothing. Donations from people, businesses, and more than 40 churches keep 7B’s operations running, Executive Director Janine Shepard said.

Such centers are known as crisis pregnancy centers or pregnancy resource centers. They offer limited resources and medical services to pregnant women and aim to dissuade them from having abortions. Healthcare groups including the have said many crisis pregnancy centers use unethical and deceptive practices to bring women into their organizations.

Traffic at 7B has picked up since the local hospital and its OB-GYNs moved out of state three years ago. The closure left a hole in reproductive health services in this town of more than 10,000 on the shores of Lake Pend Oreille and surrounding rural areas.

“We are seeing a lot more people,” Shepard said.

By December 2024, more than two years after the U.S. Supreme Court overturned nationwide abortion rights in its Dobbs decision, Idaho had of its OB-GYNs. 7B is expanding, with the goal of bringing obstetric care back to Sandpoint. The organization plans to add to its current building once it’s paid off, Shepard said, and it’s in talks with a hospital about 30 miles away in Washington state to bring in an OB-GYN once a week to provide prenatal care.

If obstetric care existed now in Sandpoint, Shepard said, “we wouldn’t even be considering” the expanded services. “But there’s such a need. And our community suffers because of it.”

As rural communities face the and , crisis pregnancy centers are growing in influence. Some states have approved legislation granting the organizations greater protections from oversight and regulation, and clinics have seen a massive and in recent years.

In a town with limited maternity care, 7B has been providing important resources to struggling low-income women. But critics say the religious nonprofit, which is not medically licensed and isn’t required to meet regulatory standards for medical facilities, has an agenda that makes it an inappropriate place for pregnant patients to seek medical care.

Jen Jackson Quintano, a Sandpoint resident and the founder of the Pro-Voice Project, a nonprofit that advocates for abortion rights in Idaho, said crisis pregnancy centers mislead patients by drawing them in with the offer of free pregnancy-related services before delivering their anti-abortion pitch.

“We all need clarity on what those services are: ministry-first, rather than comprehensive medicine,” Quintano said.

Shepard said there are misconceptions about the organization, and she invites people to take a tour of 7B to learn what it does. She said her staff talk to pregnant women about abortion, adoption, and parenting as options and hope they feel supported enough to make a “life-affirming” decision.

7B reflects a trend of crisis pregnancy centers seeking to expand their operations in maternal care deserts and regions with gaps in women’s healthcare, said Andrea Swartzendruber, an associate professor of epidemiology and biostatistics at the University of Georgia College of Public Health. Swartzendruber has studied crisis pregnancy centers in the U.S. since 2018.

“Crisis pregnancy centers have, for years and years, capitalized on gaps in access to healthcare,” she said. “In no way, shape, or form do crisis pregnancy centers have the infrastructure or ability or training to bridge those gaps.”

According to Swartzendruber’s research, more than 2,600 crisis pregnancy centers operated in the U.S. as of 2024, more than three times the number of . Many centers have been found to engage in with clients, including putting misleading information on their websites making them appear to be legitimate medical clinics with the goal of attracting women who are seeking abortions.

The organizations are also seeing support from the Trump administration. On May 10 — Mother’s Day — the Department of Health and Human Services sharing resources and information for new and expectant mothers. It includes a map to find pregnancy centers and cites services the centers provide, such as pregnancy tests, ultrasounds, and medical referrals.

‘The Perfect Place for This’

Sandpoint is a small mountain town in a deeply conservative and Christian part of a state with a strict abortion law put into place after the Supreme Court overturned Roe v. Wade.

Amelia Huntsberger, one of the OB-GYNs who left Sandpoint three years ago, said the town is “the perfect place for this,” referring to the expansion of the 7B Care Clinic.

In underresourced areas, the benefits that crisis pregnancy centers may bring are welcome.

Lori Sabin, a licensed midwife in Bonners Ferry, about 30 miles north of Sandpoint, said that 7B is a helpful resource to the community, especially for people who struggle to get healthcare because of a lack of health insurance or who face challenges in traveling for care.

“The nicest thing about 7B is all their services are free,” Sabin said, adding that the classes and free baby items are particularly helpful for young first-time mothers. “They can point them in the right direction. They tell them where the midwives are; they tell them where the OBs are.”

Huntsberger, who practiced in Sandpoint for more than a decade and now lives in Oregon, also acknowledged the benefits she saw 7B bring for patients, including the parenting classes and support groups. But she has concerns about its resemblance to a medical facility that provides healthcare.

Lisa Battisfore, founder of Reproductive Transparency Now, a Chicago-based organization that provides education and outreach about crisis pregnancy centers, acknowledged that the limited services they provide can be helpful but said the bad outweighs the good.

“If someone needs diapers or someone needs formula and a crisis pregnancy center is willing to give that to them, it’s difficult to say that that in isolation is a bad thing, but you have to look at the bigger picture,” Battisfore said.

Crisis pregnancy centers are largely unregulated and are protected by First Amendment rights to free speech and religious exercise. The Supreme Court crisis pregnancy centers to go to court to block a state attorney general’s subpoena for donor funding information. Critics say lack of oversight allows centers to spread misinformation about abortion and abortion pill “reversal,” a procedure the American College of Obstetricians and Gynecologists has called “.”

Crisis pregnancy centers have against states trying to increase regulation and oversight. Those protections have allowed some of the organizations to blur the line between anti-abortion activism and medical care.

“They seem to be really good at walking on both sides of that line when it suits them best, and that does not suit pregnant people best,” Battisfore said.

She referenced a recent case in Texas in which a woman was hospitalized for an ectopic pregnancy days after she received an ultrasound and a clean bill of health from a crisis pregnancy center. An OB-GYN who works with the Abundant Life Pregnancy Resource Center “there is nothing to fix” when asked about the error. There have been at crisis pregnancy centers.

What’s Next for Sandpoint

angered a lot of locals when it closed its labor and delivery unit three years ago. Residents lamented that women needed to travel farther to give birth and mourned the loss of the OB-GYNs. Since then, the hospital has been working to rebuild trust with the community.

This year, the hospital created a women’s health committee that includes hospital board members, staff, and others. Hospital CEO John Hennessy and Chief Medical Officer Stacey Good, a physician, said their priority is to hear from the community and increase awareness about the women’s healthcare that’s still available.

Women can still receive a range of services, including prenatal care from a nurse practitioner who travels to Bonner General from Coeur d’Alene once a week and other clinicians who can provide more basic gynecological care. A position for a gynecologist at the hospital has been open since May 2023, and Hennessy said filling it remains a priority.

Sandpoint resident Makayla Sundquist, a licensed counselor, grew up in town. She got married last year and has been thinking about starting a family with her husband. She wondered if she would feel safe knowing she’d need to travel at least an hour to the nearest hospital with labor and delivery services.

But she also has doubts about 7B as a potential option for local care. She was skeptical that an anti-abortion, faith-based organization would provide accurate information on the options available to her.

“It is something that I do think about and do have fear about,” Sundquist said. “I wish that wasn’t my reality.”

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The workers, Nathan Jones and Trent Umberger, died in the September 2024 crash, as did a passenger in the Jeep. Tests found that the driver, Patrick Sneddon, then 59, had oxycodone and six times Colorado’s presumed impairment threshold for THC — the psychoactive compound in cannabis — in his blood. He pleaded guilty and is serving on three counts of vehicular homicide and other charges.

“Our four children are completely crushed without their Dad,” wrote Kristine Umberger, the wife of Trent, in a victim impact statement for the local district attorney. “We have lost our ability to live life like we used to.”

Federal highway safety officials have long tracked the role of alcohol in fatal crashes, but they don’t track deaths that involve a driver under the influence of drugs or a combination of drugs and alcohol.

That discrepancy is partly due to the challenges of proving impairment, since some drugs remain detectable for weeks after use. Sneddon’s attorney, Jennifer Gregory, said a driver can be presumed impaired under Colorado law if their blood contains 5 nanograms of THC or higher per liter. But that “permissible inference” threshold is different from a legal limit — such as the 0.08% blood alcohol content limit — and the level set by Colorado is not supported by published scientific studies, Gregory said.

Such information could prove useful as the nation struggles with , the on marijuana, and more than 40 states have legalized or decriminalized some forms of cannabis and .

