El programa está diseñado para eliminar servicios considerados innecesarios o de “bajo valor” y representa una expansión federal del proceso llamado autorización previa, una práctica impopular que exige a los pacientes o a los médicos la aprobación del seguro antes de realizar ciertos procedimientos y exámenes médicos, o de escribir recetas.

Afectará a beneficiarios de Medicare, así como a los médicos y hospitales que los atienden, en Arizona, Ohio, Oklahoma, Nueva Jersey, Texas y Washington, a partir del 1 de enero y hasta 2031.

La medida ha generado preocupación entre políticos y expertos en políticas públicas. La versión tradicional de Medicare —que cubre a personas de 65 años en adelante y a algunas personas con discapacidades— ha evitado en general el uso de la autorización previa.

Sin embargo, las aseguradoras privadas la usan ampliamente, en especial en el mercado de Medicare Advantage.

El momento del anuncio también sorprendió: el programa piloto se anunció a finales de junio, pocos días después de que la administración Trump presentara una iniciativa voluntaria para que las aseguradoras privadas redujeran el uso de autorizaciones previas, práctica que, según Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS, en inglés), provoca “retrasos significativos” en la atención.

“Esto debilita la confianza del público en el sistema de salud”, dijo Oz a los medios. “Es algo que no podemos tolerar en esta administración”.

Pero algunos críticos, como Vinay Rathi, médico e investigador de políticas públicas en la Universidad Estatal de Ohio, acusan al gobierno de Trump de enviar mensajes contradictorios.

Por un lado, dijo Rathi, el gobierno quiere imitar estrategias del sector privado para reducir costos. “Por el otro, los regaña públicamente”.

“Es hipócrita decir una cosa y luego lo contrario”, dijo Suzan DelBene, legisladora demócrata de Washington. “Es muy preocupante”.

Pacientes, médicos y otros legisladores también han criticado lo que consideran tácticas para retrasar o negar atención médica, lo que puede causar daños irreparables o incluso la muerte.

“Las compañías de seguros tienen como mantra recibir el dinero de los pacientes y luego hacer todo lo posible para no entregárselo a quienes brindan la atención”, señaló Greg Murphy, legislador republicano de Carolina del Norte y urólogo. “Eso sucede en todas las juntas directivas de las aseguradoras”.

Las aseguradoras han defendido durante años que la autorización previa reduce el fraude, el gasto innecesario y posibles daños. La indignación pública por la negación de coberturas dominó los titulares en diciembre, cuando el asesinato del CEO de UnitedHealthcare hizo que muchos consideraran al presunto asesino como un héroe popular.

Y el rechazo público es generalizado: casi tres de cada cuatro personas encuestadas en julio por KFF dijeron que la autorización previa era un problema “grave”.

Por su parte, Oz afirmó en su conferencia de prensa de junio que la “violencia en las calles” llevó a la administración Trump a abordar la reforma de las autorizaciones previas en el sector privado.

Aún así, el gobierno está ampliando su uso en Medicare. Un vocero de los CMS, Alexx Pons, dijo que ambas iniciativas “tienen el mismo objetivo: proteger a los pacientes y a los fondos de Medicare”.

Preguntas sin respuesta

El programa piloto, llamado WISeR —siglas de Reducción de Servicios Inadecuados y Despilfarro— evaluará el uso de un algoritmo de IA para tomar decisiones de autorización previa en algunos servicios de Medicare, como sustitutos de piel y tejidos, implantes de estimuladores eléctricos de nervios y artroscopías de rodilla.

El gobierno federal sostiene que estos procedimientos son particularmente vulnerables al “fraude, despilfarro y abuso”, y que la autorización previa podría contener su uso excesivo.

Podrían agregarse más procedimientos a la lista. Sin embargo, los servicios de hospitalización, atención de emergencia o aquellos cuya demora represente un riesgo considerable para el paciente no estarán sujetos al modelo de IA, según el anuncio federal.

Aunque el uso de inteligencia artificial en seguros de salud no es nuevo, Medicare ha tardado en adoptar herramientas del sector privado. Hasta ahora, solo ha utilizado la autorización previa de forma limitada, a través de contratistas que no tienen incentivos para negar servicios. Pero expertos que han estudiado el plan creen que el plan piloto federal podría cambiar esa dinámica.

Pons afirmó a KFF Health News que ninguna solicitud de Medicare será rechazada sin antes ser revisada por “un profesional clínico calificado” y que los proveedores “tienen prohibido recibir pagos vinculados a tasas de negación”.

Sin embargo, el anuncio federal señala que los proveedores recibirán “un porcentaje de los ahorros generados por evitar atención innecesaria o inadecuada como resultado de sus revisiones”.

“Los acuerdos de ahorros compartidos implican que los proveedores se beneficien financieramente cuando se brinda menos atención médica”, y crea una estructura que puede incentivar la negación de atención médicamente necesaria, dijo Jennifer Brackeen, directora de asuntos gubernamentales de la Asociación de Hospitales del Estado de Washington.

Pero según médicos y expertos en políticas de salud, ese no es el único problema.

Rathi señaló que el plan “no está completamente desarrollado” y se basa en criterios “ambiguos y subjetivos”. El modelo, explicó, depende en última instancia de que los contratistas evalúen sus propios resultados, lo cual podría comprometer la validez de las conclusiones.

“No estoy seguro de que sepan, siquiera, cómo van a determinar si esto está ayudando o perjudicando a los pacientes”, dijo.

Pons aseguró que el uso de IA en este piloto estará “sujeto a supervisión estricta para garantizar transparencia, rendición de cuentas y cumplimiento con las normas de Medicare y la protección de los pacientes”.

“Los CMS siguen comprometidos con garantizar que las herramientas automatizadas apoyen —y no reemplacen— decisiones clínicas sólidas”, dijo.

Los expertos coinciden en que, en teoría, la inteligencia artificial podría agilizar un proceso que se caracteriza por retrasos y negaciones que afectan la salud de los pacientes. Las aseguradoras argumentan que la IA elimina errores y sesgos humanos, y reduce costos al sistema de salud. También insisten en que son personas, no algoritmos, quienes revisan las decisiones finales sobre cobertura.

Pero algunas investigaciones cuestionan que eso ocurra realmente.

“Creo que también hay ambigüedad sobre qué significa exactamente ‘revisión humana significativa’”, señaló Amy Killelea, profesora investigadora en el Centro de Reformas del Seguro de Salud de la Universidad de Georgetown.

Un informe de 2023 publicado por ProPublica reveló que, durante un período de dos meses, médicos de Cigna dedicaron en promedio 1,2 segundos para revisar cada solicitud de pago.

Justine Sessions, vocera de Cigna, dijo a KFF Health News que la compañía no utiliza inteligencia artificial para negar atención o reclamos. La investigación de ProPublica, explicó, se refería a “un proceso simple, impulsado por software, que ayudó a acelerar pagos a médicos para pruebas y tratamientos comunes y de bajo costo. No está impulsado por IA” y “no se utilizó para autorizaciones previas”, agregó Sessions.

