ST. LOUIS — Violent crime was already trending down from a covid-era spike when President Donald Trump presented a picture of unbridled crime in America on the campaign trail in 2024. Now his administration has eliminated about $500 million in grants to organizations that buttress public safety, including many working to prevent gun violence.

In Oakland, California, a hospital-based program to prevent retaliatory gun violence lost a $2 million grant just as the traditionally turbulent summer months approach. Another $2 million award was pulled from a Detroit program that offers social services and job skills to young people in violent neighborhoods. And in St. Louis, a clinic treating the physical and emotional injuries of gunshot victims also lost a $2 million award.

They are among 373 grants that the U.S. Department of Justice abruptly terminated in April. The largest share of the nixed awards were designated for community-based violence intervention — programs that range from conflict mediation and de-escalation to hospital-based initiatives that seek to prevent retaliation from people who experience violent injuries.

Gun violence is among America’s most deadly public health crises, medical experts say.

Among programs whose grants were terminated were those for protecting children, victims’ assistance, hate-crime prevention, and law enforcement and prosecution, according to an analysis by the Council on Criminal Justice, a nonpartisan think tank. The grants totaled $820 million when awarded, but some of that money has been spent.

“Not only are these funds being pulled away from worthy investments that will save lives,” said Thomas Abt, founding director of the Violence Reduction Center at the University of Maryland, “but the way that this was done — by pulling authorized funding without warning — is going to create a lasting legacy of mistrust."

The Justice Department “is focused on prosecuting criminals, getting illegal drugs off the streets, and protecting all Americans from violent crime,” according to a statement provided by agency spokesperson Natalie Baldassarre. “Discretionary funds that are not aligned with the administration’s priorities are subject to review and reallocation, including funding for clinics that engage in race-based selectivity.”

The Council on Criminal Justice analysis of the terminated grants found that descriptions of 31% of them included references to “diversity,” “equity,” “race,” “racial,” “racism,” or “gender.”

Baldassarre’s statement said the department is committed to working with organizations “to hear any appeal, and to restore funding as appropriate.” Indeed, it restored seven of the terminated grants for victims’ services after Reuters reported on the cuts in April.

But the cuts have already prompted layoffs and reductions at other organizations around the country. Five groups filed a lawsuit on May 21 to restore the grants in their entirety.

Joseph Griffin, executive director of the Oakland nonprofit Youth Alive, which pioneered hospital-based violence intervention in the 1990s, said his organization had spent only about $60,000 of its $2 million grant before it was axed. The grant was primarily to support the intervention program and was awarded for a three-year period but lasted just seven months. The money would have helped pay to intervene with about 30 survivors of gun violence to prevent retaliatory violence. He’s trying to find a way to continue the work, without overtaxing his team.

“We will not abandon a survivor of violence at the hospital bedside in the same way that the federal government is abandoning our field,” he said.

The cuts are also hitting St. Louis, often dogged by being labeled one of the most dangerous cities in America. The city created an Office of Violence Prevention with money available under former President Joe Biden, and various groups received Justice Department grants, too.

Locals say the efforts have helped: The 33% drop in the city’s homicide rate from 2019 to 2024 was the second-largest decrease among 29 major cities examined by the Council on Criminal Justice.

“I don't think there's any doubt that there's some positive impact from the work that's happening,” said University of Missouri-St. Louis criminologist Chris Sullivan, who received a grant from the Justice Department to assess the work of the city’s new Office of Violence Prevention. That research grant remains in place.

But the Justice Department slashed two other grants in St. Louis, including $2 million for Power4STL. The nonprofit operates the Bullet Related Injury Clinic, dubbed the BRIC, which provides free treatment for physical and mental injuries caused by bullets.

The BRIC had about $1.3 million left on its grant when the award was terminated in April. LJ Punch, a former trauma surgeon who founded the clinic in 2020, said it was intended to fund a mobile clinic, expand mental health services, evaluate the clinic’s programs, and pay for a patient advisory board. The BRIC won't abandon those initiatives, Punch said, but will likely need to move slower.

Keisha Blanchard joined the BRIC’s advisory board after her experience as a patient at the clinic following a January 2024 gun injury. Someone fired a bullet into her back from the rear window of a Chevy Impala while Blanchard was out for a lunchtime stroll with a friend from her neighborhood walking group. The shooting was random, Blanchard said, but people always assume she did something to provoke it. “It’s so much shame that comes behind that,” she said.

The 42-year-old said the shooting and her initial medical treatment left her feeling angry and unseen. Her family wasn’t allowed to be with her at the hospital since the police didn’t know who shot her or why. When she asked about taking the bullet out, she was told that the common medical practice is to leave it in. “We're not in the business of removing bullets,” she recalled being told. At a follow-up appointment, she said, she watched her primary care doctor google what to do for a gunshot wound.