“Impaired driving is a top public safety issue that extends beyond alcohol,” said Sean Rushton, a spokesperson for the federal highway safety agency, which is tackling the issue collaboratively, with resources to ensure a “comprehensive and coordinated approach.”

But President Donald Trump’s cuts to the federal workforce since he returned to office in 2025, along with dwindling federal investments, mean that efforts to expand and improve the tracking of impaired-driving deaths nationwide have slowed.

The gap in data can be significant. In Mesa County, Colorado, where Jones and Umberger were killed, the coroner’s office tracks various forms of impaired-driving fatalities. From 2017 through 2024, a third of traffic deaths involved alcohol alone, according to data from the county coroner’s office.

When drugs are factored in, nearly half of Mesa County’s traffic deaths over the same period involved a driver intoxicated with alcohol, drugs, or a combination, according to the coroner’s reports.

“If you want to solve a problem, you need to understand the problem,” National Transportation Safety Board researcher Jana Price said. “If you only know that alcohol is present, then it limits your ability to fully understand what might have been impairing a person or a population of people. It trickles into the countermeasures that we use as a society to address the problem.”

Identifying a Hidden Issue

NTSB researchers that, across four geographical samples of roughly 26,000 drivers, about half of those arrested for impaired driving and more than a quarter of drivers killed in crashes tested positive for more than one substance, such as cocaine, sedatives, and antidepressants. The analysis also found that only four states and the District of Columbia drug-tested more than 60% of fatally injured drivers in 2020.

Those findings led the NTSB, an independent federal agency that investigates major incidents, to make a series of recommendations to the and states to establish a comprehensive, nationwide dataset on impaired driving.

But hurdles remain to creating such a system. Fatality and injury reports submitted to the NHTSA database often feature missing or erroneous data, according to a .

Varying state laws around testing arrestees and decedents for drugs make getting uniform data difficult, according to , a former employee of NHTSA’s impaired-driving division, as does a lack of proven metrics like blood alcohol content to measure drug impairment, not just the presence of a drug.

“It’s a slow process, which is incredibly difficult when you know that each day that passes is risking a lack of safety for however many people facing the potential of a drug-impaired-driving crash,” Cash said. “But some progress is better than no progress.”

Acknowledging how long those efforts will take, the NTSB also recommended that NHTSA build an interim surveillance system that would use data from trauma centers to create a national sample of crash-involved impaired drivers.

The agency made some headway, reporting in 2023 that it was conducting its own study with the help of 11 trauma centers and medical examiner offices. It also helped California establish a 19-month statewide surveillance system, which NHTSA will use to evaluate the feasibility of a nationally representative system.

Such programs are useful for public awareness and for improving the ability of police to understand drugged driving patterns that can help them tailor enforcement, said , a University of California-Davis associate professor who researches toxicology and was involved in the California program. But some trauma centers, especially in rural areas, often lack the research infrastructure necessary for round-the-clock drug testing and participation.

Still, it’s possible, and he said the benefit is apparent in the findings from California’s surveillance system.

“If you go out there and tell people that 44% of drivers who ended up in the ER from a car accident had at least one potentially impairing substance in their blood at the time of the accident, that gets people’s attention,” Chenoweth said.

Shrinking Research Teams

Since NHTSA’s update to the NTSB three years ago, however, the agency has yet to follow up on the recommendation. Staff cuts and departures at NHTSA last year paint a poor outlook for change.

From 2021 to 2024, the agency . At the end of Trump’s first year in office, NHTSA had dropped to about 550 people due to government-wide cuts and people leaving on their own.

Cash, who now works for the nonprofit Governors Highway Safety Association, was one of five employees who left NHTSA’s last year. That leaves just two staff members in the division, she said.

Ian O’Dowd, a former employee in NHTSA’s , said he was part of a team of 16 people who studied, in part, impaired driving. Only three or four team members are still with the agency, he said.

“At some point, it becomes unwieldy for a handful of people to be managing all of the research work going on,” O’Dowd said.

NHTSA communications director Sean Rushton said the agency has “both the financial and personnel resources necessary to support its programs with multiple offices carrying out this work collaboratively, ensuring a comprehensive and coordinated approach.”

The 2021 infrastructure law, passed under the Biden administration, increased funding for NHTSA’s state highway safety program from about $667 million in 2021 to nearly $953 million this year.

The law included $750 million to modernize crash-data programs, but as of January over $475 million was unused. The funds expired in September unless they were obligated through a signed agreement.

A report by the U.S. Government Accountability Office found that nearly a quarter of entities awarded grants in 2022 had not received a signed agreement when surveyed between December 2024 and March 2025. It also found that over 1 in 5 grantees reported that obtaining timely replies from Department of Transportation staff was moderately or very challenging.

With the Biden-era infrastructure law expiring later this year, Congress could extend the unused crash-data fund or implement a new approach to impaired driving.

In mid-April, House Transportation and Infrastructure Committee Chairman Sam Graves (R-Mo.) said proposed legislation — less than half of the current bill’s $1.2 trillion — with a more “traditional” focus on roads and bridges.

The bill has amid negotiations for more funding, leaving future support uncertain.

“Certainly, we are always hoping that there will be an increase in the amount of money available to do this work,” Cash said. “Whether or not that will happen this year, I don’t know.”

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One Minnesota lawmaker wants to steer money from an existing healthcare tax back to hospitals so they can expand their charity care programs for patients who can’t afford their bills.

The proposal follows a Minnesota Star Tribune-ºÚÁϳԹÏÍø News investigation that found hospitals across the state spend far less on charity care than hospitals in many other states, and use widely different standards to decide who qualifies for free or discounted care.

State Rep. Steve Elkins said helping hospitals with their own tax contributions makes sense as more Minnesotans are losing health insurance.

“Hospitals are providing a fair amount of charity care, but they kind of have an obligation to do something more than they are doing,” said Elkins, who May 13, in the final days of the legislative session.

Elkins noted recent reports by the and Minnesota’s indicating some hospitals are gaining more in nonprofit tax benefits than they are spending on community benefits, including charity care.

Simply demanding more from hospitals isn’t necessarily the answer, though, Elkins said. Newly released financial data shows 31 Minnesota hospitals meet the state’s definition of financial distress because they lost money on operations in four of the last eight years.

Hennepin County Medical Center in Minneapolis appears poised for a this year to prevent the urban trauma center from closing.

HCMC provided the most charity care of any Minnesota hospital in 2024, an estimated $88 million, which consumed more than 3% of its operating budget. Elkins said he suspects some charity care patients from other hospitals are being diverted to HCMC, which has a process for automatically screening patients for financial needs upon admission.

Incentivizing hospitals to be more generous could take pressure off HCMC, Elkins said. The state gains about $250 million per year from a 1.56% tax on hospital patient revenue, which roughly equates to the $241 million that hospitals spent on charity care in 2024, according to estimates by the Minnesota Department of Health.

“You could pretty much make every Minnesota hospital whole with all of the charity care they’re providing,” he said.

A lack of state standards allows some hospitals to limit free care to people making less than $15,000, while others offer care to people living alone who make as much as $47,000. Being stingy with charity care can be self-defeating for hospitals, which end up wasting money in debt collection efforts from patients who couldn’t afford their bills in the first place, said Eli Rushbanks, director of policy advocacy for Dollar For, a nonprofit that helps U.S. patients apply for charity care.

“It’s not really a question of whether they are doing better than other states. It’s a question of whether they are doing enough” for Minnesota’s patient population, he said. “Minnesota has charity care-eligible patients who are not receiving charity care.”

Some state-by-state disparities in charity care are beyond the control of hospitals, and even signal positive trends. Lower rates of chronic disease mean Minnesotans need less healthcare in the first place. Higher levels of insurance coverage mean they don’t need charity care as much to afford their healthcare.

Elkins’ idea of taking money from hospitals and giving it back with strings seemed unnecessary to leaders of the Minnesota Hospital Association, which would prefer to see the tax disappear.

Joe Schindler, the association’s vice president for finance policy, said one alternative would be moving the money into the Medicaid health insurance program for people with low incomes or disabilities. He said that would unlock more federal matching dollars to benefit patients and help close the reimbursement gap in that program.

