Bre Dolan, a 35-year-old resident of Hardy County, West Virginia, understands why. Throughout her childhood, when her dad had addiction and mental health crises, police officers were often the first ones to respond. Dolan calls them “good men and women” who “care about seeing their community recover.”

But she’s skeptical that they can mitigate the root causes of an addiction epidemic that has racked her home state for decades.

“Most of the busts that go down are addicts,” she said — people who need treatment, not prison.

Dolan’s father was one of them. And so was she.

Now 14 years into recovery, she’s been surprised to see many local officials spending opioid settlement money — an influx of cash from companies accused of fueling the overdose crisis — on police Tasers, cruisers, night vision gear, and more.

“How is that really tackling an issue?” Dolan said. “How will it help families battling addiction?”

Nationwide, more than $61 million in opioid settlement funds were spent on law enforcement-related efforts in 2024, according to a yearlong investigation by KFF Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction. That included initiatives that public health experts largely support, such as hiring social workers to accompany officers on overdose calls, as well as actions they’re more skeptical of, such as beefing up police arsenals.

Over nearly two decades, state and local governments are set to receive more than $50 billion in opioid settlement money, which is intended to be used to fight addiction. The settlement agreements even outlined suggested uses and established other guardrails to limit unrelated uses of the funds — as happened with the Tobacco Master Settlement Agreement of the 1990s.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

To Stephen Loyd, an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits, some law enforcement expenses fall into that second category.

Drones and police officer salaries are not “in the spirit of what we wanted to use the money for when we were fighting for it,” Loyd said.

“People died for this money. Families were torn apart for this money. And to not spend it to try to make our system better, so that people don’t have to experience those losses going forward, to me, is unconscionable,” he said.

As part of this investigation, KFF Health News and its partners compiled the most comprehensive national database of opioid settlement spending to date, featuring more than 10,500 examples of how the money was used (or not) last year. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories, such as treatment or prevention. The findings include:

• Nearly $2.7 billion — that’s the amount states and localities spent or committed in 2024, according to public records. The lion’s share went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement initiatives — such as creating a shooting range and tinting patrol car windows — and prevention programs that experts called questionable, such as putting on a fishing tournament.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including the expenditures and untrackable percentages, should not be compared with the one KFF Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract the secrecy among some of those in charge of settlement money and confusion among those tracking it.

‘How My Population Would Like Me To Vote’

Dolan has seen intergenerational addiction up close. When her father was high, he sometimes kicked teenage Dolan out of the house with her toddler siblings. She started drinking early and progressed to other drugs, eventually landing in prison.

Although she managed to find recovery on her own, even landing a job as an EMT, she wants to make the path easier for others.

If settlement money were used to hire social workers or build family recovery programs, it could change the course of a kid’s life, she said.

“Maybe people could have helped my dad get into recovery and gave him therapy,” she said. “Anything could have happened.”

But many local officials say law enforcement is one of the few tools they have, especially in rural areas. And their constituents believe it’s effective.

“If the goal was treatment and prevention, it would have been better to throw [the money] into a big grant system and give it to treatment centers,” said Cris Meadows, city manager of Oak Hill, West Virginia, which paid more than $67,000 for a drone and surveillance cameras for its police department. “Unfortunately, local governments are really not set up to do that.”

Clarkdale, Arizona, Town Manager Susan Guthrie said her town bought nearly $15,000 worth of drones because they help with enforcement — such as recording crime scenes and conducting search-and-rescue operations — as well as education, when officers interact with kids at community events.

Similar perspectives nationwide have led to spending that includes:

• About $12,000 for rifle suppressors (also known as silencers) in Alexandria, Indiana.
• About $21,000 for Tasers in Mooresville, Indiana.
• About $49,000 to replace outdated body cameras and Tasers in Hardy County, West Virginia.
• Nearly $70,000 in Lewisburg, West Virginia, to add a police officer to the county’s drug task force, replace that officer locally, buy guns and vehicles, and tint car windows.

Several elected officials said their choices reflect local politics.

That’s “how my population would like me to vote,” Hardy County Commissioner Steven Schetrom said of his commission’s goal to spend about a quarter of its settlement money on law enforcement.

Mooresville Town Council President Tom Warthen told KFF Health News, “People have petitioned our government for less taxes but have never petitioned for less services” from the local police force. With federal and state budget cuts looming, the town must be resourceful, he said, adding that the Tasers were bought with a portion of settlement funds that have no restrictions.

After these purchases, an Indiana commission issued a list of law enforcement equipment that it cautioned against buying with restricted settlement dollars. California, Kansas, and Virginia have released similar lists.

Research backs those restrictions. Studies have shown that drug busts and arrests can exacerbate the overdose crisis. Officers responding to overdoses often arrest people, making people who use drugs fearful of calling 911 or seeking treatment through police.

In contrast, equipping police officers with overdose reversal medications has been shown to save lives. That’s a key component of an $18 million effort in Texas, the state with the highest percentage of reported law enforcement spending.

Police and Firefighter Salaries

Some places used settlement funds to maintain basic first responder services.

For example, Mantua Township, New Jersey, used about $79,000 to “offset police salary and wages” and, according to its public spending report, plans to do so annually. Township officials did not respond to requests for comment.

Los Angeles County allocated $1 million to cover a portion of firefighter salaries and benefits last year and estimates it will use another $1 million this year.

County fire department spokesperson Heidi Oliva said opioid funds were used to fill a budget gap until revenue kicked in from a new tax voters approved last November.

The use of funds was “appropriate,” she said in an email, because “the opioid crisis presents a significant burden to EMS response, from dispatch through arrival at hospitals, clinician mental health/burnout, and a variety of other factors.”

Using opioid money to replace other revenue is legal in most places. But it’s considered bad practice.

“I don’t want to see this money used to make up for stuff that would be paid for anyway,” said Daniel Busch, chair of the FED UP! Coalition, a national advocacy organization representing many parents who’ve lost children to addiction.

Settlement dollars are “the only financial representation from the governments and from the drug companies” of families’ losses, Busch said. To see that money used to maintain the status quo is “painful” and “distressing.”

Busch fears this practice will become more common as states grapple with federal budget cuts.

Already in New Jersey, lawmakers allocated $45 million in settlement funds to health systems to cushion against anticipated Medicaid losses — a move opposed by the state’s attorney general, opioid settlement advisory council, and advocates.

However, some states are taking proactive steps.

Colorado released guidance this year against such actions.

“These dollars can’t be part of budget games where we simply backfill existing programs,” state Attorney General Phil Weiser told KFF Health News. “We have to build on whatever we’re doing because it hasn’t been enough.”

Other states, such as Maine, Maryland, and Kentucky, are newly requiring local governments to report how they spend the money, which may make it easier to spot disputed practices. Officials in Delaware, Hawaii, Massachusetts, and Missouri said they expect to revamp their public reporting systems to increase transparency by early 2026.

In Mississippi, which produced no substantive public reports last year, the attorney general’s office has set up a website that will host spending information after Dec. 1.

Jennifer Twyman is anxious to see some positive changes.

“We have people literally dying on our sidewalks,” said the Louisville, Kentucky, advocate.

Twyman struggled with opioid misuse for 20 years and now works with Vocal-KY to end homelessness and the war on drugs. To her, any spending that doesn’t directly help people with addiction betrays the settlement’s purpose.

“It is the blood from many of my friends, people that I care deeply about,” she said. “That money could have been me, could have been my life.”

Read the methodology behind this project.

KFF Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

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.

USE OUR CONTENT

This story can be republished for free (details).

In many cases, this type of community event would be unremarkable. But Irvington’s concerts stood out for their funding source: settlement money from companies accused of fueling the opioid overdose crisis.

As part of national settlements, more than a dozen companies that sold prescription painkillers are expected to pay state and local governments upward of $50 billion over nearly two decades. Governments are supposed to spend most of the windfall combating addiction. Officials who negotiated the settlements even outlined suggested uses and established other guardrails to avoid a repeat of the Tobacco Master Settlement Agreement of the 1990s, from which paltry amounts went to anti-smoking programs.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

In Irvington, township officials said they used the money appropriately because the concerts reduced stigma around addiction and connected people to treatment. But acting state Comptroller Kevin Walsh called the concerts a “waste” and “misuse” of the settlements, which resulted from the overdose deaths of hundreds of thousands of Americans.

Similar disputes are intensifying nationwide as officials begin spending settlement money in earnest — all while grappling with slashed federal grants and looming cuts to Medicaid, the state-federal public insurance program that is the largest payer for addiction treatment.

To shed light on these discussions, KFF Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction, conducted a yearlong effort to document settlement spending in 2024. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories such as treatment or prevention.

The result is a database of more than 10,500 ways settlement cash was used (or not) last year — the most comprehensive national resource of its kind. Some highlights include:

• States and localities spent or committed nearly $2.7 billion in 2024, according to public records. The bulk went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement gear, such as night vision equipment, and prevention efforts that experts called questionable, such as hiring a drug awareness magician.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including expenditures and untrackable percentages, should not be compared with the one KFF Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract a tendency toward secrecy among some of those in charge of settlement money and confusion among people trying to track it.

More than $237 million — about 9% of all trackable spending in 2024 — went to efforts broadly aimed at preventing addiction, according to public records. These ranged from putting on community awareness events, like the concerts in Irvington, to hiring mental health counselors in schools.

Many of the examples raised red flags for researchers, including:

• Suffield, Connecticut, held a 1950s-style sock hop, at which kids and seniors wore poodle skirts, posed with inflatable guitars, and pledged to remain drug-free.
• Vernon, Connecticut, hosted a mixed martial arts demonstration, at which a fighter spoke about his experience with addiction.
• Hardy County, West Virginia, spent $60,000 to repair a school track.

“There is no evidence” to back those efforts, said Linda Richter, who leads prevention-oriented research at the nonprofit Partnership to End Addiction.

Elected officials like the events because “you can announce to the community that you did something,” she said. But unless they’re part of larger initiatives that incorporate other approaches, such as screening students for mental health concerns or supporting parents struggling with addiction, they’re unlikely to have lasting impact.

And when settlement funds pay for those one-offs, there’s less left for strategies “that we do know work,” Richter added.

School assembly speakers were also popular, with three Connecticut towns spending more than $30,000 total for former Boston Celtic Chris Herren to share his addiction story with students.

