A fifth patient with similar symptoms later arrived at another local facility, according to a health system spokesperson.

The day after the Sept. 4 school shooting that killed two students and two teachers, some 80 families showed up in a county office to receive counseling from volunteer therapists who converged from across the Atlanta metro area, according to one medical provider. That Sunday, nine people received free treatment at a local church for post-traumatic stress disorder from volunteering Atlanta-area providers. On Monday, the state opened a temporary recovery center to help locals find counseling, faith-based support, or other aid. The needs are still great.

“We don’t really … know how we’re doing,” Amanda McKee — whose son, Asa Deslonde, is a senior at Apalachee — said two days after the shooting. “It’s second by second. It’s minute by minute. The last couple days have been unimaginable.”

When shootings of any magnitude occur, they often leave the survivors with invisible injuries that can create life-changing symptoms that sometimes paralyze them.But such problems can take time to emerge. Panic attacks and anxiety can spike across a community after a shooting and can be most intense when people return to the scene, said Howard Liu, chair of the Council on Communications for the American Psychiatric Association.

So health providers worry that in the coming days, months, and years the community will struggle to find help for their mental health needs. Barrow County, along a highway that connects Atlanta to the college town of Athens, is a community where agriculture is steadily giving way to development.

Prior to the shooting, the area had one stand-alone inpatient mental health facility, located in Gainesville, about 30 miles away from where the shooting occurred in Barrow County, that was “constantly overwhelmed,” said Sean Couch, a spokesperson for Northeast Georgia Health System. And, the latest federal data shows, Barrow would need to add at least 13 full-time providers to no longer be considered a mental health workforce shortage area.

“We put a band-aid on a chronic situation and that band-aid isn’t going to last,” said Roland Behm, a co-founder of the Georgia Mental Health Policy Partnership, an advocacy group that represents mental health organizations in the state. “What happens three months from now?”

The scarcity of mental health providers in Barrow County is emblematic of the state as a whole. Georgia ranks nearly last among states in access to mental health care resources, according to Mental Health America, a nonprofit that advocates for increased mental health spending. More than 5 million Georgians live in mental health care professional shortage areas like Barrow County.

Paying for mental health care to treat such trauma is difficult nationwide. But Georgia is one of the 10 states that have not fully expanded eligibility for Medicaid, the nation’s safety net insurance for those with low incomes and also the largest payer for mental health services. The state has an uninsured rate of 13.6%, which is 4.1 percentage points higher than the country as a whole, according to 2022 data from the U.S Census Bureau.

Even people with private health plans have trouble finding affordable, in-network mental health care because of a lack of providers willing to accept low insurance reimbursement rates, Behm said.

Tamara Conlin, CEO of Advantage Behavioral Health Systems, said the people who came to the initial counseling sessions that her group helped arrange in a county office showed a lot of sadness and anxiety.

“Some of them are still in shock and trying to wrap their heads around what happened,” she said.

Even before the shooting, students at Apalachee High School reported significant mental health challenges.

Nearly 200 of 1,725 student respondents reported that they had seriously considered attempting suicide one or more times in the prior year, according to the latest Georgia Student Health Survey. Top motivators included problems with peers, friends, or family. About half of the students from the school who answered said they felt sad, depressed, or withdrawn at least once in the prior 30 days.

County residents complained about having to travel for psychiatric care and said the “shortage of psychologists and counseling services led to untreated high anxiety and depression rates,” during a 2019 focus group about health care access.

The lack of mental health care remained a top concern in the region during a follow-up assessment in 2022. That year, the opioid overdose death rate in Barrow County was among the highest in Georgia, according to state data, and the five-year suicide rate was above the state average.

The Barrow County School System, which includes Apalachee High School, received a $1.8 million federal grant to boost mental health resources in schools from 2023 through 2028.

But immediately following the shooting, mental health providers across the region still had to cobble together free resources for area residents. Three volunteers helped with last Wednesday’s response at Northeast Georgia Medical Center Barrow. Advantage Behavioral Health Systems kept its Barrow clinic open on Sunday and is providing counselors to community events and local schools as they reopen.

William Smith, who heads the Atlanta Center for EMDR, is planning sessions using eye movement desensitization and reprocessing therapy to address PTSD — at least one for first responders and another for residents.