Sin embargo, demandas legales colectivas presentadas contra grandes aseguradoras alegan que sus modelos de IA fallan al considerar las necesidades individuales de los pacientes y contradicen las recomendaciones médicas, obligando a algunas personas a asumir el costo de su atención.

Una encuesta realizada en febrero por la American Medical Association reveló que el 61% de los médicos cree que la IA está “aumentando las negaciones de autorización previa, agravando daños evitables a los pacientes y generando un despilfarro innecesario ahora y en el futuro”.

Chris Bond, vocero de AHIP, el grupo que representa a las aseguradoras, dijo a KFF Health News que la organización está “totalmente enfocada” en cumplir los compromisos asumidos con el gobierno. Entre ellos, reducir el alcance de la autorización previa y garantizar que las comunicaciones con los pacientes sobre negaciones y apelaciones sean fáciles de entender.

“Es un programa piloto”

El programa piloto de Medicare pone en evidencia las preocupaciones sobre la autorización previa, y agrega nuevas inquietudes.

Si bien las aseguradoras privadas han sido poco transparentes sobre cómo utilizan la IA y hasta qué punto aplican la autorización previa, investigadoras en políticas públicas creen que estos algoritmos suelen programarse para negar automáticamente la atención costosa.

“Cuanto más caro es el servicio, más probable es que se niegue”, afirmó Jennifer Oliva, profesora de la Facultad de Derecho Maurer de la Universidad de Indiana-Bloomington, experta en regulación de IA y cobertura médica.

En un artículo reciente para Indiana Law Journal, Oliva explicó que cuando un paciente tiene una expectativa de vida limitada, las aseguradoras tienden a apoyarse en el algoritmo. A medida que pasa el tiempo y el paciente o su médico apelan la negación, aumentan las probabilidades de que esa persona fallezca antes de que el seguro cubra el tratamiento. Cuanto más largo es el proceso de apelación, menos probable es que la aseguradora tenga que pagar, dijo.

“Lo primero que hacen es dificultar al máximo el acceso a servicios de alto costo”, aseguró.

Dado el crecimiento previsto del uso de IA en seguros de salud, los algoritmos de las aseguradoras representan “un punto ciego en la regulación” que exige mayor supervisión, dijo Carmel Shachar, directora del Centro de Innovación en Derecho y Políticas de Salud de la Facultad de Derecho de Harvard.

Según Shachar, el programa WISeR es “un paso interesante” para asegurarse de que los fondos de Medicare se utilicen en atención de calidad; pero la falta de detalles hace difícil saber si realmente funcionará.

Los políticos también se hacen esas preguntas.

“¿Cómo se va a probar este sistema? ¿Cómo van a asegurarse de que funciona y no está negando atención o generando más rechazos?”, preguntó DelBene, quien firmó una carta en agosto junto a otros demócratas exigiendo respuestas sobre el programa de IA.

Pero no solo los demócratas están preocupados.

Murphy, copresidente del Caucus de Médicos Republicanos de la Cámara de Representantes, reconoció que muchos médicos temen que el programa piloto WISeR interfiera con la práctica médica si el algoritmo niega tratamientos recomendados por profesionales.

Mientras tanto, miembros de ambos partidos en la Cámara de Representantes apoyaron recientemente una propuesta de Lois Frankel, demócrata de Florida, para bloquear el financiamiento del piloto en el presupuesto del Departamento de Salud y Servicios Humanos para el año fiscal 2026.

La IA llegó para quedarse en el sistema de salud, dijo Murphy, pero aún está por verse si el piloto WISeR ahorrará dinero a Medicare o empeorará los problemas ya existentes por la autorización previa.

“Es un programa piloto, y estoy dispuesto a ver qué ocurre con esto”, agregó Murphy, “pero siempre, siempre me inclinaré por confiar en que los médicos saben lo que es mejor para sus pacientes”.

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The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

The move has raised eyebrows among politicians and policy experts. The traditional version of Medicare, which covers adults 65 and older and some people with disabilities, has mostly eschewed prior authorization. Still, it is widely used by private insurers, especially in the Medicare Advantage market.

And the timing was surprising: The pilot was announced in late June, just days after the Trump administration unveiled a voluntary effort by private health insurers to revamp and reduce their own use of prior authorization, which causes care to be “significantly delayed,” said Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services.

“It erodes public trust in the health care system,” Oz told the media. “It’s something that we can’t tolerate in this administration.”

But some critics, like Vinay Rathi, an Ohio State University doctor and policy researcher, have accused the Trump administration of sending mixed messages.

On one hand, the federal government wants to borrow cost-cutting measures used by private insurance, he said. “On the other, it slaps them on the wrist.”

Administration officials are “talking out of both sides of their mouth,” said Rep. Suzan DelBene, a Washington Democrat. “It’s hugely concerning.”

Patients, doctors, and other lawmakers have also been critical of what they see as delay-or-deny tactics, which can slow down or block access to care, causing irreparable harm and even death.

“Insurance companies have put it in their mantra that they will take patients’ money and then do their damnedest to deny giving it to the people who deliver care,” said Rep. Greg Murphy, a North Carolina Republican and a urologist. “That goes on in every insurance company boardroom.”

Insurers have long argued that prior authorization reduces fraud and wasteful spending, as well as prevents potential harm. Public displeasure with insurance denials dominated the news in December, when the shooting death of UnitedHealthcare’s CEO led many to anoint his alleged killer as a folk hero.

And the public broadly dislikes the practice: Nearly three-quarters of respondents thought prior authorization was a “major” problem in a July poll published by KFF, a health information nonprofit that includes KFF Health News.

Indeed, Oz said during his June press conference that “violence in the streets” prompted the Trump administration to take on the issue of prior authorization reform in the private insurance industry.

Still, the administration is expanding the use of prior authorization in Medicare. CMS spokesperson Alexx Pons said both initiatives “serve the same goal of protecting patients and Medicare dollars.”

Unanswered Questions

The pilot program, WISeR — short for “Wasteful and Inappropriate Service Reduction” — will test the use of an AI algorithm in making prior authorization decisions for some Medicare services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.

The federal government says such procedures are particularly vulnerable to “fraud, waste, and abuse” and could be held in check by prior authorization.

Other procedures may be added to the list. But services that are inpatient-only, emergency, or “would pose a substantial risk to patients if significantly delayed” would not be subject to the AI model’s assessment, according to the federal announcement.

While the use of AI in health insurance isn’t new, Medicare has been slow to adopt the private-sector tools. Medicare has historically used prior authorization in a limited way, with contractors who aren’t incentivized to deny services. But experts who have studied the plan believe the federal pilot could change that.

Pons told KFF Health News that no Medicare request will be denied before being reviewed by a “qualified human clinician,” and that vendors “are prohibited from compensation arrangements tied to denial rates.” While the government says vendors will be rewarded for savings, Pons said multiple safeguards will “remove any incentive to deny medically appropriate care.”

“Shared savings arrangements mean that vendors financially benefit when less care is delivered,” a structure that can create a powerful incentive for companies to deny medically necessary care, said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association.

And doctors and policy experts say that’s only one concern.

Rathi said the plan “is not fully fleshed out” and relies on “messy and subjective” measures. The model, he said, ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect.