“Nobody cares what's going to happen to me after this,” Blanchard recalled thinking.

Before she was referred to the BRIC, she said, she was treated as though she should be happy just to be alive. But a part of her died in the shooting, she said. Her joyful, carefree attitude gave way to hypervigilance. She stopped taking walks. She uprooted herself, moving to a neighborhood 20 miles away.

The bullet stayed lodged inside her, forcing her to carry a constant reminder of the violence that shattered her sense of safety, until Punch removed it from her back in November. Blanchard said the removal made her feel “reborn.”

It’s a familiar experience among shooting survivors, according to Punch.

“People talk about the distress about having bullets still inside their bodies, and how every waking conscious moment brings them back to the fact that that's still inside,” Punch said. “But they're told repeatedly inside conventional care settings that there's nothing that needs to be done.”

The Justice Department grant to the BRIC had been an acknowledgment, Punch said, that healing has a role in public safety by quelling retaliatory violence.

“The unhealed trauma in the body of someone who's gotten the message that they are not safe can rapidly turn into an act of violence when that person is threatened again,” Punch said.

Community gun violence, even in large cities, is concentrated among relatively small groups of people who are often both victims and perpetrators, according to researchers. Violence reduction initiatives are frequently tailored to those networks.

Jennifer Lorentz heads the Diversion Unit in the office of the St. Louis Circuit Attorney, the city’s chief prosecutor. The unit offers mostly young, nonviolent offenders an opportunity to avoid prosecution by completing a program to address the issues that initially led to their arrest. About 80% of the participants have experienced gun violence and are referred to the BRIC, Lorentz said, calling the clinic critical to her program’s success.

“We're getting them these resources, and we're changing the trajectory of their lives,” Lorentz said. “Helping people is part of public safety.”

Punch said the BRIC staffers were encouraged during the Justice Department application process to emphasize their reach into St. Louis’ Black community, which is disproportionately affected by gun violence. He suspects that emphasis is why its grant was terminated.

Punch likened the grant terminations to only partially treating tuberculosis, which allows the highly infectious disease to become resistant to medicine.

“If you partially extend a helping hand to somebody, and then you rip it away right when they start to trust you, you assure they will never trust you again,” he said. “If your intention is to prevent violence, you don't do that.”

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

In retrospect, Peggy Dula said, she shouldn’t have taken the ambulance. She was the least injured of the three siblings who were in a car when it was struck by a pickup truck last September. Her daughter had even offered to come to the crash site and pick her up.

Jim Martens, 62, and Cynthia Martens, 63, Peggy’s brother and sister, were more seriously hurt and on their way to the hospital in separate ambulances. Peggy, 55, was told it would be a good idea for her to get checked out, too. So she accepted a ride with a third ambulance crew.

When the wreck happened, the siblings were going to see the horses that Peggy’s daughter trains at a barn west of Peggy’s home in St. Charles, Illinois, about 45 miles outside Chicago. Peggy, who was driving on unfamiliar country roads, pulled into an intersection, mistakenly thinking it was a four-way stop. The truck slammed into the car’s side, spinning it into an electrical box.

Cynthia, who wasn’t wearing a seat belt in the back seat, spent five days in the hospital with a brain bleed, a cracked rib, and a bruised lung. Jim also had fractured ribs, which he learned days later — only after he was back home in Tampa, Florida.

Peggy was “a little stunned” but mostly unhurt as three ambulances descended on the crash site, alerted by 911. She was seen briefly in an emergency room and went home with just a bruised sternum, grateful she had dodged major injury.

Then the bill came.

The Patient: Peggy Dula, 55, who works in a fine jewelry store in Geneva, Illinois.

Total Bill: $3,606 for ambulance services.

Service Provider: Pingree Grove and Countryside Fire Protection District, a fire district serving more than 50 square miles near Elgin, Illinois.

Medical Services: An ambulance ride to a nearby hospital and brief medical evaluation.

What Gives: All three siblings were charged for the same service: “Advanced Life Support Emergency Level 1.” It’s code for transportation by a ground ambulance in response to a 911 call, and it can include medical services as simple as an assessment. All three were also charged a mileage fee. Jim and Cynthia were billed for 15 miles; Peggy was billed for 14 miles. But because they rode in separate ambulances, each from a different nearby fire protection district, they were billed three separate amounts:

• Cynthia was billed $1,250 — $1,100 for life support and $10 per mile — by Burlington Community Fire Protection District.
• Jim was billed $1,415 — $1,265 for life support and $10 per mile — by Hampshire Fire Protection District.
• Peggy was billed $3,606 — $3,186 for life support and $30 per mile — by Pingree Grove and Countryside Fire Protection District.

