https://medicalxpress.com/news/2026-06-nursing-home-staffing-declined-states.html

Nursing home staffing declined in states that protected facilities from COVID-19 malpractice lawsuits, study finds
By Gretchen McCartney, University of California, Los Angeles
June 2, 2026

Nursing homes across the country had less staffing in states where legislatures granted the facilities immunity from COVID-19-related lawsuits filed by patients and their families, according to findings from a new UCLA-led study.

Study links immunity laws to staffing

Researchers examined data from 13,205 skilled nursing facilities; those in states with litigation immunity reduced staffing by 2.5% compared to facilities in states that did not pass similar protections for nursing homes. That reduction translated to an average of almost eight hours per day of staff conducting clinical care and other duties per nursing home. The data were collected from 2018 to 2023.

"During the pandemic there was a lot of understaffing. It was even worse in these states with immunity from lawsuits," said Jill Horwitz, an Emerita Professor of Law at the UCLA School of Law, where she began the research published in the Journal of the American Medical Association.

She also is an expert on health policy and continued to work on the study at Northwestern University's law and medical schools, where she is now based.

Widespread adoption of tort immunity

Researchers were surprised by the numbers, they said. "These policy changes are not associated with a defined monetary reward or fixed staffing target," said Dr. David S. Zingmond, corresponding author and professor-in-residence at the UCLA David Geffen School of Medicine's Division of General Internal Medicine and Health Services Research. "So the robust magnitude of change was surprising."

Across the country, 86% of states enacted some kind of tort immunity for nursing homes during the pandemic. Some of the laws had an end date and others were indefinite; 23 states had retroactive immunity covering a period before the legislation was passed.

The scramble to pass legislation was sparked by an anticipated deluge of medical malpractice lawsuits alleging that negligent care caused patients to contract the virus or to die from it.

However, medical malpractice law also can help protect quality of care by deterring negligence, the authors wrote in the research.

Staffing cuts hit CNAs hardest

"Relaxing medical liability results in a worse staffing environment," Zingmond said. "Lower staffing negatively impacts care, and nursing home residents are among the most vulnerable patients."

The study found that certified nursing assistants (CNAs), who provide direct clinical care for patients, made up the primary group that saw reduced staffing. Hours worked by registered nurses (RNs), who often serve in administrative roles, stayed consistent in their staffing rates.

Researchers acknowledged the financial challenges and the general instability of health care staffing during COVID-19, which at nursing homes would have compromised the amount of time caregivers could devote to patients. But the numbers suggest that facilities with reduced tort exposure "may have been less likely to employ nursing staff or work to find replacements during shortages," the authors wrote.

Questions remain about care quality

The study did not chronicle the clinical effects of reduced staffing, and that kind of analysis could be the next step in painting a full picture of nursing home care during the pandemic, Zingmond said.

"Nursing home staffing is a predictor of quality of care that we could not directly measure with the data used in this study," he said. "We would like to see how these policies are related to measurable quality and clinical outcomes."

The information analyzed was from two data systems operated by the Centers for Medicare and Medicaid Services (CMS): the Nursing Home Compare (NHC) quality initiative and the Payroll Based Journal Daily Nurse Staffing dataset.

Publication details

Jill R. Horwitz et al, Tort Immunity and Nursing Home Staffing, JAMA Health Forum (2026). DOI: 10.1001/jamahealthforum.2026.1534

Journal information: Journal of the American Medical Association , JAMA Health Forum

https://www.justice.gov/usao-edmi/pr/feds-charge-foreign-nationals-working-national-institutes-health-smuggling-monkeypox

Feds charge foreign nationals working at the National Institutes of Health with smuggling monkeypox into the United States and lying about it
For Immediate Release - Tuesday, June 2, 2026
U.S. Attorney's Office, Eastern District of Michigan

DETROIT - Vincent Munster and Claude Kwe, both researchers with the National Institutes of Health (NIH) at the Rocky Mountain Laboratory were charged today in a criminal complaint with conspiracy to smuggle monkeypox into the United States and giving false statements to federal law enforcement, United States Attorney Jerome F. Gorgon Jr. announced.

Gorgon was joined in the announcement by Jennifer Runyan, Special Agent in Charge of the Federal Bureau of Investigation, Detroit Field Office, Marty Raybon, Director of Field Operations, U.S. Customs and Border Protection and Special Agent in Charge Marcus L. Sykes of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).

According to the criminal complaint, Vincent Munster, a citizen of the Netherlands, 53, is the Chief of the Virus Ecology Section, Laboratory of Virology at the Rocky Mountain Laboratory in Hamilton, Montana. Claude Kwe, a citizen of Cameroon, 38, is a research fellow in Munster’s section. The work of both men is focused on “emerging viral pathogens” and how those pathogens “cross the species barrier.” They work at a Biosafety Level 4 laboratory, which employs the highest level of biosafety precautions for scientific research of known and potential human pathogens.

On January 25, 2026, Munster and Kwe arrived at the McNamara Terminal at Detroit Metropolitan Airport with travel originating from Brazzaville, Republic of Congo, where an outbreak of monkeypox was occurring. Monkeypox is an infectious virus that can result in painful rash, enlarged lymph nodes, fevers and other ailments.

