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By Jariel Arvin, KFF Health News

On Fridays, Stephanie Johnson has a busy schedule, driving her navy-blue Jeep from one patient’s home to the next, seeing eight in all. Pregnant with her second child, she schleps a backpack instead of a traditional black bag to carry a laptop and essential medical supplies — stethoscope, blood pressure cuff, and pulse oximeter.

Forget a lunch break; she often eats a sandwich or some nuts as she heads to her next patient visit.

On a gloomy Friday in January, Johnson, a nurse practitioner who treats older adults, had a hospice consult with Ellen, a patient in her 90s in declining health. To protect Ellen’s identity, KFF Health News is not using her last name.

“Hello. How are you feeling?” Johnson asked as she entered Ellen’s bedroom and inquired about her pain. The blinds were drawn. Ellen was in a wheelchair, wearing a white sweater, gray sweatpants, and fuzzy socks. A headband was tied around her white hair. As usual, the TV was playing loudly in the background.

“It’s fine, except this cough I’ve had since junior high,” Ellen said.

Ellen had been diagnosed with vascular dementia, peripheral vascular disease, and Type 2 diabetes. Last fall, doctors made the difficult decision to operate on her foot. Before the surgery, Ellen was always colorful, wearing purple, yellow, blue, pink, and chunky necklaces. She enjoyed talking with the half dozen other residents at her adult family home in Washington state. She had a hearty appetite that brought her to the breakfast table early. But lately, her enthusiasm for meals and socializing had waned.

Johnson got down to eye level with Ellen to examine her, assessing her joints and range of motion, checking her blood pressure, and listening to her heart and lungs.

Carefully, Johnson removed the bandage to examine Ellen’s toes. Her lower legs were red but cold to the touch, which indicated her condition wasn’t improving. Ellen’s two younger sisters had power of attorney for her and made it clear that, above all, they wanted her to be comfortable. Now, Johnson thought it was time to have that difficult conversation with them about Ellen’s prognosis, recommending her for hospice.

“Our patient isn’t just the older adult,” Johnson said. “It’s also often the family member or the person helping to manage them.”

Nurse practitioners are having those conversations more and more as their patient base trends older. They are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines. The Health Resources and Services Administration projects a 50% increase in demand for geriatricians from 2018 to 2030, when the entire baby boom generation will be older than 65. By then, hundreds of geriatricians are expected to retire or leave the specialty, reducing their number to fewer than 7,600, with relatively few young doctors joining the field.

That means many older adults will be relying on other primary care physicians, who already can’t keep up with demand, and nurse practitioners, whose ranks are booming. The number of nurse practitioners specializing in geriatrics has more than tripled since 2010, increasing the availability of care to the current population of seniors, a recent study in JAMA Network Open found.

According to a 2024 survey, of the roughly 431,000 licensed nurse practitioners, 15% are, like Johnson, certified to treat older adults.

Johnson and her husband, Dustin, operate an NP-led private practice in greater Seattle, Washington, a state where she can practice independently. She and her team, which includes five additional nurse practitioners, each try to see about 10 patients a day, visiting each one every five to six weeks. Visits typically last 30 minutes to an hour, depending on the case.

“There are so many housebound older adults, and we’re barely reaching them,” Johnson said. “For those still in their private homes, there’s such a huge need.”

Laura Wagner, a professor of nursing and community health systems at the University of California-San Francisco, stressed that nurse practitioners are not trying to replace doctors; they’re trying to meet patients’ needs, wherever they may be.

“One of the things I’m most proud of is the role of nurse practitioners,” she said. “We step into places where other providers may not, and geriatrics is a prime example of that.”

Practice limits

Nurse practitioners are registered nurses with advanced training that enables them to diagnose diseases, analyze diagnostic tests, and prescribe medicine. Their growth has bolstered primary care, and, like doctors, they can specialize in particular branches of medicine. Johnson, for example, has advanced training in gerontology.

“If we have a geriatrician shortage, then hiring more nurse practitioners trained in geriatrics is an ideal solution,” Wagner said, “but there are a lot of barriers in place.”

In 27 states and Washington, D.C., nurse practitioners can practice independently. But in the rest of the country, they need to have a collaborative agreement with or be under the supervision of another health care provider to provide care to older adults. Medicare generally reimburses for nurse practitioner services at 85% of the amount it pays physicians.

Last year, in more than 40 states, the American Medical Association and its partners lobbied against what they see as “scope creep” in the expanded roles of nurse practitioners and other health workers. The AMA points out that doctors must have more schooling and significantly more clinical experience than nurse practitioners. While the AMA says physician-led teams keep costs lower, a study published in 2020 in Health Services Research found similar patient outcomes and lower costs for nurse practitioner patients. Other studies, including one published in 2023 in the journal Medical Care Research and Review, have found health care models including nurse practitioners had better outcomes for patients with multiple chronic conditions than teams without an NP.

Five states have granted NPs full practice authority since 2021, with Utah the most recent state to remove physician supervision requirements, in 2023. In March, however, Mississippi House Bill 849, which would have increased NP independence, failed. Meanwhile, 30 Texas physicians rallied to tamp down full-scope efforts in Austin.

“I would fully disagree that we’re invading their scope of practice and shouldn’t have full scope of our own,” Johnson said.

She has worked under the supervision of physicians in Pennsylvania and Washington state but started seeing patients at her own practice in 2021. Like many nurse practitioners, she sees her patients in their homes. The first thing she does when she gets a new patient is manage their prescriptions, getting rid of unnecessary medications, especially those with harsh side effects.

She works with the patient and a family member who often has power of attorney. She keeps them informed of subtle changes, such as whether a person was verbal and eating and whether their medical conditions have changed.

While there is some overlap in expertise between geriatricians and nurse practitioners, there are areas where nurses typically excel, said Elizabeth White, an assistant professor of health services, policy, and practice at Brown University.

“We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs. That’s very much in the nursing domain,” she said.

That care coordination will become even more critical as the U.S. ages. Today, about 18% of the U.S. population is 65 or over. In the next 30 years, the share of seniors is expected to reach 23%, as medical and technological advances enable people to live longer.

Patient and family

In an office next to Ellen’s bedroom, Johnson called Ellen’s younger sister Margaret Watt to recommend that Ellen enter hospice care. Johnson told her that Ellen had developed pneumonia and her body wasn’t coping.

Watt appreciated that Johnson had kept the family apprised of Ellen’s condition for several years, saying she was a good communicator.

“She was accurate,” Watt said. “What she said would happen, happened.”

A month after the consult, Ellen died peacefully in her sleep.

“I do feel sadness,” Johnson said, “but there’s also a sense of relief that I’ve been with her through her suffering to try to alleviate it, and I’ve helped her meet her and her family’s priorities in that time.”

Jariel Arvin is a reporter with the Investigative Reporting Program at the University of California-Berkeley Graduate School of Journalism. He reported this article through a grant from The SCAN Foundation .

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

By CATHY BUSSEWITZ, Staff Writer

NEW YORK (AP) — Jeremy Didier had taken her son to a psychologist for a possible ADHD evaluation when she spotted an article about women with the condition. As she read it in the waiting room, she thought to herself: They’re describing me.

“Lots of risk-taking, lots of very impulsive behavior growing up,” Didier said. As the magazine described, she’d excelled in school but gotten in trouble for talking too much. She’d amassed too many speeding tickets as an adult. She turned to her husband and said, “I think I might have ADHD.”

Didier is now the board president of Children and Adults with Attention-Deficit/Hyperactivity Disorder, a nonprofit advocacy and support organization. Her realization mirrors the experiences of other adults who wonder if they have ADHD after a child’s diagnosis.

Attention-deficit/hyperactivity disorder is a neurodevelopmental condition characterized by inattention, hyperactivity or a combination of the two. Common symptoms such as trouble concentrating or sitting still can create challenges at work.

People with ADHD are often passed over for promotions, said Andrew Sylvester, a psychiatrist at UCHealth, a hospital in Longmont, Colorado. Difficulties with attention may lead the mind to drift during meetings, and cause someone to miss important discussion nuances. The disorder may interfere with organization, planning and remembering details.

Yet some adults think of having ADHD as a source of personality strengths and ways of thinking that benefit employers. Diagnostic manuals may call it a disorder, but it also can be a superpower, they said.

“Our brains work differently and so we’re more likely to be able to think outside the box and come up with different things, and sometimes that’s because we’ve had to do that in order to to survive,” Didier said.

Here are some ways to cope with and channel ADHD in the workplace.

Finding community

Getting diagnosed with ADHD doesn’t always lead to a quick fix. While doctors often recommend medication and therapy, not everyone can take medication, and those routes don’t necessarily eliminate all symptoms.

Didier floundered with a messy house and lots of yelling as she and four of her five children were diagnosed with ADHD. She experimented with medicine, diets and reward charts, and discovered what helped her the most: a community of parents who had children with ADHD.

“There’s nothing like talking to other people who are going through what you’re going through to help you feel … that you’re not alone,” she said.

Didier eventually became a social worker and now runs support groups for adults with ADHD, teaching skills they can use at work.

Some organizations have employee resource groups organized around neurodiversity to provide camaraderie and support to adults with ADHD, autism, dyslexia and other conditions.

GPS of the brain

People with ADHD often struggle with executive function, which Didier describes as “your brain’s GPS” for navigating your day. Executive function is a set of mental skills that includes making plans, managing time and flexible thinking. It also includes working memory, which helps us keep track of what we’re doing.

To keep from getting derailed, experts recommend breaking large tasks into chunks, writing detailed to-do lists and taking breaks.

Personal chef Bill Collins, 66, who was diagnosed with ADHD two years ago, writes structured lists when he’s making a meal for a client. He creates categories for kitchen areas — counter, stove and oven — and then lists tasks such as “chop carrots, boil water for pasta” underneath each category. Then he numbers each task so he knows exactly what to do, where and when.

“That’s how I got around my unknown ADHD early on, just making lists,” Collins said. “If it’s something I don’t want to do, I put it at the top of the list so I can be done with it.”