“I’m not sure they know, even, how they’re going to figure out whether this is helping or hurting patients,” he said.

Pons said the use of AI in the Medicare pilot will be “subject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.”

“CMS remains committed to ensuring that automated tools support, not replace, clinically sound decision-making,” he said.

Experts agree that AI is theoretically capable of expediting what has been a cumbersome process marked by delays and denials that can harm patients’ health. Health insurers have argued that AI eliminates human error and bias and will save the health care system money. These companies have also insisted that humans, not computers, are ultimately reviewing coverage decisions.

But some scholars are doubtful that’s routinely happening.

“I think that there’s also probably a little bit of ambiguity over what constitutes ‘meaningful human review,’” said Amy Killelea, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.

A 2023 report published by ProPublica found that, over a two-month period, doctors at Cigna who reviewed requests for payment spent an average of only 1.2 seconds on each case.

Cigna spokesperson Justine Sessions told KFF Health News that the company does not use AI to deny care or claims. The ProPublica investigation referenced a “simple software-driven process that helped accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI,” Sessions said. “It was not used for prior authorizations.”

And yet class-action lawsuits filed against major health insurers have alleged that flawed AI models undermine doctor recommendations and fail to take patients’ unique needs into account, forcing some people to shoulder the financial burden of their care.

Meanwhile, a survey of physicians published by the American Medical Association in February found that 61% think AI is “increasing prior authorization denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.”

Chris Bond, a spokesperson for the insurers’ trade group AHIP, told KFF Health News that the organization is “zeroed in” on implementing the commitments made to the government. Those include reducing the scope of prior authorization and making sure that communications with patients about denials and appeals are easy to understand.

‘This Is a Pilot’

The Medicare pilot program underscores ongoing concerns about prior authorization and raises new ones.

While private health insurers have been opaque about how they use AI and the extent to which they use prior authorization, policy researchers believe these algorithms are often programmed to automatically deny high-cost care.

“The more expensive it is, the more likely it is to be denied,” said Jennifer Oliva, a professor at the Maurer School of Law at Indiana University-Bloomington, whose work focuses on AI regulation and health coverage.

Oliva explained in a recent paper for the Indiana Law Journal that when a patient is expected to die within a few years, health insurers are “motivated to rely on the algorithm.” As time passes and the patient or their provider is forced to appeal a denial, the chance of the patient dying during that process increases. The longer an appeal, the less likely the health insurer is to pay the claim, Oliva said.

“The No. 1 thing to do is make it very, very difficult for people to get high-cost services,” she said.

As the use of AI by health insurers is poised to grow, insurance company algorithms amount to a “regulatory blind spot” and demand more scrutiny, said Carmel Shachar, a faculty director at Harvard Law School’s Center for Health Law and Policy Innovation.

The WISeR pilot is “an interesting step” toward using AI to ensure that Medicare dollars are purchasing high-quality health care, she said. But the lack of details makes it difficult to determine whether it will work.

Politicians are grappling with some of the same questions.

“How is this being tested in the first place? How are you going to make sure that it is working and not denying care or producing higher rates of care denial?” asked DelBene, who signed an August letter to Oz with other Democrats demanding answers about the AI program. But Democrats aren’t the only ones worried.

Murphy, who co-chairs the House GOP Doctors Caucus, acknowledged that many physicians are concerned the WISeR pilot could overreach into their practice of medicine if the AI algorithm denies doctor-recommended care.

Meanwhile, House members of both parties recently supported a measure proposed by Rep. Lois Frankel, a Florida Democrat, to block funding for the pilot in the fiscal 2026 budget of the Department of Health and Human Services.

AI in health care is here to stay, Murphy said, but it remains to be seen whether the WISeR pilot will save Medicare money or contribute to the problems already posed by prior authorization.

“This is a pilot, and I’m open to see what’s going to happen with this,” Murphy said, “but I will always, always err on the side that doctors know what’s best for their patients.”

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When Sally Nix found out that her health insurance company wouldn’t pay for an expensive, doctor-recommended treatment to ease her neurological pain, she prepared for battle.

It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials.

“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville, North Carolina.

To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests, and prescriptions.

Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to a July poll published by KFF, a health information nonprofit that includes KFF Health News.

“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”

The good news is you don’t have to be an insurance expert to get results, she said. “You just need to know how to push back.”

Here are tips to consider when faced with a prior authorization denial:

1. Know your insurance plan.

Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicare Advantage? Medicaid?

These distinctions can be confusing, but they matter a great deal. Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.

For example, federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.

Learn the language specific to your policy. Health insurance companies do not apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.

2. Work with your provider to appeal.

Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital in the Philadelphia area, spent much of her career communicating with health insurance companies on behalf of patients.

Before you contact your health insurer, call your provider, Lavanchy said, and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.

The good news is that your doctor’s office may already be working on an appeal.

Medical staffers can act as “your voice,” Nix said. “They know all the language.”

You or your provider can request a “peer-to-peer” review during the appeals process, which allows your doctor to discuss your case over the phone with a medical professional who works for the insurance company.

3. Be organized.

Many hospitals and doctors use a system called MyChart to organize medical records, test results, and communications so that they are easily accessible. Similarly, patients should keep track of all materials related to an insurance appeal — records of phone calls, emails, snail mail, and in-app messages.

Everything should be organized, either digitally or on paper, so that it can be easily referenced, Nix said. At one point, she said, her own records proved that her insurance company had given conflicting information. The records were “the thing that saved me,” she said.

“Keep an amazing paper trail,” she said. “Every call, every letter, every name.”

Linda Jorgensen, executive director of the Special Needs Resource Project, a nonprofit offering online resources for patients with disabilities and their families, has advised patients who are fighting a denial to specifically keep paper copies of everything.

“If it isn’t on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver to an adult daughter with special needs, created a free form you can print to help guide you when taking notes during phone calls with your insurance company. She advised asking the insurance representative for a “ticket number” and their name before proceeding with the conversation.

4. Appeal as soon as possible.

The silver lining is that most denials, if appealed, are overturned.

Medicare Advantage data published by KFF in January found that nearly 82% of prior authorization denials from 2019 through 2023 were partially or fully overturned upon appeal.

But the clock is ticking. Most health plans give you only six months to appeal the decision, according to rules laid out in the Affordable Care Act.

“Don’t dillydally,” Jorgensen advised, especially if you’re sending a paper appeal, or any supporting documents, through the U.S. Postal Service. She recommends filing quickly, and at least four weeks before the deadline.

For the sake of speed, some people are turning to artificial intelligence for help crafting customizable appeal letters.

5. Ask your HR department for help.

If you get your health insurance through an employer, there’s a good chance your health plan is “self-funded” or “self-insured.” That means your employer contracts with a health insurance company to administer benefits, but your employer shoulders the cost of your care.

Why does that matter? Under self-funded plans, decisions about what is or isn’t covered ultimately rest with your employer.

Let’s say, for example, your doctor has recommended that you undergo surgery, and your insurer has denied prior authorization for it, deeming the procedure “not medically necessary,” a phrase commonly used. If your plan is self-funded, you can appeal to the human resources department at your job, because your employer is on the hook for your health care costs — not the insurer.

