News from the South - Alabama News Feed
States try to rein in health insurers’ claim denials, with mixed results
by Shalina Chatlani, Alabama Reflector
March 25, 2025
This story originally appeared on Stateline.
Health insurance companies are under increasing scrutiny for allegedly using artificial intelligence bots and algorithms to swiftly deny patients routine or lifesaving care — without a human actually reviewing their claims.
The high-profile killing late last year of UnitedHealthcare CEO Brian Thompson has focused even more attention on so-called prior authorization, the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding. There had been protests and outrage over the company’s practices for months before Thompson’s death, and UnitedHealthcare has been accused in a class-action lawsuit of using AI to wrongfully deny claims.
As more patients and doctors voice their frustrations, states are responding with legislation designed to regulate prior authorization and claims reviews. So far this year, lawmakers in more than a dozen states are considering measures that would, for example, limit the use of AI in reviewing claims; exclude certain prescription medications from prior authorization rules; ensure that emergency mental health care is not delayed for more than 48 hours; and require that insurers’ review boards include licensed physicians, dentists or pharmacists with clinical experience.
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Insurers have long required doctors to obtain their approval before they’ll pay for certain drugs, treatments and procedures. They argue it is necessary to rein in health care costs and limit unnecessary services. But many doctors and patients say the practice has gotten out of hand, causing delays and denials of care that are harming and even killing people.
In a survey last year by the American Medical Association, 93% of doctors said that insurers’ prior authorization practices delayed “necessary care” for their patients. Twenty-nine percent said such delays had led to a “serious adverse event,” such as hospitalization, permanent injury or death.
In 2023, insurers selling plans on the marketplaces created under the Affordable Care Act denied a combined average of 20% of all claims. Of the 73 million in-network claims they denied, only 1% were appealed, according to KFF, a health policy research group.
The federal role
Under the Biden administration, the Federal Trade Commission and the Department of Justice took a firmer hand against health care corporations alleged to be engaging in behavior resulting in limited and more expensive care for patients. The administration also approved rules requiring that beginning in 2026, Medicare and Medicaid plans create a streamlined electronic process for reviewing claims, making decisions more quickly and providing specific reasons for denying care.
But it’s difficult to hold insurers accountable, according to Timothy McBride, a health policy analyst and co-director of a program at the Institute for Public Health at Washington University in St. Louis.
“Each part of the health care industry — hospitals, pharmaceuticals, insurers — they all have a lot of concentrated power,” McBride said in a phone interview. “And unless somebody actually takes it on directly, it’s going to stay that way. I think the Biden administration tried to take it on, but didn’t make a lot of progress.”
It’s unclear whether the Trump administration and Congress will reverse course. During his confirmation hearing on March 14, Dr. Mehmet Oz, President Donald Trump’s pick to lead the Centers for Medicare & Medicaid Services, defended the use of artificial intelligence in reviewing claims.
“AI can be used for good or for evil, and it to a large extent depends on who’s using it and for what purpose,” Oz told members of the U.S. Senate Finance Committee. “I think AI could play a vital role in accelerating preauthorization.”
In the past, Trump has supported measures to help patients, such as increasing hospital price transparency and lowering prescription drug prices, McBride noted. But “Republicans and conservatives generally are anti-regulation,” he said. “My gut feeling would be that they back off on the Biden push on this.”
States have limited power to act on their own. They have authority only over state-regulated health plans, which include Medicaid, plans for state workers and policies residents purchase from the ACA marketplaces. About 90 million people are covered that way. State laws do not apply to the 156 million workers, retirees and dependents who get their coverage through employer-sponsored health plans, which are regulated through a federal law known as ERISA.
Furthermore, health insurance companies are large and have deep pockets, allowing them to easily absorb state fines.
But Kaye Pestaina, the director of the program on patient and consumer protection at KFF, said states have an important role to play.
“Much of the focus around prior authorization at the federal level has kind of originated from state protections, so I imagine there will be continual activity by state legislatures to come at the problem,” Pestaina told Stateline.
What states are doing
Pestaina said states are trying a number of solutions. For example, states such as Arizona, Michigan and Pennsylvania have given their insurance regulators more authority to directly access claims denial information, in order to overturn decisions or potentially enforce state rules. And these efforts have largely had bipartisan support.
There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.
– North Carolina Republican state Rep. Timothy Reeder
In Pennsylvania, Republican state Sen. Kristin Phillips-Hill pushed through bipartisan legislation in 2022 to streamline prior authorization practices for state-regulated health plans after hearing numerous complaints from patients and doctors.