And although private, for-profit ambulance companies have become notorious for pricey bills, Peggy and her siblings were being billed by taxpayer-funded fire departments.

How could charges for the exact same services vary so widely?

“The simple answer is that these bills are all made up,” said Dr. Karan Chhabra, a surgical resident at Brigham & Women’s Hospital in Boston and a former research fellow at the University of Michigan.

In a 2020 paper published in the journal Health Affairs, Chhabra and his colleagues looked into surprise ambulance bills by analyzing a large national insurer’s claims data from 2013 to 2017. They found that 71% of ambulance rides were out of network, meaning the ambulance companies were not bound by a rate that was negotiated in advance with the insurer and could basically charge whatever they want. Even local fire departments can decline to join local insurance networks.

“It often is the municipalities that are sending some of the most staggering bills and often pursuing them in really aggressive ways,” Chhabra said.

The Pingree Grove and Countryside Fire Protection District’s chief, Kieran Stout, said their charges are in keeping with the federal Ground Emergency Medical Transportation program, which allows some public emergency services to receive supplemental payments for transporting patients on Medicaid, the state-federal health insurance program for people with low incomes. Ambulance services fill out a cost report, and if their average cost per ride is higher than the set rate Medicaid pays, they get paid the difference.

Hampshire Fire Protection District uses the same program to determine the rates they bill, and the Burlington Community Fire Protection District recently began the cost report process as well.

But ambulance services can get their full supplemental amount even if they charge non-Medicaid patients less than that average, said Jim Parker of the University of Illinois Office of Medicaid Innovation. The program is relatively new, though, and some services mistakenly think they need to raise their charges for every patient in order to participate, Parker said.

So for Medicaid patients, the program will pay the difference between the ambulance company’s costs and the standard Medicaid payment.

But for patients with private insurance, like Peggy, the fire protection district bills patients directly for the balance not covered by their insurance, Stout said, a practice known as balance billing. He added that the district only balance-bills patients who live outside the district. In the case of Peggy’s accident, all three siblings lived outside all three districts. (Jim and Cynthia both eventually received settlements from Peggy’s car insurance.)

Congress took aim at balance billing with the No Surprises Act, which went into effect Jan. 1. The law limits the patient’s responsibility for most surprise bills, such as those from an out-of-network anesthesiologist who puts a patient to sleep for surgery at an in-network hospital or for a ride in an air ambulance, almost all of which are privately owned.

But ground ambulances were, controversially, exempt from the law — even though ground ambulance rides are far more common. Of the 1,498,600 ambulance rides in Chhabra’s study, nearly 98% were by ground ambulances.

Chhabra suspects ground ambulances got special treatment because federal lawmakers felt a need to “tread lightly” around their relationships with local governments. Many ambulance services are run by municipalities and may need to bring in enough revenue to pay their expenses.

“This might be what they need to do in order to cover their own budget,” Chhabra said.

Resolution: Peggy said her insurer, BlueCross BlueShield of Illinois, deemed the “reasonable and customary rate” for the services Peggy received to be $1,892. It applied $400.23 to her deductible and then paid $895.06 — 60%, according to the cost-sharing requirement of Peggy’s plan. Pingree Grove and Countryside then billed Peggy for the balance of their charge, $2,710.94.

Peggy challenged the balance with Paramedic Billing Services, the company that handles the district’s billing, citing her siblings’ much lower charges. “Needless to say, I am speechless at the outrageously high bill I received,” Peggy wrote. “I am willing to pay $354.94, which (with my insurance payments) equals the amount my sister is being charged for the exact same ride.”

Paramedic Billing Services Vice President Michael Tillman said patients must dispute charges directly with the ambulance service. Peggy said her subsequent calls to Pingree Grove and Countryside have gone unanswered.

To demonstrate her good faith in the absence of an answer, Peggy said, she sent $20 to Paramedic Billing Services. She received a letter back with a coupon saying she needed to set up a payment plan for the full amount, so she sent another $20. In June, she received a letter from a collection agency saying she owed $2,670.94.

“They really weren’t working with me, were they?” she said.

In a statement, a spokesperson for Peggy’s insurer, John Simley, said the insurer pays for ambulance services according to the terms of a member’s plan. “Certain ambulance companies may charge amounts far in excess of the benefits” a member’s plan provides, Simley said. “This sometimes subjects members to pay the balance of ambulance services not covered by their benefit coverage.”