“You get 1,200 kids in the gym and you can hear a pin drop when he talks,” said Joe Kobza, superintendent of schools in Monroe. He described Herren’s talks to students and parents as “pretty impactful.”

But emotional impact isn’t necessarily effective, Richter said. Speakers often talk about drugs messing up their lives even though they’ve become wealthy celebrities. “The messages are so mixed,” she said.

Many local officials admitted their spending decisions weren’t evidence-based. But they meant well, they said. And they received little to no guidance on how to use the money.

Kelly Giannuzzi, Suffield’s former director of youth services, who organized the sock hop, said the goal was to raise awareness and combat loneliness.

Hardy County Commissioner Steven Schetrom said spending money on track repairs made sense, since he’d seen the positive impact the sport had on his son’s life. He wanted other kids to have the same opportunity.

David Owens, a spokesperson for Vernon, said the town’s mixed martial arts event was the kickoff to an ongoing campaign, meant to show people that athletics can help them build connections and avoid drugs. The event brought out young men, who are often difficult to reach, he said.

But the town has no way of knowing if the event had lasting traction.

In New Jersey, acting Comptroller Walsh released a report this summer calling on Irvington township officials to repay the settlement money spent on the concerts.

“If they’re going to hold big parties, that’s up to them and the taxpayers,” Walsh told KFF Health News. “But they can’t use opioid money for that.”

He also suggested the concerts were political rallies for the mayor, Tony Vauss.

Irvington officials strongly objected to the report and unsuccessfully sued Walsh to try to block its release. Vauss told KFF Health News it was “misleading and flat-out wrong.”

Vauss said the township distributed overdose reversal medications at the concerts and spread messages about seeking help. At least four people sought treatment on-site, the township said in its lawsuit.

“We felt as though we did everything correctly,” Vauss said.

However, some of the research Irvington cited in the lawsuit to support its case appeared irrelevant, such as a study in rural Ghana and a graduate thesis.

Irvington officials did not respond to questions about those citations.

As this dispute — and others like it nationwide — continue, people affected by the crisis say it’s crucial to remember the moral weight of these settlements.

It’s “blood money,” said Stephen Loyd, an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits.

He’s seen many family members lose parents, children, and siblings.

“I don’t know how I would look a family in the face” if this money isn’t used to prevent more losses, he said.

Read the methodology behind this project.

KFF Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

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.

USE OUR CONTENT

This story can be republished for free (details).

A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine whether care is medically necessary — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the No Surprises Act, which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for any care needed in a nursing home if the patient was not first formally admitted to a hospital for at least three days.

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is stable enough to travel to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient to sign a consent form, agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

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!

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.

USE OUR CONTENT

This story can be republished for free (details).

Se había atendido en la sala de emergencias del hospital sin fines de lucro Montrose Regional Health en 2020, pero no recordaba que le hubieran llegado facturas por atención médica.

Por eso se sorprendió cuando, tres años después, su empleador recibió una orden judicial para que le retuviera parte de su salario y comenzara a derivarlo a una agencia de cobro por una factura médica impaga de $881 que, con intereses y costos judiciales, ya sumaba $1.155,26.

El momento no podía ser peor. Luego de salir de un matrimonio problemático y vivir en un refugio, Knoll había conseguido la custodia total de sus tres hijos, una vivienda estable en Montrose, Colorado, y un trabajo en una gasolinera.

“Y justo en ese momento recibí la orden de embargo del tribunal”, contó. “Fue aterrador. Nunca había estado sola ni había criado a mis hijos sola”.

KFF Health News revisó 1.200 casos —registrados en Colorado entre el 1 de febrero de 2022 y el 1 de febrero de 2024— en los que la justicia había   autorizado embargar sueldos por deudas impagas. Al menos el 30% de esos casos estaban relacionados con servicios médicos, incluso cuando las facturas deberían haber sido cubiertas por Medicaid, el programa  de salud federal gerenciado por los estados para personas con bajos ingresos o discapacidades.

Ese 30% probablemente sea una subestimación, ya que muchas veces la deuda médica se oculta bajo otras formas de deuda, como tarjetas de crédito o adelantos de sueldos. Pero incluso esa cifra mínima equivaldría a unos 14.000 casos al año, en los que los tribunales aprueban embargos de sueldo por deudas médicas en Colorado.

Otros hallazgos

• Se persiguió a los pacientes por facturas médicas que iban desde menos de $30 hasta más de $30.000, y la mayoría era menor de $2.400. A medida que los casos avanzaban en el sistema judicial, acumulando intereses y costos legales, las deudas solían crecer en un 25%. En un caso, se multiplicó por más del 400%.
• Las personas podían ser embargadas hasta 14 años después de haber recibido atención médica, incluso si cambiaban de trabajo.
• Detrás del cobro de esas deudas hay todo tipo de proveedores médicos: grandes cadenas de salud, hospitales rurales pequeños, grupos de médicos, servicios públicos de ambulancia, entre otros. En varios casos, los hospitales obtuvieron autorización para embargar el salario de sus propios empleados por facturas pendientes de pago por haberse atendido en esas mismas instituciones.

Sin embargo, Colorado no es una excepción: es uno de los 45 estados que permiten el embargo de sueldos por deudas médicas. Solo Delaware, Nueva York, North Carolina, Pennsylvania y Texas lo prohíben.

Como ha informado KFF Health News, la deuda médica es devastadora para millones de personas en todo el país. Y es probable que el problema se agrave aún más a nivel nacional. Se prevé que millones pierdan su seguro médico en los próximos años debido a los cambios en Medicaid introducidos en la ley fiscal y de presupuesto del presidente Donald Trump y si el Congreso permite que expiren algunos subsidios de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Eso significa que, para quienes pierdan el seguro, la crisis de salud también podría convertirse en una espiral de deudas médicas

Y el daño perdurará: las grandes facturas médicas impagas seguirán apareciendo en los informes crediticios en la mayoría de los estados después de que, en julio, un juez federal anuló una nueva norma destinada a proteger a los consumidores.

“Si no puedes mantener tu salud, ¿cómo vas a trabajar para pagar una deuda?”, dijo Adam Fox, subdirector de Colorado Consumer Health Initiative, una organización sin fines de lucro cuyo objetivo es reducir los costos de atención médica. “Y si, básicamente, no puedes pagar la factura, el embargo de tu salario no te va a ayudar a hacerlo. Te va a poner en una situación financiera aún más difícil”.

A ciegas ante la deuda médica

Cuando una persona no paga una deuda, el acreedor —ya sea que deba la reparación de una puerta de garaje, un préstamo para comprar un auto o atención médica— puede llevarla a juicio. También puede vender la deuda a una agencia de cobro o a un comprador de deuda, que a su vez puede hacer lo mismo.

“En cualquier momento, alrededor del 1% de los adultos con empleo están siendo embargados por alguna razón”, dijo Anthony DeFusco, economista de la University of  Wisconsin-Madison, quien estudió datos de sueldos de ADP, una empresa que procesa las nóminas de alrededor del 20% de los trabajadores del sector privado en Estados Unidos. “Eso es una porción grande de la población”.

Sin embargo, hay pocos estudios específicos sobre la práctica de embargar salarios por deudas médicas. Estudios realizados en North Carolina, Virginia y Nueva York han demostrado que los hospitales sin fines de lucro frecuentemente embargan salarios y en muchos casos las personas afectadas tienen empleos de bajos ingresos.

Marty Makary, quien dirigió una investigación sobre este tema en Virginia desde la Johns Hopkins University, antes de unirse al gabinete de Trump como comisionado de la Administración de Alimentos y Medicamentos (FDA), calificó esta práctica como “agresiva”.

En un estudio que escribió con otros profesionales, Makary encontró que en 2017 el 36% de los hospitales en Virginia —la mayoría sin fines de lucro y en zonas urbanas— embargaban sueldos para cobrar deudas, afectando a miles de pacientes.

Sin embargo, los hallazgos de KFF Health News en Colorado muestran que los hospitales no son los únicos proveedores médicos que persiguen los cheques de pago de los pacientes.

Investigadores y defensores advierten que, además de la falta de datos en los tribunales, hay otro factor que oculta la magnitud del problema. “La gente siente vergüenza de tener deudas”, afirmó Lester Bird, gerente sénior de Pew Charitable Trusts, especialista en temas judiciales. “Todo esto ocurre en las sombras”.

Sin datos sobre la frecuencia de esta práctica, los legisladores están tomando decisiones a ciegas, aunque una encuesta de Associated Press-NORC en 2024 reveló que 4 de cada 5 adultos creen que el gobierno federal debería ayudar a aliviar la deuda médica.

Embargos imposibles

Colorado fue uno de los primeros 15 estados que eliminaron la deuda médica de los informes de crédito. Además, los compradores de deuda no pueden embargar la vivienda de un paciente. Si quienes reúnen los requisitos aceptan pagar en cuotas mensuales, los pagos no deberían superar el 6% de los ingresos familiares y la deuda restante se cancela después de unos tres años de pagos.

Pero si no aceptan un plan de pago, a los habitantes de Colorado se les puede embargar hasta el 20 % de sus ingresos disponibles. El National Consumer Law Center otorgó al estado una calificación “D” por la protección estatal de las finanzas familiares.

Grupos defensores dicen que no tienen certeza de que estas protecciones realmente se estén cumpliendo. Varias personas enviaron cartas a los tribunales advirtiendo que el embargo de salarios empeoraría su ya precaria situación financiera.

“Ya me estoy atrasando con el pago de la electricidad, el gas, el agua, las tarjetas de crédito”, escribió un hombre del oeste de Colorado en una carta a un juez, que KFF Health News obtuvo en los expedientes judiciales. Los registros muestran que trabajaba en construcción y en una tienda de alquiler con opción a compra y debía unos $8.000 por atención médica. Le dijo al juez que estaba pagando cerca de $1.000 al mes.

 “Si esto sigue así, voy a perderlo todo”, explicó.

Las personas demandadas que figuraban en la muestra se desempeñaban en muy diversos rubros: distritos escolares, ganadería, minería, construcción, gobiernos locales e incluso el propio sector de salud. Varias trabajaban en Walmart, Family Dollar, gasolineras, restaurantes o supermercados.