The legislation created an Independent External Review organization that allows Pennsylvanians to submit an online form to request a review if their insurer denies a service or treatment. If the review organization decides the service should be covered, the insurer must do so. Before then, patients could turn only to a federal review process, which may have been more challenging to navigate and taken more time.
“Our reforms created clear rules, clear timelines for the prior authorization process, and it removed ambiguity or uncertainty from the system that at times, insurers could exploit and providers could be confused over,” Phillips-Hill told Stateline. “Prior to that reform, if you had a denial from your insurer, you had very little recourse.”
The program began in January 2024, and in its first year the Pennsylvania Insurance Department overturned half of 517 denials, which amounted to claims from 259 people.
Jonathan Greer, president and CEO of the Insurance Federation of Pennsylvania, said his trade group worked with lawmakers to come to an agreement on how to change the prior authorization process in a way that worked for insurers and patient advocates. Greer says he thinks Pennsylvania could be a model for other states.
“Prior authorization, I think unfairly, has been characterized as a reason to say ‘no’ by insurers,” Greer said. “The purpose of prior authorization is to make sure that you know the care that you get is consistent with the care that you need.”
In North Carolina, Republican state Rep. Timothy Reeder is hopeful that his prior authorization bill will make it across the finish line this year. Reeder’s bill would set tight deadlines on insurers’ claim decisions and require companies to have licensed practitioners on their claim review boards. Insurers would also have to publicize a list of services they require authorization for.
“I’m not saying that we need to get rid of it completely,” Reeder told Stateline. “There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.”
But some state laws have proven to be less effective than advertised.
In 2021, Texas enacted a first-of-its-kind law creating a “gold card” standard, under which physicians whose care recommendations are approved by insurers at least 90% of the time are exempt from the prior authorization process. But as of the end of 2023, only 3% of Texas physicians had earned gold card status, according to the Texas Medical Association.
That’s why the group is pushing legislation that would require insurers to report which preauthorization exemptions they granted and denied and how many claims went to independent review. Dr. Zeke Silva of the Texas Medical Association’s legislative council said it would be “in the same spirit” as what Pennsylvania has done.
“Our focus with the [Texas Medical Association] is our physicians being able to provide the best care possible. And we want that to be free of burden,” Silva told Stateline. “We want to minimize third parties coming in and inappropriately denying care that our physicians and our patients think is in their best interest.”
Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.
Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.
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Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.
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News from the South - Alabama News Feed
Montgomery mayor praises infrastructure initiative, Montgomery Forward
SUMMARY: Montgomery Forward, led by Mayor Steven L. Reed and the City Council, is a major infrastructure initiative aimed at revitalizing community spaces like recreation centers, parks, and fire stations, especially in underserved neighborhoods. Since its inception, over $53 million in capital projects have been completed, including upgrades to the Crump Senior Center, Chisholm and Sheridan Heights Community Centers, Fire Station 10, and Lagoon Park Softball Complex. The initiative has fostered economic growth, exemplified by Lagoon Park’s $4.1 million economic impact from a youth baseball tournament. Additional projects, such as the Courtney Harman Pruitt Community Center, are nearing completion, with a focus on quality and long-term community benefit.
The post Montgomery mayor praises infrastructure initiative, Montgomery Forward appeared first on www.alreporter.com
News from the South - Alabama News Feed
Decision to unfreeze migrant education money comes too late for some kids
by Nada Hassanein, Alabama Reflector
July 31, 2025
This story originally appeared on Stateline.
Victoria Gomez de la Torre doesn’t know when — or if — the migrant children she serves are going to get the education help they’ve come to rely on.
Gomez de la Torre oversees the migrant education program for 12 central Florida counties. The federally funded service helps the children of migrant agricultural workers, who move within and between states based on planting and harvesting seasons.
Her staff identifies agricultural workers who’ve migrated to the area and helps them enroll their children in school. It also helps connect them with tutoring and medical care.
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Earlier this summer, the Trump administration froze more than $6 billion in education funding, including money for migrant education, after-school programs, English-language programs for non-native speakers and other grants. Congress had already approved the money, but the administration said it wanted to conduct a review of the programs.
The administration announced last Friday it would release the remaining $5.5 billion of the money, after unfreezing $1.3 billion earlier this month.
But for Gomez de la Torre’s program, the damage had already been done: Without the money, it had to shut down this summer.