Munster and Kwe were inspected and interviewed by Customs and Border Protection (CBP) officials upon their arrival. CBP officers observed Kwe and Munster traveling with a large black plastic case. Munster and Kwe falsely told CBP officers that the black case contained diagnostics and testing equipment. But subsequent investigation by CBP and FBI agents revealed that the case actually contained 113 vials in Styrofoam coolers. As of the date of the complaint, the FBI has tested 20 of the 113 vials. Seventeen of them contained deactivated monkeypox virus, one contained the Chickenpox virus, and two contained only human DNA.

“These NIH experts apparently broke our laws by smuggling viral pathogens on a packed commercial airplane from an outbreak in the Republic of Congo. Let that sink in,” United States Attorney Gorgon stated.

“No researchers should believe their positions, credentials, or professional status place them above the law,” said Jennifer Runyan, Special Agent in Charge of the FBI Detroit Field Office. “The allegations in this case are serious. They involve the dangerous and unlawful smuggling of deactivated Mpox virus into the United States and alleged efforts to mislead our federal agents. I am grateful for the outstanding and diligent work of the FBI Detroit JTTF, FBI Billings’ Missoula Resident Agency, the U.S. Customs and Border Protection team at Detroit Metro Airport, and the U.S. Department of Health and Human Services – OIG, for keeping our communities safe.”

“The arrest of these individuals on serious federal charges sends a clear and unmistakable message that no one—including HHS employees who have an obligation to safeguard our federal programs—is above the law. Any deliberate effort to conceal and smuggle biological materials into the United States without proper authorization is a breach of the public’s trust and could have placed the public at risk,” said Special Agent in Charge Marcus L. Sykes of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG will continue to work alongside our law enforcement partners to ensure that anyone who is entrusted with protecting the health and well-being of the public is held fully accountable.”

“We have zero tolerance for anyone who attempts to exploit our research frameworks, circumvent our border enforcement processes, or deceive investigators,” said CBP Director of Field Operations Marty C. Raybon. “Along with our law enforcement partners, we will remain fiercely vigilant in neutralizing biological threats—or otherwise— and continue to hold accountable those who jeopardize the safety and security of the American people.”

Munster and Kwe face a maximum sentence of five years in prison.

The investigation is being conducted by the Detroit Field Office of the Federal Bureau of Investigation, the U.S. Customs and Border Protection Detroit and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).

A complaint is only a charge and not evidence of guilt. The defendants are presumed innocent until proven guilty. It will be the government’s burden to prove guilty beyond a reasonable doubt.

https://www.hhs.gov/press-room/hhs-unveils-plan-to-combat-lyme-disease.html

HHS Unveils Sweeping Plan to Combat Lyme Disease and Advance Treatment
For Immediate Release

May 29, 2026

CONCORD—MAY 29, 2026—U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. today announced a series of major initiatives to strengthen the nation’s response to Lyme disease and other tick-borne illnesses. HHS actions include a multi-million-dollar pilot program focused on tick control, up to $2.5 million in innovation challenges, funding for NIH researchers to combat Alpha-gal syndrome, and a public-private collaboration to help patients connect with experienced providers.

Secretary Kennedy delivered these announcements during a press conference in New Hampshire — one of the states hardest hit by Lyme disease — after convening a roundtable with state lawmakers and Lyme disease advocates as part of his “Take Back Your Health” tour.

“Millions of Americans battling Lyme disease and other tick-borne illnesses have spent years searching for answers, treatment, and support,” said Secretary Kennedy. “Today, the Trump Administration is launching one of the most ambitious federal efforts ever to combat Lyme disease by accelerating research, expanding innovation, and improving care for patients and families. We are going after this disease at its source, driving faster diagnostics and new prevention strategies, and delivering the urgency and action Americans deserve.

”Lyme disease remains one of the nation’s fastest-growing vector-borne health threats. More than 476,000 Americans are diagnosed with Lyme disease each year, and recent data show emergency room visits for tick bites reached their highest springtime level in nearly a decade.

As part of the Department’s broader strategy to address tick-borne diseases, HHS announced a new multi-million-dollar pilot program led by the Centers for Disease Control and Prevention (CDC) and HHS in collaboration with leading tick-control researchers. The initiative will develop and deploy practical strategies to target and eliminate ticks on wildlife before they can spread disease to humans.

The effort will begin with researchers at the New England Center of Excellence in Vector-Borne Diseases and will build on existing community collaboration, including collaboration with the Indian Health Service (IHS) and the Wampanoag Tribe in Massachusetts. By reducing tick populations and disrupting breeding cycles, the initiative aims to slow disease transmission and protect more Americans from infection.

The Department also reaffirmed its goal of reducing Lyme disease cases by 25 percent by 2035 compared to 2022 levels.

HHS continues to support robust research into Lyme disease and other tick-borne illnesses. The National Institutes of Health currently invests nearly $50 million annually in Lyme disease research and approximately $122 million annually in broader tick-borne disease research, including efforts focused on prevention, diagnostics, and treatment.