Over the weekend, Lutheran Church Charities brought nine golden retrievers as “comfort dogs” to help the grieving. The group’s dogs have been deployed in the wake of other school shootings, including the Uvalde, Texas, massacre.

“We can’t fix what they’re feeling,” said volunteer Paul Soost, as people gathered around a campus flagpole where they delivered flowers and messages. “We can provide comfort.”

Many health care providers expect the community’s needs to spike when students return to Apalachee High School and as the national attention on the shooting recedes.

“That’s when people start experiencing the trauma,” said Conlin, with Advantage Behavioral Health Systems, who compared the current crisis to the surge of patients she saw after the immediate threat of the covid-19 pandemic passed.

Her clinic in Barrow County already had about 750 active clients before the shooting, with about 120 under the age of 18.

McKee said she knows healing will be a long process for her son, Asa. One of his football coaches, Richard Aspinwall, was among the four killed. A key step came the day after the shooting, she said, when the school’s head football coach convened the team to share how much he was hurting.

“The coach validated that they were hurt, and encouraged them to embrace that they were injured,” McKee said. “They’re not the physical injuries that were incurred by the senseless act, but they are injuries nonetheless.”

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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The state launched the program in July 2023, requiring participants to document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage. At the event, booths were set up to help people join the Marines or pursue a GED diploma.

Taylor, 20, already met the program’s requirements — she studies nursing and works at a fast-food restaurant. But she said it wasn’t clear what paperwork to submit or how to upload her documents. “I was struggling,” she said.

Georgia is the only state that requires certain Medicaid beneficiaries to work to get coverage. Republicans have long touted such programs, arguing they encourage participants to maintain employment. About 20 states have applied to enact Medicaid work requirements; 13 won approval under the Trump administration. The Biden administration has worked to block such initiatives.

The Georgia Pathways to Coverage program shows the hurdles ahead for states looking to follow its lead. Georgia’s GOP leaders have spent millions of dollars to launch Pathways. By July 29, nearly 4,500 people had enrolled, the state’s Medicaid agency told KFF Health News.

That’s well short of the state’s own goal of more than 25,000 in its first year, according to its application to the federal government, and a fraction of the 359,000 who might have been eligible had Georgia simply expanded Medicaid under the Affordable Care Act, as 40 other states did.

So far, the pricey endeavor has forced participants to navigate bureaucratic hurdles rather than support employment. The state would not confirm whether it could even verify if people in the program are working.

Research shows such red tape disproportionately affects Black and Hispanic people.

“The people that need access to health care coverage the most are going to struggle with that administrative burden because the process is so complicated,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

At an August press event, Georgia Republican Gov. Brian Kemp announced a $10.7 million ad campaign to boost enrollment in Pathways, one of his administration’s major health policy initiatives. The plan has cost more than $40 million in state and federal tax dollars through June, with nearly 80% going toward administration and consulting fees rather than paying for medical care, according to data the state Medicaid agency shared with KFF Health News.

Enrollment advisers, consumer advocates, and policy researchers largely blame a cumbersome enrollment process, complicated program design, and back-end technology flaws for Pathways’ flagging enrollment. They say that the online application is challenging to navigate and understand and lacks a way for people to receive immediate support, and that state staffers don’t respond to applicants in a timely manner.

“It’s just an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, who helps Pathways applicants appeal denials.

Administrative challenges have also undermined a key part of the program’s philosophy: that people maintain employment to keep coverage. As of July, the state was not removing enrollees for not meeting Pathways’ work requirement, according to Fiona Roberts, a spokesperson for Georgia’s Medicaid agency.

“We understand that people need to be held accountable to those 80 hours for the spirit of the program, and we intend to do that,” said Russel Carlson, the agency’s commissioner.

Pathways is set to expire Sept. 30, 2025, unless the state asks the Centers for Medicare & Medicaid Services for an extension. Georgia officials say they won’t have to make that request until next spring, well after November’s election. So the state could be asking for an extension from the Trump administration, which approved the program in the first place.

Georgia officials sued the Biden administration this year to keep Pathways running without going through the official extension process, which requires the state to conduct public comment sessions, gather extensive financial data, and prove that Pathways has met its goals. A federal judge ruled against Georgia.