“Están golpeando a la gente cuando ya está en el suelo”, dijo Lois Lupica, exabogada de la organización Community Economic Defense Project, con sede en Denver, y del proyecto Debt Collection Lab de la Princeton University. “Básicamente están demandando a gente que no tiene ni un centavo para dar”.

En 2022, los tribunales autorizaron al sistema de salud Valley View, con sede en Glenwood Springs, a embargar el sueldo de una paciente por una factura médica de $400. La paciente trabajaba en una organización local que el sistema sanitario apoyaba como parte de los beneficios comunitarios que ofrece para mantener su estatus libre de impuestos.

Los hospitales sin fines de lucro como Valley View están obligados a proporcionar beneficios comunitarios, que pueden incluir atención gratuita que ayuda a cubrir las facturas médicas de los pacientes.

Stacey Gavrell, directora de relaciones comunitarias de Valley View, dijo que ofrecen opciones como planes de pago sin intereses y atención gratuita o con descuento para familias con ingresos de hasta el 500% del nivel federal de pobreza.

“Como el proveedor de salud más grande de nuestra región rural, es fundamental para la salud y el bienestar de nuestra comunidad que Valley View siga siendo financieramente viable”, señaló. “La mayoría de nuestros pacientes trabajan con nosotros para desarrollar un plan de pago o solicitan asistencia financiera”.

La agencia de cobro que llevó a juicio a esa trabajadora, A-1 Collection Agency, se presenta en su sitio web como empática: “Entendemos que los tiempos son difíciles y el dinero escasea”.

Pilar Mank, encargada de operaciones de Healthcare Management —la empresa matriz de A-1— dijo que aceptan pagos desde $50 dólares mensuales y que la mayoría de los hospitales con los que trabajan permiten ofrecer un descuento si el paciente abona todo de una vez.

“Demandar a un paciente es absolutamente el último recurso”, afirmó. “Hacemos todo lo posible para trabajar con ellos”.

En algunas ocasiones, los hospitales embargan el salario de sus propios empleados por atención médica recibida en la misma institución. En un caso, una trabajadora del hospital pasó de ser empleada de limpieza a registradora y luego analista de calidad. Incluso participó en eventos públicos representando a su empleador y apareció en el sitio web del hospital como empleada destacada. Aun así, los tribunales emitieron órdenes de embargo hasta que pagó su deuda médica de $10.000.

“El cuidado hospitalario cuesta dinero”, argumentó Julie Lonborg, vocera de la Colorado Hospital Association, sobre esta práctica. “En cierto modo, me parece gracioso que nos hagan esta pregunta. Entendería si alguien preguntara: ‘¿Por qué no están embargando su salario?’”.

Según April Kuehnhoff, abogada sénior del National Consumer Law Center (Centro Nacional de Derecho del Consumidor), los embargos salariales representan solo el 0,2% de los ingresos hospitalarios.

“Y sabemos que hay estados que directamente no lo permiten”, añadió. “Los hospitales siguen brindando atención médica a los pacientes”.

Bueno para unos, malo para otros

Los prestadores de salud aparecieron como demandantes directos en solo el 2% de los casos de deuda médica. Casi todas las demandas fueron presentadas por agencias de cobro o compradores de deuda, siendo BC Services y Professional Finance Company responsables de más de la mitad, seguidos por A-1 Collection Agency y Wakefield & Associates.

Estas empresas ganan dinero comprando deudas que los proveedores ya dieron por perdidas y luego intentando cobrar lo que puedan, con intereses. Cobran un porcentaje de lo que logran recuperar. Algunas compañías hacen ambas cosas.

BC Services no hizo comentarios y Wakefield & Associates no respondió a las preguntas.

Charlie Shoop, presidente de Professional Finance Company, dijo que su empresa inicia embargos en menos del 1% de todas las cuentas que recibe para cobro.

Los proveedores de atención médica de Colorado ya no pueden esconderse detrás de los nombres de los cobradores de deudas cuando demandan a las personas. Lo prohibió una ley estatal de 2024 impulsada por una investigación de 9News-Colorado Sun en colaboración con un proyecto informativo de Colorado News Collaborative-KFF Health News.

En muchos estados, el proceso de demanda y embargo es relativamente sencillo, sobre todo si la persona demandada no se presenta ante el tribunal.

“Es increíblemente fácil”, dijo Dan Vedra, un abogado de Colorado que representa a consumidores en casos de deuda. “Si tienes un procesador de textos y una hoja de cálculo, puedes generar miles de demandas en horas o minutos”.

En la muestra revisada por KFF Health News, casi todos los casos de deuda médica terminaron con sentencias en rebeldía, lo que significa que el paciente no se defendió en el tribunal ni por escrito. Las ausencias pueden deberse a varios motivos: no recibir la notificación por correo, suponer que es una estafa, ignorarla deliberadamente o no poder ausentarse del trabajo.

Vedra y otros expertos dijeron que un alto número de sentencias en rebeldía indica un sistema que favorece a los acreedores por sobre los deudores y que aumenta la probabilidad de que alguien termine perjudicado por una factura incorrecta.

En New Hampshire, por ejemplo, los acreedores deben acudir al tribunal por cada cheque que desean embargar, ya que solo se les permite retener  salarios ya devengados, explicó Maanasa Kona, profesora investigadora asociada al Center on Health Insurance Reforms de la Georgetown University.

“No parece gran cosa en los papeles”, dijo. “Pero si tienen que regresar al tribunal una y otra vez, no les conviene”.

Demandados por error

El sistema de facturación médica en Estados Unidos tiende a generar errores debido a su complejidad, afirmó Barak Richman, profesor de Derecho en la George Washington University y académico sénior de Stanford Medicine. Richman ha estudiado prácticas de cobro de deudas médicas en varios estados. “Las facturas no solo son incomprensibles, sino que a menudo están equivocadas”, sostuvo.

De hecho, el Health Care Policy & Financing Department de Colorado, que administra Medicaid en el estado, indicó que durante el último año fiscal envió cerca de 11.000 cartas a proveedores y agencias de cobro que, erróneamente, intentaron exigir pagos a pacientes que estaban cubiertos por Medicaid. Las facturas de estos pacientes deben enviarse a Medicaid, no a ellos directamente, ya que normalmente solo pagan una cantidad simbólica, si acaso.

Shoop, de Professional Finance Company, dijo que su industria le ha pedido sin éxito al estado de Colorado acceso a una base de datos que le permita verificar si los pacientes están cubiertos por Medicaid.

El programa de Medicaid de Colorado no hizo comentarios.

Patricia DeHerrera, residente de Rifle, Colorado, tuvo que demostrar que ella y sus hijos estaban inscritos en Medicaid cuando recibieron atención en Grand River Health. Pero eso fue después de que A-1 contactara a quien era entonces su empleador, la cadena de gasolineras Kum & Go, llevando una orden judicial para retener parte de sus salarios.

DeHerrera contactó al estado, que envió cartas al hospital y a la agencia de cobro notificándoles que estaban llevando a cabo una “acción de cobro ilegal” y ordenándoles detenerse. Las empresas acataron.

Theresa Wagenman, jefa de contabilidad de Grand River Health, explicó que si un paciente presenta un documento de Medicaid que demuestre su elegibilidad, la deuda se retira del proceso de cobro.

Wagenman también dijo que los pacientes reciben al menos ocho cartas por correo y varias llamadas telefónicas antes de que el hospital autorice al cobrador a llevar el caso a los tribunales.

El consejo principal de DeHerrera para otras personas en esta situación es este: “Conozcan sus derechos. Si no, se van a aprovechar de ustedes”.

Pero defenderse no es fácil.

Nicole Silva, que vive en Sanford, un pueblo de 900 habitantes en el sur de Colorado, contó que toda su familia tenía cobertura de Medicaid cuando su hija sufrió un accidente automovilístico. Aun así, los registros judiciales muestran que le embargaron el salario por un traslado en ambulancia que costó $2.181,60  y que, con intereses y tarifas judiciales, superó los $3.000.

Silva intentó demostrar que la factura era incorrecta y se puso en contacto con la oficina de servicios sociales de su condado, pero dijo que no recibió ayuda y que no pudo comunicarse con la persona adecuada en la oficina estatal. El programa de Medicaid del estado confirmó a KFF Health News que su hija tenía cobertura en el momento del accidente.

Luchar contra la factura era demasiado para Silva y su marido, que tenían que criar a un número cada vez mayor de hijos, uno de ellos con una discapacidad grave. Y, además, trabajan: ella como profesora de preescolar y él en un rancho.

Dejar de recibir aproximadamente $500 al mes, que, según dijo, se le descontaban del sueldo, afectó su capacidad para pagar otras cuentas. “Teníamos que decidir entre comprar comida o pagar la electricidad”, explicó.

Cuando les cortaron el servicio eléctrico, tuvieron que pedir dinero prestado a colegas y amigos para restablecerlo, con un cargo adicional incluido.

Silva dijo que todo este proceso la hace dudar si en el futuro llamaría a una ambulancia.

Fox, de Colorado Consumer Health Initiative, señaló que muchos consumidores piensan que no pueden hacer nada para evitar que les retengan el salario. Sin embargo, pueden impugnar el embargo en el tribunal. Por ejemplo, señalando que deberían haber tenido derecho a una atención médica con descuento o gratuita si el hospital que brindó el servicio es una institución sin fines de lucro.

El economista DeFusco cree que declararse en  bancarrota bajo el Capítulo 7 es una opción subutilizada por los deudores. La bancarrota detiene el embargo de inmediato, aunque no siempre de forma permanente, y tiene otras consecuencias. Pero entiende que es una situación sin salida: es un proceso complejo y usualmente requiere contratar a un abogado.

“Para deshacerse de la deuda, se necesita dinero”, afirma. “Y la razón por la que se encuentra en esta situación es precisamente porque no tiene dinero”.

El pasante de KFF Health News Henry Larweh, la editora de datos Holly K. Hacker, el editor de Mountain States Matt Volz y la editora web Lydia Zuraw contribuyeron con este informe.

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.

USE OUR CONTENT

This story can be republished for free (details).

So she was shocked when, three years after the trip to the hospital, her employer received court orders requiring it to start funneling a chunk of her paychecks to a debt collector for an unpaid $881 medical bill — which had grown to $1,155.26 from interest and court fees.