The Takeaway: Getting into an ambulance involves financial risk. Your health may demand it. But your wallet may suffer. So understand your options.

Obviously, if you’re seriously hurt in an accident, you have no way to figure out whether the ambulance that turns up is in your network.

However, if you feel well — just a bit banged up or with a laceration from a car crash or a fall from a bike — remember this: You do not have to get in just because an ambulance rolls up. They arrive because they’ve been informed of an accident by police or because a bystander has called 911.

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Calling a friend or car service like Uber or Lyft to drive you to a doctor, urgent care, or a hospital emergency room could save you thousands of dollars. (And please do seek timely follow-up care on any possible head injury.)

It’s also worth knowing whether your local fire department’s ambulance service is in your insurance network, information that might influence your decision.

Of course, this all raises the larger question of whether ambulance operations should be revenue generators at all.

“Or should it just be something that’s a public good that we pay for out of our taxes like the fire department or police department,” Chhabra said, “none of whom I’ve ever heard of anybody getting a bill from?”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Vincent Wasney and his fiancée, Sarah Eberlein, had never visited the ocean. They’d never even been on a plane. But when they bought their first home in Saginaw, Michigan, in 2018, their real estate agent gifted them tickets for a Royal Caribbean cruise.

After two years of delays due to the coronavirus pandemic, they set sail in December 2022.

The couple chose a cruise destined for the Bahamas in part because it included a trip to CocoCay, a private island accessible to Royal Caribbean passengers that featured a water park, balloon rides, and an excursion swimming with pigs.

It was on that day on CocoCay when Wasney, 31, started feeling off, he said.

The next morning, as the couple made plans in their cabin for the last full day of the trip, Wasney made a pained noise. Eberlein saw him having a seizure in bed, with blood coming out of his mouth from biting his tongue. She opened their door to find help and happened upon another guest, who roused his wife, an emergency room physician.

Wasney was able to climb into a wheelchair brought by the ship’s medical crew to take him down to the medical facility, where he was given anticonvulsants and fluids and monitored before being released.

Wasney had had seizures in the past, starting about 10 years ago, but it had been a while since his last one. Imaging back then showed no tumors, and doctors concluded he was likely epileptic, he said. He took medicine initially, but after two years without another seizure, he said, his doctors took him off the medicine to avoid liver damage.

Wasney had a second seizure on the ship a few hours later, back in his cabin. This time he stopped breathing, and Eberlein remembered his lips being so purple, they almost looked black. Again, she ran to find help but, in her haste, locked herself out. By the time the ship’s medical team got into the cabin, Wasney was breathing again but had broken blood vessels along his chest and neck that he later said resembled tiger stripes.

Wasney was in the ship’s medical center when he had a third seizure — a grand mal, which typically causes a loss of consciousness and violent muscle contractions. By then, the ship was close enough to port that Wasney could be evacuated by rescue boat. He was put on a stretcher to be lowered by ropes off the side of the ship, with Eberlein climbing down a rope ladder to join him.

But before they disembarked, the bill came.

The Patient: Vincent Wasney, 31, who was uninsured at the time.

Medical Services: General and enhanced observation, a blood test, anticonvulsant medicine, and a fee for services performed outside the medical facility.

Service Provider: Independence of the Seas Medical Center, the on-ship medical facility on the cruise ship operated by Royal Caribbean International.

Total Bill: $2,500.22.

What Gives: As part of Royal Caribbean’s guest terms, cruise passengers “agree to pay in full” all expenses incurred on board by the end of the cruise, including those related to medical care. In addition, Royal Caribbean does not accept “land-based” health insurance plans.

Wasney said he was surprised to learn that, along with other charges like wireless internet, Royal Caribbean required he pay his medical bills before exiting the ship — even though he was being evacuated urgently.

“Are we being held hostage at this point?” Eberlein remembered asking. “Because, obviously, if he’s had three seizures in 10 hours, it’s an issue.”

Wasney said he has little memory of being on the ship after his first seizure — seizures often leave victims groggy and disoriented for a few hours afterward.

But he certainly remembers being shown a bill, the bulk of which was the $2,500.22 in medical charges, while waiting for the rescue boat.

Still groggy, Wasney recalled saying he couldn’t afford that and a cruise employee responding: “How much can you pay?”

They drained their bank accounts, including money saved for their next house payment, and maxed out Wasney’s credit card but were still about $1,000 short, he said.

Ultimately, they were allowed to leave the ship. He later learned his card was overdrafted to cover the shortfall, he said.

Royal Caribbean International did not respond to multiple inquiries from KFF Health News.

Once on land, in Florida, Wasney was taken by ambulance to the emergency room at Broward Health Medical Center in Fort Lauderdale, where he incurred thousands of dollars more in medical expenses.