A CMS spokesperson said the agency wouldn’t comment on the program.

During the August press event, Kemp said the Biden administration’s attempt to stop the program in 2021 delayed its rollout and stymied enrollment. A federal court blocked the administration and allowed Georgia to proceed.

People familiar with the enrollment process said Pathways has been mired in design flaws and system failures. As of the end of May, 13,702 applications were waiting to be processed, according to state documents.

The program’s lengthy questionnaires and technical language are confusing, guidance is opaque, and tools to upload documents are tricky to navigate, according to interviews with health insurance enrollment specialists conducted for the Georgia Budget and Policy Institute.

“It’s not an easy, ‘Oh, I want to apply for Pathways,’” said Deanna Williams, who helps people enroll in insurance plans at Georgians for a Healthy Future, a consumer advocacy group. People generally learn about the program after being denied other Medicaid coverage, she said.

In the online application, people click through pages of questions before they’re shown a screen with information about Pathways, Williams said. Then they must check a box and sign a form saying they understand the program’s requirements.

Sometimes the Pathways application doesn’t pop up, and she must start over. The process to apply is “not smooth,” she said.

Data shows that people who don’t earn enough to qualify for free ACA plans but also make too much for Medicaid are disproportionately people of color. Pathways offers Medicaid coverage to adults earning up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.

Some people eligible for Pathways who work in retail or restaurants with fluctuating hours are nervous they can’t meet requirements every month, Williams said.

Many current enrollees don’t know how to upload documents, and the website sometimes stops working, said Jahan Becham, an employment specialist for Pathways at Amerigroup Community Care. Or people just forget.

Every month Becham gets a list of 200 to 300 enrollees who haven’t submitted their hours. “It is something new, and not many people are used to this,” Becham said.

“I would get reminders,” said Taylor, who attended the event for enrollees in August. “I just didn’t know how.”

In a June 2023 meeting with Georgia Medicaid staffers weeks before the program launched, federal officials questioned why the state wasn’t automatically verifying eligibility with existing data sources, according to meeting minutes KFF Health News obtained through a state open-records request. Georgia officials said they were unsure when they’d be able to simplify the verification process.

Many potential participants face improper denials, advocates said. Gibson, at the Georgia Legal Services Program, said not enough workers are trained to properly evaluate applications.

Fewer than 1 in 5 people who have their Pathways applications processed had been accepted into the program as of May, according to a KFF Health News analysis of state data. Roberts, with the state, said people were denied because they earned too much, didn’t meet requirements, or didn’t complete the paperwork.

A full-time graduate student was wrongly blocked from the program, and in February a state administrative judge ordered her case be reconsidered. In another case, a different judge ruled a 64-year-old woman who couldn’t work because she was her disabled husband’s full-time caregiver would not qualify for Pathways.

Despite the challenges, state records from May show no individuals were removed from the program since it launched for failing to meet work requirements.

Georgia’s experiment comes after a 2018 effort in Arkansas to implement work requirements on an existing Medicaid expansion population led to 18,000 people losing coverage, many of whom either met requirements or would have been exempted.

Taylor found out about Pathways when she applied for food stamps last year. It wasn’t until August that she learned she could submit her school schedule to meet the qualifying hours requirement. With a full Medicaid expansion, Taylor would have been eligible for health coverage without the extra effort. But, for her, it’s still worth it.

“It’s important to have health insurance,” said Taylor, who has been to the dentist several times and plans to visit a doctor. “I’m glad I have it.”

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In the town of Cuthbert, some 160 miles away, the Southwest Georgia Regional Medical Center also remains shut after closing four years ago, another Southern hospital casualty in a region dotted with them. Even a smaller facility replacing the former Cuthbert hospital “would be tremendous for the county,” said Steve Whatley, chair of the Randolph County Hospital Authority.

The two hospitals — one inner-city, the other rural — faced some of the same financial pressures, including not having enough patients with private insurance.

This year, they also shared the attention of some of Georgia’s most powerful lawmakers. Legislation signed in April by Gov. Brian Kemp, a Republican, included a provision pushed by U.S. Sen. Jon Ossoff, a Democrat.