The timing was terrible. After leaving a bad marriage and staying in a shelter, she had just gotten full custody of her three children, steady housing in Montrose, Colorado, and a job at a gas station.

“And that’s when I got that garnishment from the court,” she said. “It was really scary. I’d never been on my own or raised kids on my own.”

KFF Health News reviewed 1,200 Colorado cases in which judges, over a two-year period from Feb. 1, 2022, through Feb. 1, 2024, gave permission to garnish wages over unpaid bills. At least 30% of the cases stemmed from medical care — even when patients’ bills should have been covered by Medicaid, the public insurance program for those with low incomes or disabilities. That 30% is likely an underestimate since medical debt is often hidden behind other types of debt, such as from credit cards or payday loans. But even that minimum would translate to roughly 14,000 cases a year in Colorado in which courts approved taking people’s wages because of unpaid medical bills.

Among the other findings:

• Patients were pursued for medical bills ranging from under $30 to over $30,000, with most of the bills amounting to less than $2,400. As the cases rolled through the legal system, accumulating interest and court fees, the amount that patients owed often grew by 25%. In one case, it snowballed by more than 400%.
• Cases trailed people for up to 14 years after they received medical care, with debt collectors reviving their cases even as they moved from job to job.
• Medical providers of all stripes are behind these bills — big health care chains, small rural hospitals, physician groups, public ambulance services, and more. In several cases, hospitals won permission to take the pay of their own employees who had unpaid bills from treatment at the facilities.

Colorado has company. It is one of 45 states that allow wage garnishment for unpaid medical bills. Only Delaware, New York, North Carolina, Pennsylvania, and Texas have banned wage garnishment for medical debt.

As KFF Health News has reported, medical debt is devastating for millions of people across the country. And now the problem is likely to grow more pressing nationwide. Millions of Americans are expected to lose health insurance in the coming years due to Medicaid changes in President Donald Trump’s tax and spending law and if Congress allows some Affordable Care Act subsidies to expire. That means health crises for the newly uninsured could lead them, too, into a spiral of medical debt.

And the hurt will linger: Large unpaid medical bills are staying on credit reports in most states after a July decision from a federal judge reversed a new rule aimed at protecting consumers.

“If you can't maintain your health, how are you going to work to pay back a debt?” said Adam Fox, deputy director of the Colorado Consumer Health Initiative, a nonprofit aimed at lowering health costs. “And if you fundamentally can't pay the bill, wage garnishment isn't going to help you do that. It's going to put you in more financial distress.”

Flying Blind on Medical Debt

When someone fails to pay a bill, the creditor that provided the service — whether for a garage door repair, a car loan, or medical care — can take the debtor to court. Creditors can also pass the debt to a debt collector or debt buyer, who can do the same.

“At any given point, about 1% of working adults are being garnished for some reason,” said Anthony DeFusco, an economist at the University of Wisconsin-Madison, who studied paycheck data from ADP, a payroll processor that distributes paychecks to about a fifth of private sector U.S. workers. “That's a big chunk of the population.”

But specific research into the practice of garnishing wages over medical debt is scant. Studies in North Carolina, Virginia, and New York have found that nonprofit hospitals commonly garnish wages from indebted patients, with some studies finding those patients tend to work in low-wage occupations.

Marty Makary, who led research on medical debt wage garnishment in Virginia at Johns Hopkins University before joining Trump’s cabinet as Food and Drug Administration commissioner, has called the practice “aggressive.” He co-authored a study that found 36% of Virginia hospitals, mostly nonprofit and mostly in urban areas, were using garnishment to collect unpaid debts in 2017, affecting thousands of patients.

The Colorado findings from KFF Health News show that hospitals are far from the only medical providers going after patients’ paychecks, though.

Researchers and advocates say that, in addition to a dearth of court case data, another phenomenon tends to obscure how often this happens. “People find debt shameful,” said Lester Bird, a senior manager at the Pew Charitable Trusts who specializes in courts. “A lot of this exists in the shadows.”

Without data on how often this tactic is employed, lawmakers are flying blind — even as a 2024 Associated Press-NORC poll showed about 4 in 5 U.S. adults believe it’s important for the federal government to provide medical debt relief.

‘Blood From a Turnip’

Colorado was among the first of 15 states to scratch medical debt from credit reports. Debt buyers in the state aren’t allowed to foreclose on a patient’s home. If qualified patients opt to pay in monthly installments, those payments shouldn’t exceed 6% of their household income — and the remaining debt gets wiped after about three years of paying.

But if they don’t agree to a payment plan, Coloradans can have up to 20% of their disposable earnings garnished. The National Consumer Law Center gave the state a “D” grade for state protections of family finances.

Consumer advocates said they aren’t sure how well even those Colorado requirements are being followed. And people wrote letters to the courts saying wage garnishment would exacerbate their already dire financial situations.

“I have begun to fall behind on my electricity, my gas, my water my credit cards,” wrote a man in western Colorado in a letter to a judge that KFF Health News obtained in the court filings. Court records show he was working in construction and at a rent-to-own store, with about $8,000 in medical debt. He wrote to the judge that he was paying close to $1,000 a month. “The way things are going now I will lose everything.”

The people being sued in KFF Health News’ Colorado review worked in a wide array of jobs. They worked in school districts, ranching, mining, construction, local government, even health care. Several worked at stores such as Walmart and Family Dollar, or at gas stations, restaurants, or grocery stores.

“You're really kicking people when they're down,” said Lois Lupica, a former attorney working with the Denver-based Community Economic Defense Project and the Debt Collection Lab at Princeton. “They're basically suing the you-can't-get-blood-from-a-turnip population.”

In 2022, court records show, Valley View health system based in Glenwood Springs was allowed to garnish the wages of one of its patients over a $400 medical bill. The patient was working at a local organization that the health system supported as part of the community benefits it provides to keep its tax-exempt status. Nonprofit hospitals like Valley View are required to provide community benefits, which can also include charity care that covers patients’ bills.

Stacey Gavrell, the health system’s chief community relations officer, said it offers options such as interest-free payment plans and care at reduced or no cost to families with incomes up to 500% of the federal poverty level.

“As our rural region’s largest healthcare provider, it is imperative to the health and well-being of our community that Valley View remains a financially viable organization,” she said. “Most of our patients work with us to develop a payment plan or pursue financial assistance.”

The collection agency that took the employee to court, A-1 Collection Agency, advertises itself on its website as empathetic: “We understand times are tough and money is tight.”

Pilar Mank, who oversees operations at A-1’s parent company, Healthcare Management, said it accepts payment plans as small as $50 a month and that most of the hospitals it works with allow it to offer a discount if patients pay all at once.

“Suing a patient is the absolute last resort,” she said. “We try everything we can to work with the patient.”

If you can't maintain your health, how are you going to work to pay back a debt?

Adam Fox, deputy director of the Colorado Consumer Health Initiative

Hospitals sometimes also garnish wages from their own employees for care they provided them. In one case, a hospital employee worked her way up from housekeeper to registrar to quality analyst. She even participated in public events representing her employer and appeared on the hospital’s website as a featured employee — while the court issued writs of garnishment until her $10,000 in medical bills from the hospital was paid off.

“Hospital care costs money to deliver,” said Colorado Hospital Association spokesperson Julie Lonborg about hospitals’ garnishing their own employees’ wages. “In some ways, I think it's funny to be asked the question. I would understand if someone said, ‘Why aren't you garnishing their wages?’”

Studies show that hospital debt collection efforts through wage garnishment bring in only about 0.2% of hospital revenues, said April Kuehnhoff, a senior attorney with the National Consumer Law Center, which advocates for people with low incomes.

"We also know that there are states that don't allow this at all,” she said. “Hospitals are continuing to provide medical care to consumers.”

Smooth Sailing for Collectors — But Not for Patients

Health care providers appeared as the plaintiffs in only 2% of the medical debt cases. Instead, cases were filed almost entirely by third-party debt collectors and buyers, with BC Services and Professional Finance Company behind more than half of the cases, followed by A-1 Collection Agency and Wakefield & Associates.

Debt buyers make money by buying debt from providers who’ve given up on getting paid then collecting what they can of the money owed, plus interest. Debt collectors get paid a percentage of what they recover. Some companies do a bit of both.

BC Services declined to comment, and Wakefield & Associates did not respond to questions.

Charlie Shoop, president of Professional Finance Company, said his company initiates wage garnishment on less than 1% of all accounts placed with it for collection.

Health care providers in Colorado can no longer hide behind debt collectors’ names when they sue people, according to a 2024 state law prompted by a 9News-Colorado Sun investigation in partnership with a Colorado News Collaborative-KFF Health News reporting project.

In many states, the path for filing a case against a debtor and garnishing their wages is relatively smooth — especially if the debtor doesn’t appear in court.

“It's unbelievably easy,” said Dan Vedra, a lawyer in Colorado who often represents consumers in debt cases. “If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.”

Within KFF Health News’ sample, nearly all the medical debt cases were default judgments, meaning the patient did not defend themselves in court or in writing. Missing a court date can happen for a variety of reasons, such as not receiving the notice in the mail, assuming it was a scam, knowingly ignoring it, or not having the time to take off from work.

Vedra and other debt law experts said a high rate of default judgments indicates a system that favors the pursuers over the pursued — and increases the chances someone will be harmed by an erroneous bill.

But in New Hampshire, creditors now have to keep going to court for each paycheck they want to garnish, because the state allows creditors to garnish only wages that have already been earned, said Maanasa Kona, an associate research professor at the Center on Health Insurance Reforms at Georgetown University.

“It might not look like much on paper,” she said. “It's just not worth it if they have to keep going back to court.”

If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.

Dan Vedra

Wrongly Pursued for Bills

The nation’s medical billing setup is already prone to errors due to its complexity, according to Barak Richman, a law professor at George Washington University and a senior scholar at Stanford Medicine who has studied medical debt collection practices in several states. “Bills are not only noncomprehensible, but often wrong,” Richman said.

Indeed, Colorado’s Health Care Policy & Financing Department, which runs Medicaid in the state, said it sent out nearly 11,000 letters in the past fiscal year to health providers and collectors that erroneously went after patients on Medicaid. Bills for Medicaid recipients are supposed to be sent to Medicaid, not the patients, who typically pay a nominal amount, if anything, for their care.