He still isn’t entirely sure what caused the seizures.

On the ship he was told it could have been extreme dehydration — and he said he does remember being extra thirsty on CocoCay. He also has mused whether trying escargot for the first time the night before could have played a role. Eberlein’s mother is convinced the episode was connected to swimming with pigs, he said. And not to be discounted, Eberlein accidentally broke a pocket mirror three days before their trip.

Wasney, who works in a stone shop, was uninsured when they set sail. He said that one month before they embarked on their voyage, he finally felt he could afford the health plan offered through his employer and signed up, but the plan didn’t start until January 2023, after their return.

They also lacked travel insurance. As inexperienced travelers, Wasney said, they thought it was for lost luggage and canceled trips, not unexpected medical expenses. And because the cruise was a gift, they were never prompted to buy coverage, which often happens when tickets are purchased.

The Resolution: Wasney said the couple returned to Saginaw with essentially no money in their bank account, several thousand dollars of medical debt, and no idea how they would cover their mortgage payment. Because he was uninsured at the time of the cruise, Wasney did not try to collect reimbursement for the cruise bill from his new health plan when his coverage began weeks later.

The couple set up payment plans to cover the medical bills for Wasney’s care after leaving the ship: one each with two doctors he saw at Broward Health, who billed separately from the hospital, and one with the ambulance company. He also made payments on a bill with Broward Health itself. Those plans do not charge interest.

But Broward Health said Wasney missed two payments to the hospital, and that bill was ultimately sent to collections.

In a statement, Broward Health spokesperson Nina Levine said Wasney’s bill was reduced by 73% because he was uninsured.

“We do everything in our power to provide the best care with the least financial impact, but also cannot stress enough the importance of taking advantage of private and Affordable Care Act health insurance plans, as well as travel insurance, to lower risks associated with unplanned medical issues,” she said.

The couple was able to make their house payment with $2,690 they raised through a GoFundMe campaign that Wasney set up. Wasney said a lot of that help came from family as well as friends he met playing disc golf, a sport he picked up during the pandemic.

“A bunch of people came through for us,” Wasney said, still moved to tears by the generosity. “But there’s still the hospital bill.”

The Takeaway: Billing practices differ by cruise line, but Joe Scott, chair of the cruise ship medicine section of the American College of Emergency Physicians, said medical charges are typically added to a cruise passenger’s onboard account, which must be paid before leaving the ship. Individuals can then submit receipts to their insurers for possible reimbursement.

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He recommended that those planning to take a cruise purchase travel insurance that specifically covers their trips. “This will facilitate reimbursement if they do incur charges and potentially cover a costly medical evacuation if needed,” Scott said.

Royal Caribbean suggests that passengers who receive onboard care submit their paid bills to their health insurer for possible reimbursement. Many health plans do not cover medical services received on cruise ships, however. Medicare will sometimes cover medically necessary health care services on cruise ships, but not if the ship is more than six hours away from a U.S. port.

Travel insurance can be designed to address lots of out-of-town mishaps, like lost baggage or even transportation and lodging for a loved one to visit if a traveler is hospitalized.

Travel medical insurance, as well as plans that offer “emergency evacuation and repatriation,” are two types that can specifically assist with medical emergencies. Such plans can be purchased individually. Credit cards may offer travel medical insurance among their benefits, as well.

But travel insurance plans come with limitations. For instance, they may not cover care associated with preexisting conditions or what the plans consider “risky” activities, such as rock climbing. Some plans also require that travelers file first with their primary health insurance before seeking reimbursement from travel insurance.

As with other insurance, be sure to read the fine print and understand how reimbursement works.

Wasney said that’s what they plan to do before their next Royal Caribbean cruise. They’d like to go back to the Bahamas on basically the same trip, he said — there’s a lot about CocoCay they didn’t get to explore.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

Ryan Wettstein Nauman was inconsolable one evening last December. After being put down for bed, the 3-year-old from Peoria, Illinois, just kept crying and crying and crying, and nothing would calm her down.

Her mother, Maggi Wettstein, remembered fearing it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers around them were closed for the night, so around 10:30 p.m. she decided to take Ryan to the emergency room at Carle Health.

The Medical Procedure

The ER wasn’t very busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryan’s symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.

Wettstein said they sat down and waited to be called. And they waited.

As Wettstein watched Ryan in the waiting room’s play area, she noticed her daughter had stopped crying.

In fact, she seemed fine.

So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake for who knew how much longer and getting stuck with a big ER bill.

There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.

Ryan went to her preschool the next day, and Wettstein said they forgot all about the ER trip for eight months.