Another technique is called “body doubling,” which involves a pair of work colleagues meeting over Zoom or in-person to focus on completing projects. The two may choose to perform separate tasks — one might build a presentation deck while the other files tax reports — but help each other stay accountable.

“You’re just sitting there during that dedicated time, getting things done,” Didier said.

Insurance company Liberty Mutual provides an AI tool that helps break down large projects into manageable tasks and provides reminders about deadlines, to help employees with ADHD stay focused and organized, said Head of Benefits Verlinda DiMarino.

Getting through meetings

Meetings can be difficult for people with ADHD if their minds drift or they feel an urge to get up out of a chair. They also may struggle with impulse control and find it hard to wait their turn to speak.

Nicole Clark, CEO of the Adult and Pediatric Institute, a mental health practice in Stuart, Florida, suggests asking for meeting topics in advance and writing up talking points. If you think of questions during the meeting, write them down.

Some employers use a voice-to-text service, projecting what a speaker is saying on a screen, which helps people with attention difficulties stay focused, Clark said.

Sylvester, the psychiatrist, recommends practicing active listening by repeating in your head what someone just said, or taking a brief time-out from a meeting to reset.

Tell them, “’I need five minutes. I’ll be right back.’ Get up and walk out. Do what you need to do,” he said.

Mariel Paralitici-Morales, chief medical officer of the Adult and Pediatric Institute, who has ADHD, sits close to whoever will be speaking to help sustain attention.

“Having something in my hand helps,” said Paralitici-Morales, who sometimes holds a fidget spinner. “If we have to talk, I found it’s easier for me to be the first one and break the ice” to keep herself from second-guessing what she planned to say.

Seek accommodations

People with an ADHD diagnosis can request accommodations at work through the Americans with Disabilities Act. Noise-canceling headphones may help. Consider asking for the ability to take a break every 20 minutes, Sylvester said.

“Set a timer for five to 10 minutes. Get up and walk around. Make some coffee. Go play with the dog,” he said. “When that timer goes off, go back to a 15 to 20 minute hard productivity cycle.”

Employees can also request a flexible schedule or ability to work from home, which can enable time for therapy or self-care.

Antoinette Damico, 23, who coordinates events at an executive search firm in San Francisco, said she practices meditation, writes daily goals in a journal and stays off short-form media to improve her concentration.

Celebrate your strengths

Having ADHD can be an asset in the workplace, and many CEOs and entrepreneurs are neurodiverse, Didier said.

“We bring all kinds of unique talents to our workplaces. Hyper-focus, lots of energy, resilience, the ability to multitask,” she added. “There’s something about people with ADHD that seems to unmask or give us a greater capacity for creativity and innovation.”

Damico also thinks her ADHD provides some advantages. When she’s interested in a topic, she can be extremely focused, reading extensively and talking about the topic nonstop, a trait others with ADHD report.

“It can generate a real passion in you that is a bit unique,” she said. “It really creates this grit in me in terms of when I really want to accomplish something, there’s this boost of energy.”

Share your stories and questions about workplace wellness at cbussewitz@ap.org. Follow AP’s Be Well coverage, focusing on wellness, fitness, diet and mental health at https://apnews.com/hub/be-well

A judge is set to decide whether low-level radioactive material left over from the creation of the first atomic bomb can find its forever home in a metro Detroit landfill.

The state of New York wants to send about 6,000 cubic yards of tainted soil and 4,000 gallons of contaminated groundwater to a waste disposal site near Belleville, Michigan.

It’s one of a handful in the country licensed to dispose of such waste.

Communities near the site, including Canton Township, filed a lawsuit to stop shipments of the toxic material from New York.

Canton Township Supervisor Anne Marie Graham-Hudak says the suit kept those remnants of the Manhattan Project out of Michigan so far. But not other contaminated material.

Listen: Graham-Hudak on keeping toxic waste out of Michigan landfill

The following interview has been edited for clarity and length.

Anne Marie Graham-Hudak: At this time, we still have this kind of waste coming into Michigan, whether it be into the injection well in Romulus or into the Wayne disposal site. But we’re hoping this lawsuit helps us launch some precedents to stop that.

Quinn Klinefelter, WDET News: But the specific one from New York has not come yet?

AMH: No. And it was supposed to start coming basically in January. So we’re glad that we were able to stop it. We met with the judge, the hearing was in May and the judge is scheduled to make a ruling on July 2. We hope that happens. We’ve been working also with Michigan state Sen. Darrin Camilleri (D-Trenton) and state Rep. Reggie Miller (D-Van Buren Twp). They have two bills that are going to increase tipping fees, amongst many other things.

“The EPA were saying that this was safe. Our question was, ‘If this is so safe, why is it being moved? Why don’t you just mitigate it in place?’ And that’s still what we’re questioning.”

– Anne Marie Graham-Hudak, Canton Township supervisor

Our tipping fees are one of the lowest in the nation. We’re at roughly 36 cents a ton, so we’re basically inviting people to come dump into Michigan. In other states you’re looking at $13 a ton — that just exacerbates what we already have. And at some point our landfills will be full and we will be looking for other places. The Canton landfill maybe has five years left. The EPA were saying that this was safe. Our question was, “If this is so safe, why is it being moved? Why don’t you just mitigate it in place?” And that’s still what we’re questioning. Radioactive waste in the body is absorbed and it’s additive, so if you live near where they’re dumping it, that’s a problem.

Also, Michigan has 21% of the world’s fresh water, and we’re putting this in a dense area. They’ve got schools nearby. The groundwater takes it out to the Rouge River, which takes it to the Detroit River, which takes it out to the Great Lakes. So why are we even thinking of putting it there? Also, they’re going to store the waste in what they call “burritos.” They wrap the waste in these plastic burritos and then come here and bury it and put a cap on it. But they could not even guarantee that the plastic they’re going to wrap it in will match the half-life of some of this radioactive dirt. I’m a retired engineer. One of the things that I worked on before I left Ford Motor Company was electromagnetic radiation — that was actually one of my favorite classes in college. And they can’t guarantee how this waste will stay encompassed in this plastic. There’s no test on this plastic that had been done to see that. I think their guidelines are way too narrow. But they’re going to keep dumping it, which makes it additive, and it doesn’t go away. It’s a constant radiation.

QK: So you don’t trust what the agencies or the company are saying about this?

AMH: Correct. I do not trust it. I think some of the guidelines that have been made in Michigan, especially, are leaning more towards favoring companies. We’re an automotive area and we know that we’ve got PFAS. We know that, in the early days, automotive companies would dump (material.) There’s brownfields here for a reason, because companies dumped. And I really believe that some of our land is contaminated. I think our guidelines in Michigan are way too low. They protect companies more than they do our residents. This is a public health issue, it really is.

QK: So what remedy would you seek at this point?

AMH: That we stop this. State Sen. Darrin Camilleri’s bill actually states that we just stop everything from coming in. We do more studies and more testing. We do not allow any more radioactive waste to come into Michigan. We do not allow any more new sites to be established. I know a lot of the businesses are concerned about this, but if you look at it, even hospitals generate radioactive waste. They do X-rays, MRI’s, things like that. So how do we mitigate in place what we have instead of transporting it? I don’t think we should be transporting it. Quit thinking about kicking things down the road and saying, “Oh, hey, we’re just gonna keep doing this. We’re gonna keep making nuclear reactors and we’ll just keep burying it, not really thinking about what’s going to happen in the future.” I think that we’ve done that for too long and too haphazardly. Our limits need to be looked at. I think that they’re more pro-business than they are pro-public health. That is my biggest concern.

QK: So that’s what you would hope to have happen. You’ve been dealing with this issue for a while now. What do you think is within the realms of reality?

AMH: I think if we want it to be more in the business of reality it can be. Look at the concerns raised by the agencies, the mayors and supervisors and the townspeople. That’s why we have this injunction, that’s why we’re trying to push this legislation through. The U.S. Chamber of Commerce needs to take a look at things a little bit more. Let’s just talk about changing tipping fees. They’re saying they don’t agree with that. But we’re just a dumping state based on 36 cents a ton.

QK: If the disposal company comes back and says, “We’re licensed to do this. As you say, hospitals and other places keep making this kind of material. This site is allowed to take it and we’ve got to put it somewhere. So why not here?” How would you answer them back?

AMH: My answer is that we need to study this even more. I can understand that we have to decide what to do with Michigan’s waste, where this is happening. But taking outside waste, it just gives us less space to figure out what to do with our own. And it also is in a densely populated area. There is an interstate commerce clause that does not allow us to stop. There would have to be a constitutional change on the federal level also, because this is considered trading commerce and money.

QK: Have you ever had much reaction back from the federal government on this entire topic, no matter which administration was running it at the time?

AMH: Not really. They keep pointing to the interstate commerce clause. People always say it’s hard to change a constitution and it will never happen. But the U.S. Supreme Court just changed some things that were in the Constitution for 50 years. So I think it’s a possibility. I think the need is there. The want has to make it happen.

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The Trump administration continued to reshape U.S. health policy in recent days with several moves that could change what vaccines people can get to protect themselves from common illnesses.

Some of the changes are immediate, others are still being discussed, and Health Secretary Robert F. Kennedy Jr. must still sign off on some.

Doctors’ groups have expressed alarm at the moves made by Kennedy, a longtime anti-vaccine activist, and his appointees, who at times have ignored well-established science. Nearly 80 medical groups, including the American Medical Association, issued a statement backing vaccines against common respiratory ailments as “among the best tools to protect the public.”

“We come together as physicians from every corner of medicine to reaffirm our commitment to these lifesaving vaccines,” the groups wrote.

Here’s what to know about some of the recent vaccine policy changes:

Flu shots and thimerosal

On Thursday, a vaccine advisory group handpicked by Kennedy recommended that just about every American get a flu shot this fall.

But the group also said people should avoid shots containing thimerosal, a preservative used only in large multi-dose vials that has been proven to be safe. The ingredient isn’t used in single-dose flu shots, the type of syringe used for about 95% of U.S. flu shots last season.

Status: Kennedy must sign off on the recommendations. Read more AP coverage here.