HHS also announced new actions to combat Alpha-gal syndrome, a tick-associated condition that can trigger potentially serious allergic reactions to red meat and other mammalian products. According to CDC estimates, nearly 500,000 Americans are living with Alpha-gal syndrome, though emerging evidence suggests the true number may be significantly higher.

Through ongoing discussions with private-sector innovators, NIH has preliminarily identified promising products that may help protect individuals from developing Alpha-gal syndrome following a tick bite. Under the anticipated collaboration, participating companies would provide candidate products while NIH would support and fund the clinical research needed to evaluate their effectiveness. HHS expects to provide additional details on the initiative in the coming months as part of its broader effort to accelerate innovation and improve outcomes for Americans affected by tick-borne illnesses.

HHS also announced three new LymeX innovation challenges, offering up to $2.5 million in total prize funding to accelerate breakthroughs in public awareness, treatment, and patient care.

The new challenges include:

• LymeX Visible Voices Prize, offering up to $250,000 to support educational tools and public awareness campaigns developed with input from patients, clinicians, and advocates.
• LymeX Healthathon Innovation Sprint, offering up to $250,000 to identify promising frontline solutions, including novel uses of existing medicines and drug repurposing strategies.
• TOPx HHS Tech Sprint for AI and Invisible Illness, offering up to $2 million — including a $1 million grand prize to harness artificial intelligence and open data to help patients with Lyme disease and other invisible illnesses receive answers and access care more quickly.

These initiatives build on the success of the LymeX Innovation Accelerator, the public-private collaboration between HHS and the Steven & Alexandra Cohen Foundation that was originally launched during President Trump’s first term.

Through LymeX, HHS recently launched a $10 million Diagnostics Prize aimed at accelerating the development of faster, more accurate next-generation Lyme disease tests. Over the past two years, two improved FDA-cleared Lyme disease diagnostics have reached the market through the LymeX innovation ecosystem.

In addition, HHS announced a new public-private collaboration with the International Lyme and Associated Diseases Society (ILADS). Through hhs.gov/lyme, patients will be able to access ILADS’ clinician locator tool, helping connect individuals and families with experienced providers and educational resources related to Lyme disease and associated chronic conditions.

Secretary Kennedy also reiterated his support for reauthorization of the bipartisan Kay-Hagan Tick Act, which established the nation’s first coordinated federal strategy for preventing and controlling vector-borne diseases.

The legislation was signed into law by President Trump in 2019 and recently advanced unanimously through the House Energy and Commerce Committee.

HHS’ Lyme disease initiatives reflect the Trump administration’s ongoing commitment to improving prevention, accelerating research, fostering innovation while ensuring patients receive timely and effective care.

For more information, visit hhs.gov/lyme.

Contact:
HHS Press Office
202-690-6343

https://bridgemi.com/michigan-health-watch/backlash-led-michigan-to-ease-student-vaccine-waivers-what-happened-next/

Backlash led Michigan to ease student vaccine waivers. What happened next
By Kate Wells, KFF Health News
June 3, 2026

PORT HURON — State health officials urged parents in several counties to vaccinate babies against measles ahead of schedule this spring as cases multiplied in Michigan. The outbreaks of the highly contagious virus — which can lead to brain swelling, deafness, and death — came as parents are opting school-age kids out of vaccinations at a record-high rate.

It’s a situation state officials have spent more than a decade trying to avoid. For years, they’ve been trying to make it harder for parents to send their kids to school unvaccinated.

But those efforts have backfired in places like St. Clair County, in Michigan’s conservative Thumb region. Remington Nevin, the county’s medical director, has declared “a new era of vaccine choice.” Local parents there can now bypass the usual protocols and get school vaccine waivers via email, days after they fill out a brief digital form.

State health officials aren’t fighting it.

In fact, Michigan’s health agency has been helping more than 30 counties move away from a state policy once credited with sharply reducing the number of parents who opted their kids out of shots.

In 2015, the state started requiring parents seeking waivers to first attend a vaccine education session, in person, at their local health department.

But in the post-covid era, local health officials say, the sessions became hostile, ineffective, and sometimes even unsafe for staff. One high school called police last fall over an escalating dispute with parents who refused to obtain a state-recognized waiver for their children, with a sheriff’s deputy warning the parents that they could face criminal charges.

In response, the state has helped create a hybrid waiver process for dozens of counties, allowing parents to take a brief vaccine education course online while still requiring they get their waivers signed in person. It’s part of a broader shift in strategy in a state that had some of the most polarizing and politically divisive covid restrictions.

At Michigan schools where only 30% to 40% of students are now vaccinated, it is “simply not possible to keep diseases like measles at bay,” said Natasha Bagdasarian, the state’s chief medical officer. “And when one of these measles cases ends up in a low-immunization community, that’s when the ember really has a chance to expand and become a wildfire.”

A short-lived success story

In 2014, Michigan had the fourth-highest vaccine waiver rate in the country.

Health officials suspected some parents were just signing waivers during the stress of school registration, not because of a deeply held conviction.

“‘Oops, I forgot to do this. I’m just going to sign a waiver and be done with it,’” said Norm Hess, executive director of the Michigan Association for Local Public Health. “That’s not really the way we want parents to make decisions on this issue.”