Then the bill came.

The Final Bill

$445 for the combined covid and flu test — from an ER visit in which the patient never made it beyond the waiting room.

The Billing Problem: A Healthy Hospital Markup and Standard Insurance Rules

Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.

At first, Wettstein said, she couldn’t recall Ryan being tested at all. It wasn’t until she received the bill and requested her daughter’s medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)

While Wettstein said the bill isn’t going to break the bank, it seemed high to her, considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145.

Under the public health emergency declared in 2020 for the covid pandemic, insurance companies were required to pay for covid tests without copayments or cost sharing for patients.

That requirement ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill — and ER bills are notoriously high.

“That’s a pretty healthy markup the hospital is making on it,” Loren Adler, associate director of the Brookings Institution Center on Health Policy, told KFF Health News when contacted about Ryan’s case.

The rates the insurance companies negotiate with hospitals for various procedures are often based on multipliers of what Medicare pays, Adler said.

Lab tests are one of the few areas in which insurance companies can often pay less than Medicare, he said — the exception being when the test is performed by the hospital laboratory, which is often what happens during ER visits.

Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was over three times as much.

The hospital is “utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back,” Adler said. A markup of a few hundred dollars is a drop in the bucket for big insurers. But for the patients who get unexpected bills, it can be a big burden.

Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, “We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.”

While Ryan’s family would not have had to pay for a covid test during the public health emergency, it was the family’s insurer, Cigna, that did not have to pay this time, since the family had not yet met a $3,000 yearly deductible.

A Cigna representative did not respond to requests for comment.

The Resolution

Wettstein said she knew she could just pay the bill and be done with it, “but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.”

She contacted the hospital’s billing department to make sure the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it up for further review.

“‘Don’t pay this until you hear from me,’” Wettstein remembered being told.

Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.

Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead, she got a bill “that they have verified that I have to pay.”

“Like I said, it’s mind-blowing to me.”

The Takeaway

ERs are among the most expensive options for care in the nation’s health system, and the meter can start running as soon as you check in — even if you check out before receiving care.

If your issue isn’t life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether it’s actually an urgent care clinic). The urgent care centers near Ryan’s home were closed that evening, but some facilities stay open late or around the clock.

In some ways, Wettstein was lucky. KFF Health News’ “Bill of the Month” has received tips from other patients who left an ER after a long wait without seeing a doctor — and got slapped with a facility fee of over $1,000.

Making the decision about where to go is tough, especially in a stressful situation — such as when the patient is too young to communicate what’s wrong. Trying to figure out what’s going on physically with a 3-year-old can feel impossible.

If you decide to leave an ER without treatment, don’t just walk out. Tell the triage nurse you’re leaving. You might get lucky and avoid some charges.

Wettstein won’t think twice about taking Ryan to the pediatrician or an urgent care center the next time she’s ailing. But, Wettstein said, after getting this bill, “I’m not going to create a habit out of going to the emergency room.”

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

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

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

Voters backed abortion rights in seven of the 10 states where the issue appeared on ballots Tuesday — at first glance, seemingly reshaping the nation’s patchwork of abortion rules.

Colorado, Maryland, Montana, and New York — states where abortions are already permitted at least until fetal viability — all will add abortion protections to their state constitutions. Nevada voters also favored protections and can enshrine them by passing the measure again in the next general election.

Florida and South Dakota voters, meanwhile, did not pass abortion rights amendments, and Nebraska voters essentially affirmed the state’s existing ban on abortions after the first trimester, while rejecting a measure that would have protected abortions later into pregnancy.

The biggest changes came in Arizona, where, in 2022, abortion was banned after 15 weeks, and in Missouri, which has had a near-total ban. Voters in those states approved constitutional amendments to protect abortion rights through fetal viability, opening the door to overturning those states’ restrictions and increasing access to abortion services.

But when Alison Dreith, director of strategic partnerships at the Midwest Access Coalition abortion fund, which has helped people from Missouri and 27 other states get abortions, was asked before the results came in how her organization was preparing for logistical changes, she said simply: “We’re not.”

That’s because actual access to abortion in the country remains largely unchanged, despite the Nov. 5 results. The web of preexisting state laws on abortions will likely remain in place while they are contested in court, a process that could take months or even years.

Dreith said she doesn’t think many voters understood all that before heading to the polls. “It might not get them the results that they want, especially immediately,” Dreith said.

Further complicating these state results: The election wins of Donald Trump as president-elect and Republicans in the U.S. Senate, giving their party control, have raised the question of whether a national abortion ban will be on the table. Republicans had demurred on the campaign trail. Such a law would take time to enact, too.