How to get a COVID-19 shot

Universal access to updated COVID-19 shots for the fall remains unclear, even after Kennedy’s vaccine advisers were shown data showing how well the vaccines are working.

Kennedy changed CDC guidance last month, saying the shots are no longer recommended for healthy children and pregnant women — even though doctors groups disagree. And the Food and Drug Administration has moved to limit COVID-19 vaccinations among healthy people under age 65.

Status: Upcoming advisory meetings, regulatory decisions and policies from insurers and employers are likely to influence access. Read more AP coverage here.

Expanded warnings on COVID-19 vaccine labels

At the request of the FDA, makers of the two leading COVID-19 vaccines on Wednesday expanded existing warnings about a rare heart side effect mainly seen in young men.

Prescribing information from both Pfizer and Moderna had already advised doctors about rare cases of myocarditis, a type of heart inflammation that is usually mild. The FDA had asked the drugmakers to add more detail about the problem and to cover a larger group of patients.

Status: Labels are being updated now. Read more AP coverage here.

Changes considered for the childhood vaccine schedule

On Wednesday, Kennedy’s vaccine advisers said they would be evaluating the “cumulative effect” of the children’s vaccine schedule — the list of immunizations given at different times throughout childhood.

The announcement reflected vaccine skeptics’ messaging: that too many shots may overwhelm kids’ immune systems. Scientists say those claims have been repeatedly investigated with no signs of concern.

The American Academy of Pediatrics said it would continue publishing its own vaccine schedule for children but now will do so independently of the government advisory panel, calling it “no longer a credible process.”

Status: The examination is in its early stages. Read more AP coverage here.

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.

By Paula Span, KFF Health News

Kim Beckham, an insurance agent in Victoria, Texas, had seen friends suffer so badly from shingles that she wanted to receive the first approved shingles vaccine as soon as it became available, even if she had to pay for it out-of-pocket.

Her doctor and several pharmacies turned her down because she was below the recommended age at the time, which was 60. So, in 2016, she celebrated her 60th birthday at her local CVS.

“I was there when they opened,” Beckham recalled. After getting her Zostavax shot, she said, “I felt really relieved.” She has since received the newer, more effective shingles vaccine, as well as a pneumonia shot, an RSV vaccine to guard against respiratory syncytial virus, annual flu shots and all recommended COVID-19 vaccinations.

Some older people are really eager to be vaccinated.

Robin Wolaner, 71, a retired publisher in Sausalito, California, has been known to badger friends who delay getting recommended shots, sending them relevant medical studies. “I’m sort of hectoring,” she acknowledged.

Deana Hendrickson, 66, who provides daily care for three young grandsons in Los Angeles, sought an additional MMR shot, though she was vaccinated against measles, mumps, and rubella as a child, in case her immunity to measles had waned.

For older adults who express more confidence in vaccine safety than younger groups, the past few months have brought welcome research. Studies have found important benefits from a newer vaccine and enhanced versions of older ones, and one vaccine may confer a major bonus that nobody foresaw.

The new studies are coming at a fraught political moment. The nation’s health secretary, Robert F. Kennedy Jr., has long disparaged certain vaccines, calling them unsafe and saying that the government officials who regulate them are compromised and corrupt.

On June 9, Kennedy fired a panel of scientific advisers to the Centers for Disease Control and Prevention, and later replaced them with some who have been skeptical of vaccines. But so far, Kennedy has not tried to curb access to the shots for older Americans.

The evidence that vaccines are beneficial remains overwhelming.

The phrase “Vaccines are not just for kids anymore” has become a favorite for William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center.

“The population over 65, which often suffers the worst impact of respiratory viruses and others, now has the benefit of vaccines that can prevent much of that serious illness,” he said.

Take influenza, which annually sends from 140,000 to 710,000 people to hospitals, most of them seniors, and is fatal to 10% of hospitalized older adults.

For about 15 years, the CDC has approved several enhanced flu vaccines for people 65 and older. More effective than the standard formulation, they either contain higher levels of the antigen that builds protection against the virus or incorporate an adjuvant that creates a stronger immune response. Or they’re recombinant vaccines, developed through a different method, with higher antigen levels.

In a meta-analysis in the Journal of the American Geriatrics Society, “all the enhanced vaccine products were superior to the standard dose for preventing hospitalizations,” said Rebecca Morgan, a health research methodologist at Case Western Reserve University and an author of the study.

Compared with the standard flu shot, the enhanced vaccines reduced the risk of hospitalization from the flu in older adults, by at least 11% and up to 18%. The CDC advises adults 65 and older to receive the enhanced vaccines, as many already do.

More good news: Vaccines to prevent respiratory syncytial virus in people 60 and older are performing admirably.

RSV is the most common cause of hospitalization for infants, and it also poses significant risks to older people. “Season in and season out,” Schaffner said, “it produces outbreaks of serious respiratory illness that rivals influenza.”

Because the FDA first approved an RSV vaccine in 2023, the 2023-24 season provided “the first opportunity to see it in a real-world context,” said Pauline Terebuh, an epidemiologist at Case Western Reserve School of Medicine and an author of a recent study in the journal JAMA Network Open.

In analyzing electronic health records for almost 800,000 patients, the researchers found the vaccines to be 75% effective against acute infection, meaning illness that was serious enough to send a patient to a health care provider.

The vaccines were 75% effective in preventing emergency room or urgent care visits, and 75% effective against hospitalization, both among those ages 60 to 74 and those older.

Immunocompromised patients, despite having a somewhat lower level of protection from the vaccine, will also benefit from it, Terebuh said. As for adverse effects, the study found a very low risk for Guillain-Barré syndrome, a rare condition that causes muscle weakness and that typically follows an infection, in about 11 cases per 1 million doses of vaccine. That, she said, “shouldn’t dissuade people.”

The CDC now recommends RSV vaccination for people 75 and older, and for those 60 to 74 if they’re at higher risk of severe illness (from, say, heart disease).

As data from the 2024-25 season becomes available, researchers hope to determine whether the vaccine will remain a one-and-done, or whether immunity will require repeated vaccination.

People 65 and up express the greatest confidence in vaccine safety of any adult group, a KFF survey found in April. More than 80% said they were “very “or “somewhat confident” about MMR, shingles, pneumonia, and flu shots.

Although the COVID vaccine drew lower support among all adults, more than two-thirds of older adults expressed confidence in its safety.

Even skeptics might become excited about one possible benefit of the shingles vaccine: This spring, Stanford researchers reported that over seven years, vaccination against shingles reduced the risk of dementia by 20%, a finding that made headlines.

Biases often undermine observational studies that compare vaccinated with unvaccinated groups. “People who are healthier and more health-motivated are the ones who get vaccinated,” said Pascal Geldsetzer, an epidemiologist at the Knight Initiative for Brain Resilience at Stanford and lead author of the study.

“It’s hard to know whether this is cause and effect,” he said, “or whether they’re less likely to develop dementia anyway.”

So the Stanford team took advantage of a “natural experiment” when the first shingles vaccine, Zostavax, was introduced in Wales. Health officials set a strict age cutoff: People who turned 80 on or before Sept. 1, 2013, weren’t eligible for vaccination, but those even slightly younger were eligible.

In the sample of nearly 300,000 adults whose birthdays fell close to either side of that date, almost half of the eligible group received the vaccine, but virtually nobody in the older group did.

“Just as in a randomized trial, these comparison groups should be similar in every way,” Geldsetzer explained. A substantial reduction in dementia diagnoses in the vaccine-eligible group, with a much stronger protective effect in women, therefore constitutes “more powerful and convincing evidence,” he said.

The team also found reduced rates of dementia after shingles vaccines were introduced in Australia and other countries. “We keep seeing this in one dataset after another,” Geldsetzer said.

In the United States, where a more potent vaccine, Shingrix, became available in 2017 and supplanted Zostavax, Oxford investigators found an even stronger effect.

By matching almost 104,000 older Americans who received a first dose of the new vaccine (full immunization requires two) with a group that had received the earlier formulation, they found delayed onset of dementia in the Shingrix group.

How a shingles vaccine might reduce dementia remains unexplained. Scientists have suggested that viruses themselves may contribute to dementia, so suppressing them could protect the brain. Perhaps the vaccine revs up the immune system in general or affects inflammation.

“I don’t think anybody knows,” said Paul Harrison, a psychiatrist at Oxford and a senior author of the study. But, he added, “I’m now convinced there’s something real here.”

Shingrix, now recommended for adults over 50, is 90% effective in preventing shingles and the lingering nerve pain that can result. In 2021, however, only 41% of adults 60 and older had received one dose of either shingles vaccine.

A connection to dementia will require further research, and Geldsetzer is trying to raise philanthropic funding for a clinical trial.

And “if you needed another reason to get this vaccine,” Schaffner said, “here it is.”

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

By Melissa Nann Burke, The Detroit News

Michigan hospitals would take an estimated hit of more than $1 billion a year if a Medicaid cut proposed in the Republican-led U.S. Senate this week were to become law, according to the industry group that represents them.

Hospitals across Michigan already operate on average with a negative margin, and some ― especially rural facilities with higher shares of low-income patients on Medicaid ― are likely to reduce services and staff or even shut their doors under the proposal, according to the Michigan Health & Hospital Association.

“What’s in the Senate version, I want to be very clear, is specifically cutting Medicaid. It’s not addressing waste, fraud and abuse,” said Laura Appel, MHA’s executive vice president for government relations and public policy, in a dig at Republicans’ messaging on Medicaid reforms.

“It’s cutting the funding that Michigan uses ― as do 48 other states ― to support Medicaid,” the government health care program for mostly low-income residents.

Appel was referring to a provision in the Senate Finance Committee’s proposed version of President Donald Trump’s so-called “one big beautiful bill” that would gradually shrink states’ use of so-called provider taxes from a safe-harbor threshold of 6% to 3.5% by 2031. The Medicaid reforms are part of a larger tax cut and spending bill that is the cornerstone of Trump’s second-term agenda.