Shoop said his industry has pushed Colorado, without success, for access to a database that would allow them to confirm if patients had Medicaid coverage.

Colorado’s Medicaid program declined to comment.

Patricia DeHerrera in Rifle, Colorado, had to prove that she and her children had Medicaid when they received care at Grand River Health — but only after A-1 contacted her employer at the time, the gas station chain Kum & Go, with court-approved paperwork to take a portion of her paychecks.

She contacted the state, which sent letters to the hospital and the collector notifying them they were engaging in “illegal billing action” and telling the collector to stop. The companies did.

Theresa Wagenman, controller for Grand River Health, said if a patient can present a letter from a Medicaid caseworker saying they’re eligible, then their bills get removed from the collections pipeline. Wagenman also said patients get at least eight letters in the mail and several phone calls before Grand River gives the go-ahead for the collector to send them to court.

DeHerrera’s main advice to others in this situation: “Know your rights. Otherwise, they’re going to take advantage of you.”

Yet fighting back isn’t easy.

Nicole Silva, who lives in the 900-person town of Sanford in south-central Colorado, said she and her family were all on Medicaid when her daughter was in a car crash. Still, court records show, her wages were garnished for a $2,181.60 ambulance ride, which grew to more than $3,000 from court fees and interest.

She tried to prove the bill was wrong, contacting her county’s social services office, but Silva said it wasn’t helpful and she wasn’t able to reach the right person at a state office. The state Medicaid program confirmed to KFF Health News that her daughter was covered at the time of the wreck.

Fighting the bill felt like too much for Silva and her husband to handle while parenting a growing number of kids, one of them severely disabled, and working — she as a preschool teacher and he as a rancher.

Not receiving the roughly $500 a month that she said came out of her pay was enough to affect their ability to pay other bills. “It was deciding to buy groceries or pay the electric bill,” Silva said.

When their electricity got shut off, she said, they had to scramble to borrow money from colleagues and friends to get it turned back on — with an extra fee.

She said the saga makes her hesitant to call an ambulance in the future.

Fox, of the Colorado Consumer Health Initiative, said consumers often think they cannot do anything to stop their wages from being garnished, but they can contest it in court, for example by pointing out they should have qualified for discounted — or charity — care if the hospital that provided the treatment is a nonprofit.

DeFusco, the economist, believes filing for Chapter 7 bankruptcy is an underused option for debtors. It halts garnishment in its tracks, though not always permanently, and it comes with other consequences. But he understands it’s a Catch-22: It’s a complex process and typically necessitates hiring a lawyer.

“To get rid of your debt, you need money,” he said. “And the whole reason you're in this situation is because you don't have money.”

Methodology

We wanted to know how often Coloradans get their wages garnished due to medical debt. Courts don’t compile this information, and researchers and advocates haven’t tracked it systematically.

So we created our own database. We requested a list of all civil cases across the state in which judges gave permission for a person’s earnings to be garnished — known as writs of garnishment in court lingo — from Feb. 1, 2022, through Feb. 1, 2024. The Colorado Supreme Court Library provided a list from all courts except for Denver County Court, which provided its own records. The combined list comprised nearly 90,000 unique court cases. We split up the cases by county population — small (fewer than 10,000 people), medium (10,000 to 100,000 people), and large (more than 100,000 people) — then generated a random sample of 400 cases from each group to ensure we evaluated medical debt across counties of all sizes.

To identify medical debt cases, we looked at the original creditors named in court records, primarily the complaints or affidavits of indebtedness. Often, this information was available through a state website. When it wasn’t available online, we asked county courthouses to send us supporting documents. We counted dentists as medical providers. We excluded 14 cases in which the debt wasn’t exclusively medical.

We looked only at cases in which courts approved money to be garnished from someone’s paycheck, as opposed to from other sources such as their bank accounts. We did not review garnishment cases involving child support, taxes, or federal student loans.

KFF Health News intern Henry Larweh, data editor Holly K. Hacker, Mountain States editor Matt Volz, and web editor Lydia Zuraw 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.

USE OUR CONTENT

This story can be republished for free (details).

At this decades-old psychiatric hospital on the edge of the Tennessee River, an intense storm could submerge the building in 11 feet of water, cutting off all roads around the facility, according to a sophisticated computer simulation of flood risk.

Aurora, a young woman who was committed to Peninsula as a teenager, said the hospital sits so close to the river that it felt like a moat keeping her and dozens of other patients inside. KFF Health News agreed not to publish her full name because she shared private medical history.

“My first feeling is doom,” Aurora said as she watched the simulation of the river rising around the hospital. “These are probably some of the most vulnerable people.”

Covenant Health, which runs Peninsula Hospital, said in a statement it has a “proactive and thorough approach to emergency planning” but declined to provide details or answer questions.

Peninsula is one of about 170 American hospitals, totaling nearly 30,000 patient beds from coast to coast, that face the greatest risk of significant or dangerous flooding, according to a months-long KFF Health News investigation based on data provided by Fathom, a company considered a leader in flood simulation. At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.

Much of this risk to hospitals is not captured by flood maps issued by the Federal Emergency Management Agency, which have served as the nation’s de facto tool for flood estimation for half a century, despite being incomplete and sometimes decades out of date. As FEMA’s maps have become divorced from the reality of a changing climate, private companies like Fathom have filled the gap with simulations of future floods. But many of their predictions are behind a paywall, leaving the public mostly reliant on free, significantly limited government maps.

“This is highly concerning,” said Caleb Dresser, who studies climate change and is both an emergency room doctor and a Harvard University assistant professor. “If you don’t have the information to know you’re at risk, then how can you triage that problem?”

The deadliest hospital flooding in modern American history occurred 20 years ago during Hurricane Katrina, when the bodies of 45 people were recovered from New Orleans’ Memorial Medical Center, including some patients whom investigators suspected were euthanized. More flooding deaths were narrowly avoided one year ago when helicopters rescued dozens of people as Hurricane Helene engulfed Unicoi County Hospital in Erwin, Tennessee.

Rebecca Harrison, a paramedic, called her children from the Unicoi roof to say goodbye.

“I was scared to death, thinking, ‘This is it,’” Harrison told CBS News, which interviewed Unicoi survivors as part of KFF Health News’ investigation. “Alarms were going off. People were screaming. It was chaos.”

The investigation — among the first to analyze nationwide hospital flood risk in an era of warming climate and worsening storms — comes as the administration of President Donald Trump has slashed federal agencies that forecast and respond to extreme weather and also dismantled FEMA programs designed to protect hospitals and other important buildings from floods.

When asked to comment, FEMA said flooding is a common, costly, and “under appreciated” disaster but made no statement specific to hospitals. Spokesperson Daniel Llargués defended the administration’s changes to FEMA by reissuing an August statement that dismissed criticism as coming from “bureaucrats who presided over decades of inefficiency.”

Alice Hill, an Obama administration climate risk expert, said the Trump administration’s dismissal of climate change and worsening floods would waste billions of dollars and endanger lives.

In 2015, Hill led the creation of the Federal Flood Risk Management Standard, which required that hospitals and other essential structures be elevated or incorporate extra flood protections to qualify for federal funding.

FEMA stopped enforcing the standard in March.

“People will die as a result of some of the choices being made today,” Hill said. “We will be less prepared than we are now. And we already were, in my estimation, poorly prepared.”

‘Flood Risk Is Everywhere’

The KFF Health News investigation identified more than 170 hospitals facing a flood risk by comparing the locations of more than 7,000 facilities to peer-reviewed flood hazard mapping provided by Fathom, a United Kingdom company that simulates flooding in spaces as small as 10 meters using laser-precision elevation measurements from the U.S. Geological Survey.

Hospitals were determined to have a significant risk if Fathom’s 100-year flood data predicted that a foot or more of water could reach a considerable portion of their buildings, excluding parking garages, or cut off road access to the hospital. A 100-year flood is an intense weather event that has roughly a 1% chance of occurring in any given year but can happen more often.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to military documents obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by KFF Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe have estimated that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit Climate Central. “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, First Street, which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its reopening is uncertain.

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, KFF Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the West Virginia GIS Technical Center, “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has taken the position that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to publish a letter in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had repeatedly pushed the agency to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its Building Resilient Infrastructure and Communities program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA intends to rescind the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to KFF Health News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

After Hurricane Helene made landfall a year ago, a raging river flooded a rural hospital in eastern Tennessee. Patients and employees were rescued from the rooftop. Floods have hit hospitals from New York to Nebraska to Texas in recent years. We wanted to determine how many other U.S. hospitals face similar peril. Ultimately, we found more than 170 hospitals at risk.

For this analysis, we used data from Fathom, a United Kingdom-based company that specializes in flood-risk modeling across the globe. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been peer-reviewed and used by insurance companies, the World Bank, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has validated Fathom’s U.S. data.

Through a data use agreement, Fathom shared its U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of three main types of flooding: coastal, fluvial (from overflowing rivers, lakes, or streams), and pluvial (rainfall that the ground can’t absorb). The data also accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk hospitals, we used a publicly available Department of Homeland Security database containing the GPS coordinates of more than 7,000 short-term acute, critical access, rehab, and psychiatric hospitals — basically any hospital with inpatient services. (DHS under the Trump administration has discontinued public access to the database, so data for hospitals and other infrastructure is no longer widely available.)

Using GPS coordinates as the centerpoint, we created a circle with a 150-yard radius around each hospital, which in most cases captured the building plus nearby grounds and access roads. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for hospitals where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 320 hospitals across the U.S.

From there, we visually inspected those hospitals using mapping software and Google Maps, both satellite and street view. We trimmed our list to only the hospitals where a considerable portion of the building or all access roads were predicted to have at least a foot of flooding.

If two hospitals were mapped to the same building — for instance, a small rehab facility within a large hospital — we counted only one hospital. We also excluded hospitals recently converted to nursing homes or for other uses.

We ended up with a list of 171 hospitals across the U.S. That is most likely an undercount. Some hospitals could still face significant impact from flooding that is not deep enough or widespread enough to fit our methodology. Our analysis also does not account for how flooding farther from a hospital could affect employees or patients. And it does not assess what steps hospitals may have already taken to prepare for severe weather events.