The law amends the state’s “certificate of need” system, which allows existing hospitals and other health facilities to block would-be competitors’ plans to expand by arguing there’s insufficient need for their services.

Certificate of need laws exist in 35 states and Washington, D.C., according to the National Conference of State Legislatures. The hospital industry, especially nonprofit facilities, generally support the rules, and have argued they reduce health care costs and preserve access to quality medical services. Under CON requirements, health providers must obtain approval from the state before offering some new services or before building or expanding facilities.

Whether the laws improve care or reduce costs is questionable, researchers have found, and critics say more competition would decrease spending by insurers and consumers. In 2018, the Trump administration issued a report recommending that states repeal or revise their certificate of need requirements, arguing they increase health care costs.

“The evidence is pretty darn overwhelming that CON laws don’t achieve the initially stated goals of increasing access, lowering costs, and improving quality,” said Matthew Mitchell, a senior research fellow at West Virginia University.

Dan Sullivan, a Georgia-based consultant who often helps hospitals and other medical providers in their effort to preserve the laws, said that by limiting the number of providers offering very specialized health services, such as organ transplants, states can better maintain high quality of care.

Certificate of need laws can reduce fraud, Sullivan said. Florida repealed its certificate of need requirements for hospitals and many other health providers following the Trump administration’s recommendation. Fraud accelerated in the state after regulations were phased out, he said.

“At least when you file a CON, there’s at least a minimum of investigation,” Sullivan said.

He argued another benefit of the laws is that they frequently mandate a baseline level of charity care.

Other Southern states recently peeled back their certificate of need laws. Tennessee’s legislature passed a bill this year exempting more medical providers from needing to apply for a certificate. North Carolina rolled back some restrictions in an overhaul that paved the way for Medicaid expansion last year. South Carolina made a significant change to its rules last year.

This year, Republicans in Georgia’s legislature attempted to repeal the state’s certificate of need rules. The effort fell short in the face of fervent hospital opposition.

The narrower legislation that Kemp signed would instead ease the rules for building rural hospitals and exempts a potential new hospital that would partner with Morehouse School of Medicine, one of the country’s few historically Black medical schools.

That could potentially fill much of the gap left by Atlanta Medical Center’s closing.

Hospital industry officials said Morehouse would probably need a well-heeled partner, and Atrium Health, part of Charlotte, North Carolina-based Advocate Health, may be a logical match. The growth-oriented nonprofit health system has partnered with Morehouse Healthcare to run a clinic in East Point, south of Atlanta, and has a growing presence in the state. Both Morehouse and Atrium declined to discuss a potential hospital partnership with KFF Health News.

The shuttered AMC main campus, meanwhile, is ensnared in a moratorium the city imposed on redeveloping the site — a response to the jolting decision by its owner, Wellstar Health System, to close the hospital.

In 2022, Mayor Andre Dickens issued an executive order temporarily halting any new development on the site. He has criticized the “unusually abrupt closure of one of Atlanta’s most important medical centers.”

Atlanta’s city council extended the ban another 120 days in June.

A new inner-city hospital “would be a heavy lift financially,” said Josh Berlin, CEO of rule of three, an Atlanta-based health care consulting firm. That’s because it would draw largely from the area’s high level of uninsured and Medicaid patients. Georgia is one of 10 states that have not fully expanded Medicaid, and thus has a high rate of uninsured patients.

“You’ve got a community that is struggling to find care in the wake of the Atlanta Medical Center closure,” he said.

Grady Memorial Hospital and other Atlanta facilities have seen a bump in patient volume since the closure of AMC. Grady is regularly deemed “dangerously overcrowded” in one state dashboard.

The need to handle additional patients has sped up expansion plans for Grady, including adding more than 150 beds, said its chief strategy officer, Shannon Sale. “We knew that was going to be needed over time. The Atlanta Medical Center closure sped up that process,” she said.

In southwestern Georgia, plans are more modest.

Community leaders, including Whatley, are awaiting the results of a feasibility study that is expected to propose a downsized “rural emergency hospital,” a new federal designation that directs extra funding to eligible facilities.