Of course, there’s no guarantee your employer will agree to pay. But, at the very least, it’s worth reaching out for help.

6. Find an advocate.

Many states operate free consumer assistance programs, available by phone or email, which can help you file an appeal. They can explain your benefits and may intervene if your insurance company isn’t complying with requirements.

Beyond that, some nonprofit advocacy groups, such as the Patient Advocate Foundation, might help. On the foundation’s website is guidance about what to include in an appeal letter. For those battling severe disease, foundation staffers can work with you one-on-one to fight a denial.

7. Make noise.

We’ve written about this before. Sometimes, when patients and doctors shame insurers online, denials get overturned.

The same holds when patients contact lawmakers. State laws regulate some categories of health insurance, and when it comes to setting policy, state lawmakers have the power to hold insurance companies accountable.

Reaching out to your legislator isn’t guaranteed to work, but it might be worth a shot.

Finally, if you’re interested in sharing your experiences with a journalist, fill out this form. We’d like to hear from you.

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During a typical shift, she shows up at her clients’ home at 10 p.m. She answers questions they may have about basic infant care and keeps an eye out for signs of postpartum depression.

After bedtime, she may feed the baby a bottle or wake the mother to breastfeed. She soothes the infant back to sleep. Sometimes, she prepares meals for the family in a Crock-Pot or empties the dishwasher.

She leaves the following morning and returns, often nightly, for two or three weeks in a row.

“I’m certified to do all of it,” said Oliver, of Hardeeville, South Carolina, who runs Compassionate Care Doula Services. It takes a village to raise a child, as the adage goes, but “the village is not what it used to be,” Oliver said.

Doulas are trained to offer critical support for families — before delivery, during childbirth, and in those daunting early days when parents are desperate for sleep and infants still wake up around the clock. While doulas typically don’t hold a medical or nursing degree, research shows they can improve health outcomes and reduce racial health disparities.

Yet their services remain out of reach for many families. Oliver charges $45 an hour overnight, and health insurance plans often don’t cover her fees. That’s partly why business “ebbs and flows,” Oliver said. Sometimes, she’s fully booked for months. Other times, she goes several weeks without a client.

That may soon change.

Two bipartisan bills, introduced in separate chambers of the South Carolina General Assembly, would require both Medicaid, which pays for more than half of all births in the state, and private insurers to cover the cost of doula services for patients who choose to use one.

South Carolina isn’t an outlier. Even as states brace for significant reductions in federal Medicaid funding over the next decade, legislatures across the country continue to pass laws that grant doula access to Medicaid beneficiaries. Some state laws already require private health insurers to do the same. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana, and Montana, have passed laws to facilitate Medicaid coverage of doula services.

All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so.

Notably, these coverage requirements align with one of the goals of Project 2025, whose “Mandate for Leadership” report, published in 2023 by the conservative Heritage Foundation, offered a blueprint for President Donald Trump’s second term. The document calls for increasing access to doulas “for all women whether they are giving birth in a traditional hospital, through midwifery, or at home,” citing concerns about maternal mortality and postpartum depression, which may be “worsened by poor birth experiences.” The report also recommends that federal money not be used to train doctors, nurses, or doulas to perform abortions.

The Heritage Foundation did not respond to an interview request.

Meanwhile, the idea that doulas can benefit babies, parents, and state Medicaid budgets by reducing costly cesarean sections and preterm birth complications is supported by a growing body of research and is gaining traction among conservatives.

A study published last year in the American Journal of Public Health found that women enrolled in Medicaid who used a doula faced a 47% lower risk of delivering by C-section and a 29% lower risk of preterm birth. They were also 46% more likely to attend a postpartum checkup.

“Why wouldn’t you want somebody to avail themselves of that type of care?” said Republican state Rep. Tommy Pope, who co-sponsored the doula reimbursement bill in the South Carolina House of Representatives. “I don’t see any reason we shouldn’t be doing that.”

Pope said his daughter-in-law gave birth with the assistance of a doula. “It opened my eyes to the positive aspects,” he said.

Amy Chen, a senior attorney with the National Health Law Program, which tracks doula reimbursement legislation around the country as part of its Doula Medicaid Project, said lawmakers tend to support these efforts when they have a personal connection to the issue.

“It’s something that a lot of people resonate with,” Chen said, “even if they, themselves, have never been pregnant.”

Conservative lawmakers who endorse state-level abortion bans, she said, often vote in favor of measures that support pregnancy, motherhood, and infant health, all of which these doula reimbursement bills are intended to do.

Some Republicans feel as if “they have to come out in favor of that,” Chen said.

Health care research also suggests that Black patients, who suffer significantly higher maternal and infant mortality rates than white patients, may particularly benefit from doula care. In 2022, Black infants in South Carolina were more than twice as likely to die from all causes before their 1st birthday as white infants.

That holds true for women in rural parts of the country where labor and delivery services have either closed or never existed.

That’s why Montana lawmakers passed a doula reimbursement bill this year — to narrow health care gaps for rural and Indigenous communities. To that end, in 2023, the state enacted a bill that requires Medicaid to reimburse midwives for home births.

Montana state Sen. Mike Yakawich, a Republican who backed the Democratic-sponsored doula reimbursement bill, said pregnant women should have someone to call outside of a hospital, where health care services can be costly and intimidating.

“What help can we provide for moms who are expecting? My feeling is, it’s never enough,” Yakawich said.

Britney WolfVoice lives on the Northern Cheyenne Indian Reservation in southeastern Montana, about two hours from the closest birthing hospital. In early July, she was seven months pregnant with her fourth child, a son, and said she planned to have a doula by her side for the second time in the delivery room. During WolfVoice’s previous pregnancy, an Indigenous doula named Misty Pipe brought cedar oil and spray into the delivery room, rubbed WolfVoice’s back through contractions, and helped ensure WolfVoice’s husband was the first person their daughter saw.

“Being in a hospital, I felt heard for the very first time,” WolfVoice said. “I just can’t explain it any better than I felt at home. She was my safe place.”

Pipe said hospitals are still associated with the government forcibly removing children from Native American homes as a consequence of colonization. Her goal is to help give people a voice during their pregnancy and delivery.

Most of her clients can’t afford to pay for doula services out-of-pocket, Pipe said, so she doesn’t charge anything for her birth services, balancing her role as a doula with her day job at a post office.

“If a mom is vulnerable, she could miss a prenatal appointment or go alone, or I can take time off of work and take her myself,” Pipe said. “No mom should have to birth in fear.”

The new state law will allow her to get paid for her work as a doula for the first time.

In some states that have enacted such laws, initial participation by doulas was low because Medicaid reimbursement rates weren’t high enough. Nationally, doula reimbursement rates are improving, Chen said.

For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client.

But Chen said it is unclear how federal Medicaid cuts might affect the fate of these state laws.

Some states that haven’t passed doula reimbursement bills, including South Carolina, might be hesitant to do so in this environment, she said. “It’s just a really uncertain time.”

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Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials.

While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement.

“The pledge is not a mandate,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. “This is an opportunity for the industry to show itself.”