We also ran a spatial analysis comparing Fathom’s data with flood hazard maps from the Federal Emergency Management Agency, which in many cases are incomplete or haven’t been updated in years. We found that about a third of hospitals identified as flood risks by Fathom’s data did not overlap at all with FEMA’s 100- or 500-year hazard areas.

Fathom provided guidance and feedback as we developed our analysis.

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani 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.

USE OUR CONTENT

This story can be republished for free (details).

The settlement resolves two whistleblower lawsuits alleging the Florida company violated the federal False Claims Act by billing government health care programs such as Medicare for knee replacement parts it knew were defective.

“Patients who need a medical device to enjoy their lives rely on device manufacturers to put patient safety first. When a manufacturer learns that its device is defective, it must promptly and transparently address the problem,” Kelly Hayes, U.S. attorney for the District of Maryland, said in announcing the settlement this week.

The Gainesville-based company declared bankruptcy last October, leaving in limbo thousands of injured patients suing the company for compensation. The U.S. Bankruptcy Court for the District of Delaware has approved the whistleblowers’ settlement.

Exactech declined to comment. In making the settlement, the company did not admit liability.

Exactech, which grew over three decades from a mom-and-pop device manufacturer into a global entity, was the subject of a KFF Health News investigation published in October 2023.

Florida lawyer Joseph Saunders, who represents patients suing the company in other lawsuits, said more than 2,500 people alleging injuries have filed claims seeking compensation. Many underwent operations to remove and replace the implants, some within three years of their original surgeries. Many of those cases have been put on hold because of the bankruptcy.

“There are people who are lifelong cripples from this or had multiple surgeries,” Saunders said.

So far, patients have received no compensation. Sue Sacker, a New Jersey resident who had two Exactech knee implants replaced at the Hospital for Special Surgery in New York City, said she was “very disappointed” by the settlement deal.

“I’m fuming,” she said. “People are suffering, and the government is getting the money. Where are the patients? Who’s taking care of us?”

Saunders said that a committee of creditors hopes to pursue TPG, a private equity firm that paid $737 million to acquire Exactech in February 2018. TPG won dismissal of a similar attempt last year, when it successfully argued it did not exercise control over operations at Exactech. TPG declined to comment.

The first whistleblower case was filed in 2018 in federal court in Alabama by Brooks Wallace and Robert Farley, two former Exactech sales agents, and Manuel Fuentes, a former Exactech senior product manager.

They alleged serious defects in the Optetrak total knee replacement systems, which Exactech started selling in 1994. By 2008, the company knew that a component of the implant “failed prematurely at a higher than acceptable rate,” but Exactech marketed the implants through December 2018, according to the settlement. Together, the whistleblowers will receive $1,329,360 under a provision of the law that allows private citizens to act on behalf of the government.

In the second whistleblower case, Pasquale Petrera, a Maryland orthopedic surgeon, alleged that as early as January 2019 Exactech knew that a polyethylene part in certain Exactech Logic and Truliant brand knee replacement systems also failed prematurely. The company sold them through early February 2022, when it expanded a recall of the product. The Maryland whistleblower will receive $565,360, according to the settlement amount.

KFF Health News found and reported in 2023 about 400 examples in which Exactech reported adverse events to the government two years or more after learning of them. The reports are supposed to be submitted within 30 days unless a special exemption is granted.

The KFF Health News analysis of more than 300 pending cases in Florida’s Alachua County found that surgeons removed about 200 knee and hip implants after less than seven years, far sooner than the 15 to 20 years these products typically last. The company stressed the durability of its implants in advertising, even suggesting they would likely outlive their human recipients.

In court filings, Exactech steadfastly denied that Optetrak had any defects.

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.

USE OUR CONTENT

This story can be republished for free (details).

The Centers for Medicare & Medicaid Services is scouring payments covering health care for immigrants without legal status to ensure there isn’t any waste, fraud, or abuse, according to public records obtained by KFF Health News and The Associated Press. While acknowledging that states can bill the federal government for Medicaid emergency and pregnancy care for immigrants without legal status, federal officials have sent letters notifying state health agencies in California, Colorado, Illinois, Minnesota, Oregon, and Washington that they are reviewing federal and state payments for medical services such as prescription drugs and specialty care.

The federal agency told the states it is reviewing claims as part of its commitment to maintain Medicaid’s fiscal integrity. California is the biggest target after the state self-reported overcharging the federal government for health care services delivered to immigrants without legal status, determined to be at least $500 million, spurring the threat of a lawsuit.

“If CMS determines that California is using federal money to pay for or subsidize healthcare for individuals without a satisfactory immigration status for which federal funding is prohibited by law,” according to a letter dated March 18, “CMS will diligently pursue all available enforcement strategies, including, consistent with applicable law, reductions in federal financial participation and possible referrals to the Attorney General of the United States for possible lawsuit against California.”

The investigations come as the White House and a Republican-controlled Congress slashed taxpayer spending on immigrant health care through cuts in President Donald Trump’s spending-and-tax law passed this summer. The administration is also pushing people living in the U.S. without authorization off Medicaid rolls. Health policy experts say these moves could hamper care and leave safety net hospitals, clinics, and other providers financially vulnerable. Some Democratic-led states — California, Illinois, and Minnesota — have already had to end or slim down their Medicaid programs for immigrants due to ballooning costs. Colorado is also considering cuts due to cost overruns.

At the same time, 20 states are pushing back on Trump’s immigration crackdown by suing the administration for handing over Medicaid data on millions of enrollees to deportation officials. A federal judge temporarily halted the move. California’s attorney general, Rob Bonta, who led that challenge, says the Trump administration is launching a political attack on states that embrace immigrants in Medicaid programs.

“The whole idea that there’s waste, fraud, and abuse is contrived,” Bonta said. “It’s manufactured. It’s invented. It’s a catchall phrase that they use to justify their predetermined anti-immigrant agenda.”

Trump Targets Immigrants

Immigrants lacking permanent legal status are not eligible to enroll in comprehensive Medicaid coverage. However, states bill the federal government for emergency and pregnancy care provided to anyone.

Fourteen states and Washington, D.C., expanded their Medicaid programs with their own funds to cover low-income children without legal status. Seven of those states, plus Washington, D.C., have also provided full-scope coverage to some adult immigrants living in the country without authorization.

The Trump administration appears to be targeting only states with full Medicaid coverage for both kids and adults without legal status. Utah, Massachusetts, and Connecticut, which provide Medicaid coverage only to immigrant children, have not received letters, for instance. CMS declined to provide a full list of states it is targeting.

Federal officials say it is their legal right and responsibility to scrutinize states for misspending on immigrant health coverage and are taking “decisive action to stop that.”

“It is a matter of national concern that some states have pushed the boundaries of Medicaid law to offer extensive benefits to individuals unlawfully present in the United States,” CMS spokesperson Catherine Howden said about the agency’s probe of selected states. The oversight is intended to “ensure federal funds are reserved for legally eligible individuals, not for political experiments that violate the law,” she said.

Health policy researchers and economists say providing Medicaid coverage to immigrants for preventive services and treatment of chronic health conditions staves off more costly care for patients down the road. It also tamps down insurance premium increases and the amount of uncompensated care for hospitals and clinics.

Francisco Silva, president and CEO of the California Primary Care Association, said the Trump administration is threatening to drive up health care costs and make it more difficult to access care.

“The impact is emergency rooms would get so crowded that ambulances have to be diverted away and people in a real emergency can’t get into the hospital, and public health threats like disease outbreaks,” Silva said.

California has taken a health-care-for-all approach, providing coverage to 1.6 million immigrants without legal status. The expansion, which was rolled out from 2016 to 2024, is estimated to cost $12.4 billion this year. Of that, $1.3 billion is paid by the federal government for emergency and pregnancy-related care.

As California rolled out its expansion, the state erroneously billed the federal government for care provided to immigrants without legal status — details that have not previously been reported and that former state officials shared with KFF Health News and the AP. The state improperly billed for services such as mental health and addiction services, prescription drugs, and dental care.

Jacey Cooper, who served as California’s Medicaid director from 2020 to 2023, said she discovered the error and reported it to federal regulators. Cooper said the state had been working to pay back at least $500 million identified by the federal government.

“Once I identified the problem, I thought it was really important to report it and we did,” Cooper said. “We take waste, fraud, and abuse very seriously.”

It’s not clear whether that money has been repaid. The state’s Medicaid agency says it does not know how CMS calculated the overpayments or “what is included in that amount, what time period it covers, and if or when it was collected,” said spokesperson Tony Cava.

California has an enormously complicated Medicaid program: It serves the largest population in the nation — nearly 15 million people — with a budget of nearly $200 billion this fiscal year.

Matt Salo, a national Medicaid expert, said these types of mistakes happen in states throughout the country because the program is rife with overlapping federal and state rules. Salo and other policy analysts agreed that states have the authority to administer their Medicaid programs as they see fit and root out misuse of federal funds.

And Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Trump administration’s actions “persecute a minority that’s unpopular with the powers that be.”

“The Trump administration cannot maintain that this effort has anything to do with maintaining the fiscal integrity of the Medicaid program,” Cannon said. “There are so much bigger threats to Medicaid’s fiscal integrity, that that argument just doesn’t wash.”

Immigrants’ Medicaid Under Attack

National Republicans have targeted health spending on immigrants in different ways. The GOP spending law, which Trump calls the “One Big Beautiful Bill,” will lower reimbursement to states around the country in October 2026. In California, for example, federal reimbursement for immigrants without legal status will go to 50% for emergency services, down from 90% for the Medicaid expansion population, according to Cava.

The Trump administration is also scaling back Medicaid coverage to immigrants with temporary legal status who were previously covered and announced in August that it would provide states with monthly reports pointing out enrollees whose legal status could not be confirmed by the Department of Homeland Security.

“Every dollar misspent is a dollar taken away from an eligible, vulnerable individual in need of Medicaid,” CMS Administrator Mehmet Oz said in a statement. “This action underscores our unwavering commitment to program integrity, safeguarding taxpayer dollars, and ensuring benefits are strictly reserved for those eligible under the law.”

States under review say they are following the law.

“Spending money on a congressionally authorized medical benefit program that helps people get emergency treatments for cancer, dialysis, and anti-rejection medications for organ transplants is decidedly not waste, fraud and abuse,” said Mike Faulk, deputy communications director for Washington state Attorney General Nick Brown.