Around that time, national headlines were focused on a Disneyland-linked measles outbreak in which 131 people were infected. California cracked down, becoming the first state in decades to end nonmedical vaccine waivers.

With Republicans then in control of the Michigan Legislature and governor’s office, health officials found a side door. They created an administrative rule saying nonmedical waivers required certification by the local health department “that the individual received education on the risks of not receiving the vaccines being waived and the benefits of vaccination to the individual and the community.”

“We were not aware of the rule until the day it happened,” Suzanne Waltman, president of Michigan for Vaccine Choice, later told PBS News. “We thought it was a stealth move.”

At first, it seemed to work. Kindergarten waiver rates dropped by 32% in 2015. “Kids were protected more from these vaccine-preventable diseases,” Hess said.

But after that year, waiver rates started rebounding. When the pandemic hit five years later, immunization rates plunged.

‘An unsafe setting’ for medical staff

Juan Marquez is the medical director of a county where a measles outbreak sickened several people this spring, but even he wouldn’t want to do those in-person sessions again.

“It was really creating an unsafe setting, actually, for our nurses,” said Marquez, the medical director for two counties, Livingston and Washtenaw, just west of Detroit.

“Our nurses are just trying to do their job,” Marquez said. “And you can imagine, to have somebody yell at you or just say not nice things to your face and sit through that for hours is demoralizing.”

Washtenaw has had seven measles cases since March and is believed to be the source of an eighth case in a neighboring county. As of May 28, the state had a total of 14 cases this year.

Since the start of the pandemic, waiver requests in Michigan have been increasing.

Tensions over public health became especially high during the state’s covid lockdowns, which critics lambasted as too long and too strict. Republicans made it a campaign issue, and Donald Trump flipped the state in the 2024 presidential contest.

Some parents felt it was demeaning to have to go in for counseling sessions they perceived as judgmental.

Republican state Rep. Jennifer Wortz, who represents a district along the state’s southern border, recalled her session, speaking at a vaccine choice rally in Lansing last year. “I had a very negative experience there, simply because we made decisions as parents and did the research and made the choices that we felt were best for each one of our children.”

That resentment has also made it harder to do basic public health work, like contact tracing for measles cases, Marquez said.

Of the 10,000 vaccine waivers Marquez’s counties have given out in the past 10 years, he said, the education sessions changed the minds of maybe one or two people.

“If we’re not changing folks’ minds, can we do this in a safe way?” Marquez said. “So that was really the idea behind the hybrid model.”

The workaround

At first, state immunizations director Ryan Malosh thought dropping the in-person requirement was a bad idea.

He was skeptical when Livingston County health officials said they wanted to replace in-person sessions with a 20-minute online course about the benefits of vaccines and the risks of vaccine-preventable diseases.

State health department staffers were worried that if the waiver process became more convenient, more people would get exemptions, which could lead to more outbreaks. And because parents could get a waiver from any local health department, people from across the state might start flooding Livingston County with requests.

“We were worried that this could be sort of a sinkhole,” Malosh said.

It wasn’t. Parents took the online course, then made an appointment at the health department to get their nonmedical waivers signed. Waiver rates increased in Livingston County, but at the same rate they were rising in the rest of the state.

So the state turned to the University of Michigan to create a standardized, online course that any county could use. Parents would go through a 20- to 30-minute course, answering questions about the content, and then be able to get their waivers signed at their local health department office.

Michael Rubyan, a public health associate professor at the university, worked with some 40 public health nurses from throughout the state to design it. They wanted it to be simple and fact-based: Here’s what you should know about these diseases. Here’s how vaccines work. And if there is an outbreak at your school, your kids may have to stay home if they’re not vaccinated.

No judgment. No pressure.

This needed to be a building block in a much longer relationship with local public health, the nurses said. And while this change alone probably won’t lead to a dramatic decrease in waivers, Malosh said, it may start to rebuild some trust. “That then opens the door for further conversations, which maybe then gets these folks vaccinated,” he said.

Hybrid may not be enough

About a third of the state’s counties have adopted the hybrid approach, but the waiver system is still creating confusion and conflict.

Last fall, a dispute over the waiver process involving a St. Clair County family blew up into a local controversy, and school officials asked local law enforcement to get involved.

Although the family lived in St. Clair, the children attended high school in neighboring Macomb County. Macomb had already switched to the hybrid model, but the parents didn’t want to file the documents, because they didn’t want their children’s vaccination status to be known by local health officials at all.

The father, Andrew Eberly, said at a St. Clair County public health meeting that getting a certified waiver “forces parents like me to register personal health decisions” with an agency they don’t trust. (Eberly did not respond to multiple attempts to contact him via email, via phone, and at his home.)

At one point during the ongoing conflict, school officials asked the sheriff’s department to intervene. A deputy’s conversation with Eberly on Nov. 5 was captured in body-camera footage obtained by KFF Health News through a public records request.

The deputy described the counseling requirement as a set of “stupid hoops.”

“I know it’s super inconvenient to go into the health department, go through their stupid 10-minute class for them to tell you something you already know, to sign the waiver,” the deputy said.