The $1 billion impact that the Michigan hospitals group has estimated is specific to the GOP-run Senate’s changes. It doesn’t account for a projected spike in uncompensated care that hospitals would encounter due to coverage losses as a result of other provisions in the legislation, such as expanded Medicaid work requirements and twice-annual eligibility assessments for Medicaid participants.

“We’re going to keep pushing right up until the very last vote to protect coverage and funding, because cutting funding is cutting coverage is cutting care,” Appel said. “We’re going to keep taking care of people. But it’s already hard enough. Let’s not make it harder for people to get the care that they need.”

Senate Majority Leader John Thune, a South Dakota Republican, said Tuesday that reducing the Medicaid provider tax rate that states may charge represents “important reforms.”

“We think they rebalance the program in a way that provides the right incentives to cover the people who are supposed to be covered by Medicaid,” Thune said.

“But we continue to hear from our members specifically on components or pieces of the bill that they would like to see modified or changed or have concerns about. And we’re working through that.”

Pressure to rein in Medicaid use

Medicaid is a health insurance safety net for low-income adults and children funded jointly by the states and the federal government. Every state except Alaska imposes provider taxes to help finance the state share of Medicaid costs.

Michigan uses provider taxes ― with federal approval ― on hospitals, nursing homes, ambulance companies and health insurers (managed care organizations) to generate 20% or $3 billion of the state’s share of Medicaid program costs. The extra tax leads to higher payments from the U.S. government, which critics argue is a loophole that lets states abuse the system and swell enrollment in the program.

In a report last month, the state health department said Michigan’s hospital provider tax was projected to generate enough revenue in fiscal year 2025 to support $5.84 billion in Medicaid payments to Michigan hospitals, including the federal matching funds that the tax revenue draws down.

But if the hospital provider tax were limited to 3%, reimbursement payments to Michigan hospitals would decline $2.33 billion, according to estimates by the Michigan Department of Health and Human Services. (The state hasn’t provided a revised estimate based on the 3.5% limit proposed by the Senate.)

Michigan is one of 22 states that could be required to lower their provider taxes on hospitals or health plans because their rates are currently more than 5.5% of patient revenues, according to an analysis by the Kaiser Family Foundation. So Michigan hospitals would feel the impact of the new limits almost immediately if the provision goes into effect in 2027.

The reduced provider tax limits only apply to states like Michigan that have expanded Medicaid. Some experts view the change as a way for Congress to pressure these states to drop their expansions, rather than face the drastic cuts to provider taxes that would devastate state budgets.

“States are going to be in a bind: Either raise other taxes ― income taxes, sales taxes ― or they’re going to cut other parts of the budget like K-12 education or most likely make big cuts to their Medicaid program,” said Edwin Park, a research professor and Medicaid policy expert at Georgetown University’s McCourt School of Public Policy.

“This is an attempt to really roll back the Medicaid expansion,” Park said. “The clear intent is to undermine financing of the program.”

Michigan expanded Medicaid eligibility under Republican Gov. Rick Snyder in 2014. The Medicaid program known as Healthy Michigan currently enrolls 749,000 low-income adults, according to state figures. Overall, Medicaid provides health care coverage to more than 1 in 4 people in Michigan, totaling 2.6 million beneficiaries, including 1 million children, according to state data.

Michigan House Speaker Matt Hall, R-Richland Township, last week embraced the proposed federal spending cuts to Medicaid and food assistance, despite their potential to blow a $3 billion hole in the state budget.

“I can’t force (Democratic Gov. Gretchen) Whitmer’s administration … to spend tax dollars wisely,” Hall said at the White House.

“But President Trump and the Congress can, because they’re the ones who are entrusting her with the dollars. So if they just pay out accurately and don’t pay out fraud, they won’t get penalized.”

That kind of language grinds on J.J. Hodshire, president and CEO of Hillsdale Hospital, who is “disgusted” by lawmakers claiming that the average Medicaid participant is a 27-year-old man playing video games in his parents’ basement. In his rural south-central Michigan community, Medicaid covers the pastor of a local church, farmers, pregnant moms and grocery-store workers ― the working poor, Hodshire said.

“This is me speaking as a Republican. This is me speaking as someone who has supported his party, but you’re also talking to someone who has been on the recipient side of Medicaid growing up one of seven children of my parents, when we were on Medicaid,” Hodshire said.

“This notion that Medicaid is for the lazy or those that are refusing to work isn’t true,” he added.

Hodshire estimated that the Senate’s proposal to limit provider tax rates would result in his hospital losing $6 million a year in reimbursement payments. That amount would reduce services at Hillsdale Hospital, and he predicted that it would result in hospital or program closures in some communities.

“Board rooms across this country are gonna have to make tough decisions. One side might say, ‘They’re just fear-mongering that you’re going to lose your Medicaid. You’re not going to lose your Medicaid,’” Hodshire said. “That might be true. But where are they going to get those services if their local hospital is closed?”

More revenue losses

The Senate’s proposal keeps language that passed the U.S. House in late May that would freeze states’ provider taxes and prohibit certain types of taxes because of how they’re structured using variable rates.

Michigan’s Insurance Provider Assessment (IPA) tax generates about $450 million a year toward the state’s base Medicaid costs, according to the Michigan Department of Health and Human Services, and would be prohibited under the GOP’s proposal, posing another hit for the state budget.

The Michigan Association of Health Plans has estimated that changing the variable IPA tax to equalize the rate would result in a 300% tax increase on commercial insurance providers in the state ― something that would be passed along to customers through premium increases, said Dominick Pallone, executive director of the industry group representing health insurers.

However, the current bill text makes no provision for states to revise the tax to eliminate the variable rates that are no longer allowed, Georgetown’s Park said.

Michigan and other states are also barred under the legislation from creating a new provider tax or increasing existing taxes to replace the lost revenues.

“It’s a little bit like changing the speed limit and then giving a ticket to somebody who sped before you changed the speed limit,” Pallone said.

A proposed rule from the Centers for Medicare and Medicaid Services also seeks to bar certain provider taxes on managed care plans that lack uniformity in seven states, including Michigan. Neither the legislation nor the proposed rule would guarantee a transition period for the states to adjust.

While Michigan’s health plans would like to see the provider taxes continue, it’s “pretty clear” that Congress won’t allow them to operate as they have in Michigan, Pallone said.

“Now, we’re just really asking for a three-year timetable, so that we can have some very difficult conversations in Lansing about how deep and how broad the cuts to Medicaid will have to be,” Pallone said. “And giving us several years to get there would be helpful.”

On the insurer side, he said, the cuts would likely mean lower reimbursement rates paid to Medicaid providers, which would hit rural hospitals hard and could prompt closures. Health plans would also, where allowed, use more prior authorizations to “squeeze” out low-value care, Pallone said.

“It’s pretty dire consequences here of reducing this without being able to find revenue sources to offset it,” Pallone said.

Gabe Schneider, director of government relations for Munson Healthcare ― the state’s largest rural hospital system ― was in Washington, D.C., lobbying Michigan lawmakers this week, urging them not to support the changes by the Senate Finance Committee, he said.

Munson has eight hospitals across 24 counties in the northern Lower Peninsula — an area that includes 140,000 people who receive insurance through Medicaid, he said.

Schneider said he’s reminding lawmakers that Munson can’t turn away Medicaid patients just because their reimbursement rate is being slashed. That loss of revenue will hurt all patients, he said.

Munson’s medical facilities across northern Michigan include hospitals in Cadillac, Charlevoix, Frankfort, Gaylord, Grayling, Kalkaska, Manistee and Traverse City.

“We are the sole community hospital where we’re at, and so patients can’t just go down the road by 15 minutes and get to another hospital because there are no other hospitals,” Schneider said.

“In rural areas, this really has an outsized impact because we’re talking about services that are really critical for our patients and our communities that we serve.”

Nursing homes hit

Provider taxes on skilled nursing facilities and intermediate care facilities that care for people with disabilities would be exempt from the new limits.

However, Michigan’s provider tax on nursing homes wouldn’t be allowed under the prohibition against differential rates, said Melissa Samuel, president and CEO of the Health Care Association of Michigan, which represents nearly 370 nursing facilities in the state.

“If you’re a state that needs to fix your provider tax after May 1, 2025, you wouldn’t be eligible for the exemption,” Samuel said. “It’s clear that they’re directing us to fix it, but in doing so, it’s almost like you’re being penalized.”

Michigan’s skilled nursing facility tax generates $680 million toward the state budget, according to HCAM. The Senate’s new proposed limit would mean a $120 million cut in reimbursements to skilled nursing facilities, Samuel said.

She anticipated the cut would hit labor and benefits and potentially prompt owners to reduce hours or staff, which would in turn limit the number of patients who could be admitted and cared for.

Like Pallone, the Health Care Association is hoping for a transition period to restructure the provider tax so it can continue to be used in Michigan, Samuel said.

“I know there’s language around ‘fraud’ and ‘misuse’ of the provider tax. But the skilled nursing facility tax came in under (Republican Gov.) John Engler in the ‘90s. It’s very straightforward in the state of Michigan and goes directly into skilled nursing reimbursements,” she said.

“We assume that the restructuring of our provider tax is something we’ll have to do, because it was in both the House and Senate versions. That’s something we’re willing to do. But give us another glide path to do that, so then, how much do we have to close the gap?”

U.S. Sen. Gary Peters, D-Bloomfield Township, said he was “deeply frustrated” that GOP senators are pushing for cuts to Medicaid in their bill and said he’d oppose it.

“The bill would take away health care and food assistance from millions of Americans, and hundreds of thousands of Michiganders, in order to give a tax cut to billionaires,” Peters said in a statement.

“It would increase our nation’s deficit and put our country on worse financial footing, all while hurting hardworking families. I will never vote for a bill that does that.”

By Nada Hassanein, Stateline.org

More American children and teens die from firearms than any other cause, but there are more deaths — and wider racial disparities — in states with more permissive gun policies, according to a new study.

The study, published in the medical journal JAMA Pediatrics on June 9, analyzes trends in state firearm policies and kids’ deaths since 2010, after the landmark U.S. Supreme Court decision in McDonald v. City of Chicago. The ruling struck down the city’s handgun ban, clearing the way for many states to make it easier for people to buy and carry guns.