Hospital systems have discretion to decide the income and financial thresholds by which patients qualify for financial assistance in the form of free care or partial discounts. Elkins’ proposal wouldn’t change that, but other state leaders and advocates have proposed models that standardize how charity care is offered.

Dollar For recommends policies that at least provide discounts to households with incomes around 400% of the federal poverty level, because there are fewer bad debt cases and lawsuits involving patients with incomes above that level, Rushbanks said. The Star Tribune-ºÚÁϳԹÏÍø News analysis of 123 Minnesota nonprofit or government-run general hospitals showed 52 provide discounts to patients with household incomes at 350% or higher, but the rest fall below that level.

After investigating irregularities in charity care at Mayo Clinic last year, Minnesota Attorney General Keith Ellison recommended that the state set a minimum floor for charity care eligibility across all hospitals. He also recommended all hospitals adopt presumptive eligibility systems that assume patients need financial help until proven otherwise.

This week’s article “makes it clear there is more work in front of us, and I will continue to use the power of my office to help Minnesotans get the medical care they need, no matter what’s in their bank accounts,” Ellison said in a statement.

Charity care is only one category of community benefits reported by hospitals for which they don’t receive direct payment. Other examples include providing medical education services for training doctors and nurses, and maintaining money-losing services such as obstetrics or emergency care in rural and underserved communities.

Whether hospitals gain more in nonprofit tax savings than they spend on community benefits depends on what’s included in the state auditor’s analysis. Hospitals are chronically underpaid for the cost of medical care by Medicaid, and the state hospital association reports that as a community benefit.

The legislative audit found that only 28 Minnesota hospitals spent less on community benefits than they saved in taxes in 2023, when that underpayment was part of the total. When excluded along with other research and education expenses, 62 hospitals spent less on the remaining community benefits than they gained in tax benefits as nonprofits.

Elkins said his idea to redistribute tax revenue could motivate hospitals to spend more on charity care or other community benefits. The state also could recruit more doctors, he said, if Minnesota hospitals increased residency slots for required on-the-job training after medical school.

The idea is an easier sell right now, given Minnesota’s budget surplus, he acknowledged, but could create challenges in future years when lawmakers would have to find ways to replace the lost revenue for other state needs. The lawmaker said he intends to bring it up next year if it doesn’t make it into the state’s health budget this session.

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The certified professional midwife pressed the button on a handheld Doppler ultrasound machine she placed on Collins’ belly. “That’s her heartbeat,” she said to Collins’ 3-year-old daughter, who sat beside her mom as a whooshing sound filled the room. “I think Mommy’s baby’s right here.”

The midwife is not licensed as a nurse. In Georgia, that makes what she’s doing illegal. ºÚÁϳԹÏÍø News agreed not to identify her by name.

Georgia is one of seven states where delivering babies can earn non-nurse midwives, at minimum, a cease-and-desist letter requiring them to end their careers. In North Carolina, it’s a . In New York, .

Meanwhile, demand for their services is increasing. Intended home births rose by 42% nationally from 2020 to 2024, according to the National Center for Health Statistics, and those births are often overseen by certified professional midwives. In Georgia, they rose by 72%. Midwives who assist with home births typically see clients from prenatal appointments through after childbirth, providing more postpartum checkups than most new mothers receive.

Home births make up nationwide. In the eight states where they were most common in 2024 — Hawai‘i, Idaho, Montana, Pennsylvania, Utah, Vermont, Wisconsin, and Wyoming— they made up 3-5% of births.

As that number rises, midwifery advocates said, regulating the practice with licenses would allow home births to be safer. Free birth — without the help of a skilled professional before or after labor — can be .

“People are going to keep having their babies at home, and they deserve a trained provider,” said Missi Burgess, president of the Georgia chapter of the National Association of Certified Professional Midwives.

For decades, professional midwives have been advocating for laws to legalize and regulate their profession. More lawmakers have supported those efforts in the past 15 years, with 36 states and Washington, D.C., allowing them to get licensed to deliver babies. Last year, a wave of state lawmakers — in Georgia, Mississippi, Nebraska, New York, North Carolina, Ohio, and West Virginia — tried to add their states to the list, although none of their bills has become law.

Certified professional midwives deliver babies in homes or birth centers. Rather than attend nursing school — which many can’t afford — they earn a nationally recognized certificate by attending at least 55 births and demonstrating their knowledge. Nurse-midwives more often deliver babies in hospitals or clinics than in patients’ homes.

Some hospitals and doctors oppose midwife licensing proposals without certain guardrails. The American College of Obstetricians and Gynecologists showing that infants are twice as likely to die during planned births at home or in birth centers as in hospitals, while acknowledging that the data remains limited. It doesn’t account for several factors, including who assisted in the birth.

Still, prominent stories of home births with midwives gone wrong contribute to the skepticism around licensing laws. In 2023, The Washington Post of a licensed midwife who pleaded guilty to felonies in Virginia after an infant death and assisted with home births in Maryland in which two more babies died.

In Mississippi, a bill that would have regulated and licensed professional midwives died after a state senator blocked a vote in the committee he chaired. Democratic Sen. Hob Bryan he didn’t “wish to encourage that activity.”

But midwives said they have a sympathetic ear now in the Trump administration, with its Make America Healthy Again movement. Cassaundra Jah, executive director of the , said she has been on calls with midwifery groups pushing for the Department of Health and Human Services to provide legal protections for them, and some midwives have been in contact with the agency.

HHS spokesperson Emily Hilliard declined to comment on policy proposals but told ºÚÁϳԹÏÍø News that the administration “regularly meets with a wide range of stakeholders to hear input from the American public.”

Hospitals Want Guardrails

Advocates for the license say allowing certified professional midwives to provide care would help address a shortage of maternity care providers.

“Some midwives are leaving our state,” Rep. , a chiropractor who sponsored the Georgia bill, said during a hearing on the measure last year. “They’re being forced to quit. And now we have a shortage of these providers to take care of our pregnant moms.”

A by the March of Dimes found that 35% of counties in the U.S. have no birthing facility or obstetric provider. Georgia has the 13th-highest maternal mortality rate in the nation, according to the .

After the U.S. Supreme Court’s reversal of Roe v. Wade in 2022 eliminated federal protection for abortion, six-week abortion bans prompted more providers to leave states such as Georgia and Texas. Idaho lost by December 2024, two years after its abortion ban took effect. Doctors who left states with such laws cited fear of prosecution and an inability to provide the standard of care.

Of the 13 states with the fewest maternity care providers per capita, nine had a full or six-week abortion ban as of 2024, .

Licensing midwives won’t solve the larger maternity care shortage, but it’s a first step, said , a professor of midwifery and the principal investigator at the Birth Place Lab at the University of British Columbia. Certified professional midwives currently attend only about 1.4% of births in the U.S., according to federal data.

The would have granted certified professional midwives licenses through a state board, allowed them to administer lifesaving medications, and required their services to be covered by private insurance and Medicaid. They would not have needed a physician to supervise them. Without that mandate, giving birth outside of a hospital could be an option for more people.

But the Georgia Department of Public Health and the Georgia Hospital Association opposed the licensing bill, primarily because they wanted more regulations than the midwives were willing to accept — including physician supervision.

Anna Adams, a spokesperson for the hospital association, suggested establishing transfer agreements that required all women planning to have a home birth to register at the hospital first. When a laboring woman is transferred to a hospital, which happens in about , “we have no prior knowledge of this patient,” Adams said. “It’s a tricky situation to inherit when you’re trying to save the mother and the baby without any background.”

Georgia midwives said they planned to bring the licensing proposal back next year.

In early April, three midwives for restricting their ability to practice, arguing that the rules violate the state constitution.

“Every pregnant person should be able to choose where they give birth and with whom,” said Jamarah Amani, a plaintiff in the lawsuit and co-founder of the .

Black women are three times as likely to die during or after childbirth as white pregnant patients. In January, a prominent Black nurse-midwife in South Carolina died after unexpected complications from childbirth.

Today, midwives and their clients are predominantly white, but the home birth rate among Black women rose 42% nationally from 2019 to 2024, according to the Centers for Disease Control and Prevention.