The program guarantees hospitals in rural communities extra Medicare payments and an additional payment of about $3.2 million a year if they close costly inpatient services and offer only emergency and outpatient care.

Ossoff won almost $12 million in three different appropriations bills to support a rural emergency hospital in Cuthbert. He said he met with state leaders to secure the provision in the Georgia certificate of need bill that would allow it to reopen. Southwest Georgia Regional Medical Center would also have to get an exemption from federal officials to qualify for a rural emergency hospital because of its closing date.

“This is a very challenging thing to do, and we’ve still got significant hurdles to clear,” Ossoff told KFF Health News.

Even if it reopens, the Cuthbert facility will face the same pressures that led to its shuttering in the first place — what Ossoff called “failures of state policy.” At the time, he cited Georgia’s decision not to fully expand Medicaid in the wake of the closure.

Brenda Clark, who works in a wellness center across the street from the closed Cuthbert hospital, said some locals are skeptical about the facility reopening.

“It’s much needed. People are hoping and praying we get it back,” she said. But “there are some people who say, ‘We’ll believe it when we see it.’”

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Whitehouse, a consultant for a local health care company that wants to build a hospital there with at least 150 beds, said the group could break ground within a year. The idea, he said, is to provide medical services beyond those currently provided by Wellstar Sylvan Grove Medical Center, an aging, nonprofit “critical access” hospital that offers limited services, including emergency care, rehabilitation, wound care, and imaging.

But it took a new law, pushed by the state’s powerful Republican lieutenant governor, Burt Jones, to clear the way for construction. The land is partly owned by his father, Bill Jones, a successful businessman whose interest in developing a hospital in his home county drew attention from state Democrats and the hospital industry.

The situation has been portrayed as “this billionaire entrepreneur, Bill Jones, exploiting the legal system through his son, imposing his will on people and trying to cash in,” Whitehouse said. “Nothing could be further from the truth.”

Woven through the drama in Butts County are arcane but consequential rules that require state approval for hospital construction and expansion. The rules, used nearly nationwide until the 1980s, require potential builders to apply for permission for new projects. State officials evaluate need based on criteria such as population growth and existing hospital capacity.

This year, Georgia lawmakers joined several other states in targeting those “certificate of need,” or CON, regulations for dramatic change. Some states have exempted certain medical providers from the process; others have been more dramatic, including South Carolina, which is sunsetting most of its rules.

Attempts to pave the way for a new hospital in Butts County show how debate over certificate of need laws can intensify as legislatures try to reconcile the often conflicting priorities of politicians, the health care industry, and communities.

The laws have been criticized for limiting competition, and some health care analysts, like Matthew Mitchell, a senior research fellow at West Virginia University, feel everyday people may get the short end of the stick.

“This kind of a regulation is often there because powerful businesses want them,” Mitchell said, “not because they protect consumers.”

Bill Jones, a 79-year-old former state legislator, supported a 2022 legislative push to open a new hospital in Butts County. But the effort ran into formidable opposition from Wellstar Health System, which operates Sylvan Grove and 10 other hospitals in Georgia.

“As a nonprofit health system, we are always exploring partnerships that expand our mission of enhancing wellbeing in the communities we serve,” said Matthew O’Connor, a Wellstar spokesperson. “Our analysis indicates that another hospital in this area is not needed at this time.”

This year, Georgia Democrats thought they could leverage Republicans’ interest in loosening the rules to gain support for Medicaid expansion. But Democrats were outnumbered in the legislature, and lawmakers eased several rules without that trade-off.

For example, certain hospital projects in rural counties are now exempt. Jones’ project and his home county look likely to benefit.

Burt Jones, Georgia’s lieutenant governor, who is being investigated for his role as a fake elector for Donald Trump in the 2020 presidential election, maintains his push for changes to the rules isn’t about helping his father.

“It will give people access to health care in a reasonable travel time and convenience for them as well,” Burt Jones said.

Bill Jones has used Butts County as the home base to build his business network, which includes petroleum distribution, retail convenience stores, and fast-food restaurants. In a recent interview, he complained about media coverage of his son’s legislative connection to the hospital project.

He said his interest in opening another local hospital is about community need and, at least in part, stems from his personal experience. His wife gets medical services at Emory Healthcare, more than 40 miles away in Atlanta.