Oz said that insurance preapprovals for some procedures are appropriate, citing knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems that some studies suggest is performed too often. Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care.

The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer.

But health policy analysts say prior authorization — a system that forces some people to delay care or abandon treatment — may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments.

“So much of the prior authorization process is behind the black box,” said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Often, she said, patients aren’t even aware that they’re subject to prior authorization requirements until they face a denial.

“I’m not sure how this changes that,” Pestaina said.

The pledge from insurers follows the killing of UnitedHealthcare CEO Brian Thompson, who was shot in midtown Manhattan in early December on the way to an investor meeting, forcing the issue of prior authorization to the forefront.

Oz acknowledged “violence in the streets” prompted Monday’s announcement. Klomp told KFF Health News that insurers were reacting to the shooting because the problem has “reached a fever pitch.” Health insurance CEOs now move with security details wherever they go, Klomp said.

“There’s no question that health insurers have a reputation problem,” said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina.

The pledge shows that insurers are hoping to stave off “more draconian” legislation or regulation in the future, Hartwig said.

But government interventions to improve prior authorization will be used “if we’re forced to use them,” Oz said during the news conference.

“The administration has made it clear we’re not going to tolerate it anymore,” he said. “So either you fix it or we’re going to fix it.”

Here are the key takeaways for consumers:

1. Prior authorization isn’t going anywhere.

Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism that patients and providers level against insurance companies. And it isn’t clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment.

2. Reform efforts aren’t new.

Most states have already passed at least one law imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted “gold card” programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements.

Nationally, rules proposed by the first Trump administration and finalized by the Biden administration are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid.

Beyond that, some insurance companies committed to improvement long before Monday’s announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February.

3. Insurance companies are already supposed to be doing some of these things.

For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage.

But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term “non-approved requests” in Monday’s announcement.

Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is “a standard already in place.” But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds.

4. Health insurers will increasingly rely on artificial intelligence.

Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved.

The use of AI in making prior authorization decisions isn’t new — and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions “in real-time” by 2027.

“Artificial intelligence should help this tremendously,” Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference.

“But remember, artificial intelligence is only as good as what you put into it,” he added.

Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials.

5. Key details remain up in the air.

Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January.

He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn’t clear when that platform will be unveiled. The same holds true for “performance targets” that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them.

While the AMA, which represents doctors, applauded the announcement, “patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions,” the association’s president, Bobby Mukkamala, said in a statement. He noted that health insurers made “past promises” to improve prior authorization in 2018.

Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements.

Patient advocates are in the process of identifying “low-value codes,” Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules.

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Two years later, grueling rounds of chemotherapy have slowed the cancer’s progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant’s body and his quality of life.

Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.

Early this year, Tennant’s oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that’s when his family began fighting another adversary: their health insurer, which decided the treatment was “not medically necessary,” according to insurance paperwork.

Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they’ve never met who may lack relevant training.

Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by KFF Health News and NBC News found.

When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn’t cover it, they appealed the denial four times.

“It’s a big mess,” said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.

“There’s literally nothing we can do to get them to change,” she said in an April interview with KFF Health News. “They’re, like, not accountable to anyone.”

While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.

“You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment,” Pickern said. Yet, once the news cycle died down, “everything went back to the status quo.”

An Unintended Consequence of Health Reform?

Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.

The practice isn’t new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a 2024 U.S. Senate report. By denying costly care, companies pay less for health care expenses while still collecting premiums.

“At the end of the day, they’re a business and they exist to make money,” said Pickern, who wrote about the negative impacts of prior authorization on patient care for The American Journal of Managed Care.

For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.

But the use of prior authorization has also increased in recent years. That’s partly due to the growth of enrollment in Medicare Advantage plans, which rely heavily on prior authorization compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.

“But we can’t really prove this,” said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes KFF Health News. Health insurers haven’t been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.

Meanwhile, many states are looking to overhaul the prior authorization process.

In March, Virginia passed a law that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient’s provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.

And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.

Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.

These changes were supported by AHIP, a trade group that represents health insurers.

‘Sick With Little Recourse’

But the new federal rules won’t prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.

For some patients, the stakes couldn’t be higher.

On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It’s used to treat breast cancer but has shown promise in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.

But Schrift’s insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.

In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.

Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer’s decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.

“Never in a million years did I think I’d end up here,” Ekirch said, “sick with little recourse.”

Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, introduced a bill that would eliminate prior authorization altogether. But history suggests that would create new problems.

When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department’s costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General’s Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.

What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.

On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.

On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.

Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.

Hall said that after he was forced to “step down” to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company’s coverage limits set his recovery back by months — and, ironically, cost the insurer more. His wife, Julie, estimated Jeff’s medical bills have exceeded $5 million, and most of his care has been covered by his insurer.

“Getting better is not always the goal of an insurance company. It’s a business,” Jeff Hall said. “They don’t care.”

In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands “it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment.” He encouraged members affected by coverage limits to contact their health care providers to “explore service and treatment options.”

A ‘Rare and Exceptional’ Reversal

Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric’s prognosis.

They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.

As a safety instructor with the West Virginia Office of Miners’ Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia’s Public Employees Insurance Agency.

As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer’s decision in March, citing that histotripsy is “unproven in this case and is not medically necessary.”

None of their appeals worked. After KFF Health News and NBC News reached out to West Virginia’s Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.

“This decision reflects a rare and exceptional situation” and does not represent a change in the Public Employees Insurance Agency’s overall coverage policies,” Director Brent Wolfingbarger said in a prepared statement to KFF Health News.

In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with “anyone navigating through life-threatening care decisions.”

“Currently, there is no evidence that histotripsy is as effective as alternative treatment options available,” he said in late May, after the earlier insurance denials were reversed, “and its impact on survival or cancer recurrence is unknown.”

MES Peer Review Services did not respond to a request for an interview.

Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.

Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband’s insurance plan for wasting months of their time.

“Time is precious,” she said. “They know he has stage 4 cancer, and it’s almost like they don’t care if he lives or dies.”

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

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

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

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“I’ve struggled with my weight for so long,” said Campbell, 40, a single mother of two. “I’m not opposed to trying anything.”

In early April, about four weeks after she’d started taking Wegovy, Campbell said she hadn’t experienced any side effects, such as nausea or bowel irritation. But she doesn’t use a scale at home, she said, so she didn’t know whether she’d lost any weight since her most recent medical appointment earlier this year, when she weighed 314 pounds. Still, she was confident about achieving weight loss.

“It’s going to work because I’m putting in the work. I’m changing my eating habits. I’m exercising,” said Campbell, a shipping manager at a Michaels store. “I’m not going to second-guess myself.”

Wegovy belongs to a pricey class of drugs called GLP-1s (short for glucagon-like peptide-1 agonists) that have upended the treatment of obesity in recent years, offering hope to patients who have tried and failed to lose weight in myriad other ways.

Campbell gained access to Wegovy through South Carolina Medicaid’s decision in late 2024 to cover these weight loss drugs. But the medications remain out of reach for millions of patients across the country who could benefit from them, because many public and private health insurers have deemed the drugs too expensive.