“Ultimately the system has failed us as a people,” said Tina Braimah, a Black nurse-midwife who attended home births for a decade. She then opened a in North Carolina, allowing her to see more clients from a variety of backgrounds. “When the system consistently fails you, you look for other options.”

Becoming Part of the System

Many maternal health researchers say mothers fare better when midwives are a key part of the health system. In 2018, researchers at the Birth Place Lab published a study of all 50 states showing that integrating midwives was associated with better outcomes for moms and babies, including lower rates of infant deaths. Integration involves collaboration among all kinds of midwives and doctors so that patients can easily transfer to or from a hospital. It also involves giving all midwives the authority to practice the full range of their skills, including prescribing lifesaving medication.

A by the National Academies of Sciences, Engineering, and Medicine states that data from other countries suggests home births can be as safe as hospital births for low-risk women who are part of an integrated, regulated system.

Washington state has one of the highest rates of in the U.S., according to the . Its home birth rate is consistently higher than the national rate, while its remains lower than the national average.

One in 5 women report being mistreated during maternity care, according to a . Pregnant patients tend to be more satisfied when midwives lead their care, whether at a hospital, a birth center, or home.

Hannah Haynes gave birth to her first three children in a hospital near her home in Jefferson, Georgia. During the third labor, which was induced, she received a catheter that led to a urinary tract infection and then sepsis, a life-threatening condition. She was separated from her newborn for four days while receiving treatment.

“Something has to change,” Haynes said.

Haynes regrets electing to get induced when it wasn’t medically necessary. She gave birth to her fourth child at home, with the help of a certified professional midwife she trusted. She’s pregnant with her fifth and plans to use the same midwife. She said she won’t deliver at a hospital again.

“I was a little nervous,” Haynes said, because she had heard rumors that midwives didn’t know what they were doing. But after meeting the midwife, “I just felt so confident in her.”

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“What do you guys want to be when you grow up?” Health and Human Services Secretary Robert F. Kennedy Jr. asked a carpet full of preschoolers.

“A dinosaur!” the boy replied, squeezing tighter.

Just weeks ago, Kennedy sat before lawmakers on Capitol Hill and about a dangerous uptick in infectious diseases among American children.

Now, with midterm primaries underway, Kennedy was seated in a toddler-sized chair in Ohio, on a mission to change the subject.

Advised to stay away from the anti-vaccine rhetoric that rocketed him to political stardom, Kennedy has been dispatched by the White House to evangelize about the least controversial — and most popular — parts of his agenda. Republicans hope Kennedy’s “Take Back Your Health” tour will help them hang on to voters, many of whom are deeply .

So there Kennedy was in early May, crisscrossing a strip of northern Ohio that includes one of the few congressional districts that Republicans are confident they can flip in November, rotating through a wardrobe of blue suits and blue jeans.

He inspected the kitchen of a Toledo daycare center, where hundreds of the city’s tiniest residents learn and play through the federally funded Head Start program. Under the careful watch of a surgeon, and with the machine disconnected, Kennedy briefly tested the teaching console of the renowned Cleveland Clinic’s robotic hands with a live patient splayed open for heart surgery in the room. And he munched on pesticide-free squash blossoms from a 400-acre farm.

“I am dismantling a corrupt system and replacing it with something better, replacing it with something that actually addresses the declining healthy American population,” Kennedy said from the dining room table of a farmhouse during an exclusive interview with ºÚÁϳԹÏÍø News. He pointed to what he views as his biggest accomplishments over the past year: pressuring some companies to remove dyes from certain foods, updating nutritional guidance, and defining ultraprocessed foods.

“People are paying attention to what they eat, and the industry is listening; the industry is changing.”

But hundreds of miles from Washington’s partisan interrogations, Kennedy couldn’t escape the uncomfortable contradictions and consequences of the Trump administration’s policies.

Taboo Budget Cuts

The classrooms of the Clever Bee Academy displayed freshly printed posters featuring Kennedy’s “Eat Real Food” slogan and the redesigned food pyramid.

Kennedy came with an offering, a $30,000 federal grant to help the center upgrade its kitchen and community garden.

Perched in front of staff and parents, he distanced himself from a last year that could have been devastating to many of Clever Bee’s young students, most of whom live in poverty: the proposal to eliminate the $12 billion Head Start program.

“We were asked to cut our agencies substantially,” Kennedy said. “The two programs that I went to the wall to protect, and find the money somewhere else, was the Indian Health Services, which is always starved for funding, and Head Start.”

The next day, Kennedy stood before goats on a farm in Medina, Ohio, cared for by people sobering up from drug or alcohol misuse at the Hope Recovery Community.

He was there to promise more investments from an administration that has steeply cut staff and budgets over the past year.

Kennedy, who still attends daily Alcoholics Anonymous meetings to cope with a heroin addiction that gripped him for 14 years, said he hopes to replicate the recovery center’s model nationwide, describing it as an “essential role of government to make sure those services are there.”

Broader access to addiction treatment is part of the Trump administration’s newly released . But recovery advocates are skeptical more people will get help, with millions expected to lose health insurance under Trump’s watch because of rising Affordable Care Act premiums and the nearly $900 billion in Medicaid cuts under the One Big Beautiful Bill Act.

Kennedy dismissed those challenges, pointing to a $100 million investment in addiction treatment services, including sober housing, announced this year.

“We’re trying to make it more accessible,” Kennedy told ºÚÁϳԹÏÍø News.

Trouble in MAHA Paradise

Rows of beds featuring green and purple microgreens awaited Kennedy at The Chef’s Garden, a Huron, Ohio, farm that rejects chemical use in growing its produce.

The health secretary plucked handfuls and tossed them into his mouth, quickly chewing before a new sample was brought before him.

“We are absolutely thrilled that someone at this level of government cares about how food is grown and where it is coming from,” said Bob Jones Jr., a co-owner of The Chef’s Garden.

Seeing more farmers produce chemical-free leafy greens has topped the wish list of those who support Kennedy and the Make America Healthy Again movement, and many who backed Trump in 2024. But in a move that’s threatening to fracture that constituency, Trump has pushed to protect the production of glyphosate, a weed-killing, potentially cancer-causing chemical commonly sprayed on crops and lawns.

Though the group MAHA Ohio extols Kennedy’s agenda and endorses candidates aligned with his movement, director Elizabeth Frost acknowledged tensions between MAHA and conservative policies.

The glyphosate issue is an example “where you have the conservative interests to look out for the interests of the industry, and you have your MAHA interest to be cognizant of the downstream health impacts,” said Frost, who volunteered on Kennedy’s presidential campaign.

Some prominent MAHA influencers have suggested that Trump’s White House staffers are stopping Kennedy from implementing more aggressive policies on certain issues, including further limiting vaccine use, a notion he dismissed.

“To say the White House has tied my hands — the only people who could say that are people who haven’t been paying attention for a year,” Kennedy said. “President Trump has let me do more than any HHS secretary in history.”

He added: “The only thing that people in the MAHA movement complain about is the president’s glyphosate order.”

Staying on Message

Republicans consider Kennedy an asset in the recently redrawn northern Ohio congressional district that Democrat Marcy Kaptur has represented for more than 40 years, and which as one of the most competitive in the nation.

Fresh off winning the Republican primary for the district last week, Derek Merrin smiled as he shook hands with Kennedy.

“We discussed protecting Lake Erie, strengthening rural hospitals, and our shared vision to improve food quality,” Merrin later posted on Facebook. “Let’s Make America Healthy Again!”

Still, even with Kennedy under advisement to avoid anti-vaccine rhetoric, the issue found him in Ohio. At a forum in Cleveland, family doctor Patricia Kellner said the best way to prevent hepatitis B is by vaccinating newborns — a recommendation that under Kennedy. She told Kennedy about treating patients with the disease.

“Some of them didn’t know because it can be asymptomatic. Some of them found out when they got liver cancer,” Kellner said. “So why are you opposed to a birth dose of hepatitis B?”

Kennedy responded by suggesting that the hepatitis B vaccine was not safe for babies and was necessary only for certain people.

“Hepatitis B is for high-risk groups like drug addicts or prostitutes, or for promiscuous homosexuals,” he added, eliciting gasps from the crowd.

While the risk of contracting hepatitis B is higher for those who inject drugs or men who have sex with men, the disease can be transmitted in other ways, including through contact with contaminated surfaces or childbirth.