“You’re not going to get the attention you need medically” at the 25-bed Sylvan Grove hospital in Jackson, he said. “Health care ought not to be about politics.”

But the lieutenant governor had to be somewhat aware that legislation he was pushing could be seen as financially benefiting a close family member, said Josh McLaurin, a Democratic state senator whose district runs from Atlanta into its northern suburbs. Fellow members of the Democratic Party were encouraged to support the certificate of need bill, even though the GOP has a majority in the Georgia Legislature, he said.

“If they want Democrats on board on a bill they could probably pass without our votes, that tends to suggest that there’s a concern about the narrative,” McLaurin said.

Hospital industry lobbyists, aware of the Jones-Butts County connection, watched the debate with fear of wholesale repeal of the certificate of need laws, which ultimately didn’t happen.

The final bill doesn’t name Butts County specifically. But it does exempt “a new general acute care hospital in a rural county” from having to obtain a certificate of need. With a population of about 27,000, Butts County meets the definition of “rural” outlined in Georgia law.

Now, the small local company for which Whitehouse works — Interstate Health Systems, which is partly owned by Bill Jones — is moving forward. Land is being cleared for medical office buildings, potentially to lure providers to the area.

Whitehouse said major hospital systems already operating in Georgia are interested in partnering on construction and operation of a new facility.

Members of the Butts County Hospital Authority, which oversees Sylvan Grove, declined to comment. But last year, county commissioners passed a resolution encouraging the hospital authority to pursue a new facility.

Byrd Garland, a retired attorney and former hospital authority member, said he’d appreciate any project that gives people local access to health care, “so they don’t have to drive an hour or two hours to get to it.”

Garland said he’s received both good and bad care at Sylvan Grove, and sometimes would rather make the trek to Atlanta to a better-resourced hospital.

“You get that kind of mindset when you’ve grown up out here in this medical desert that we’re in now,” he said.

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The case is called Braidwood Management Inc. v. Becerra, and it was brought by plaintiffs looking to strike down Obamacare’s requirements that private insurers cover certain kinds of preventive care without cost sharing. (Think everything from no-cost cancer screenings to free IUDs.)

Studies have shown the requirements to cover preventive care have increased consumers’ use of short- and long-term birth control methods.

Without those nationwide standards, the United States would return to a “wild West” dynamic “in which insurers and employers pick and choose which services they want to cover or which services they want to charge for,” said Zachary Baron, a health policy researcher at Georgetown Law.

The plaintiffs, a group of individuals and Christian-owned businesses, argue the three groups that set coverage standards — including an independent advisory panel to the Health Resources and Services Administration — haven’t been properly appointed by Congress.

In June, the U.S. Court of Appeals for the 5th Circuit issued a self-described “mixed bag” of an opinion. It agreed that one body hadn’t been properly appointed, making its recommendations since the Affordable Care Act became law unconstitutional. But the court said only the plaintiffs get to ignore its standards.

The appeals court sent questions about the other two groups — including the advisory panel to HRSA that makes recommendations on contraception — back to a lower court to consider.

The case is likely headed back to U.S. District Judge Reed O’Connor. O’Connor’s previous ruling that one body hadn’t been properly appointed was supported by the appeals court. His remedy — blocking its mandates nationwide — wasn’t.

O’Connor is notoriously hostile to the ACA — he struck down the law in 2018. The Supreme Court later overturned that ruling.

And that makes reproductive rights advocates nervous.

O’Connor “is someone who is willing to impose remedies where he takes access to care away from everybody in the country,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center.

A lack of federal requirements for birth control coverage would leave it up to the states to mandate what insurers have to provide. Fourteen states and D.C. currently protect the right to contraception.

But states can go only so far with those rules, because of a federal law that prevents them from regulating employer-funded health plans, which cover about 65 percent of workers.

“If the plaintiffs win here, it would leave significant gaps in coverage that states would be unable to fill,” Baron said.

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“It was wild. I had to call the office seven times to get kids pulled out,” he said. “The next day, I called Kaiser and said, ‘I’d like to know how much a vasectomy is.’”