The study authors split states into three groups: “most permissive,” “permissive” and “strict,” based on the stringency of their firearm policies. Those policies include safe storage laws, background checks and so-called Stand Your Ground laws. The researchers analyzed homicide and suicide rates and the children’s race.

Using statistical methods, the researchers calculated 6,029 excess deaths in the most permissive states between 2011 and 2023, compared with the number of deaths that would have been expected under the states’ pre-McDonald rules. There were 1,424 excess deaths in the states in the middle category.

In total, about 17,000 deaths were expected in the post-decision period, but 23,000 occurred, said lead author Dr. Jeremy Faust, an emergency physician at Brigham and Women’s Hospital in Boston, in an interview.

Among the eight states with the strictest laws, four — California, Maryland, New York and Rhode Island — saw statistically significant decreases in their pediatric firearm death rates. Illinois, which was directly affected by the court’s decision in the McDonald case, and Connecticut saw increases in their rates. In Massachusetts and New Jersey, the changes were not statistically significant.

The rate increased in all but four (Alaska, Arizona, Nebraska and South Dakota) of the 41 states in the two permissive categories. (Hawaii was not included in the study due its low rates of firearm deaths.)

Non-Hispanic Black children and teens saw the largest increase in firearm deaths in the 41 states with looser gun laws. Those youths’ mortality rates increased, but by a much smaller amount, in the states with strict laws.

Experts say the study underscores the power of policy to help prevent firearm deaths among children and teens. The analysis comes less than a month after the release of a federal report on children’s health that purported to highlight the drivers of poor health in America’s children but failed to include anything on firearm injuries — the leading cause of death for children and teens in 2020 and 2021, according to the federal Centers for Disease Control and Prevention.

Trauma surgeon Dr. Marie Crandall, chair of surgery at MetroHealth medical center and a professor at Case Western Reserve University School of Medicine in Cleveland, researches gun violence. She previously practiced at a Jacksonville, Florida, urban trauma unit, where she frequently saw children and teens caught in gun violence.

“When I see children come in with 10 holes in them that I can’t save — that is a loss. That is a completely preventable death, and it is deeply emotionally scarring to have to have those conversations with families when we know, as a society, there are things we could do to de-escalate,” said Crandall, who wasn’t involved in the new study.

In her state of Ohio, firearm death rates among children and teens increased from 1.6 per 100,000 kids in the decade before the McDonald decision to 2.8 after it, according to the study. Ohio was categorized in the group with the most permissive laws.

The study adds to previous research that shows state laws around child access to firearms, such as safe storage and background checks, tend to be associated with fewer child firearm deaths.

“We know that child access prevention decreases unintentional injuries and suicides of children. So having your firearms locked, unloaded, stored separately from ammunition, decreases the likelihood of childhood injuries,” Crandall said. “More stringent regulation of those things also decreases childhood injuries.”

But she said it’s hard to be optimistic about more stringent regulation when the current administration dismisses gun violence as a public health emergency. The Trump administration earlier this year took down an advisory from the former U.S. surgeon general, issued last year, that emphasized gun violence as a public health crisis.

Faust, the lead author of the new study, stressed that firearm injuries and deaths were notably missing from the Make America Healthy Again Commission report on children’s health. He said the failure to include them illustrates the politicization of a major public health emergency for America’s kids.

“It’s hard to take them seriously if they’re omitting the leading cause of death,” Faust said. “They’re whiffing, they’re shanking. They’re deciding on a political basis not to do it. I would say by omitting it, they’re politicizing it.”

Faust and pediatric trauma surgeon Dr. Chethan Sathya, who directs the Center for Gun Violence Prevention at the Northwell Health system in New York, each pointed to the development of car seat laws and public health education, as examples of preventive strategies that helped reduce childhood fatalities. They support a similar approach to curbing youth gun deaths.

“We really have to apply a public health framework to this issue, not a political one, and we’ve done that with other issues in the past,” said Sathya, who wasn’t involved in the study and oversees his hospital’s firearm injury prevention programs. “There’s no question that this is a public health issue.”

In Louisiana, which the study categorized as one of the 30 most permissive states, the child firearm mortality rate increased from 4.1 per 100,000 kids in the pre-McDonald period to 5.7 after it — the nation’s highest rate. The study period only goes to 2023, but the state last year enacted a permitless carry law, allowing people to carry guns in public without undergoing background checks. And just last month, Louisiana legislators defeated a bill that would have created the crime of improper firearm storage.

Louisiana Democratic state Rep. Matthew Willard, who sponsored the safe storage legislation, said during the floor debate that its purpose was to protect children. Louisiana had the highest rate of unintentional shootings by children between 2015 to 2022, according to the research arm of Everytown for Gun Safety, which advocates for stricter gun access. Willard cited that statistic on the floor.

But Republican opponents said Willard’s proposal would infringe on residents’ gun rights and make it more difficult for them to use guns in self-defense.

“Nobody needs to come in our houses and tell us what to do with our guns. I think this is ridiculous,” Republican state Rep. R. Dewith Carrier said during the debate.

Another Republican opponent, state Rep. Troy Romero, said he was concerned that having a firearm locked away would make it harder for an adult to quickly access it.

“If it’s behind a locked drawer, how in the world are you going, at 2 or 3 in the morning, going to be able to protect your family if somebody intrudes or comes into your home?” Romero said.

Gun violence researcher Julia Fleckman, an assistant professor, and her team at Tulane University in New Orleans have started to collect data on the impact of the state’s permitless carry law.

“It places a disproportionate impact on really vulnerable people, really, our most vulnerable people,” Fleckman said, noting kids bear the brunt of legislators’ decisions. “They don’t have a lot of control over this or the decisions we’re making.”

In South Carolina, another one of the most permissive states, the mortality rate increased from 2.3 to 3.9 per 100,000 kids in the time before and after the McDonald decision. South Carolina Democratic state Rep. JA Moore, who lost his adult sister in the 2015 racist shooting that killed nine at a Charleston church, said state policy alone isn’t enough. He implored his colleagues to also examine their perception of guns.

“We have a culture here in South Carolina that doesn’t lend itself to a more safe South Carolina,” said Moore, who added he’s been advocating for background checks and stricter carry laws. “There is a need for a culture change in our state, in our country, when it comes to guns and our relationships with guns as Americans, realizing that these are deadly weapons.”

And investing in safer neighborhoods is crucial, he said.

“People are hurt by guns in places that they’re more comfortable, like their homes in their own neighborhoods,” he said.

Community-based interventions are important to stemming violence, experts said. Crandall, the Cleveland surgeon, said there’s emerging evidence that hospital-based and community-based violence prevention programs decrease the likelihood of violent and firearm-related injury.

Such programs aim to break cycles of violence by connecting injured patients with community engagement services. After New York City implemented its hospital-based violence interruption program, two-thirds of 3,500 violent trauma patients treated at five hospitals received community prevention services.

After her 33-year-old son was killed in her neighborhood in 2019, Michelle Bell started M-PAC Cleveland — “More Prayer, Activity & Conversation” — a nonprofit collaborative of people who have lost loved ones to violent crime. She’s encountered many grieving parents who lost their children to gunfire. The group advocates and educates for safe storage laws and holds peer grief support groups.

She also partners with the school district in a program that shares stories of gun violence’s long-lasting impact on surviving children, families and communities and nonviolent interpersonal conflict resolution.

“Oftentimes, the family that has lost the child, the child’s life has been taken by gun violence, there are other children in the home,” she said.

“It’s so devastating. It’s just so tragic that the No. 1 cause of death for children 18 and under is gun violence,” Bell continued.

The decision to “pull a trigger,” she said, changes a “lifetime of not only yours, but so many other people.”

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

©2025 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

By Anna Claire Vollers, Stateline.org

Nine months after Monroe County Hospital in rural South Alabama closed its labor and delivery department in October 2023, Grove Hill Memorial Hospital in neighboring Clarke County also stopped delivering babies.

Both hospitals are located in an agricultural swath of the state that’s home to most of its poorest counties. Many residents of the region don’t even have a nearby emergency department.

Stacey Gilchrist is a nurse and administrator who’s spent her 40-year career in Thomasville, a small town about 20 minutes north of Grove Hill. Thomasville’s hospital shut down entirely last September over financial difficulties. Thomasville Regional hadn’t had a labor and delivery unit for years, but women in labor still showed up at its ER when they knew they wouldn’t make it to the nearest delivering hospital.

“We had several close calls where people could not make it even to Grove Hill when they were delivering there,” Gilchrist told Stateline shortly after the Thomasville hospital closed. She recalled how Thomasville nurses worked to save the lives of a mother and baby who’d delivered early in their ER, as staff waited for neonatal specialists to arrive by ambulance from a distant delivering hospital.

“It would give you chills to see what all they had to do. They had to get inventive,” she said, but the mother and baby survived.

Now many families must drive more than an hour to reach the nearest birthing hospital.

Nationwide, most rural hospitals no longer offer obstetric services. Since the end of 2020, more than 100 rural hospitals have stopped delivering babies, according to a new report from the Center for Healthcare Quality & Payment Reform, a national policy center focused on solving health care issues through overhauling insurance payments. Fewer than 1,000 rural hospitals nationwide still have labor and delivery services.

Across the nation, two rural labor and delivery departments shut their doors every month on average, said Harold Miller, the center’s president and CEO.

“It’s the perfect storm,” Miller told Stateline. “The number of births are going down, everything is more expensive in rural areas, health insurance plans don’t cover the cost of births, and hospitals don’t have the resources to offset those losses because they’re losing money on other services, too.”

Staffing shortages, low Medicaid reimbursement payments and declining birth rates have contributed to the closures. Some states have responded by changing how Medicaid funds are spent, by allowing the opening of freestanding birth centers, or by encouraging urban-based obstetricians to open satellite clinics in rural areas.

Yet the losses continue. Thirty-six states have lost at least one rural labor and delivery unit since the end of 2020, according to the report. Sixteen have lost three or more. Indiana has lost 12, accounting for a third of its rural hospital labor and delivery units.