Public health researchers that dropping the universal hepatitis B recommendation will result in hundreds of new infections in children, costing millions of dollars in additional health care costs.

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Recently divorced, the former stay-at-home mother had started working again in her mid-40s, taking a human resources job that paid $41,000 a year. Then, despite having insurance, she was hit with more than $8,000 in medical bills.

“I had my car and a basket of clothes,” Roberts recalled. “Medical bills were not something I could have afforded.”

Roberts sought financial assistance from CentraCare, the St. Cloud-based health system that treated her. It’s a nonprofit charity that receives millions of dollars in federal, state, and local tax breaks. In exchange, it’s obliged to offer charity care to patients who can’t afford their medical bills. But Roberts said CentraCare told her she made too much to qualify.

Roberts instead scrimped on groceries and Christmas gifts for her kids and paid off more than $6,000 over two years. Then CentraCare sued her last year because she hadn’t paid off all the debt.

“They’re supposed to be a nonprofit,” Roberts said. “It’s like, ‘Come on!’”

CentraCare earmarks a tiny fraction of its budget for helping patients with medical bills they can’t pay, but it’s not alone, a Minnesota Star Tribune-ºÚÁϳԹÏÍø News investigation found.

Minnesota’s hospitals and health systems are among the least charitable in the country, the investigation found, providing less financial aid as a percentage of their operating budgets on average than hospitals in almost every other state, including Illinois, Iowa, Nevada, and Texas.

The investigation drew on a detailed review of every hospital charity care program in the state, an analysis of five years of hospital financial data, and dozens of interviews with patients, hospital executives, and state officials.

Nationally, hospitals spend an average of about 2.4% of their operating budgets on charity care, according to federal hospital data compiled by Hossein Zare, a researcher at Johns Hopkins University. Minnesota hospitals spend about a third of that, on average.

Some spend considerably less. Of Minnesota’s 123 general hospitals, 62 devoted less than 0.5% of their operating budgets to charity care from 2020 through 2024, the Star Tribune-ºÚÁϳԹÏÍø News investigation found.

“The system is not working,” said Erin Hartung, director of legal services at Cancer Legal Care, a Minnesota nonprofit that helps patients with medical debt and other financial challenges. “And the burden is falling hardest on the people who are least able to bear it.”

CentraCare’s flagship St. Cloud Hospital spent less than 0.25%, according to the analysis. That works out to $25 in patient aid for every $10,000 spent on hospital operations.

Charity care will become even more vital in coming years as Minnesotans lose health coverage or can’t afford rising copays and deductibles. The state’s uninsured rate rose sharply last year, since 2017, and it’s expected to increase further as budget cuts pushed by President Donald Trump force states to pare Medicaid and other safety net programs. Charity care is also critical to many people with health insurance who can’t afford their bills.

Hospital officials say it’s unfair to expect them to solve this affordability problem when many of their facilities are financially strained. “No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans. The need is simply too great,” Minnesota Hospital Association spokesperson Tim Nelson said in a statement.

But state Attorney General Keith Ellison said hospitals have a duty to boost charitable help for all needy patients in exchange for the tax breaks they receive.

“There is a benefit you get from being a nonprofit hospital in the state of Minnesota,” he said. “But do the people get the benefit?”

Several small Minnesota hospitals give financial aid to fewer than two dozen patients a year. Mahnomen Health Center, which recently converted to a rural emergency center, didn’t provide any charity care in eight years, despite serving one of Minnesota’s . Other hospitals serving large low-income populations were among those providing the least charity care, the analysis found.

Several factors help explain why Minnesota hospitals provide so little financial aid. For one, job-based insurance and an expanded Medicaid program offer broad coverage. Hospitals in states with less government assistance and more uninsured people typically spend more on charity care.

But Minnesota patients also face significant barriers accessing financial aid at many hospitals, including inconsistent eligibility standards and extensive applications, the Star Tribune-ºÚÁϳԹÏÍø News investigation found.

To qualify at many hospitals, patients must submit detailed personal information, including bank statements, retirement accounts, mortgage documents, and estimates of other assets such as cars, homes, or livestock.

And because Minnesota has not standardized the criteria for charity care, patients might receive aid at one hospital but not another. The investigation found that some hospitals give free care to patients with an annual household income of $47,000, while others cap it at about $15,000.

Had Roberts driven 30 miles east to Princeton or 35 miles north to Little Falls, she would have found medical providers with more generous financial aid policies than CentraCare. But she didn’t know to look.

Roberts, now 49, has remarried and lives in a split-level home in St. Cloud decorated with inspirational plaques such as “Faith, Family, Friends.” CentraCare recently dropped the lawsuit against her, but only after she took out a loan against her retirement plan to pay off the medical debt. “It just feels very unfair,” she said.

‘We Have To Defend Being Paid’

CentraCare spokesperson Karna Fronden said medical privacy laws prevented her from discussing Roberts’ case. She also declined interview requests about the health system’s charity care spending.

In a statement, Fronden said CentraCare provides assistance in addition to charity care, such as helping enroll patients in insurance. “This helps provide broader, longer-term protection for patients,” she said.

Other hospital leaders said they serve their communities in ways besides forgiving medical bills, including training doctors and nurses and preserving money-losing services such as obstetrics and mental health care.

“Rural hospitals like ours are often portrayed as though we are sitting on piles of cash and simply choosing not to spend it on charity care. That is far from the reality,” said Robert Pastor, chief executive of Rainy Lake Medical Center in International Falls.

“We are the second- or third-largest employer in town, running on razor-thin margins while navigating escalating labor and supply costs and routine underpayment by public programs,” Pastor said. “Meanwhile, many health insurers post billions in profits.”

Hospitals typically are paid less for care provided to Medicare and Medicaid patients. More than 80% of Rainy Lake’s patients are on one of those government programs.

Minnesota hospitals collectively write off about $200 million of what’s deemed bad debt every year after trying unsuccessfully to collect unpaid bills from patients through calls, letters, and even lawsuits. By comparison, they devote about $163 million annually to charity care, state figures show. In 2024, hospitals collectively posted $2.4 billion in net income.

“I feel like I’m put in the position, being the hospital, where we have to defend being paid,” said Patti Banks, the head of Ely-Bloomenson Community Hospital and a senior Minnesota Hospital Association board member.

Some hospitals face intense financial pressures. Thirty-one have lost money on operations in four of the past eight years. HCMC in Minneapolis — the state’s largest safety net hospital, which provides the most charity care — is losing so much money that, without additional taxpayer support, .

But larger health systems such as Mayo Clinic, Essentia Health, and Sanford Health have remained financially sound. And the operating margins at most CentraCare hospitals exceeded 10% in 2024, state data shows.

Medical Debt’s High Toll

Nationwide, health care debt — much of it from hospitals — burdens an estimated 100 million people, increasing their stress and even leading to premature deaths, .

Abby Kelley-Hands, a special education coordinator in St. Paul, has a rare immune condition that causes frequent, severe allergic reactions. Her illness can be controlled only with a costly drug, which a Mayo Clinic doctor prescribed.

When Kelley-Hands briefly lost health coverage in 2021 in an insurance mix-up, she was hit with more than $20,000 in bills. And although she and her husband earned less than $100,000 a year, Kelley-Hands said Mayo denied her financial assistance because she earned too much.

“I was in tears,” Kelley-Hands said. “It was so scary and so hard. And it causes all of this additional stress, which then makes you sicker and less able to even figure things out.”

Kelley-Hands and her husband sold a car and agreed to a payment plan before Mayo would resume her treatment, she said. Her husband now bikes 5 miles to work. They have no dishwasher. And she and her husband took a honeymoon only last fall, seven years after their wedding. “We live very simply,” she said.

Mayo spokesperson Kristyn Jacobson declined to discuss Kelley-Hands’ case.

In 2024, state lawmakers from denying care to patients with outstanding debt. And in 2025, Attorney General Ellison reached an agreement with Mayo to overhaul its charity care program after an investigation found the multibillion-dollar institution was systematically discouraging patients from applying.

After the state began investigating Mayo, the system’s , topping 1.5% of operating expenses in 2024.