Records show Washington Medicaid officials have been inundated with questions from CMS about federal payments covering emergency and pregnancy care for immigrants without legal status.

Emails show Illinois officials met with CMS and sought an extension to share its data. CMS denied that request and federal regulators told the state that its funding could be withheld.

“Thousands of Illinois residents rely on these programs to lawfully seek critical health care without fear of deportation,” said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services, noting that any federal cut would be “impossible” for the state to backfill.

Shastri reported from Milwaukee.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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.

USE OUR CONTENT

This story can be republished for free (details).

The outbreak soon became the worst the United States has endured in over three decades.

In the month after Donald Trump took office, his administration interfered with Centers for Disease Control and Prevention communications, stalled the agency’s reports, censored its data, and abruptly laid off staff. In the chaos, CDC experts felt restrained from talking openly with local public health workers, according to interviews with seven CDC officials with direct knowledge of events, as well as local health department emails obtained by KFF Health News through public records requests.

“CDC hasn’t reached out to us locally,” Katherine Wells, the public health director in Lubbock, Texas, wrote in a Feb. 5 email exchange with a colleague two weeks after children with measles were hospitalized in Lubbock. “My staff feels like we are out here all alone,” she added.

A child would die before CDC scientists contacted Wells.

“All of us at CDC train for this moment, a massive outbreak,” one CDC researcher told KFF Health News, which agreed not to name CDC officials who fear retaliation for speaking with the press. “All this training and then we weren’t allowed to do anything.”

Delays have catastrophic consequences when measles spreads in undervaccinated communities, like many in West Texas. If a person with measles is in the same room with 10 unvaccinated people, nine will be infected, researchers estimate. If those nine go about their lives in public spaces, numbers multiply exponentially.

The outbreak that unfolded in West Texas illustrates the danger the country faces under the Trump administration as vaccination rates drop, misinformation flourishes, public health budgets are cut, and science agencies are subject to political manipulation.

While the Trump administration stifled CDC communications, health secretary Robert F. Kennedy Jr. fueled doubt in vaccines and exaggerated the ability of vitamins to ward off disease. Suffering followed: The Texas outbreak spread to New Mexico, Oklahoma, Kansas, Colorado, and Mexico’s Chihuahua state — at minimum. Together these linked outbreaks have sickened more than 4,500 people, killed at least 16, and levied exorbitant costs on hospitals, health departments, and those paying medical bills.

“This is absolutely outrageous,” said Jennifer Nuzzo, director of the Pandemic Center at Brown University. “When you’re battling contagious diseases, time is everything.”

‘The CDC Is “Stressed” Currently’

Wells was anxious the moment she learned that two unvaccinated children hospitalized in late January had the measles. Hospitals are legally required to report measles cases to health departments and the CDC, but Wells worried many children weren’t getting tested.

“I think this may be very large,” she wrote in a Feb. 3 email to the Texas Department of State Health Services. Wells relayed in another email what she’d learned from conversations around town: “According to one of the women I spoke with 55 children were absent from one school on 1/24. The women reported that there were sick children with measles symptoms as early as November.”

In that email and others, Wells asked state health officials to put her in touch with CDC experts who could answer complicated questions on testing, how to care for infants exposed to measles, and more. What transpired was a plodding game of telephone.

One email asked whether clinics could decontaminate rooms where people with measles had just been if the clinics were too small to follow the CDC’s recommendation to keep those rooms empty for two hours.

“Would it be possible to arrange a consultation with the CDC?” Wells wrote on Feb. 5.

“It never hurts to ask the CDC,” said Scott Milton, a medical officer at the Texas health department. About 25 minutes later, he told Wells that an information specialist at the CDC had echoed the guidelines advising two hours.

“I asked him to escalate this question to someone more qualified,” Milton wrote. “Of course, we know the CDC is ‘stressed’ currently.”

Local officials resorted to advice from doctors and researchers outside the government, including those at the Immunization Partnership, a Texas nonprofit.

“The CDC had gone dark,” said Terri Burke, executive director of the partnership. “We had anticipated a measles outbreak, but we didn’t expect the federal government to be in collapse when it hit.”

Technically, the Trump administration’s freeze on federal communications had ended Feb. 1. However, CDC scientists told KFF Health News that they could not speak freely for weeks after. 

“There was a lot of confusion and nonanswers over what communications were allowed,” one CDC scientist said.

Georges Benjamin, executive director of the American Public Health Association, said the situation was not unique to measles. “Like most public health organizations, we weren’t able to get ahold of our program people in February,” he said. Information trickled out through the CDC’s communications office, but CDC scientists gave no press briefings and went dark on their closest partners across the country. “The CDC was gagged,” he said.

Through private conversations, Benjamin learned that CDC experts were being diverted to remove information from websites to comply with executive orders. And they were afraid to resume communication without a green light from their directors or the Department of Health and Human Services as they watched the Trump administration lay off CDC staffers in droves.

“It’s not that the CDC was delinquent,” Benjamin said. “It’s that they had their hands tied behind their backs.”

To work on the ground, the CDC needs an invitation from the state. But Anne Schuchat, a former CDC deputy director, said that during her 33 years with the agency, federal health officials didn’t need special permission to talk freely with local health departments during outbreaks. “We would always offer a conversation and ask if there’s anything we could do,” she said.

Lara Anton, a press officer at the Texas health department, said the state never prevented the CDC from calling county officials. To learn more about the state’s correspondences with the CDC, KFF Health News filed a public records request to the Texas health department. The department refused to release the records. Anton called the records “confidential under the Texas Health and Safety Code.”

Anton said the state sent vaccines, testing supplies, and staff to assist West Texas in the early weeks of February. That’s corroborated in emails from the South Plains Public Health District, which oversees Gaines County, the area hit hardest by measles.

“Texas will try to handle what it needs to before it goes to the CDC,” Zach Holbrooks, the health district’s executive director, told KFF Health News.

Responding to an outbreak in an undervaccinated community, however, requires enormous effort. To keep numbers from exploding, public health workers ideally would notify all people exposed to an infected person and ask them to get vaccinated immediately if they weren’t already. If they declined, officials would try to persuade them to avoid public spaces for three weeks so that they wouldn’t spread measles to others.

Holbrooks said this was nearly impossible. Cases were concentrated in close-knit Mennonite communities where people relied on home remedies before seeking medical care. He said many people didn’t want to be tested, didn’t want to name their contacts, and didn’t want to talk with the health department. “It doesn’t matter what resources I have if people won’t avail themselves of it,” Holbrooks said.

Historically, Mennonites faced persecution in other countries, making them leery of interacting with authorities, Holbrooks said. A backlash against covid restrictions deepened that mistrust.

Another reason Mennonites may seek to avoid authorities is that some live in the U.S. illegally, having immigrated to Texas from Canada, Mexico, and Bolivia in waves over the past 50 years. Locals guess the population of Seminole, the main city in Gaines County, is far larger than the U.S. Census count.

“I have no idea how many cases we might have missed, since I don’t know how many people are in the community,” Holbrooks said. “There’s a lot of people in the shadows out here.”

Public health experts say the situation in Gaines sounds tough but familiar. Measles tends to take hold in undervaccinated communities, and therefore public health workers must overcome mistrust, misinformation, language barriers, and more.

About 450 people — including local health officials, CDC scientists, nurses, and volunteers — helped control a measles outbreak sparked in an Eastern European immigrant community in Clark County, Washington, in 2018.

Alan Melnick, Clark County’s public health director, said his team spoke with hundreds of unvaccinated people who were exposed. “We were calling them basically every day to see how they were doing and ask them not to go out in public,” he said.

Melnick spoke with CDC scientists from the start, and the intensity of the response was buoyed by emergency declarations by the county and the state. Within a couple of months, the outbreak was largely contained. No one died, and only two people were hospitalized.

In New York, hundreds of people in the city’s health department responded to a larger measles outbreak in 2018 and 2019 concentrated among Orthodox Jewish communities. The work included meeting with dozens of rabbis and distributing booklets to nearly 30,000 households to combat vaccine misinformation.

The effort cost more than $7 million, but Jane Zucker, New York City’s assistant health commissioner at the time, said it yielded immense savings. The average medical bill for measles hospitalizations is roughly $18,500, according to data from prior outbreaks. Then there’s the cost of diverting hospital resources, of children missing school, of parents staying home from work to care for sick kids, and the lasting toll of some measles infections, including deafness or worse.

“I don’t think there’s a price tag to put on a child’s death that would otherwise be prevented,” Zucker said.

Local health departments in West Texas were understaffed from the start. About 18 people work at the South Plains health department, which oversees four vast rural counties. About 50 staff the department in Lubbock, where patients were hospitalized and health workers struggled to figure out who was exposed. In mid-February, Wells emailed a colleague: “I’m so overwhelmed.”

A Death Ignites a Response

On Feb. 26, Texas announced that a 6-year-old child had died of measles. Wells heard from CDC scientists for the first time the following day. Also that day, the CDC issued a brief notice on the outbreak. The notice recommended vaccines, but it worried public health specialists because it also promoted vitamin A as a treatment under medical supervision.

In emails, Texas health officials privately discussed how the CDC’s notice might exacerbate a problem: Doctors were treating children with measles for toxic levels of vitamin A, suggesting that parents were delaying medical care and administering the supplements at home. A local Lubbock news outlet reported on a large drugstore where vitamin A supplements and cod liver oil, which contains high levels of vitamin A, were “flying off the shelf.”

Too much vitamin A can cause liver damage, blindness, and dire abnormalities during fetal development.

Milton worried that parents were listening to misinformation from anti-vaccine groups — including one founded by Kennedy — that diminished the need for vaccination by inaccurately claiming that vitamin A staved off the disease’s worst outcomes.

“How many people will choose Vitamin A and not a vaccine because it appears to them there are two options?” Milton asked in an email.

Scientists at the CDC privately fretted, too. “HHS pressed us to insert vitamin A into all of our communications with clinicians and health officials,” one CDC scientist told KFF Health News, referring to the agency’s notices and alerts. “If pregnant women took too much vitamin A during the outbreak, their babies could be profoundly disabled. We haven’t seen those babies born yet.”

Another CDC official said they’ve had to “walk a fine line” between protecting the public based on scientific evidence and aligning with HHS.