A report published in November by KFF, a health information nonprofit that includes KFF Health News, found only 13 states were covering GLP-1s for the treatment of obesity for Medicaid beneficiaries as of August. South Carolina became the 14th in November.

Liz Williams, one of the report’s authors and a senior policy manager for the Program on Medicaid and the Uninsured at KFF, said she was not aware of any other state Medicaid programs joining the list since then. Looking ahead, the remaining states may be reluctant to add a new, expensive drug benefit while they brace for potential federal cuts coming from Congress, she said.

“As the budget debate, federally, is developing, that may impact how states are thinking about this,” Williams said.

The federal government won’t be helping anytime soon, either. Medicare covers GLP-1s to treat diabetes and some other health conditions, including obstructive sleep apnea and cardiovascular disease, but not obesity. In early April, the Trump administration announced it will not finalize a rule proposed by the Biden administration that would have allowed an estimated 7.4 million people covered by Medicare and Medicaid to access GLP-1s for weight loss. Meanwhile, the FDA is poised to force less expensive, compounded versions of these drugs off the market.

And the barrier to entry remains high, even for Medicaid patients in those few states that have agreed to cover the drugs without a federal mandate.

Case in point: In South Carolina, where more than one-third of all adults, and nearly half of the African American population, qualify as obese, the state Medicaid agency estimates only 1,300 beneficiaries will meet the stringent prerequisites for GLP-1 coverage.

Under one of those requirements, Medicaid beneficiaries who wish to access these drugs to lose weight must attest to “increased exercise activity,” said Jeff Leieritz, a spokesperson for the South Carolina Department of Health and Human Services.

Campbell, who is insured by Medicaid, was granted coverage for Wegovy based on her body mass index. First, though, she was required to submit six months’ worth of documentation proving that she’d tried and failed to lose weight after receiving nutrition counseling and going on a 1,200-calorie-a day diet, said Kenneth Mitchell, one of Campbell’s doctors and the medical director for bariatric surgery and obesity medicine at Roper St. Francis Healthcare.

Campbell’s Wegovy prescription was approved for six months, Mitchell said. When that authorization expires, Campbell and her health care team will need to submit more documentation, including proof that she has lost at least 5% of her body weight and has kept up with nutrition counseling.

“It’s not just, ‘Send a prescription in and they cover it.’ It’s rather arduous,” Mitchell said. “Not a lot of folks are going to do this.”

Mitchell said South Carolina Medicaid’s decision to cover these drugs was met with excitement among those working in his medical specialty. But he wasn’t surprised that the state anticipates relatively few people will access this benefit annually, since the approval process is so rigorous and the cost high. “The problem is the medicines are so expensive,” Mitchell said.

Novo Nordisk, which manufactures Wegovy, announced in March that it was cutting the monthly price for the drug from $650 to $499 for cash-paying customers. The price that health insurance plans and beneficiaries pay for these drugs varies, but some GLP-1s cost more than $1,000 per patient per month, Mitchell said, and many people will need to take them for the rest of their lives to maintain weight loss.

“That is a tremendous price tag that someone has to foot the bill for,” Mitchell said.

That’s the reason California Gov. Gavin Newsom on May 14 proposed eliminating Medicaid coverage of GLP-1s for weight loss starting Jan. 1, to save an estimated $680 million a year by 2028.

And the North Carolina State Health Plan Board of Trustees voted last year to end coverage of GLP-1s for state employees, after then-North Carolina Treasurer Dale Folwell’s office estimated in 2023 that the drugs were projected to cost the State Health Plan $1 billion over the next six years. The decision came only a few months after a separate North Carolina agency announced it would start covering these drugs for Medicaid beneficiaries. North Carolina Medicaid has estimated it will spend $16 million a year on GLP-1s.

South Carolina Medicaid, which insures fewer than half the number of people enrolled in North Carolina Medicaid, anticipates spending less. Leieritz estimated GLP-1s and nutrition counseling offered to Medicaid beneficiaries in South Carolina will cost $10 million a year. State funding will cover $3.3 million of the expense; the remainder will be paid for by matching Medicaid funds from the federal government.

In a recent interview, Health and Human Services Secretary Robert F. Kennedy Jr. didn’t rule out the possibility that Medicare and Medicaid might cover GLP-1s for obesity treatment in the future as costs come down.

They’re “extraordinary drugs” and “we’re going to reduce the cost,” Kennedy told CBS News in early April. He said he would like GLP-1s to eventually be made available to Medicare and Medicaid patients who are seeking obesity treatment after they have tried other ways to lose weight. “That is the framework that we’re now debating.”

Meanwhile, public health experts have applauded South Carolina Medicaid’s decision to cover GLP-1s. Yet the new benefit won’t help the vast majority of the 1.5 million adults in South Carolina who are classified as obese, according to data published by the South Carolina Department of Public Health.

“We still have some work to do,” acknowledged Brannon Traxler, the public health department’s chief medical officer.

But the state’s new “Action Plan for Healthy Eating and Active Living,” written by a coalition of groups in South Carolina, including the Department of Public Health, makes no mention of GLP-1s or the role they might play in lowering obesity rates in the state.

The action plan, underwritten by a $1.5 million federal grant, isn’t meant to lay out an overarching approach for lowering obesity in South Carolina, Traxler said. Instead, it promotes physical activity in schools, nutrition, and the expansion of outdoor walking trails, among other strategies. A more comprehensive obesity plan might address the benefits of surgical intervention and GLP-1s, but those also carry risk, expense, and side effects, Traxler said.

“Certainly, I think, there is a need to bring it all together,” she said.

Campbell, for one, is taking the comprehensive approach. On top of injecting Wegovy once weekly, she said, she is prioritizing protein intake and moving her body. She also underwent weight loss surgery in late April.

“Weight loss is my biggest goal,” said Campbell, who expressed appreciation for Medicaid’s coverage of Wegovy. “It’s one more thing that’s going to help me get to my goal.”

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

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The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn’t had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They’d tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken’s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that’s not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, “How did this happen?” They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. “Surely this is a misunderstanding.”

But their insurer sided with UI Health’s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois decided that “the labs were billed correctly as diagnostic.”

Under the plan’s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken’s bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.”

“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.

Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

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The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA’s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”

The Resolution

After the insurer denied their appeal, they “fell down a hole into despair about it for a while,” Aiken said.

“And then someone really wise was like, ‘You can pay it and then just stop thinking about it.’”

So that’s what Aiken did: “I put it on my credit card.”

UI Health’s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

“However, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost sharing,” she said. “In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they’d incur another large bill.

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it’s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

“Get vaccinated,” Hicks said. “We just do not have the same tools for many other cancers.”

Keep in mind that your coverage may vary — some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown’s Corlette said, “then we all potentially lose access to free, high-value preventive care, and that would be a real shame.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they’re on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.

“I don’t feel like I am the person I was a year and a half ago,” said Ekirch, who was on the cusp of launching her law career, before getting sick. “Like, my body isn’t my own.”

Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain. But Ekirch’s insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.

Patients with Ekirch’s condition don’t always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.