‘Optimized To Get Payment’

Complying with a 2023 , Minnesota hospitals now post their financial aid policies online, although several, including CCM Health in Montevideo and Northfield Hospital, did so only after being contacted by the Star Tribune or ºÚÁϳԹÏÍø News.

But many hospitals make financial aid more difficult to find than information about paying bills, said Jared Walker, founder of Dollar For, a nonprofit that helps patients nationally apply for charity care.

“Hospitals have optimized to get payment,” he said. “If you want to get on a payment plan, if you want to get on a credit card, it’s so easy.”

Glacial Ridge Health System in Glenwood posts a “Bill Pay” tab at the . But it takes several clicks to find the hospital’s financial assistance plan. The information couldn’t be found on the site searching for “charity care” or “financial assistance.” The public hospital 130 miles northwest of Minneapolis devoted less than 0.7% of its operating budget to charity care from 2019 to 2024.

Patients in interviews frequently said they weren’t told about charity care.

Joe Robling, 29, was treated at St. Francis Regional Medical Center in Shakopee for a broken pelvis and fractured spine after a 2024 motorcycle accident. His mother, Janet, who helped him navigate the bills, said the hospital never informed him about financial aid.

“They didn’t offer any of that,” she said.

Robling, a construction worker in Henderson, was between jobs and uninsured. “He had zippo,” Janet Robling said. “What he had in reserves were all depleted.”

The Allina Health-affiliated hospital billed him more than $19,000, the Roblings said.

An internet ad connected the family to Dollar For, which helped Robling qualify for charity care five months after his accident.

Allina spokesperson Jennifer Steingas declined to comment on the case, citing medical privacy restrictions, but said the health system has since reached out to the family.

In another case, M Health Fairview’s University of Minnesota Medical Center didn’t offer financial aid to an unemployed and uninsured man from Idaho while he was hospitalized for two months for psychiatric care and amassed $150,000 in bills.

Attorney Margaret Henehan, who represented the man, said the hospital instead offered him a two-year payment plan at $6,500 a month. “He had no income, which he told Fairview,” Henehan said.

The man, who is not identified because of his mental health condition, eventually received charity care after his sister, a doctor, reached out to Henehan for help.

Aimee Jordan, a Fairview spokesperson, said she couldn’t comment on the case because of patient privacy laws, but she said patients who are offered payment plans can always apply for charity care, even after a hospitalization.

A Maze of Standards

State law prohibits hospitals from making “unreasonable” demands of patients when they apply for charity care. But the law sets few specific standards.

The result is a dizzying array of policies, including 11 income thresholds used by Minnesota hospitals to determine whether patients qualify for free care, the Minnesota Star-Tribune-ºÚÁϳԹÏÍø News review found.

HCMC parent company in Minneapolis and Olmsted Medical Center in Rochester offer the highest threshold for free care, at — almost $48,000 a year for an individual.

Sometimes standards vary even between neighboring hospitals. Madelia Health in south-central Minnesota to patients who make less than twice the federal poverty level. About 13 miles away at Mayo’s hospital in St. James, can qualify for aid.

To determine eligibility, some Minnesota hospitals consider only income, but most demand information about patients’ bank accounts as well. More than two-thirds require even more information, including the value of retirement accounts, life insurance policies, property, and vehicles. Madelia’s “may be required to sell recreational vehicles.”

Stringent requirements ensure that limited resources go to patients who need them, said Travis Olsen, chief executive of Hendricks Community Hospital, near the South Dakota border. “We don’t feel it’s fair for someone with lower annual income but yet owns numerous acres of land, debt-free, to be able to qualify for charity care.”

In addition to copies of tax returns, W-2 forms, pay stubs, and bank statements, 53 questions about their finances. These include questions about the make, model, and value of vehicles; the current market value of farm equipment, livestock, and land; and the purchase price and square footage of homes.

Other hospital applications ask patients to detail their monthly spending on food, utilities, and other medical bills.

Olsen said community pressure is more of a deterrent to applying for aid than the application: “People are too proud to pick up an application. We all know each other.”

But Walker at Dollar For said the biggest barrier is complexity. “The drop-off rates are much higher the more questions you ask and the more documentation you have to provide,” he said.

Arleen Mullenax had a cancerous tumor removed from her neck at Mayo in Rochester. Assembling her aid application and following up with the hospital billing department amid her “cancer fog” was almost more than she could take, she said.

“I knew as a former office manager I had to stay on top of it,” she said. “But it was the most daunting thing I had to do as a patient.”

Fixing the System

Ellison and several state lawmakers say Minnesota’s hospitals should make it simpler for patients to access charity care.

They’ve called for, among other things, common eligibility standards and a standard application across hospitals. New York and Maryland already have both.

“Eliminating as many barriers as possible for people is really important,” said state Sen. Liz Boldon, who also said she hopes lawmakers can enact these standards next session.

The Minnesota Hospital Association has opposed standardizing financial assistance, saying hospital boards are in the best position to assess the need for charity care in their communities. “Adding mandates for providers across the state will not close that gap, and will only increase bureaucratic and procedural barriers to patient care,” spokesperson Nelson said.

Ellison also has pushed to require hospitals to use a process that automatically screens and qualifies low-income patients for financial aid without requiring an application.

Some hospital systems, including South Dakota-based Sanford Health, already use software that checks patients’ eligibility based on information such as their credit history, said Nick Olson, the system’s chief financial officer. At Sanford Health’s 10 hospitals in Minnesota, about a quarter of the patients who receive financial aid get it this way, he said.

Nearly all Sanford hospitals devote more than 1% of their operating expenditures to charity care — higher than most hospitals in the state.

Screening software can be costly. Several executives at small Minnesota hospitals said they can’t afford it. But there are other options. In California, Los Angeles County is developing a public system to allow hospitals to quickly assess patients’ eligibility so they don’t have to buy a system themselves.

Other states — including Texas and Nevada — have laws requiring hospitals to provide minimum amounts of charity care.

Back in St. Cloud, Roberts said that when she drives past CentraCare’s $200 million expansion at its Plaza campus in St. Cloud, she wonders why Minnesota hospitals don’t live up to higher standards themselves.

“They have all the money,” she said. “But they can’t grant a good person some grace?”

Minnesota Star Tribune staff writers Bill Lukitsch and Victor Stefanescu contributed to this report.

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The 152-bed hospital, which sits on a sprawling medical campus close to the predominantly Latino and Black neighborhood of Watts, is struggling for financial stability. Its patients are poorer and sicker than average, many of them are uninsured, and three-quarters of MLK’s patient care revenue comes from Medi-Cal, the state’s version of the Medicaid program, which pays low rates. For hospitals statewide, by comparison, less than one-third of patient revenue comes from Medi-Cal.

And MLK Community Healthcare, which comprises the hospital and two nearby clinics, is independent, so it cannot fall back on a larger chain to absorb some of the financial pressure.  

Similar problems plague hospitals around the country, in rural and urban areas. And their financial woes are about to get worse.

The Republican budget measure known as the One Big Beautiful Bill Act, signed into law by President Donald Trump last July, is expected to cut federal Medicaid spending by $911 billion over 10 years. And it could contribute to an increase of in the number of uninsured people, many of whom will go to already crowded emergency rooms to get care they can’t pay for.

The law does include a special fund to boost rural healthcare, totaling $50 billion over five years. But that’s far less than it is expected to cut from rural health spending over the next decade. And the rural health fund does little or nothing to help the numerous that also face serious financial troubles.

MLK, like many other hospitals, is scrambling to secure outside financing to avert serious disruptions of medical services when the brunt of the policies contained in the federal law begins to hit early next year. The hospital’s leadership team projects a revenue hole of $80 million to $100 million annually for the foreseeable future. It would be MLK’s largest budget gap since it opened in 2015.

“Even if we cut services that our community needs — maternity care, behavioral healthcare, diabetes management — it wouldn’t make a significant dent in the gap we’re facing,” said Elaine Batchlor, the CEO of MLK Community Healthcare. ”Many of those same people would still come to us through our emergency department, only they’d be in worse shape and might need more expensive care.”