But the deputy went on to warn Eberly that if they continued taking their kids to school, despite being repeatedly informed they couldn’t be enrolled without a state-recognized waiver, then they could be charged with contributing to the truancy of minors.

The clash became a local cause célèbre. Nevin, the St. Clair medical director, seized on it — and the state’s falling immunization rates — at a public health board meeting as proof that people who mistrust the state’s public health establishment “have sound reasons for doing so.”

So far, state health officials have declined to engage in verbal or legal conflict with Nevin, who has drawn cheers and jeers at public meetings over his vaccine stance. He has also been the subject of internal workforce complaints at the county health department.

Instead, state officials are stressing the importance of parents understanding the risks that vaccine-preventable diseases, like measles, pose for their kids.

“Local health departments get to decide for themselves in a lot of ways what’s best for their residents,” Malosh said. “And I think that what’s best is to be as upfront as possible, to be as truthful as possible, and to try to give the best information that we have available to us to parents so that they can actually make an informed decision.”

https://www.cms.gov/newsroom/press-releases/cms-launches-nationwide-framework-implement-medicaid-work-requirements

https://www.congress.gov/119/plaws/publ21/PLAW-119publ21.pdf

https://public-inspection.federalregister.gov/2026-11094.pdf

CMS Launches Nationwide Framework to Implement Medicaid Work Requirements
June 1, 2026

CMS Launches Nationwide Framework to Implement Medicaid Work Requirements

The Centers for Medicare & Medicaid Services (CMS) released an Interim Final Rule with Comment (IFC) requiring that certain adult Medicaid applicants and enrollees must, as a condition of Medicaid eligibility, meet an 80 hours per month work requirement, through employment, education, work programs, or community service. The rule establishes a nationwide operational framework designed to promote economic stability, self-sufficiency, and independence.

“The Working Families Tax Cut legislation made historic changes to the Medicaid program, and CMS is working closely with states to put those changes into action,” said CMS Administrator Dr. Mehmet Oz. “This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families.”

Issued under Public Law 119-21, which CMS refers to as the Working Families Tax Cut (WFTC) legislation, the rule establishes the standards states must use to implement the statutory work requirement, including clear expectations for eligibility determinations, exemptions, verification, and state reporting requirements. It reflects extensive coordination with states and builds on CMS’ ongoing work to modernize eligibility systems and improve beneficiary interactions with states, while improving accountability.

A new study from the Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation finds the new requirements could reduce poverty by as much as 2.9 million people depending on a variety of conditions such as employment availability.

This rule defines which adults ages 19 through 64 will be required to demonstrate work requirement activities. The rule also defines which individuals are not subject to the requirement because of health-related needs and other qualifying circumstances. These exemptions include, but are not limited to, individuals who are pregnant, postpartum, disabled, medically frail, American Indian or Alaska Native, parents or caregivers of young children and people with disabilities, and those who are already complying with similar requirements through the Supplemental Nutrition Assistance Program (SNAP) or the Temporary Assistance for Needy Families (TANF) program.

The rule also includes state data reporting requirements and establishes requirements for how states must assess and verify compliance and communicate the new requirement to Medicaid applicants and beneficiaries. These provisions are expected to promote transparency, reduce administrative burden, and ensure states provide clear, actionable guidance to new applicants and Medicaid beneficiaries on how to meet the new eligibility requirement.

CMS is supporting states as they implement the requirement through a combination of federal resources, technical assistance, and private-sector collaboration. This includes $200 million in Government Efficiency Grants authorized under the WFTC legislation to support state system modernization and administrative capacity, as well as more than $600 million in committed support from private-sector technology vendors to help states update eligibility and enrollment systems, and support for outreach to Medicaid beneficiaries. These investments build on CMS’ broader modernization efforts, including expanding the use of automation, data integration, and real-time verification to improve efficiency, strengthen oversight, and enhance the beneficiary experience.

The work requirement must be implemented no later than January 1, 2027, in applicable states, although some states—such as Nebraska —has already implemented, and other states are considering early implementation.

This rule is being issued with comment period to remain consistent with the legislative directive and implementation timeline established by the WFTC legislation. This approach helps to ensure timely implementation while allowing CMS to continue to collect and consider public feedback.

For a fact sheet on the Medicaid Community Engagement Requirement Interim Final Rule (CMS-2454-IFC), visit: https://www.cms.gov/newsroom/fact-sheets/medicaid-community-engagement-requirement-certain-individuals-interim-final-rule-comment-period-cms.

To view the IFC on the Federal Register, visit: https://www.federalregister.gov.

https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2026/06/01/medicare-fraud-prevention-week-highlights-need-to-combat-fraud-and-abuse

https://www.mass.gov/news/ag-campbell-sues-united-healthcare-for-defrauding-masshealth-out-of-100-million

AG Campbell Sues United Healthcare for Defrauding MassHealth Out of $100 Million
Lawsuit Alleges that United Manipulated and Misrepresented Member Health Statuses to Obtain Higher Payments from MassHealth
Office of the Attorney General for immediate release - May 29, 2026

BOSTON — Massachusetts Attorney General Andrea Joy Campbell today filed a lawsuit in Suffolk Superior Court against UnitedHealthcare Insurance Company, d/b/a UnitedHealthcare Community Plans of Massachusetts (United), alleging the company falsely manipulated the health status of MassHealth members enrolled in its Senior Care Options (SCO) plan to secure higher payments from the Commonwealth. The complaint estimates that the scheme defrauded MassHealth, the state’s Medicaid program, of at least $100 million.