In rural counties the loss of hospital-based obstetric care is associated with increases in births in hospital emergency rooms, studies have found. The share of women without adequate prenatal care also increases in rural counties that lose hospital obstetric services.

And researchers have seen an increase in preterm births — when a baby is born three or more weeks early — following rural labor and delivery closures. Babies born too early have higher rates of death and disability.

Births are expensive

The decline in hospital-based maternity care has been decades in the making.

Traditionally, hospitals lose money on obstetrics. It costs more to maintain a labor and delivery department than a hospital gets paid by insurance to deliver a baby. This is especially true for rural hospitals, which see fewer births and therefore less revenue than urban areas.

“It is expensive and complicated for any hospital to have labor and delivery because it’s a 24/7 service,” said Miller.

A labor and delivery unit must always have certain staff available or on call, including a physician who can perform cesarean sections, nurses with obstetric training, and an anesthetist for C-sections and labor pain management.

“There’s a minimum fixed cost you incur (as a hospital) to have all of that, regardless of how many births there are,” Miller said.

In most cases, insurers don’t pay hospitals to maintain that standby capacity; they’re paid per birth. Hospitals cover their losses on obstetrics with revenue they get from more lucrative services.

For a larger urban hospital with thousands of births a year, the fixed costs might be manageable. For smaller rural hospitals, they’re much harder to justify. Some have had to jettison their obstetric services just to keep the doors open.

“You can’t subsidize a losing service when you don’t have profit coming in from other services,” Miller said.

And staffing is a persistent problem.

Harrison County Hospital in Corydon, Indiana, a small town on the border with Kentucky, ended its obstetric services in March after hospital leaders said they were unable to recruit an obstetric provider. It was the only delivering hospital in the county, averaging about 400 births a year.

And most providers don’t want to remain on call 24/7, a particular problem in rural regions that might have just one or two physicians trained in obstetrics. In many rural areas, family physicians with obstetrical training fill the role of both obstetricians and general practitioners.

Ripple effects

Even before Harrison County Hospital suspended its obstetrical services, some patients were already driving more than 30 minutes for care, the Indiana Capital Chronicle reported. The closure means the drive could be 50 minutes to reach a hospital with a labor and delivery department, or to see providers for prenatal visits.

Longer drive times can be risky, resulting in more scheduled inductions and C-sections because families are scared to risk going into labor naturally and then facing a harrowing hourlong drive to the hospital.

Having fewer labor and delivery units could further burden ambulance services already stretched thin in rural areas.

And hospitals often serve as a hub for other maternity-related services that help keep mothers and babies healthy.

“Other things we’ve seen in rural counties that have hospital-based OB care is that you’re more likely to have other supportive things, like maternal mental health support, postpartum groups, lactation support, access to doula care and midwifery services,” said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health, whose research focuses in part on maternal health policy with a focus on rural communities.

State action

Medicaid, the state-federal public insurance for people with low incomes, pays for nearly half of all births in rural areas nationwide. And women who live in rural communities and small towns are more likely to be covered by Medicaid than women in metro areas.

Experts say one way to save rural labor and delivery in many places would be to bump up Medicaid payments.

As congressional Republicans debate President Donald Trump’s tax and spending plan, they’re considering which portions of Medicaid to slash to help pay for the bill’s tax cuts. Maternity services aren’t on the chopping block.

But if Congress reduces federal funding for some portions of Medicaid, states — and hospitals — will have to figure out how to offset that loss. The ripple effects could translate into less money for rural hospitals overall, meaning some may no longer be able to afford labor and delivery services.

“Cuts to Medicaid are going to be felt disproportionately in rural areas where Medicaid makes up a higher proportion of labor and delivery and for services in general,” Kozhimannil said. “It is a hugely important payer at rural hospitals, and for birth in particular.”

And though private insurers often pay more than Medicaid for birth services, Miller believes states shouldn’t let companies off the hook.

“The data shows that in many cases, commercial insurance plans operating in a state are not paying adequately for labor and delivery,” Miller said. “Hospitals will tell you it’s not just Medicaid; it’s also commercial insurance.”

He’d like to see state insurance regulators pressure private insurance to pay more. More than 40% of births in rural communities are covered by private insurance.

Yet there’s no one magic bullet that will fix every rural hospital’s bottom line, Miller said: “For every hospital I’ve talked to, it’s been a different set of circumstances.”

©2025 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

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The Michigan Department of Health and Human Services (MDHHS) Bureau of Aging, Community Living and Supports Health Services, Oakland University and the Michigan Falls Prevention Coalition have partnered with Michigan 211 to offer fall prevention resources on mi211.org. The information is designed to connect health care providers, community organizations and residents with vital fall prevention resources.

About 30% of Michiganders ages 65 and older report falling each year and most of these falls occur at home.

“This initiative aims to improve statewide access to evidence-based fall prevention programs, durable medical equipment and nutrition services that support older adults and individuals at risk of a fall,” said Dr. Natasha Bagdasarian, chief medical executive. “Falls can lead to serious injuries, including head trauma and broken bones. By collaborating and sharing resources, we can work together to make Michigan a safer place for everyone.”

Individuals and health care professionals can access resources and services through the site or by calling 211. Searches for education and safety planning resources, physical health and wellness services, daily living supports and home accessibility modifications can be conducted by ZIP code. In addition, 211 specialists have been trained to assist callers in locating fall prevention services.

The website was made possible through a $408,499 grant from the Michigan Health Endowment Fund Healthy Aging Grant. Funding also supported development of the Michigan Falls Coalition website and an awareness campaign about the Michigan 211 resource. The coalition is supported through partnerships with MDHHS and Oakland University and brings together organizations and providers to collaborate to reduce fall risks among older adults and adults with disabilities, identify state or community needs, recommend policy changes and build capacity.

“Oakland University is proud to lead innovative research and community partnerships that improve the health and safety of Michiganders,” said Dr. Chris Wilson, lead author on the grant application and associate professor in the Physical Therapy Program at Oakland University’s School of Health Sciences. “Through our leadership within the Michigan Falls Prevention Coalition and initiatives like the 211 resource platform, we are committed to connecting older adults and individuals with disabilities to the services and supports they need to stay safe, active, and independent in their homes and communities.”

“The National Kidney Foundation of Michigan (NKFM), which provides falls prevention programs in the community, is excited to have this resource available so people can locate programs,” said Ann Andrews, MPH, senior program manager, National Kidney Foundation. “The MI Falls Prevention Coalition started in 2021 as a small advisory group for a federal grant the NKFM received. There was great interest in the group from among stakeholders across the state and it’s exciting to see what the coalition has grown into from these initial efforts.”

Health care providers and community organizations can help expand this resource by adding fall prevention programs to the website. Eligible programs include:

• Fall prevention education and exercise programs
• Senior-focused exercise programs
• Urinary incontinence prevention initiatives
• Nutrition services supporting fall risk reduction
• Durable medical equipment providers offering fall prevention-related items
• Home and environmental modification programs
• Other related fall prevention-focused programming

Organizations and providers interested in listing their programs or updating existing details can visit mi211.org/providers. Once a 211 representative speaks with the organization liaison directly, updates and new listings will typically be posted within 10 business days.

For more information, visit the 211 falls prevention page mi211.org or the Michigan Falls Prevention Coalition’s website at mifallsprevention.org.

Source: Michigan Department of Health and Human Services

By TOM MURPHY

A small, growing number of employers are putting health insurance decisions entirely in the hands of their workers.

Instead of offering traditional insurance, they’re giving workers money to buy their own coverage in what’s known as Individual Coverage Health Reimbursement Arrangements, or ICHRAs.

Advocates say this approach provides small companies that couldn’t afford insurance a chance to offer something. It also caps a growing expense for employers and fits conservative political goals of giving people more purchasing power over their coverage.

But ICHRAs place the risk for finding coverage on the employee, and they force them to do something many dislike: Shop for insurance.

“It’s maybe not perfect, but it’s solving a problem for a lot of people,” said Cynthia Cox, of the nonprofit KFF, which studies health care issues.

Here’s a closer look at how this approach to health insurance is evolving.

What’s an ICHRA?

Normally, U.S. employers offering health coverage will have one or two insurance options for workers through what’s known as a group plan. The employers then pick up most of the premium, or cost of coverage.

ICHRAs are different: Employers contribute to health insurance coverage, but the workers then pick their own insurance plans. The employers that use ICHRAs hire outside firms to help people make their coverage decisions.

ICHRAs were created during President Donald Trump’s first administration. Enrollment started slowly but has swelled in recent years.

What’s the big deal about ICHRAs?

They give business owners a predictable cost, and they save companies from having to make coverage decisions for employees.

“You have so many things you need to focus on as a business owner to just actually grow the business,” said Jeff Yuan, co-founder of the New York-based insurance startup Taro Health.

Small businesses, in particular, can be vulnerable to annual insurance cost spikes, especially if some employees have expensive medical conditions. But the ICHRA approach keeps the employer cost more predictable.

Yuan’s company bases its contributions on the employee’s age and how many people are covered under the plan. That means it may contribute anywhere from $400 to more than $2,000 monthly to an employee’s coverage.

How is this approach different?

ICHRAs let people pick from among dozens of options in an individual insurance market instead of just taking whatever their company offers.

That may give people a chance to find coverage more tailored to their needs. Some insurers, for instance, offer plans designed for people with diabetes.

And workers can keep the coverage if they leave — potentially for longer periods than they would be able to with traditional employer health insurance plans. They likely will have to pay the full premium, but keeping the coverage also means they won’t have to find a new plan that covers their doctors.

Mark Bertolini, CEO of the insurer Oscar Health, noted that most people change jobs several times.

“Insurance works best when it moves with the consumer,” said the executive, whose company is growing enrollment through ICHRAs in several states.

What are the drawbacks for employees?

Health insurance plans on the individual market tend to have narrower coverage networks than employer-sponsored coverage.

It may be challenging for patients who see several doctors to find one plan that covers them all.

People shopping for their own insurance can find coverage choices and terms like deductibles or coinsurance overwhelming. That makes it important for employers to provide help with plan selection.