Across the U.S., hospitals and patient advocates are looking to state lawmakers and local officials to help shore up shaky finances. In California, Assembly member Esmeralda Soria, a Democrat representing Fresno, is to expand a 2023 “distressed hospital loan fund” that allocated nearly $300 million in zero-interest loans to in the state, including $14 million to MLK. The state would pony up another $300 million under Soria’s bill.

At least two other states are weighing similar programs. A would create a $100 million “distressed hospital grant” program. And a funding bill for the Illinois Department of Healthcare and Family Services contains a provision to create for troubled hospitals.

Carmela Coyle, the CEO of the California Hospital Association, said the original $300 million disbursed by the state legislature helped but was not enough.

“This program is focused on those who are standing on the edge of that financial cliff, and it’s intended to give them a little space, brush them a little bit back from the edge,” Coyle said. “But we’ve got many more hospitals that are taking giant leaps toward the edge of that cliff every day.”

Despite the association’s influence, an expansion of the loan program is far from certain, given fiscal constraints that have already induced state leaders to roll back California’s ambitious healthcare agenda, with restrictions on coverage for immigrants and funding cuts for community clinics. Democratic Gov. Gavin Newsom recently warned lawmakers to expect more cuts in his revised May budget — and that’s before the main federal spending reductions kick in.

“This is a very difficult budget environment,” said Kristof Stremikis, director of market analysis and insight at the California Health Care Foundation, a nonprofit that advocates for healthcare improvement. “It is hard to come up with funding for new programs and even existing programs right now.”

Some lawmakers noted skeptically that the initial loans are now on their way to at which is allowed under existing law. Soria’s bill spells out a clearer path to loan forgiveness.

“Are these loans or are these grants? Because they seem to be turning, really, into grants,” Assembly member Pilar Schiavo, a Democrat in Santa Clarita, said during an April 21 hearing on the bill.

Ultimately, it might not be desirable to save struggling institutions by pouring dollars into them, because care is increasingly offered outside of hospitals, Stremikis said.

In the short term, though, the financial health of hospitals that received loans appears to have improved, according to a ºÚÁϳԹÏÍø News analysis of state data. The average operating margin of the 15 loan recipients for which comparable data is available shifted from a loss of 15.4% the year before the program to a gain of 2.3% after the money was disbursed.

It is unclear how much of the improvement can be attributed to the loans. Hospitals also secured other sources of funding, and they adopted efficiencies as a condition for the interest-free money.

MLK reduced the use of high-cost temporary labor by hiring more permanent staff, cut the average length of patient hospital stays to decrease staffing hours, streamlined billing, and negotiated more-favorable contracts with insurers, said Atul Nakhasi, a practicing physician who is also MLK’s vice president of government affairs and community relations. Batchlor said that the loan helped MLK get through a cash flow crunch and that a second loan, if it became available, would be used for the same purpose.

This summer, MLK expects to open a psychiatric assessment unit, where patients in mental distress can be stabilized in an environment replete with plush reclining chairs and “calming” rooms. Hospital executives hope the new unit will provide a significant new source of revenue, while taking pressure off the emergency department.

in Visalia, California, suspended some services, temporarily stopped contributing to employees’ retirement, and briefly froze wages in exchange for a loan of just under $21 million, said the organization’s CEO, Marc Mertz.

Madera Community Hospital got a $57 million loan — the largest disbursement from the state fund — to reopen after being shuttered for more than two years. The hospital reopened early last year, but it has not yet stabilized financially, said Matthew Beehler, the chief strategy officer at American Advanced Management, a privately held company that bought Madera out of bankruptcy.

“You can definitely say the hospital would not have been opened without the distressed hospital loan,” though the company has also invested more than $50 million, Beehler said. He said Madera would hope for another loan if the program were extended.

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The waiver program, run by the Department of Health and Human Services, allows physicians who aren’t U.S. citizens to stay in the country while transitioning from the visa they used during their training to temporary worker status. In exchange, the doctors agree to work in underserved areas for at least three years.

“It will be the patients that suffer the most because in about three months, there’s going to be hundreds of places that are not going to have a physician that should have,” said a psychiatrist caught in the delay.

The doctor — whom ºÚÁϳԹÏÍø News agreed not to identify because they fear government reprisal — was among hundreds who applied this year for a J-1 visa waiver through the HHS Exchange Visitor Program.

If they receive one, the psychiatrist — who attended medical school in their home country in Europe before coming to the U.S. for their residency and fellowship — would work with vulnerable and disadvantaged patients in New York.

In recent years, the HHS program reviewed waiver applications in one to three weeks, according to two immigration attorneys.

But it currently has a backlog of hundreds of applications, which still need to be reviewed by the State Department and approved by U.S. Citizenship and Immigration Services, according to four attorneys interviewed by ºÚÁϳԹÏÍø News.

They said the foreign physicians will likely have to return to their home countries if their applications don’t advance to USCIS by July 30.

For them to reenter the U.S., their employers would have to pay a new $100,000 fee associated with the H-1B work visa. It’s a cost that many hospitals and clinics in rural and underserved areas say they can’t afford. “That’s the cliff that this train is headed for,” said Charles Wintersteen, a Chicago-based attorney who specializes in health workforce-related immigration.

HHS spokesperson Emily Hilliard didn’t answer questions about the number of pending applications or explain what caused the delays. But she said the Exchange Visitor Program has reviewed all fiscal year 2025 clinical J-1 waiver applications, as well as some from fiscal 2026.

The department is “implementing key process improvements to prevent future delays” and “working diligently” to evaluate remaining applications ahead of the July 30 deadline, she said.

The psychiatrist in limbo said employers hiring J-1 waiver physicians have to show they were unable to fill positions with American workers. If the doctors they planned to hire can’t arrive on time — or at all — patients will have to wait even longer for those vacancies to be filled, they said.

Wintersteen said postgraduate medical education positions are largely funded through Medicare and that “the taxpayers who pay for that training will not get the benefit of it.”

Physicians and immigration attorneys said HHS hasn’t explained the delays or let them know what to expect from their applications.

“Why would HHS want to take a program that is working — a program that places hundreds of U.S. trained international physicians in highly underserved parts of the country every year — and slow-walk it into non-existence,” Jennifer Minear, a Virginia-based health workforce immigration lawyer, said in an email. “How does that serve the public health? It is baffling.”

Waylaid Waivers

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

Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to .

Once noncitizens complete postgraduate education in the U.S., which typically ends on June 30, they must return to their home country and wait two years before applying for an H-1B work visa. Or, they can seek , which lets them remain in the U.S. on H-1B status in exchange for working for three years in a provider shortage area.

The attorneys said they’re seeing delays only in the Exchange Visitor Program, not in the other federal or state J-1 waiver programs.

The HHS clinical care program received 750 waiver applications last year, Minear and Wintersteen said, and is reserved for doctors working in pediatrics, psychiatry, family and internal medicine, or obstetrics and gynecology.

The program typically needs to forward recommendations to the State Department by mid-March, from John Whyte, CEO of the American Medical Association.

Minear said HHS stopped processing applications in late September or early October before it started forwarding them again a few months ago.

“But the pace is dramatically slower” than usual, she said.

Minear said the State Department usually takes two or three months to review HHS recommendations and must send them to USCIS before July 30 for most of the doctors to stay in the country.

If they don’t make that deadline, Wintersteen said, doctors will have to leave the country unless they obtain another kind of visa, get a J-1 waiver through another program, or extend their current visa by taking board exams or doing additional training.

The psychiatrist, who is supposed to start work on July 1, said they applied for a waiver in order to stay in the U.S with their partner, and because it would let them help the most vulnerable mental health patients. They said their future clients would likely include trafficking survivors, homeless people, and prison or jail inmates. “That’s the population I want to work with,” they said.

Waiver Delay Meets H-1B Dilemma

President Donald Trump issued a that railed against the tech industry’s use of H-1B work visas. The order created the $100,000 fee that applies to workers in all fields — not only tech — living outside the U.S. The payment doesn’t apply to those already in the country.

As of Feb. 15, employers had paid the fee for 85 workers, from USCIS. It’s unclear if any of those payments were for physicians or other medical providers.

The psychiatrist said officials at the hospital that plans to hire them said they can’t afford to pay to bring them back to the U.S. if they must go home.

“A lot of hospitals who hire J-1 waiver physicians are in underserved areas, and so they treat Medicare and Medicaid patients,” they said. “By definition, for the most part, they’re not rich hospitals.”