“The state’s managed care plans need to act in good faith on behalf of their members and the financial resources of our state’s Medicaid program. Our investigation found that United Healthcare knowingly violated these obligations by manipulating health assessments to increase its profits,” said AG Campbell. “This lawsuit sends a clear message that no company is above the law, and my office will hold companies accountable for exploiting vulnerable residents and misusing taxpayer dollars.”

MassHealth’s SCO program serves eligible members age 65 or older living in designated service areas across Massachusetts. Enrollees must receive a comprehensive in-home clinical assessment to determine the member’s health status and assign them one of three levels of care, ranging from least serious and lowest payment rate (Level 1) to most serious and highest payment rate (Level 3). United is the largest provider of SCO plans in Massachusetts.

The Attorney General’s Office (AGO) alleges that United manipulated the health statuses of its members to increase profits in three principal ways. First, United submitted assessments of members in the United SCO Plan that led to their classification as Level 2, which is reserved for members with behavioral health or substance use disorders. United classified members by identifying, in its submissions to MassHealth, that members had diagnoses like depression or anxiety, even though those members lacked any corresponding diagnosis or treatment associated with behavioral health or substantive use disorders.

Second, the AGO further alleges that United improperly assessed many members in the United SCO Plan with health conditions satisfying Level 3, reserved for members with the most serious health conditions, even though those members did not qualify for Level 3 services. Beginning in 2018 and continuing into 2019, United became aware through a series of internal reviews that many of its members at Level 3 had been improperly classified. United never disclosed to MassHealth that it had been improperly paid at higher rates for these members prior to their being downgraded, nor has it repaid MassHealth for any of the improperly inflated payments United received while the members were incorrectly classified at Level 3.

Third, United submitted assessments to MassHealth for members in the United SCO Plan that represented that those members needed daily skilled nursing services. Despite these representations, most of those members did not need or receive daily skilled nursing services. As a result, United received higher payments from MassHealth for these members than it should have.

The AGO alleges that these were intentional failures, the result of a “growth at all costs” strategy employed by United that incentivized and encouraged its field nurses to code MassHealth members as sicker or less able than they were.

This matter is being handled by Assistant Attorneys General Kevin O’Keefe and Mary-Ellen Kennedy, Senior Data Scientist William Welsh, Senior Healthcare Fraud Investigator Christine Barker, and Investigator Rachel Wiesler, all of the AGO’s Medicaid Fraud Division. MassHealth provided substantial assistance with the investigation.

The AGO’s Medicaid Fraud Division is a Medicaid Fraud Control Unit, annually certified by the U.S. Department of Health and Human Services to investigate and prosecute health care providers who defraud the state’s Medicaid program, MassHealth. The Medicaid Fraud Division also has jurisdiction to investigate and prosecute complaints of abuse, neglect and financial exploitation of residents in long-term care facilities and of Medicaid patients in any health care setting. Individuals may file a MassHealth fraud complaint or report cases of abuse or neglect of Medicaid patients or long-term care residents by visiting the AGO’s website.

The Massachusetts Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,458,176 for federal fiscal year 2026. The remaining 25 percent, totaling $2,152,724 for FY 2026, is funded by the Commonwealth of Massachusetts.

Nevertheless, you should know what benefits a national health care database could create:

https://www.realclearhealth.com/articles/2026/05/29/taking_back_control_1185651.html

Taking Back Control
A Rallying Cry for Health Care in America
By Lynn Barr - May 29, 2026

There ought to be at least one issue in American life that rises above partisan reflex: the health of the American people.
Republicans, Democrats, and independents may disagree on taxes, spending, regulation, and the size of government. But every one of us should want the same basic things from our healthcare system: better access, better outcomes, lower costs, and more confidence.

Yet in the wealthiest nation on earth, despite building the most expensive healthcare system in history (costing more than $15,000 per person per year, nearly one-fifth of our national economy) Americans live shorter lives than those in peer nations. Preventable disease remains rampant. Medical debt remains one of the most common financial shocks in American life, and care is often delayed because families can’t afford it.

It is an embarrassing systemic failure that demands honesty, innovation, and significant reform.

The seeds have been planted for a movement in which Americans take back control from a healthcare system that costs too much, delivers too little, and leaves too many feeling anxious, angry, and powerless.

Specifically, the first reform is the most obvious one. America needs a standardized national healthcare database — a transparent backbone for accumulating claims and outcomes data across all payers, public and private.

Not government-run healthcare. Not eliminating private insurance. Not rationing care.

Just a modern system of accountability in a $4.5 trillion sector that today operates without a single, transparent set of books.

Only about 10% of Americans — those in traditional Medicare — have claims data that can be systematically analyzed for waste, fraud, cost, and outcomes. For the other 90%, healthcare claims are scattered across more than a thousand private insurers, each operating under different rules, formats, and systems.