The broker or technology platform setting up a company’s ICHRA generally does this by asking about their medical needs or if they have any surgeries planned in the coming year.

How many people get coverage this way?

There are no good numbers nationally that show how many people have coverage through an ICHRA or a separate program for companies with 50 workers or less.

However, the HRA Council, a trade association that promotes the arrangements, sees big growth. The council works with companies that help employers offer the ICHRAs. It studies growth in a sample of those businesses.

It says about 450,000 people were offered coverage through these arrangements this year. That’s up 50% from 2024. Council Executive Director Robin Paoli says the total market may be twice as large.

Still, these arrangements make up a sliver of employer-sponsored health coverage in the United States. About 154 million people were enrolled in coverage through work last year, according to KFF.

Will growth continue?

Several things could cause more employers to offer ICHRAs. As health care costs continue to climb, more companies may look to limit their exposure to the hit.

Some tax breaks and incentives that encourage the arrangements could wind up in a final version of the Republican tax bill currently under consideration in the Senate.

More people also will be eligible for the arrangements if extra government subsidies that help buy coverage on the Affordable Care Act’s individual marketplaces expire this year.

You can’t participate in an ICHRA if you are already getting a subsidy from the government, noted Brian Blase, a White House health policy adviser in the first Trump administration.

“The enhanced subsidies, they crowd out private financing,” he said.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

Wayne State University is opening the city’s first standalone School of Public Health. The school is designed to train health care professionals who will embed in Detroit’s neighborhoods. Construction is set to begin this fall on a $200 million dollar health sciences research building, with community input central to the operation.

Dr. Bernard Costello, Wayne State’s senior vice president for health affairs, is utilizing this opportunity as a tool to lead an effort to reignite public trust in Detroit health institutions via real and equitable change. Knowing Detroiters struggle with chronic illnesses and limited access to care, he joined The Metro to talk about what opening this school means for our community.

Use the media player above to hear the full conversation.

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming on-demand.

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WDET strives to make our journalism accessible to everyone. As a public media institution, we maintain our journalistic integrity through independent support from readers like you. If you value WDET as your source of news, music and conversation, please make a gift today.

Donate today »

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By LAURAN NEERGAARD, AP Medical Writer

WASHINGTON (AP) — A federal judge ruled Monday it was illegal for the Trump administration to cancel several hundred research grants, adding that the cuts raise serious questions about racial discrimination.

U.S. District Judge William Young in Massachusetts said the administration’s process was “arbitrary and capricious” and that it did not follow long-held government rules and standards when it abruptly canceled grants deemed to focus on gender identity or diversity, equity and inclusion.

In a hearing Monday on two cases calling for the grants to be restored, the judge pushed government lawyers to offer a formal definition of DEI, questioning how grants could be canceled for that reason when some were designed to study health disparities as Congress had directed.

Young, an appointee of Republican President Ronald Reagan, went on to address what he called “a darker aspect” to the cases, calling it “palpably clear” that what was behind the government actions was “racial discrimination and discrimination against America’s LGBTQ community.”

After 40 years on the bench, “I’ve never seen government racial discrimination like this,” Young added. He ended Monday’s hearing saying, “Have we no shame.”

During his remarks ending the hearing, the judge said he would issue his written order soon.

Young’s decision addresses only a fraction of the hundreds of NIH research projects the Trump administration has cut — those specifically addressed in two lawsuits filed separately this spring by 16 attorneys general, public health advocacy groups and some affected scientists. A full count wasn’t immediately available.

While Young said the funding must be restored, Monday’s action was an interim step. The ruling, when formally issued, is expected to be appealed. The Trump administration didn’t immediately respond to a request for comment.

While the original lawsuits didn’t specifically claim racial discrimination, they said the new NIH policies prohibited “research into certain politically disfavored subjects.” In a filing this month after the lawsuits were consolidated, lawyers said the NIH did not highlight genuine concerns with the hundreds of canceled research projects studies, but instead sent “boilerplate termination letters” to universities.

The topics of research ranged widely, including cardiovascular health, sexually transmitted infections, depression, Alzheimer’s and alcohol abuse in minors, among other things. Attorneys cited projects such as one tracking how medicines may work differently in people of ancestrally diverse backgrounds, and said the cuts affected more than scientists — such as potential harm to patients in a closed study of suicide treatment.

Lawyers for the federal government said in a court filing earlier this month that NIH grant terminations for DEI studies were “sufficiently reasoned,” adding later that “plaintiffs may disagree with NIH’s basis, but that does not make the basis arbitrary and capricious.” The NIH, lawyers argued, has “broad discretion” to decide on and provide grants “in alignment with its priorities” — which includes ending grants.

Monday, Justice Department lawyer Thomas Ports Jr. pointed to 13 examples of grants related to minority health that NIH either hadn’t cut or had renewed in the same time period — and said some of the cancellations were justified by the agency’s judgement that the research wasn’t scientifically valuable.

The NIH has long been the world’s largest public funder of biomedical research.

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

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So little is discussed about “The Change”. That’s right Menopause is not widely discussed and can bring a sense of feeling ashamed. It’s something that’s often held close to a woman’s chest, a secret that only she knows. 

While some do share their experiences, many women continue to struggle with finding community when preparing for and enduring menopause. 

Menopause It’s a biological process when a menstruating woman no longer has periods. Each woman experiences the stage differently, whether it’s with hot flashes, sleep problems or a low libido. But all menstruating women will experience menopause; it’s just a matter of when. 

A new comedy special aims to tackle the inevitable process with laughter. “Confessions of a menopausal femme fatale” is a stand-up storytelling concert by multidisciplinary artist, storyteller, and social entrepreneur Satori Shakoor. 

Shakoor is the founder and Executive Producer of The Secret Society of Twisted Storytellers, host of PBS’s Detroit Performs. The special, which was taped at Detroit Public Theatre will be available to stream Thursday, June 12th.

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming  on demand.

Trusted, accurate, up-to-date.

WDET strives to make our journalism accessible to everyone. As a public media institution, we maintain our journalistic integrity through independent support from readers like you. If you value WDET as your source of news, music and conversation, please make a gift today.

Donate today »

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By MATTHEW PERRONE, AP Health Writer

WASHINGTON (AP) — Calley Means has built a following within the “Make America Healthy Again” movement by railing against the failings of the U.S. health system, often pinning the blame on one issue: corruption.

Means, a top aide to Health Secretary Robert F. Kennedy Jr., was hired as a White House adviser in March. He has used that perch to attack the nation’s leading physician groups, federal agencies and government scientists, claiming they only protect their own interests in the nation’s $4.9 trillion-a-year industry.

In recent interviews, speeches and podcasts he has called the American Medical Association “a pharma lobbying group,” labeled the Food and Drug Administration “a sock puppet of industry,” and said federal health scientists have “overseen a record of utter failure.”

Means, however, has his own financial stake in the sprawling health system. He’s the co-founder of an online platform, Truemed, that offers dietary supplements, herbal remedies and other wellness products. Some of the vendors featured on Truemed’s website are supporters of Kennedy’s MAHA movement, which downplays the benefits of prescription drugs, vaccines and other rigorously tested medical products.

Kennedy has pledged to run the Department of Health and Human Services with “radical transparency,” but Means has never had to publicly disclose his own financial details or where exactly they intersect with the policies he’s advancing.

“It reeks of hypocrisy,” said Dr. Reshma Ramachandran, a health researcher at Yale University. “In effect, he is representing another industry that is touting nonregulated products and using his platform within the government to financially benefit himself.”

In a written statement, Means said his government work has not dealt with matters affecting Truemed and has focused on issues like reforming nutrition programs and pressuring companies to phase out food dyes.

“Pursuing these large-scale MAHA goals to make America healthy has been the sole focus in my government work,” Means said.

Truemed helps users take tax-free money out of their health savings accounts, or HSAs, to spend on things that wouldn’t normally qualify as medical expenses, such as exercise equipment, meal delivery services and homeopathic remedies — mixtures of plants and minerals based on a centuries-old theory of medicine that’s not supported by modern science.

The business model caught the attention of the IRS last year, which issued an alert: “Beware of companies misrepresenting nutrition, wellness and general health expenses as medical care.”

Truemed co-founder and CEO, Justin Mares, said in a statement the company is “in full alignment” with IRS guidelines.

“Truemed enables patients to work with providers to use medical funds for root cause interventions like exercise and vitamin D to reverse disease under current law,” Mares said.

The full extent of Means’ potential conflicts — including his personal investments— are unclear because of his status as a special government employee.

Unlike presidential appointees and other senior officials, special government employees are temporary staffers who do not have to leave companies or sell investments that could be impacted by their work. Also, their financial disclosure forms are shielded from public release.

“It’s a big problem,” says Richard Painter, a former White House ethics lawyer under George W. Bush now at the University of Minnesota. Painter and other experts have raised alarms over a whirlwind of Trump administration actions to dismantle the government’s public integrity guardrails.

Still, part-time government employees are subject to the same law that bars all federal staffers from working on issues that could directly benefit their finances. When such cases arise, they must recuse themselves or risk criminal penalties.

Means regularly opines on matters before HHS, including rethinking the use of drugs for depression, weight loss, diabetes and other conditions. Recently he’s been promoting a new government report that calls for scaling back prescription medications in favor of exercise, dietary changes and other alternatives.

“If we rely less on our medical system, less on drugs, it necessitates the spiritual, cultural conversation about what we’re doing to our children’s bodies,” Means said in a recent podcast appearance.

Experts note that government ethics rules are intended to both prevent financial conflict violations, but also the appearance of such conflicts that might undermine public trust in government.

“If I were running the ethics office over at HHS, I sure as heck wouldn’t want anybody going around giving interviews and speeches about government matters that could have an effect on their own financial interests,” Painter said.

A rising star in the MAHA movement

Means’ rapid rise reflects the seeming contradictions within the MAHA movement itself, which urges followers to distrust both big corporations and the government agencies which regulate them.

Means rails against big pharma and food conglomerates, two industries that he says he spent years working for as a consultant in Washington.