Barry Walker, an attorney in Tupelo, Mississippi, focused on health workforce-related immigration, said employers have already spent money on recruiters and attorneys like him to help with the waiver process.

Adding the H-1B fee is “just a deal killer, especially for the small, rural hospitals,” he said.

Attorneys said most employers will sponsor physicians in need of an H-1B visa only if they’re in lucrative specialties, such as cardiology or orthopedics, in which they can recover the cost of the fee.

They said healthcare facilities are much less likely to pay the fee to hire foreign nurses, lab technicians, and other healthcare professionals who are more likely than physicians to complete their training outside the U.S.

Employers , but attorneys said they haven’t heard of a hospital or clinic being granted one.

Fighting on Two Fronts

Physicians, hospital leaders, lawmakers, and immigration experts are trying to draw attention to the J-1 waiver delays at HHS while hoping to overturn or limit the new H-1B fee.

The Trump administration hasn’t acted on letters from , , and that requested an exception to the $100,000 fee for physicians or all healthcare workers.

In March, a bipartisan group of lawmakers that would create a healthcare exemption. It has not yet had a hearing.

At least three lawsuits — from the , a , and a that includes a company that recruits foreign nurses and a union that represents medical graduates — are seeking to end the fee entirely.

As for the J-1 waiver delays, the American Medical Association CEO asked the Exchange Visitor Program to use “emergency batch processing” for physicians with contracts to start work this summer.

Efrén Manjarrez, president of the Society of Hospital Medicine, which represents doctors who work in inpatient units, also called for emergency measures.

“Every day this backlog persists is a day that hospitalized patients in these communities face greater risk,” to the program.

Meanwhile, Canadian hospitals have been recruiting foreign physicians completing their training in the U.S, the psychiatrist said. They said one of their friends accepted an offer, withdrawing their HHS waiver application to head north.

The psychiatrist said if they must leave the U.S., they’ll be separated from their partner and out of a job for months as they work to get licensed in their home country.

Even if their employer were able to afford the H-1B fee, they’re not sure they’d want to return.

“This entire process has been so incredibly painful and just soul-crushing,” they said. “I would rather go to a country that would appreciate my motivation to work with patients.”

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If you or someone you know is seeking help for addiction recovery, contact the free and confidential treatment referral hotline, 1-800-662-HELP, or visit findtreatment.gov.

A day after Hurricane Helene ripped through western North Carolina in late September 2024, Toni Brewer had no power or water. The storm had strewn fallen trees across most roads, wiped out phone and internet communications, and put some neighborhoods near her Asheville home underwater.

Brewer cleared out the food in her refrigerator, grabbed some clothes, and drove more than an hour southwest with her partner to Franklin, to stay with relatives.

When she arrived, she opened the center console of her car, where she kept medication, and discovered another crisis. She had only three days’ worth of Suboxone, a brand of buprenorphine, a prescription drug that eases opioid cravings. Without it, she risked relapsing into a life she described as miserable.

She recalled what it felt like to have those cravings and panicked.

“It’s terrifying just to have that feeling again of, ‘I need this, and I’ll do whatever it takes to get this,’” said Brewer, who had been in recovery from opioid addiction for 18 months at the time. She needed a new prescription but knew communication lines at her doctor’s office were down.

Now, a group of doctors is using the example of Hurricane Helene to urge federal lawmakers to help improve access to substance use medications in severe weather emergencies. Four physicians working in addiction medicine that outlines strategies for getting medication to people in recovery during natural disasters.

As climate change  in the U.S., the group of doctors urged state and federal governments to act soon or risk allowing more disasters to aggravate overdoses, relapses, and deaths caused by opioid use disorder, an ongoing epidemic that has  people in the U.S. since 1999.

that after Superstorm Sandy in 2012, 70% of New Yorkers who relied on recovery medications couldn’t get enough of them. In the two years following Hurricane Maria’s devastation in Puerto Rico in 2017, , another study found. The Tubbs and Camp fires in Northern California in patients’ access to opioid addiction medications, found a study published in 2022.

A combination of factors aggravates the opioid crisis in the U.S., the AJPH editorial authors noted. Mental health stressors, treatment disruptions, drug market volatility, and economic decline all create conditions in which climate-related disasters heighten the risk of overdose deaths.

“We make it so challenging for them to access treatment medications in the first place,” said , the climate health director at Rowan University’s Cooper Medical School and a co-author of the editorial. “When people are displaced or unable to get to their usual clinics or pharmacies, those challenges just become insurmountable.”

Their push comes as President Donald Trump has had a markedly different approach to substance use policy in the past year than in his first term. Trump in 2017 declared the nation’s opioid crisis a national public health emergency and, in 2018, signed a law, known as the , to expand access to treatments.

But his administration has also reduced federal resources for mental health and substance use services, cutting staffers last year at the Substance Abuse and Mental Health Services Administration and ending numerous grants to advance research on prevention efforts.

Disasters Threaten Treatment

SAMHSA works with states to ensure that access to opioid use disorder medication isn’t disrupted, Health and Human Services spokesperson Emily Hilliard said. States can approve emergency measures to allow people more flexibility to obtain their treatments, she added, .

, another co-author of the editorial, saw these access issues play out in the wake of Hurricane Helene.

Stearns, the chief medical officer at High Country Community Health in North Carolina’s Blue Ridge Mountains, said the first calls to her clinics were for buprenorphine. She said people who needed the medication traveled over mountains and crossed rivers to get to her clinics.

“The things that my patients did to be able to access their bupe,” Stearns said, “it was astonishing.”

The that the federal government work with pharmacies to allow patients to take home more medication during emergencies. They suggest keeping a registry of patients with recovery medication prescriptions who can get treatment when evacuating across state lines.

And they propose factoring the need for such medications into disaster response plans, whether that means stocking rescue vehicles with buprenorphine, adding backup generators to opioid treatment clinics, or training volunteer responders.

People with substance use disorders already must often navigate strict, complex regulations to get the medications. For example, methadone can be obtained only through an in-person visit to federally controlled opioid treatment centers, many of which closed for days or weeks after Hurricane Helene.

Buprenorphine is controlled by the Drug Enforcement Administration’s , which restricts supply when pharmacies order more than allowed under specified thresholds. The system is meant to catch potential overuse of recovery medication in a region.

, a clinical director of substance use disorder initiatives at the Mountain Area Health Education Center in western North Carolina, said that system delayed medications numerous times in the aftermath of Helene. No exceptions were allowed, .

The agency did not respond to questions about the system.

Individual pharmacies also control who gets medication and who doesn’t. When people try to get medication for opioid use disorder far from home, it can raise alarms.

“We realized there were some pharmacies that would just be like, ‘I don’t know this person. I will only give you three days’ worth, and I’m sure they’ll be back in Asheville soon,’” Fagan said. “They didn’t want to fill a month’s worth. And in our mind, we’re sitting in the disaster, and we’re like, ‘They’re not coming back in a month.’”

Risk of Relapse

When Brewer made it to Franklin, she immediately logged in to the Mountain Area Health Education Center patient portal, dubious about whether she would be able to have her three-month Suboxone prescription refilled.

She didn’t know that her doctors had left the area, too, to get a stable internet connection. They were trying to call and email patients to fill prescriptions.

Trying to be thorough, Brewer messaged several doctors. Two responded, and one filled her prescription.

But when she went to a local Walgreens, it was out of Suboxone. So Brewer took another trip, this time to Clayton, Georgia, where she was finally able to pick up a month’s worth.

The medication that would have been mostly covered by North Carolina Medicaid if she’d stayed in-state was about $130, a high price for Brewer, who had temporarily lost her job when her workplace, a sober living facility, lost power and closed because of the storm.

Despite what little income she had at the time, Brewer said, she paid for her prescription. The thought of relapsing back to her previous life when her addiction was untreated scared her, she said.

“I would wake up every day, and the only thing on my mind was finding my next fix so I could go on about my day, or even just take care of things like feed myself, or bathe, and show up for my daughter,” she said.

Brewer recalled feeling relief after getting her prescription refilled. Her panic washed away.

“Now I can worry about everything else,” she recalled thinking as she drove home to Asheville.

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