The abortion landscape changed dramatically when the U.S. Supreme Court overturned federal abortion protections with its 2022 decision in Dobbs v. Jackson Women’s Health Organization. That left abortion rules up to the states, prompting 14 to enact bans with few exceptions and several others to limit access.

The ruling also led to a raft of ballot measures: Voters in 16 states have now weighed in on abortion-related ballot measures. Thirteen have favored access to abortions in some way. And while the Florida amendment to protect abortion access failed to meet the necessary 60% threshold to pass, it did receive a majority of the vote.

Abortion opponents such as Susan B. Anthony Pro-Life America praised the votes rejecting amendments in Florida and South Dakota and lamented the amendments that passed in states, such as Missouri, with restrictive abortion rules and bans.

“We mourn the lives that will be lost,” Sue Liebel, its director of state affairs, wrote in a statement. “The disappointing results are a reminder that human rights battles are not won overnight.”

States that passed abortion rights amendments in 2022 and 2023 offer a view into the lengthy legal road ahead for abortion policies to take effect. It took nine months after Ohio voters added abortion protections to their state’s constitution for a judge to strike down the state’s 24-hour waiting period for abortions. And some of Michigan’s abortion restrictions, including its own 24-hour waiting period, were suspended only in June, 19 months after Michigan voters approved their state’s abortion rights amendment.

Missouri has an extensive set of such rules. Legal abortions had almost ceased even before the state’s ban was triggered by the Dobbs decision. Over three decades, state lawmakers passed a series of restrictions on abortion providers that made it increasingly difficult to operate there. By 2018, only one clinic was providing abortions in the state, a Planned Parenthood affiliate in St. Louis. Anticipating further tightened restrictions, it opened a large facility 20 miles away in Illinois in 2019.

Those laws that reduced the number of recorded abortions in the state from 5,772 in 2011 down to 150 in 2021 remain on the books, despite the newly passed amendment protecting abortion rights.

Abortion services often get talked about like a light switch, according to Kimya Forouzan, principal state policy adviser at the Guttmacher Institute, a nonprofit that supports abortion rights. But the infrastructure needed to provide abortions is not so easy to turn on and off.

North Dakota’s abortion ban was repealed by the courts in September, for example, but the lone provider of abortions in the state before the ban took effect has no plans to return, having moved operations a five-minute drive away to Minnesota.

And even when clinics quickly ramp up services, the legal wrangling over abortion rules can lead to policy whiplash, with patients caught in the middle.

Georgia’s law banning most abortions after about six weeks spent years in the courts after it passed in 2019. During two brief stretches after the Dobbs decision, once in 2022 and again in 2024, court rulings meant that clinics in the state could provide abortions up to 22 weeks of pregnancy.

Demand for abortion surged during those times, and clinics were able to resume offering services quickly. But when state courts later said the ban should be enforced, those windows slammed shut. During the 2022 period, some patients scheduled for abortions were left sitting in waiting rooms, according to Megan Cohen, medical director of Planned Parenthood Southeast.

The various abortion rights amendments that passed Nov. 5 could also face challenges.

In Missouri, the state’s Republican-dominated legislature has attempted to ignore voter-passed amendments before. After Missouri voters added Medicaid expansion to the state’s constitution in 2020, the state legislature refused to fund the program until a judge ordered the state to start accepting applications, prompting significant delays in enrollment.

The state’s presumptive House speaker, Republican Jon Patterson, has said the legislature must respect the outcome of the Nov. 5 ballot measure vote, while others have pledged to bring the issue to voters again.

In the meantime, Dreith of the Midwest Access Coalition said people seeking abortions in the Midwest will do what they often do in the region for everything from groceries to health care: drive.

“We expect that the resources we need are not in our communities,” Dreith said, “and I think that’s been helpful to us in this crisis.”

KFF Health News’ Renuka Rayasam and Sam Whitehead in Georgia and Arielle Zionts in South Dakota contributed to this report.

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In June 2019, Lija Greenseid handed Minnesota Gov. Tim Walz an empty vial of insulin that her 13-year-old daughter had painted gold.

Greenseid’s daughter has Type 1 diabetes, which means she requires daily injections of manufactured insulin to stay alive. The price of a single vial of insulin rose by about 1,200% between 1996 and 2018, and the gold vial was a reminder, Greenseid said, that this lifesaving pharmaceutical shouldn’t be as expensive as precious metal.

“What I heard is that that gold vial remained on his desk at the governor’s office, and he brought it up throughout that summer and fall when he was trying to talk to legislators to get them moving,” Greenseid said.