Means has no medical training. A graduate of Harvard Business School, he previously ran a bridal gown startup with his wife. On Wednesday, he’s scheduled to be the keynote speaker at FDA’s annual science forum, according to a copy of the program shared with The Associated Press.

He traces his passion for health care reform to the death of his mother from pancreatic cancer in 2021. Shortly thereafter, Means and his sister, Dr. Casey Means, took psychedelics together and had “a mind-blowing, life-changing experience,” which led them to co-author a wellness book, launch separate health startups and begin appearing on podcasts.

Casey Means was recently nominated to be surgeon general and has faced scrutiny over her qualifications, including an unfinished medical residency.

Asked about her nomination, President Donald Trump said: “Bobby thought she was fantastic,” adding that he did not know her.

Meanwhile, her brother has stepped up his rhetoric for the MAHA agenda, recently declaring that Kennedy has “a spiritual mandate to reform our broken system.”

While promoting the administration’s accomplishments, Means does not shy away from plugging his own brand or those of his business partners.

When asked to offer health advice to listeners of a sports podcast, Outkick The Show, in April, Means said: “Read our book, ‘Good Energy.’”

He also recommended blood tests sold by Function Health, which provides subscription-based testing for $500 annually. The company was cofounded by Dr. Mark Hyman, a friend of Kennedy and an investor in Truemed, which also offers Hyman’s supplements through its platform. Casey Means is also an investor in Hyman’s company.

“If you’re sick, most likely you have some kind of nutrient deficiency, some kind of biomarker that you can actually then target with your diet and your supplements,” Calley Means said.

Like dietary supplements, the marketing claims on laboratory tests sold by Hyman are not approved by the FDA. The agency has warned for years about the accuracy of such tests and tried to start regulating them under President Joe Biden.

Experts say MAHA entrepreneurs like Hyman are following a playbook common to the wellness industry: Identify a health concern, market a test to diagnose it and then sell supplements or other remedies to treat it.

“It ends up favoring these products and services that rest on flimsy grounds, at the expense of products that have actually survived a rigorous FDA approval process,” said Dr. Peter Lurie, a former FDA official who is now president of the Center for Science in the Public Interest.

Many of the items sold via Truemed, including sweat tents, cold plunge tanks and light therapy lamps, wouldn’t typically qualify as medical expenses under rules for HSAs, tax-free accounts created by Congress to manage medical costs.

The IRS generally states that HSA purchases must help diagnose, cure, treat, mitigate or prevent disease.

Truemed allows users to request a “letter of medical necessity” from a doctor, stating that the product in question could have medical value for them. Like other telehealth services, there’s usually no real-time communication with the patient. The physician reviews a “simple survey solution,” filled out by the Truemed user, according to the company’s website.

Industry representatives say customers should be careful.

“You need to be prepared to defend your spending habits under audit,” said Kevin McKechnie, head of the American Bankers Association’s HSA council. “Companies are popping up suggesting they can help you manage that process and maybe they can — so the debate continues.”

Americans have an estimated $147 billion in HSA accounts, a potential windfall for companies like Truemed that collects fees for transactions made using their platforms.

Means sees an even bigger opportunity — routing federal funds out of government programs and into more HSAs.

“The point of our company is to steer medical dollars into flexible spending,” Means told fitness celebrity Jillian Michaels, on her podcast last year. “I want to get that $4.5 trillion of Medicare, Medicaid, everything into a flexible account.”

Who benefits most from HSAs?

Means’ pitch for expanding HSAs echoes two decades of Republican talking points on the accounts, which were created in 2003 to encourage Americans in high-deductible plans to be judicious with their health dollars.

But HSAs have not brought down spending, economists say. They are disproportionately used by the wealthiest Americans, who have more income to fund them and a bigger incentive to lower their tax rate.

Americans who earn more than $1 million annually are the group most likely to make regular HSA contributions, according to an analysis by the nonprofit Center on Budget and Policy Priorities. More than half Americans with HSAs have balances less than $500.

Trump’s “One Big Beautiful Bill” would further expand HSA purchases, making gym memberships and other fitness expenses eligible for tax-free spending. That provision alone is expected to cost the government $10 billion in revenue.

“These are really just tax breaks in the guise of health policy that overwhelmingly benefit people with high incomes,” said Gideon Lukens, a former White House budget official during the Obama and Trump administrations, now with the Center on Budget and Policy Priorities.

Expanding HSA eligibility was listed as a goal for a coalition of MAHA entrepreneurs and Truemed partners, founded by Means, which lobbied Congress last year, according to the group’s website.

Means said in a statement that the group focused only on broad topics like “health care incentives and patient choice — but did not lobby for specific bills.”

In total, the HSA expansions in Trump’s bill are projected to cost the federal government $180 billion over the next 10 years. As HSAs expand to include more disparate products and services, Lukens says the U.S. government will have fewer dollars to expand medical coverage through programs like Medicaid.

“We have a limited amount of federal resources and the question is whether we want to spend that on health and wellness products that may or may not be helpful for wealthy people,” Lukens said.

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

By KATHERINE ROTH, Associated Press

NEW YORK (AP) — My first tip-off were the little things, the high-pitched little things: the doorbell and ringtones my kids could hear but I could not.

Then it was the garbled-sounding conversations, and the accompanying annoyance of having to ask people to repeat themselves. Or worse, giving up and just playing along without being able to follow everything that was being said.

Even then, I stalled for years before finally going through the process of getting a hearing aid. How do you even begin? Will it look clunky and make me feel like a dinosaur? And the cost!

Getting a hearing test, and confirmation that I needed a hearing aid, was just the beginning.

Finding an expert

The doctor handed me a list of places I could go to get fitted. I made some calls and narrowed it down to the places that took my insurance and my zero-interest health care credit card.

The first couple places were demoralizing: I walked in, was told it’d be $7,000 for the “best” option (they mysteriously didn’t happen to have any other options handy), then marched right back out the door, utterly discouraged.

I started asking friends and neighbors whether they wore a hearing aid, or knew anyone at all with a hearing aid, and could point me to a good audiologist.

It took a lot of poking around, but I found one — and it made all the difference.

The joy of reconnecting with the world

I’ve been wearing my hearing aids for several months now, and they are as easy as slipping on a pair of glasses, are almost invisible, have reconnected me with the world, and, as crazy as this may sound, they bring me joy.

After talking with a few audiologists around the country, it turns out that my experience is pretty typical.

“There are a lot of people who stall before getting one,” says Meagan P. Bachmann, director of audiology at Atrium Health Wake Forest Baptist, in North Carolina.

“Hearing is important because it connects us with people,” she says. “Multiple studies show that not hearing can affect your ability to connect with others and participate in life, so you have to think of it in terms of overall health. Maybe you no longer go to family events, or you don’t understand your doctor. People start to withdraw. A lot of people come in because it’s gotten so bad that it is impacting their relationships.”

Steps to take

To speed up the process and make it less frustrating, here’s what the pros recommend:

1. Get tested, take the results seriously, and know that many if not most hearing aids these days are small, nearly invisible, rechargeable, and pretty easy to wear and maintain. And believe it or not, hearing aids can be fun — these days, there are colors to choose from and ways to bejewel them. One company, Deafmetal, makes jazzy-looking “safety rings” to help keep hearing aids in place.

2. Shop for an expert audiologist. Look for someone who takes your insurance or any sort of medical credit card you might have, or has a payment plan of some kind, if needed. This is a world at the awkward juncture of consumerism and medical care, but a good audiologist should come across as a medical provider, not a salesperson. And a good audiologist should take the time to work with you to find a hearing aid that meets your individual needs, and also fits your budget.

A good place to start is often with your doctor; with the American Academy of Audiologists, which lists providers on its website; or by word of mouth.

“Although all hearing aids are amplifiers, not everybody needs the same thing,” says Bachmann. “Fitting a hearing aid is an art. It changes the acoustics, and everyone is different. You want someone who listens to your lifestyle needs. Do you have a lot of difficulty with noise? Are you mostly in quiet situations? How much technology do you need, and what kind?”

Greta Stamper, an audiologist at the Mayo Clinic in Jacksonville, Florida, agrees. “Hearing loss is not a one-time thing. It’s a chronic health condition. It should be a partnership between you and your audiologist,” she said. “It’s someone asking you what you’re looking for and how it’s going. You shouldn’t feel pressured or pushed.”

3. A note on cost. Although hearing aids can be pricey, there are affordable options, and a good audiologist should be able to let you try out options at several price points. Insurance often covers much of the cost, and there are ways to pay for the remaining cost in installments. Also, avoidance has pretty high costs as well, audiologists say, and the longer the wait, the harder it may be to solve the problem with a hearing aid. Although there are cheaper hearing aids at big box stores, Bachmann warns that it’s good to check with your audiologist before taking that route. “Some of those hearing aids are locked, so that you’re not allowed to have them programmed by an outside audiologist,” she says.

Remember, says Stamper, that hearing aids are an investment, and usually last between five and six years.

4. Know your rights. “We select what is the most likely to be successful, and if it doesn’t work out you come back and do something else,” says Stamper. She said most states mandate a trial period. In some cases, hearing-aid companies also cover the cost of multiple visits to your audiologist while you are getting used to your new hearing aid and get training in how to use and maintain it.

5. Embrace the process, and expect it to take a little time and a few expert tweaks. Audiologists say your brain needs time to adjust to a hearing aid, and that hearing-aid settings should be adjusted little by little as your brain adapts to them.

“A big misconception is that you can just wear them a couple hours a day. Your brain does better with it if you use them most of the day. Your brain needs to adapt to hearing sounds it hasn’t heard for a while, and it takes the brain awhile to relearn how to process all those sounds,” says Stamper.

6. Be realistic. “Although hearing aids can be enormously beneficial, they may not give you back your normal hearing,” says Stamper. Depending on the situation, there might be limitations to what a hearing aid can do.

“It might just be lots of improvement in the key areas in which you’re struggling,” said Stamper.

Using hearing aids is a process, the audiologists say, and although it requires some patience, it can be well worth the journey.