“I’m paying a lot of money for health insurance,” said Ekirch, who pays more than $600 a month in premiums. “I don’t understand why they won’t help me, why my life means so little to them.”

For patient advocates and health economists, cases like Ekirch’s illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.

The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient’s health insurance company before proceeding with a drug, treatment, or medical procedure.

The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven’t been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Yet it’s widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.

Some insurers’ efforts to improve prior authorization practices aren’t as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.

“When you really dive deep,” he said, these improvements don’t seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. “When we started looking into it,” he said, “it was almost a PR stunt.”

The ‘Tipping Point’

When Arman Shahriar’s father was diagnosed with follicular lymphoma in 2023, his father’s oncologist ordered a whole-body PET scan to determine the cancer’s stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.

Shahriar, an internal medicine resident, said he spent hours on the phone with his father’s insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father’s scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.

EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is “actively developing new ways to make the submission process simpler and faster for physicians,” Ziomek said.

In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of “artificially creating problems in people’s lives” at the wrong time.

“If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can’t,” said Shahriar, who wrote about his father’s case in an essay published last year by JAMA Oncology. “We’re kind of reaching a tipping point where we’re realizing, collectively, something needs to be done.”

The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.

An Emerson College poll conducted in mid-December found 41% of 18- to 29-year-olds thought the actions of Thompson’s killer were at least somewhat acceptable. In a NORC survey from the University of Chicago conducted in December, two-thirds of respondents indicated that insurance company profits, and their denials for health care coverage, contributed “a great deal/moderate amount” to the killing. Instagram accounts established in support of Luigi Mangione, the 26-year-old Maryland suspect accused of murder and terrorism, have attracted thousands of followers.

“The past several weeks have further challenged us to even more intensely listen to the public narrative about our industry,” Cigna Group CEO David Cordani said during an earnings call on Jan. 30. Cigna is focused on “making prior authorizations faster and simpler,” he added.

The first Trump administration and the Biden administration put forth policies designed to improve prior authorization for some patients by mandating that insurers set up electronic systems and shortening the time companies may take to issue decisions, among other fixes. Hundreds of House Democrats and Republicans signed on to co-sponsor a bill last year that would establish new prior authorization rules for Medicare Advantage plans. In January, Republican congressman Jefferson Van Drew of New Jersey introduced a federal bill to abolish the use of prior authorization altogether.

Meanwhile, many states have passed legislation to regulate the use of prior authorization. Some laws require insurers to publish data about prior authorization denials with the intention of making a confusing system more transparent. Reform bills are under consideration by state legislatures in Hawaii, Montana, and elsewhere. A bill in Virginia approved by the governor March 18 takes effect July 1. Other states, including Texas, have established “gold card” programs that ease prior authorization requirements for some physicians by allowing doctors with a track record of approvals to bypass the rules.

No one from AHIP, an insurance industry lobbying group formerly known as America’s Health Insurance Plans, was available to be interviewed on the record about proposed prior authorization legislation for this article.

But changes wouldn’t guarantee that the most vulnerable patients would be spared from future insurance denials or the complex appeals process set up by insurers. Some doctors and advocates for patients are skeptical that prior authorization can be fixed as long as insurers are accountable to shareholders.

Kindyl Boyer, director of advocacy for the nonprofit Infusion Access Foundation, remains hopeful the system can be improved but likened some efforts to playing “Whac-A-Mole.” Ultimately, insurance companies are “going to find a different way to make more money,” she said.

‘Unified Anger’

In the weeks following Thompson’s killing, UnitedHealthcare was trying to refute an onslaught of what it called “highly inaccurate and grossly misleading information” about its practices when another incident landed the company back in the spotlight.

On Jan. 7, Elisabeth Potter, a breast reconstruction surgeon in Austin, Texas, posted a video on social media criticizing the company for questioning whether one of her patients who had been diagnosed with breast cancer and was undergoing surgery that day needed to be admitted as an inpatient.

The video amassed millions of views.

In the days following her post, UnitedHealthcare hired a high-profile law firm to demand a correction and public apology from Potter. In an interview with KFF Health News, Potter would not discuss details about the dispute, but she stood by what she said in her original video.

“I told the truth,” Potter said.

The facts of the incident remain in dispute. But the level of attention it received online illustrates how frustrated and vocal many people have become about insurance company tactics since Thompson’s killing, said Matthew Zachary, a former cancer patient and the host of “Out of Patients,” a podcast that aims to amplify the experiences of patients.

For years, doctors and patients have taken to social media to shame health insurers into approving treatment. But in recent months, Zachary said, “horror stories” about prior authorization shared widely online have created “unified anger.”

“Most people thought they were alone in the victimization,” Zachary said. “Now they know they’re not.”

Data published in January by KFF found that prior authorization is particularly burdensome for patients covered by Medicare Advantage plans. In 2023, virtually all Medicare Advantage enrollees were covered by plans that required prior authorization, while people enrolled in traditional Medicare were much less likely to encounter it, said Jeannie Fuglesten Biniek, an associate director at KFF’s Program on Medicare Policy. Furthermore, she said, Medicare Advantage enrollees were more likely to face prior authorization for higher-cost services, including inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

But Neil Parikh, national chief medical officer for medical management at UnitedHealthcare, explained prior authorization rules apply to fewer than 2% of the claims the company pays. He added that “99% of the time” UnitedHealthcare members don’t need prior authorization or requests are approved “very, very quickly.”

Recently, he said, a team at UnitedHealthcare was reviewing a prior authorization request for an orthopedic procedure when they discovered the surgeon planned to operate on the wrong side of the patient’s body. UnitedHealthcare caught the mistake in time, he recounted.

“This is a real-life example of why prior authorization can really help,” Parikh said.

Even so, he said, UnitedHealthcare aims to make the process less burdensome by removing prior authorization requirements for some services, rendering instant decisions for certain requests, and establishing a national gold card program, among other refinements. Cigna also announced changes designed to improve prior authorization in the months since Thompson’s killing.

“Brian was an incredible friend and colleague to many, many of us, and we are deeply saddened by his passing,” Parikh said. “It’s truly a sad occasion.”

The Final Denial

During the summer of 2023, Ekirch was working full time and preparing to take the bar exam when she noticed numbness and tingling in her arms and legs. Eventually, she started experiencing a burning sensation throughout her body.

That fall, a Richmond-area neurologist said her symptoms were consistent with small fiber neuropathy, and, in early 2024, a rheumatologist recommended IVIG to ease her pain. Since then, other specialists, including neurologists at the University of Virginia and Virginia Commonwealth University, have said she may benefit from the same treatment.

There’s no guarantee it will work. A randomized controlled trial published in 2021 found pain levels in patients who received IVIG weren’t significantly different from the placebo group, while an older study found patients responded “remarkably well.”

“It’s hard because I look at my peers from law school and high school — they’re having families, excelling in their career, living their life. And most days I am just struggling, just to get out of bed,” said Ekirch, frustrated that Anthem continues to deny her claim.

In a prepared statement, Kersha Cartwright, a spokesperson for Anthem’s parent company, Elevance Health, said Ekirch’s request for IVIG treatment was denied “because it did not meet the established medical criteria for effectiveness in treating small fiber neuropathy.”