Ten months later, in April 2020, Walz signed the Alec Smith Insulin Affordability Act. The law was named after the 26-year-old Minnesotan whose 2017 death from rationing insulin became a catalyst for the patient advocates who turned the high cost of insulin in the U.S. into a national political priority.

Now it’s an issue in the presidential campaign. Both former President Donald Trump and Vice President Kamala Harris and her running mate, Walz, have sought to appeal to the nation’s 8.4 million insulin users and their families by touting policies that make insulin cheaper for some patients.

But advocates for diabetes patients fret that neither presidential candidate would go as far as Walz’s Minnesota law, which helps patients even if they are uninsured, despite the law being under legal attack by the drug industry.

The landscape on insulin pricing has already changed significantly in the past five years. One month after Walz signed the Minnesota law, the Trump administration announced a voluntary program for Medicare prescription drug plans to cap copayments for some insulin products at $35. Two years later, President Joe Biden signed a law requiring all Medicare drug plans to cap copayments for insulin at $35 a month.

Now, amid the current presidential campaign, Harris has proposed extending that $35 cap on insulin copayments to Americans with commercial health insurance.

The Trump campaign’s national press secretary, Karoline Leavitt, touted his efforts on prescription drug prices when he was in the White House, including approval of a pathway for prescription drugs to be imported from Canada as well as the voluntary $35 insulin Medicare copayment cap. But she did not offer new insulin-specific initiatives for his possible second stint as president.

“President Trump will finish what he started in his first term,” Leavitt wrote in a statement.

Copayment caps, which have been enacted by 25 states, are popular policies because they provide an immediate financial benefit that many patients see at the pharmacy, according to University of Southern California economist Neeraj Sood. They’re also relatively easy to implement.

But copayment caps don’t address the high list price of insulin itself, so uninsured patients don’t benefit from such rules. About 1 in 12 Americans lacked health insurance last year.

That’s what makes Minnesota’s insulin safety net different. The system has two parts: an emergency program that allows individuals to get a one-time, 30-day supply of insulin for $35, and a continuing need program that provides insulin to eligible patients for a year at no more than $50 for a 90-day supply.

By contrast, list prices for a 30-day supply of insulin can easily top $215, depending on the insulin.

The bill that created Minnesota’s program was bipartisan out of necessity. Republicans controlled the state Senate at the time, while the Minnesota Democratic-Farmer-Labor Party held the House and governor’s office.

Nicole Smith-Holt, whose son the bill was named after, watched in tears as it finally passed the state legislature in 2020.

“I was happy. I was relieved,” Smith-Holt said. “I was sad that it took Alec dying to get to the point where people could walk into the pharmacy and pick up their prescription for an affordable price.”

But because Minnesota’s program requires insulin manufacturers to provide the insulin, it has prompted a backlash from manufacturers. Pharmaceutical industry lobbying group PhRMA filed a lawsuit in 2020 to block the Minnesota law, arguing it violates the “takings clause” of the U.S. Constitution, which says private property can’t be taken for public use “without just compensation.”

That suit is ongoing, yet the state program is up and running and by the end of 2023 it had been used over 1,500 times.

PhRMA spokesperson Reid Porter said his group is committed to helping patients afford medicines. Insulin makers voluntarily dropped list prices last year and now offer patient assistance programs for affording the drugs. And the CEO of insulin maker Eli Lilly first proposed the voluntary Medicare copay cap Trump announced in 2020.

Porter said insulin costs have been driven up by insurance companies and pharmacy benefit managers, also known as PBMs — the middlemen between insurance plans or employers and drug manufacturers — when they pocket the discounts from the list price of drugs that they negotiate with manufacturers.

“Minnesota’s insulin program does not solve this problem and is unconstitutional,” Porter said. “This is not how the system should work, and why it’s critical that policymakers should prioritize reforming the PBM system, a solution that puts patient health over politics.”

In 2021, Sood co-authored a study that found that, despite insulin list prices rising between 2014 and 2018, income received by drugmakers decreased while increasing for intermediaries like PBMs and pharmacies.

In September, the Federal Trade Commission announced a lawsuit against the nation’s three biggest PBMs, alleging they created a system that inflated insulin prices. The companies denied the claims.

Jing Luo, a physician at the University of Pittsburgh, said that regardless of who wins in November he doesn’t expect existing insulin policies like Medicare’s popular copay cap to be rolled back, due in part to the advocacy of people like Smith-Holt and Greenseid.

“They’ve been really effective at tying high insulin prices with really bad, morally repugnant outcomes,” Luo said.

The key in Minnesota was including real stories, Greenseid said.

“We had enough real people who reached out and had conversations and helped to show politicians the extent of the problem,” Greenseid said, “and they listened.”

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