Imagine if the federal government tried to track tax revenue using a thousand incompatible accounting systems. That is how we run healthcare.

It is financially draining us and, too often, costing lives.

Administrative costs consume about 10% of total healthcare spending — far higher than in many peer nations. Providers must submit bills to countless insurers. Employers struggle to compare prices. Patients are left guessing what anything costs until the bill arrives.

We do not just spend more because Americans are sicker. We spend more because the system is opaque, fragmented, and built to obscure prices.

Perhaps most unconscionably, prevention has never become the national priority it should be. We spend trillions managing avoidable illness on the back end while underinvesting in the transparency, data, diagnostics, and accountability that could help prevent suffering in the first place.

This is not a failure of doctors, nurses, or hospitals. American medicine is innovative and world-class. The failure is structural.
A national database would allow modern analytics and AI tools to detect fraud, overbilling, and pricing disparities in real time. It would give patients real price transparency instead of marketing slogans. It would help employers and families understand what they are paying for. It would give researchers the ability to study outcomes across the entire population, not just a sliver of it.

Imagine having tens of millions of records to compare the best treatments for diabetes, heart disease, cancer, maternity care, and chronic illness. That is how a system begins moving from treating sickness late to preventing illness earlier.

Patients would retain the right to opt out of data exchange, just as they do with electronic health records. But most Americans want lower costs and better results, not higher prices and more secrecy.

If transparency, fraud detection, administrative simplification, and better prevention helped reduce U.S. healthcare costs by even one-third, the savings could reach roughly $1.5 trillion per year — nearly equivalent to the annual federal deficit – easing pressure on both families and businesses.

That’s not marginal reform. It is economic oxygen.

Better still, reform should not be framed as punishment, but as leadership.

Hospitals, insurers, pharmaceutical companies, and providers that voluntarily embrace data integration and cost reduction should be publicly recognized for doing so. Congress, or an independent bipartisan commission, should establish a “Healthcare Patriot Award” honoring those who materially lower costs, improve outcomes, and share data in the national interest.

Prestige and public trust matter. Employers would favor recognized institutions. Patients would seek them out. Investors would reward them. Transparency would become a competitive advantage rather than a regulatory burden.

Healthcare should never have become a partisan issue. Transparency is neither liberal nor conservative. Efficiency is not ideological. Patriotism is not political.

Taking back control begins with knowing what we are paying for, what is working, what is failing, and who is willing to help fix it.
The American people deserve, and need, a renewed national health strategy.

In the approaching midterm elections, voters should apply a simple litmus test: is a candidate merely talking about healthcare reform, or are they prepared to advance a new national health paradigm — one that makes wellness, prevention, early diagnostics, and rooting out fraud central to the way America thinks about health because a system devoted mainly to treating illness after it appears will never be as strong, affordable, or humane as one designed to help prevent it in the first place.

Lynn Barr, MPH, is the Founder of Caravan Health and a Health Policy Expert

https://www.medicaid.gov/Medicaid/downloads/michigan-mcp.pdf

https://manhattan.institute/article/reining-in-medicaid-managed-care

Reining in Medicaid Managed Care
By Chris Pope - May 28, 2026

Table of Contents

• Executive Summary
• What Is Medicaid Managed Care?
• The Debate Over Medicaid Managed Care
• Evidence on MMC
• Recommendations
• Conclusion
• Appendix
• About the Author
• Endnotes

Executive Summary

When Medicaid, the U.S. program that purchases health care for the poorest Americans, originally went into effect, states paid directly for health-care services provided to beneficiaries. But in recent decades, states increasingly subcontract procurement to private insurers known as managed care organizations (MCOs). From 1992 to 2022, the proportion of Medicaid beneficiaries enrolled in MCOs increased from 9% to 77%. This health-care delivery system of state Medicaid agencies contracting with MCOs is called Medicaid managed care (MMC).

Private insurers design benefits, raise funds, manage risk, and develop networks of providers to treat their policyholders. But in MMC, the government dictates the bulk of benefits, provides all of the revenue, carries most of the risk, and largely determines the terms of payment to medical providers.

States argue that their employment of MCOs reduces costs and improves benefits. However, payments to these private insurers are usually not set through competitive bidding; the nature of plan expenditures cannot easily be compared from state to state; and there is little evidence of savings being passed on to taxpayers. In fact, the lack of transparency has encouraged states to increasingly use MCOs to bypass traditional restrictions on the amount and purposes for which they can claim federal Medicaid matching funding.

Federal policymakers have exempted MMC from many regulatory constraints on payments for Medicaid services under the assumption that it is inherently more cost-effective. This is a mistake. Payments made to Medicaid MCOs should be subject to stricter federal controls and their activities subject to much greater transparency. This will ensure that Medicaid’s structure gives taxpayers the best value for money.

What Is Medicaid Managed Care?

Medicaid is a system of federal matching funds for states to provide comprehensive health-care benefits to low-income residents. Initially, states paid health-care providers directly to treat Medicaid beneficiaries, but over recent decades they have increasingly used private insurers known as MCOs to purchase services.