On Feb. 17, her treatment was denied by Anthem for the final time. Ekirch said her patient advocate, a nurse who works for Anthem, suggested she reach out to the drug manufacturer about patient charity programs.

“This is absolutely crazy,” Ekirch said. “This is someone from Anthem telling me to plead with a pharmacy company to give me this drug when Anthem should be covering it.”

Her only hope now lies with the Virginia State Corporation Commission Bureau of Insurance, a state agency that resolves prior authorization disputes between patients and health insurance companies. She found out through a Facebook group for patients with small fiber neuropathy that the Bureau of Insurance has overturned an IVIG denial before. In late March, Ekirch was anxiously waiting to hear the agency’s decision about her case.

“I don’t want to get my hopes up too much, though,” she said. “I feel like this entire process, I’ve been let down by it.”

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“Patients who speak Spanish really prefer a Spanish-speaking provider,” Deem said. “I’ve gotten to know this community pretty well.”

Clemson doesn’t operate an academic medical center, nor does it run a medical school. Arguably, the public university is best known for its football program. Yet, with millions of dollars earmarked from the state legislature, it has expanded into delivering health care, with clinics in Walhalla and beyond. School leaders are attempting to address gaps in rural and underserved parts of a state where health outcomes routinely rank among the worst in the country.

“Some of these communities have such high need,” said Ron Gimbel, director of Clemson Rural Health, which operates four clinics and a fleet of mobile health units as part of the university’s College of Behavioral, Social and Health Sciences. “They have so many barriers that impact their ability to be healthy.”

Clemson Rural Health is one of several programs attempting to meet this need in the state.

“Rural health is trendy,” said Graham Adams, CEO of the South Carolina Office of Rural Health.

State lawmakers nationwide are spending millions of dollars to address a rural health care crisis long in the making. For more than a decade, though, Republican-controlled legislatures in most Southern states have refused billions in federal funds that would provide public health insurance coverage to more low-income adults. These are the same states where racial health disparities and health outcomes are often worse than in other regions.

Nearly every state has extended Medicaid coverage for women in the months after they give birth. But 10 states haven’t fully expanded Medicaid coverage with federal money made available under the 2010 Affordable Care Act. Seven of these states — Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas — are in the South. With few exceptions, adults without children in these states don’t qualify for Medicaid coverage, regardless of their income level.

Georgia Gov. Brian Kemp and South Carolina Gov. Henry McMaster, both Republicans, recently announced plans to expand Medicaid in limited ways to include some parents. The South Carolina plan would impose work requirements on some of these newly eligible Medicaid beneficiaries, while the Georgia plan would allow some parents of young children to skirt the state’s existing Medicaid work rules. Both plans require federal approval.

Jonathan Oberlander, a professor and health policy scholar at the University of North Carolina, said he doesn’t expect to see any of the remaining states rushing to fully expand Medicaid. Before Donald Trump took office on Jan. 20, Republicans in Washington had already expressed their intention to dramatically cut spending for Medicaid, which covers 72 million people at a cost of nearly $900 billion.

“There’s a large gray cloud hanging over Medicaid expansion right now, and that’s because there’s so much uncertainty about what the Trump administration and congressional Republicans are going to do,” Oberlander said.

Even so, in South Carolina this year the advocacy group CoverSC plans to lobby the General Assembly to pass a bill to adopt Medicaid expansion, said Beth Johnson, regional government relations director for the American Cancer Society Cancer Action Network and a CoverSC board member. The state’s legislative session began Jan. 14.

If such a measure were approved, the federal government would cover 90% of the state’s Medicaid expansion costs and South Carolina would be expected to pay 10%, or an estimated $270 million during the first year, according to a 2024 report by the Milken Institute School of Public Health at George Washington University.

Across all 10 non-expansion states — which, outside the South, also include Kansas, Wisconsin, and Wyoming — about 1.5 million people fall into a coverage gap, according to 2024 estimates from KFF, the health information nonprofit that includes KFF Health News. That means they do not qualify for Medicaid coverage or financial assistance to buy insurance through the federal marketplace.

Many of the people who would qualify for Medicaid if these states were to expand eligibility are gig workers, Johnson said. They play music, drive for Uber, or deliver pizza, and they typically don’t qualify for health insurance through their jobs.

“They are providing services that we all appreciate,” she said. “And they simply can’t afford health insurance.”

In some South Carolina communities, Clemson Rural Health attempts to fill this gap by providing primary care, cancer screenings, nutrition education, and diabetes management for uninsured patients free of charge or at reduced rates. Only about half of the patients seen by Clemson Rural Health have health insurance, Gimbel said, compared with 92% of the U.S. population.

During the current state fiscal year, Clemson Rural Health has been underwritten by a $2.5 million contract, its largest source of funding, from the state Department of Health and Human Services, which administers Medicaid in South Carolina and operates with a budget approved by state lawmakers.

That’s a relatively small amount of money compared with the $47.5 million the state legislature has given to the Medical University of South Carolina in recent years to move into rural communities. MUSC has served Charleston for most of its 200-year history, but since 2019 it has expanded across the state by purchasing, building, or partnering with seven rural hospitals — some on the brink of closure — and one freestanding emergency department. MUSC is set to open an additional rural hospital this year.

Other states have made similar investments. The University of Georgia, for example, has established a new medical school, partly to send more physicians into underserved and rural areas. The Georgia General Assembly kicked in half the cost of a new $100 million building for medical education and research in Athens.

Meanwhile, the Tennessee General Assembly passed a budget last year that included $81 million for a variety of rural health initiatives.

Outside the South, state legislatures in Colorado, Nevada, West Virginia, and elsewhere have made recent investments in rural health, in addition to expanding Medicaid eligibility.

Some of this spending has been prompted by a wave of rural hospital closures — more than 100 since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

It’s not yet clear what long-term impact some of these initiatives will have — for instance, whether the Clemson program will “reduce premature mortality, decrease preventable hospitalizations, and improve overall quality of life,” as it aims to do, according to its website. Some public health experts point out that bolstering the number of rural clinics, hospitals, and doctors in the South won’t matter much if patients can’t afford to make an appointment.

“Lack of ability to pay is one of the greatest barriers,” said Adams, the Office of Rural Health chief.

Oberlander said conservative lawmakers often consider projects such as building new rural clinics more politically palatable than expanding Medicaid coverage.

“The further away you get from the ACA, the less polarized the politics of health care,” he said.

South Carolina Senate President Thomas Alexander, a Republican who lives in Walhalla, said the General Assembly is willing to invest in some rural health initiatives to improve health care access.

“Just because you expand Medicaid doesn’t mean you’ve expanded access to the services,” Alexander said. “I want to focus on expanding access to the services.”

Gimbel would not comment on Medicaid expansion in South Carolina, and he said it’s too soon to know how federal Medicaid changes under the Trump administration might affect funding for Clemson Rural Health, which currently receives money from the state’s Medicaid agency. But making the Clemson program financially solvent might take several more years, he said.“If rural health was profitable,” he said, “we wouldn’t have a rural health problem.”

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

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