“We didn’t have enough money left over to carry the program,” said Joram Rejouis, the director of program development for the public schools in Alachua County, which includes Gainesville and is the largest of the 12 counties. “Definitely, stopping the program caused damage.”
The program came to a complete halt when Gomez de la Torre’s 11 staff members were offered other positions in the school district. Throughout July, about five dozen migrant children across the 12 counties were without summer services. The funds were supposed to go out before the start of the month.
“It’s going horrendously,” said Gomez de la Torre. “Migrant families depend on us, rely on our system and our help.”
The Alachua County program serves about 1,000 to 1,200 children of migrant workers throughout the year, many in rural farming communities. Each year, roughly 17,000 migrant children are served by programs across Florida.
“It is a very valuable program for a very vulnerable population,” Rejouis said. “Definitely, stopping the program caused damage, period — for the families, for the program and for the district.”
Migrant children are less likely to have regular primary care and are more likely to face health conditions such as anemia and high blood pressure. Many migrant families who harvest food in the fields don’t have enough food themselves.
The program also helps with communication and translation among parents, teachers and guidance counselors. “We were their go-to for whenever they needed something,” Gomez de la Torre said. “Now, they don’t have us.”
Stopping the program caused damage, period — for the families, for the program and for the district.
– Joram Rejouis, director of program development for the public schools in Alachua County, Fla.
The freeze in funds added to the uncertainty and fear created by the Trump administration’s broader moves to target benefits for immigrants. The U.S. Department of Health and Human Services recently announced it had added Head Start to the list of public programs that would be closed to immigrants who are here illegally. After the funding announcement earlier this month, a senior official said the administration had established “guardrails” to ensure the funds are not used “in violation of Executive Orders.”
“It’s anybody’s guess when we’ll come back,” Gomez de la Torre said. “If we’ll come back. If people who chose to retire will return, if their retirement can be rescinded. … Nobody knows exactly how it’s going to play out.”
A similar story is unfolding in California.
The statewide Mini Corps program, run by the Butte County Office of Education, north of Sacramento, connects migrant children at schools and labor camps with bilingual tutors who help them during the school day. Many of the tutors are former migrant children themselves, said Yvette Medina, who oversees the program.
The funding freeze forced the office to lay off around 400 workers statewide, according to spokesperson Travis Souders. Despite Friday’s announcement, the organization is waiting for official word — in writing — before reversing layoffs.
“There’s going to be many students out there who are just going to have another disadvantage to the disadvantages that we already have,” Medina said.
In Santa Clara County, which includes San Jose, the program was forced to shut down altogether, according to Medina.
Medina grew up in migrant labor camps, following her parents to the fields at 4 a.m. as they picked cherries and grapes before she went to school. Her parents worked throughout the Central Valley, back in Mexico and up and down the West Coast, all the way to Oregon.
“It is devastating,” she said. “If it wasn’t for the migrant program, I know for a fact there’s no way I would have graduated high school.”
Migrant families already are gripped with fear as the Trump administration ramps up immigration raids and arrests, which President Donald Trump insists are focused on those with criminal histories.
“They are terrified,” Gomez de la Torre said. “We had families stop sending kids to school and others who fled the country.”
Ruby Luis, a consultant who helps school districts across Florida identify and enroll migrant students in school, also was a migrant child. Her parents worked in orange groves, at strawberry and Christmas tree farms and produce-packing houses.
Program tutors read books with her and gave her school supplies. The program took her on college tours and she enrolled via a scholarship for migrant children — a first-generation college student. She eventually graduated with a degree in biology.
“Just having even somebody to talk to you about going to college — because you don’t have anybody to talk to about [that],” she said. “Having that support was really impactful.
“To take that away, and then now they just have to navigate it themselves, it creates these barriers,” Luis said. “And it can ultimately leave these children not having access to education.”
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org. Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.
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Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.
The post Decision to unfreeze migrant education money comes too late for some kids appeared first on alabamareflector.com
Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.
Political Bias Rating: Center-Left
This content focuses on the negative impact of the Trump administration’s funding freeze on migrant education programs, highlighting the struggles faced by vulnerable immigrant children and their families. It emphasizes the detrimental effects of reduced federal support and frames the administration’s actions as causing harm to these communities. While it reports on factual developments, the article takes a sympathetic stance toward migrant populations and is critical of policies perceived as restrictive or harmful to them, aligning with typical center-left concerns about social welfare and immigrant rights.
News from the South - Alabama News Feed
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