A representative with Engler’s insurer, Kaiser Permanente, told him the procedure would be free because it was a form of birth control, he said. But after undergoing the vasectomy last winter, he received a bill for $1,080.

“I felt defeated, tricked, and frustrated,” said Engler, who lives in Portland, Oregon.

Engler’s experience highlights how a labyrinthine patchwork of insurance coverage rules on reproductive health care creates confusion for patients. Oregon requires that vasectomies be covered for most people who work in the public sector. But the federal Affordable Care Act — which mandates that most health plans cover preventive health services, such as contraception, at no cost to the consumer — does not require vasectomies to be covered.

And that perplexity surrounding coverage may get more complicated.

An ongoing federal lawsuit aims to strike down the ACA’s preventive care coverage requirements for private insurers. If the case knocks out the mandates, state-level laws — which vary widely across the country — would carry more weight, a change that would resume the “wild West” dynamic from before Obamacare, said Zachary Baron, a health policy researcher at Georgetown Law.

It would create an environment “in which insurers and employers pick and choose which services they want to cover or which services they want to charge for,” Baron said. “It would certainly threaten access to care for millions of Americans.”

Studies have shown the requirements to cover preventive care have reduced consumers’ out-of-pocket costs and increased their use of short- and long-term birth control methods.

The job of defining which contraceptive services should be covered falls to the Health Resources and Services Administration, or HRSA. Two other groups — the U.S. Preventive Services Task Force, or USPSTF, and the Advisory Committee on Immunization Practices, or ACIP — make recommendations on other kinds of care that the ACA requires insurers to cover.

The plaintiffs in the lawsuit, a group of individuals and Christian-owned businesses, argue the members of these three panels haven’t been properly appointed by Congress. They also say the recommendations for insurance plans to cover medication for HIV prevention violate their religious rights.

On June 21, the U.S. Court of Appeals for the 5th Circuit issued what it called a “mixed bag” opinion in the case. It said one group — the USPSTF — had not been properly appointed, and therefore its recommendations made after the ACA was signed into law were unconstitutional. The plaintiffs had asked for a nationwide ruling, but the court said only the plaintiffs’ organizations could be exempted from its recommendations.

The court then sent the plaintiffs’ challenges to the recommendations made by HRSA and ACIP — including those on contraception — back to a lower court to consider.

The case is likely headed to Reed O’Connor, a federal judge in Texas who has issued decisions undermining the ACA — including a ruling striking down the entire law that the U.S. Supreme Court later overturned.

“O’Connor is a judge notoriously hostile to the Affordable Care Act,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center. “He is someone who is willing to impose remedies where he takes access to care away from everybody in the country based on what’s happening in one situation.”

A win for the plaintiffs, she worried, could create confusion about what kind of contraception is covered and how much it costs, which would ultimately lead to more unintended pregnancies — all at a time when women have less access to abortions.

Nearly two dozen organizations — including the American Medical Association, the American Public Health Association, and the Blue Cross Blue Shield Association — have joined Borchelt’s group in filing briefs warning about the potential disruptions a ruling for the plaintiffs could cause.

Jay Carson, an attorney with the Buckeye Institute, a conservative think tank, said he’s happy with the court’s ruling. His group, along with the state of Texas, filed briefs in support of the plaintiffs.

“Unelected bureaucrats” shouldn’t have the power to decide what insurance plans should be required to cover, said Carson. “We’ve gotten so far afield of Congress actually making the laws and, instead, relying on Congress to just empower some agency to do the heavy lifting.”

What power agencies do have is likely to be curtailed in the wake of a June 28 U.S. Supreme Court decision that overturned a decades-old precedent dictating that courts should defer to federal agencies when it comes to regulatory or scientific decisions.

“Courts are going to be more able to scrutinize experts,” said Richard Hughes, a health care regulatory attorney with the firm Epstein, Becker, and Green. “It’s a vibe shift — we’re moving in the direction of the administrative state being curtailed.”

Eliminating federal coverage requirements for contraception would leave it up to states to determine what services health insurance plans would be required to provide.

Fourteen states and Washington, D.C., currently protect the right to contraception. But states can go only so far with those rules, said Baron, because a federal statute prevents them from regulating self-funded health plans, which cover about 65% of workers.

“It would leave significant gaps in coverage,” Baron said.