While CDC scientists held their tongues, Kennedy exaggerated the power of nutrition and vitamin A while furthering mistrust in vaccines. “We’re providing vitamin A,” Kennedy said in an interview on Fox News. “There are many studies, some showing 87% effectiveness,” he claimed, “against serious disease and death.”

The studies Kennedy referenced were conducted in low-income countries where children are malnourished. Evidence suggests that vitamin A supplementation is seldom useful against measles in the United States, because deficiency is exceedingly rare.

Kennedy deflected criticism from those who call him anti-vaccine, saying that any parent in Texas who wants a measles vaccine can get one. He followed this with dangerously inaccurate statements. “There are adverse events from the vaccine. It does cause deaths every year,” he said. “It causes all the illnesses that measles itself causes, encephalitis and blindness, et cetera.” There is no evidence that measles vaccines “cause deaths every year.” Scores of studies show that the vaccine doesn’t cause encephalitis, that most potential side effects resolve quickly on their own, and serious adverse reactions are far rarer than measles complications.

In another interview, Kennedy said, “The MMR vaccine contains a lot of aborted fetus debris.” The measles, mumps, and rubella, or MMR, vaccine does not contain an iota of fetal cells.

HHS spokesperson Andrew Nixon and spokespeople at the CDC did not respond to queries from KFF Health News.

‘Staff Are Exhausted’

Despite national attention after the country’s first measles death in a decade, West Texas was overwhelmed. In late February and March, hospital administrators and health officials exchanged emails about how to lobby for resources.

“Local hospitals are at capacity,” wrote Jeffrey Hill, a senior vice president at the University Medical Center Health System in Lubbock. “The state reports emergency funds that typically cover a response like the measles outbreak are not available from the federal government right now,” he added.

“I am writing to express our urgent need for additional staff and funding,” Ronald Cook, medical director for Lubbock, said in an email, drafted with other Lubbock health authorities, to the deputy city manager. “Our Capacity is Stretched Thin: The health department has been operating seven days a week since February 2nd. Staff are exhausted.”

The city of Lubbock fronted money to help the local health department hire temporary staff. The state did not provide money, but it asked the CDC to send epidemiologists. Some came to Texas in early March. Then Texas requested federal funds.

None arrived, even as the outbreak approached 500 cases. It spread to Mexico when an unvaccinated Mennonite child returned home after visiting family in Seminole. This would fuel the largest outbreak Mexico has seen in decades, with at least 3,700 cases and 13 deaths in the state of Chihuahua.

Then another child in West Texas died of measles.

In a rare moment of openness, CDC scientist David Sugarman mentioned the outbreak at a vaccine advisory meeting in late April. “There are quite a number of resource requests coming in, in particular from Texas,” Sugarman said. “We are scraping to find the resources and personnel needed to provide support to Texas and other jurisdictions.”

Federal funds arrived in Texas on May 21, said Anton, the state health department spokesperson. By then, the crisis was fading. The outbreak seemed to have burned until every unvaccinated person in Seminole was infected, said Richard Eby, a doctor at Permian Regional Medical Center who treated some measles patients. Hundreds, if not thousands, of cases have probably gone undetected, he said. “A lot of people presumed their kids had measles,” he said, “and didn’t see the need to confirm it.”

On Aug. 18, health officials declared the West Texas outbreak over, but the consequences of the catastrophe will be lasting.

The outbreaks it sparked across the U.S. and Mexico are still spreading.

More are inevitable, Nuzzo said. A growing number of parents are deciding not to vaccinate their kids, worried over unfounded rumors about the shots. Misinformation is flourishing, especially after Kennedy fired vaccine experts who advise the CDC and replaced them with doctors and researchers on the fringes of the scientific establishment. For example, one of his recent appointees, Robert Malone, blamed the deaths of children with measles on “medical mismanagement,” without evidence.

At the same time, states are downsizing programs for emergency response, disease surveillance, and immunization after the Trump administration clawed back more than $11 billion in public health funds earlier this year.

Amid Lubbock’s toughest months, Wells sent an email to the department’s exhausted staff. “The future is uncertain, and I know this is an unsettling time for many of us,” she wrote. “Every day we show up and do our jobs is an act of resilience.”

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.

USE OUR CONTENT

This story can be republished for free (details).

The number of people receiving treatment at the National Institutes of Health Clinical Center — the renowned research hospital that cares for patients with rare or life-threatening diseases — has tumbled under the second Trump administration, according to government documents and interviews with current and former NIH employees.

NIH documents viewed by KFF Health News show a pronounced decline in patients at the 200-bed hospital from February through April, a time that coincides with the Department of Health and Human Services’ mass firings of government employees, the gutting of scientific research, and the administration’s broad crackdown on immigration. The average number of patients being treated daily during that time hovered between 60 and 80, with the April numbers falling to the lower end of that range. By contrast, in October, about 80 patients a day on average were at the hospital.

The number of cancer clinical trial participants at the hospital as of July was down about 20% from last year, one NIH cancer scientist said. KFF Health News agreed not to identify the scientist and others who participated in this article who were not authorized to speak to the press and feared retaliation.

The numbers “really don’t look too good,” Pius Aiyelawo, acting CEO of the clinical center, said during a May 23 meeting of the NIH Clinical Center Research Hospital Board.

As of April 30, the average number of patients in the hospital per day had declined by 5.7% from the same period a year ago.

Adults and children with cancer, people who need bone marrow transplants, and people with rare diseases or infections are among the patients who receive care at no charge at the NIH hospital, according to former officials. Clinicians there provide potentially lifesaving treatments as part of clinical trials, often to people who have run out of options.

Research at the hospital has also led to breakthroughs about cancer, traumatic brain injury, and AIDS, among other ailments. James Gilman, a physician who was CEO of the clinical center from 2017 until retiring in January, said the center has driven important advances against disease “that couldn’t have happened anywhere else.”

Former officials said the drop in patients this year is a consequence of the upheaval the Trump administration has caused at the NIH, the world’s largest public funder of scientific research.

Current and former employees say an exodus of clinicians, scientists, and other staffers has limited how many patients can be treated. Morale has tanked because of widespread firings and the administration’s cancellation of grants that funded research into health disparities, vaccines, the health of LGBTQ+ people, and more. Contracts have been cut, and scientists have seen delays in getting essential supplies for clinical research.

“Every day seems to be some type of breaking point,” one NIH worker said.

During the May board meeting, a video of which KFF Health News viewed, Aiyelawo attributed the decrease in patients coming to the hospital to the departure of NIH investigators — the researchers on studies — and less patient recruitment. He also noted 11 recent departures of clinical center staffers. They included Christine Grady, a nurse who led the center’s bioethics department and the wife of Anthony Fauci, the former head of the NIH’s infectious diseases institute who became a lightning rod for conservatives during the covid pandemic.

HHS has fired more than 1,200 NIH employees this year as part of its purge of the federal workforce, but the true number of departures is almost certainly higher. Others have opted for early retirement or quit because they opposed the Trump administration’s orders.

Gilman said the NIH hospital relies on a “very complex ecosystem and network to find patients who are not too sick” to potentially be enrolled in a clinical trial. When researchers leave, “those patients are lost,” he said.

The clinical center’s 2025 annual report said there were roughly 1,500 research studies underway in 2024, including studies focused on cancer, infectious disease, heart and lung conditions, and blood disorders. Clinical trials accounted for about half.

The National Cancer Institute — which is the largest of the NIH’s 27 institutes and has been crippled by cuts and chaos this year — typically has the most patients needing inpatient care, Gilman said.

“What has happened here since January has been a pretty traumatic time for that ecosystem,” he said, “and there are pieces of it that will take a long time to rebuild, if indeed they get a chance to rebuild.”

During the May board meeting, Aiyelawo said NIH Director Jay Bhattacharya “is very aware” that fewer people are getting treated at the hospital “and we’re doing everything we can to be able to get those numbers up.”

The drop in patients this year isn’t isolated to people needing inpatient care, NIH documents show. As of the end of April, outpatient visits were down 8.5% from the same period in the prior fiscal year. The number of new patients overall had declined by 6.7%, to about 3,370 people.

In response to questions, HHS spokesperson Andrew Nixon wrote in an emailed statement that the clinical center “remains fully operational and continues to provide world-class clinical research and patient care. Every day, patients from across the country and around the globe come here to participate in cutting-edge studies that drive scientific discovery and improve health outcomes.”

“As the crown jewel of research and discovery, the Clinical Center is a top priority” under Bhattacharya’s leadership, Nixon said. “We are committed to fully leveraging its capabilities as the nation’s hub for clinical research innovation. Our focus remains on empowering the research community and advancing the critical mission of making medical breakthroughs possible right here on the NIH campus.”

Even before President Donald Trump began his second term, the hospital had struggled with lagging patient numbers. Before the pandemic, it averaged more than 110 patients daily. Those numbers plummeted starting in 2020, government documents show. During the 2022 fiscal year,  there were about 73 patients, on average, in the hospital per day.

While yearly figures have increased since then, they have not gone back to pre-pandemic levels. NIH documents show that the hospital saw an average of roughly 81 patients a day during fiscal 2024, which ended in September. Still, one NIH worker said: “This is a manufactured crisis. Covid was not.”

The federal government has also moved to tighten rules surrounding visitors from abroad, which likely limits how many people living in the U.S. without legal status would come to the NIH for care.

Before Trump, officials developed a new visitor policy for the NIH that required people who aren’t U.S. citizens or legal permanent residents to register online before arriving. But its implementation was delayed, Gilman said. It did not launch until late January, after President Joe Biden was no longer in office and around the time the Trump administration began its deportation operation.

The Department of Homeland Security has carried out widespread raids and arrests and allowed immigration authorities unprecedented access to various federal data sources — including tax information and Medicaid recipients’ personal data — as part of its immigration enforcement efforts.

The clinical center’s most recent annual report said around 600 patients in 2024 were from abroad.

Now “international patients are terrified to come,” said one recently departed clinician. “They don’t know what will happen to them.”

Are you a cancer patient whose care at the National Institutes of Health Clinical Center in Maryland, or another hospital, has been affected by the Trump administration’s cuts? Are you a family member or caregiver of a cancer patient who has received care at the NIH? We’d like to hear about your experience. Tell us here.

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.

USE OUR CONTENT

This story can be republished for free (details).