The federal government generally provides between $1 and $3 to states for every $1 that states spend on health-care benefits for most Medicare beneficiaries, with higher-income states entitled to a higher matching rate. States may also claim $9 in federal funding for every $1 that they spend on health-care services for beneficiaries made eligible by the 2010 Affordable Care Act.

State Medicaid programs must provide a basic set of health-care and long-term care benefits to a core group of beneficiaries. But they may also claim federal matching funding to provide additional benefits to those beneficiaries or to expand Medicaid eligibility to a broader set of residents.

There is no upper limit on the total federal matching funds that each state may claim for its own Medicaid expenditures. But the ability of states to claim federal funding is supposed to be limited to covered health-care and long-term care services, beneficiaries who are eligible for Medicaid, and payment amounts sufficient to enlist enough health-care providers to provide these services.

After Medicaid’s establishment in 1965, MMC was gradually expanded through waivers. The first managed care pilot was developed in 1968 in California, and managed care was implemented on a statewide basis from 1971. Congress found that MCOs took advantage of this system to provide inadequate networks and engage in profiteering. In 1976, lawmakers sought to ensure quality care by limiting MCO participation to insurance plans that had more privately funded enrollees than Medicaid beneficiaries. This requirement was gradually loosened before the Balanced Budget Act of 1997 formally permitted states to contract with Medicaid-only MCOs under specific regulations that ensured an adequate provider network and quality assurance.

With broad support from policymakers at state and federal levels, the proportion of Medicaid spending distributed through MMC greatly expanded over recent decades. In 2022, it accounted for 77% of Medicaid enrollees and 54% of the program’s spending (Figure 1).

Managed care share rose steadily, reaching about 75% of Medicaid enrollment and about 55% of spending by 2022.
Comprehensive MMC is currently employed to varying degrees by 41 states and the District of Columbia. In 2024, the proportion of Medicaid spending distributed through MMC in these states ranged from 3% in Colorado to 91% in Iowa (Figure 2).

Most states directed at least half of Medicaid spending to comprehensive managed care in 2024, with substantial variation by state.
Most states use MMC to deliver Medicaid benefits to children and able-bodied adults, but many still rely on direct payments to finance services for disabled and elderly beneficiaries whose medical needs are more complex (Figure 3). Behavioral health services, substance abuse treatment, and dental care are also typically carved out of MMC contracts. In 2021, only 24 states paid for long-term care though managed care. Until the 2010 Affordable Care Act allowed MCOs to claim Medicaid’s mandatory discounts on prescription drugs, most states also carved drugs out of managed care.

Managed care enrollment is highest for children and new adults and lowest for elderly beneficiaries across states in 2022.
States may allow Medicaid beneficiaries to opt for managed care plans or may require them to do so. If states require beneficiaries to enroll in managed care, they must provide a choice of at least two plans. Beneficiaries who do not choose plans may be auto-assigned to an MCO. Nationwide, 45% of beneficiaries are in plans to which they were assigned by states.

MCOs must cover all mandatory Medicaid benefits and optional benefits established by states. That means they must generally provide access to hospital and physician services without charging beneficiaries premiums or out-of-pocket costs. MCOs are subject to network adequacy requirements for primary care, specialist physicians, hospitals, pharmacists, behavioral health providers, and pediatric dentists. They must also report physician fees, service utilization, quality-of-care metrics, and denials of payment due to prior authorization. States must assure the solvency of MCOs and ensure that plans spend at least 85% of their revenues on health-care services.

States typically contract with MCOs for three- to five-year periods, with contracts subject to approval by the Centers for Medicare & Medicaid Services (CMS). States have wide discretion over the content of contracts beyond the minimum federal requirements.

State Medicaid programs generally pay MCOs up-front monthly fees for each beneficiary enrolled. Federal law requires these payments to be “actuarially sound”—in other words, “projected to provide for all reasonable, appropriate, and attainable costs.” That means they must cover the price and volume of services consumed by Medicaid beneficiaries. As a result, state payments to MCOs are typically indexed for the expected increase in medical prices.

States can set different rates for subcategories of enrollees (such as the disabled or children) or risk-adjust payments according to age and health status. These risk adjustments may be based on beneficiaries’ medical diagnoses or their use of medical services. States may also choose to compensate MCOs for certain costly patients (such as those suffering from AIDS) on a fee-for-service basis or to provide add-on “kick payments” for unanticipated costs (such as childbirth). States may provide additional bonus payments to plans for compliance with target metrics, such as the quality of medical care or reductions in racial health disparities. They also often provide additional ad hoc payments to ensure the solvency of plans, if actual costs exceed earlier official projections.

MCOs have some freedom over the procurement of medical care. For example, MMC payments to hospitals are exempt from “upper payment limits” on Medicaid hospital fees, which would otherwise limit the federal matching funds for states. In 2016, CMS formally authorized “state-directed payments” to allow states to specify terms of payment from MCOs to hospitals at levels greatly exceeding those which Medicare would pay. States may also require MCOs to pay for nonmedical goods “in lieu of services,” which would not otherwise be eligible for federal matching funds......