A group of Democratic-led states made such an argument in a court brief last year, arguing for the mandates to be upheld to discourage self-funded plans from declining to offer preventive services, as they often did before the ACA.

Even when states can regulate what health plans cover, people still fall through the cracks. “I see denials all the time in instances where the treatment clearly is covered,” said Megan Glor, a health insurance attorney in Oregon.

Patients can appeal their insurers’ decisions, but that’s not easy. And if a patient’s appeals fail, litigation is generally the only option — but that’s a long, complicated, costly process, Glor said. Likely, the best outcome for a patient is an insurer covering what should have been covered in the first place.

When Engler called Kaiser Permanente about his vasectomy charge, he said a representative told him the bill was sent by mistake. Still, he said, the insurer kept asking for money. Engler filed and lost multiple appeals and eventually settled the charge for $540.

Engler’s vasectomy likely should have been free, Glor said. As a teacher, Engler is a public sector employee, which means his insurance would be subject to an Oregon law that mandates no-cost coverage for vasectomies.

Kaiser Permanente told KFF Health News that state law does not apply because of a federal rule for high-deductible health plans paired with health savings accounts. That rule requires patients to cover out-of-pocket costs until their deductible is met.

However, after KFF Health News contacted Kaiser Permanente about Engler’s situation, he said the company promised to issue a full refund for the $540 he had paid to settle his case.

“Although we administered the benefit correctly, an employee who spoke with Mr. Engler told him incorrectly that he would not have” to share the cost, said Debbie Karman, a Kaiser Permanente spokesperson.

Engler said he’s happy with the outcome, though he’s still unsure how Kaiser Permanente’s staff was confused about his insurance coverage.

He worries that others don’t have the means he had to advocate for himself.

“It’s scary,” he said. “So many people are limited in their resources or their understanding of how to fight — or even who to fight.”

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

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“I’ve been fortunate to take care of some people with HIV for over 30 years,” said Melanie Thompson, a physician in Atlanta who said she is frequently told by patients, “You’re my longest relationship.”

But there’s a catch: People living with HIV are at increased risk for other health problems, such as diabetes, depression and heart disease.

As their health needs increase, more is required of the Ryan White HIV/AIDS Program, the comprehensive federal system that provides HIV primary medical care, medications and essential support services for low-income people living with the virus.

But core funding for the national network of clinics hasn’t changed much in the past decade.

According to a KFF analysis, inflation-adjusted spending has dropped from a peak in the early 2000s, despite the program serving tens of thousands of new patients.

Laura Cheever, who oversees the Ryan White program, said budget constraints make it hard to prioritize the needs of older people with HIV, especially when many people with the virus haven’t been diagnosed or aren’t receiving services at all.

“When a lot of people aren’t getting care, how do you decide where that next dollar is spent?” Cheever said.

President Biden’s budget request for fiscal 2025 asks for a funding bump of less than 1 percent for the program.

The latest infusion of funding for Ryan White — about $466 million since 2019 — came as part of a federal initiative to end the HIV epidemic by 2030.

But that program, launched by the Trump administration in 2019, was targeted by House Republicans last year in their push to slash the budget of the Centers for Disease Control and Prevention.

Their argument? The initiative, launched just a year before the global coronavirus pandemic drew resources and attention from other public health priorities, wasn’t meeting its goal to cut new HIV infections dramatically by 2030.

Around the same time, Republicans were threatening a different HIV program from a different GOP administration: the President’s Emergency Plan for AIDS Relief, or PEPFAR, launched by George W. Bush.

Republicans held up reauthorizing the program, which has helped millions around the world, over rumors its dollars funded abortions.

Advocates worry these cases signal a larger erosion in bipartisan support for HIV prevention and treatment that threatens to undermine years of progress lowering transmission and mortality rates — especially if older people with the virus don’t get adequate care.

“It’s tragic and shameful that elderly people with HIV have to go through what they’re going through without getting the proper attention that they deserve,” said Jules Levin, executive director of the National AIDS Treatment Advocacy Project, who, at age 74, has been living with HIV since the 1980s.

“This will be a disaster soon without a solution.”

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

USE OUR CONTENT

This story can be republished for free (details).