"Facility fees" originally meant to help struggling hospitals keep emergency room doors open 24 hours a day are now being applied to outpatient services and between 2017 and 2022, the fees cost Colorado patients and their insurers more than $13 billion, according to a new report mandated by Colorado lawmakers.

Priya Telang, communications manager for the Colorado Consumer Health Initiative, said the hidden fees are being piled onto health costs many cannot afford to pay.

"Patients are not going to seek care and health outcomes are going to be worse," Telang contended. "They are going to have to seek a higher level of more expensive care by avoiding those smaller, outpatient procedures."

Telang noted the state's critical access hospitals, which are more likely to experience financial struggles, are not responsible for the bulk of fees charged. The report showed 80% of fees went to 10 of the state's largest hospital groups. UC Health, which took in one-third of all fees, is urging lawmakers not to act on the report's findings. UC Heath said there was not enough time, data or participation from stakeholders for it to be reliable.

Telang noted facility fees, which are separate from fees charged for doctor care, have proliferated in recent years as hospitals consolidate and gain more marketplace power.

"As we see these huge hospital systems buying up smaller providers and expanding their reach, we're going to see more of these facility fees being charged, because they can," Telang asserted.

UC Health, which has $6 billion in reserves, has grown from owning five hospitals to 14 across Colorado in the past decade. Telang believes action at the state and federal level is needed to protect consumers.

"It's our lawmakers' duty to help their constituents not be saddled with immense medical debt that is crushing and they can't afford," Telang stressed.

Following Hurricane Helene, Hurricane Milton left a trail of destruction across the Sunshine State and the combination has pushed some Community Health Centers to their limits.

While some were spared from structural damage, other clinics were not so fortunate. The Florida Association of Community Health Centers represents 54 health centers across the state that see patients regardless of their ability to pay.

Jonathan Chapman, CEO of the association, said more than 30 service locations have been significantly damaged by the storms, which has prompted deep concerns about the health center network.

"I talked to a health center just a few minutes ago," Chapman recounted. "They just went on one of their sites this morning, only to find out that all the windows were smashed in from the storm; the rain, the wind caused damage."

He noted closing the six centers in the immediate Tampa area would mean at least $1.6 million a day in lost revenue. While national disaster agencies are offering assistance with mobile units and temporary locations, Chapman emphasized the available funding falls short of covering operational costs, especially as many centers had already depleted their reserves from Hurricane Helene.

Chapman added he has been frustrated with the federal response, particularly the lack of immediate financial relief for operational costs. However, he pointed out the clinics are doing their best to remain fully operational where possible, using whatever resources they can get.

"We're looking at smaller grants, maybe $10,000 or $15,000, from here and there," Chapman explained. "If we're looking at $1.5 million to $2 million a day, as good as that sounds, that's barely scratching the surface."

Chapman added in some cases, federal funding, including FEMA aid, will not be accessible for months. In Congress, House Speaker Mike Johnson faces pressure to reconvene lawmakers to pass more FEMA funding for recovery, but Johnson insists funding is not the issue, pointing to the $20 billion Congress previously allocated to FEMA.

By Sarah Jane Tribble for KFF Health News.
Broadcast version by Kathleen Shannon for Wyoming News Service reporting for the KFF Health News-Public News Service Collaboration

There’s a new morning ritual in Pinedale, Wyoming, a town of about 2,000 nestled against the Wind River Mountains.

Friends and neighbors in the oil- and gas-rich community “take their morning coffee and pull up” to watch workers building the county’s first hospital, said Kari DeWitt, the project’s public relations director.

“I think it’s just gratitude,” DeWitt said.

Sublette County is the only one in Wyoming — where counties span thousands of square miles — without a hospital. The 10-bed, 40,000-square-foot hospital, with a similarly sized attached long-term care facility, is slated to open by the summer of 2025.

DeWitt, who also is executive director of the Sublette County Health Foundation, has an office at the town’s health clinic with a window view of the construction.

Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining population has spurred decades of downsizing and closures. Yet, a few communities in Wyoming and others in Kansas and Georgia are defying the trend.

“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural “hospitals are really struggling all across the country,” he said.

There is no official tally of new hospitals being built in rural America, but industry experts such as Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.

About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.

To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1,700 eligible rural hospitals — from Georgia to New Mexico — have joined the program, according to data from the Centers for Medicare & Medicaid Services.

Tony Breitlow is health care studio director for EUA, which has extensive experience working for rural health care systems. Breitlow said his national architecture and engineering firm’s work expands, replaces, or revamps older buildings, many of which were constructed during the middle of the last century.

The work, Breitlow said, is part of health care “systems figuring out how to remain robust and viable.”

Freeman Health System, based in Joplin, Missouri, announced plans last year to build a new 50-bed hospital across the state line in Kansas. Paula Baker, Freeman’s president and chief executive, said the system is building for patients in the southeastern corner of the state who travel 45 minutes or more to its bigger Joplin facilities for care.

Freeman’s new hospital, with construction on the building expected to begin in the spring, will be less than 10 miles away from an older, 64-bed hospital that has existed for decades. Kansas is one of more than a dozen states with no “certificate of need” law that would require health providers to obtain approval from the state before offering new services or building or expanding facilities.

Baker also said Freeman plans to operate emergency services and a small 10-bed outpost in Fort Scott, Kansas, opening early next year in a corner of a hospital that closed in late 2018. Residents there “cried, they cheered, they hugged me,” Baker said, adding that the “level of appreciation and gratitude that they felt and they displayed was overwhelming to me.”

Michael Topchik, executive director of the Chartis Center for Rural Health, said regional health care systems in the Upper Midwest have been particularly active in competing for patients by, among other things, building new hospitals.

And while private corporate money can drive construction, many rural hospital projects tap government programs, especially those supported by the U.S. Department of Agriculture, Topchik said. That, he said, “surprises a lot of people.”

Since 2021, the USDA’s rural Community Facilities Programs have awarded $2.24 billion in loans and grants to 68 rural hospitals for work that was not related to an emergency or disaster, according to data analyzed by KFF Health News and confirmed by the agency. The federal program is funded through what is often known as the farm bill, which faces a September congressional renewal deadline.

Nearly all the projects are replacements or expansions and updates of older facilities.

The USDA confirmed that three new or planned Wyoming hospitals received federal funding. Hospital projects in Riverton and Saratoga received loans of $37.2 million and $18.3 million, respectively. Pinedale’s hospital received a $29.2 million loan from the agency.

Wyoming’s new construction is rare in a state where more than 80% of rural hospitals reported losses in the third quarter of 2023, according to Chartis. The state association’s Boley said he worriies about several hospitals that have less than 10 days’ cash on hand “day and night.”

Pinedale’s project loan was approved after the community submitted a feasibility study to the USDA that included local clinics and a long-term care facility. “It’s pretty remote and right up in the mountains,” Boley said.

Pinedale’s DeWitt said the community was missing key services, such as blood transfusions, which are often necessary when there is a trauma like a car crash or if a pregnant woman faces severe complications. Local ambulances drove 94,000 miles last year, she said.

DeWitt began working to raise support for the new hospital after her own pregnancy-related trauma in 2014. She was bleeding heavily and arrived at the local health clinic believing it operated like a hospital.

“It was shocking to hear, ‘No, we’re not a hospital. We can’t do blood transfusions. We’re just going to have to pray you live for the next 45 minutes,’” DeWitt said.

DeWitt had to be airlifted to Idaho, where she delivered a few minutes after landing. When the hospital financing went on the ballot in 2020, DeWitt — fully recovered, with healthy grade-schoolers at home — began making five calls a night to rally support for a county tax increase to help fund the hospital.

“By improving health care, I think we improve everybody’s chances of survival. You know, it’s pretty basic,” DeWitt said.


Sarah Jane Tribble wrote this story for KFF Health News.


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Providence Health and Services could close an at-home program enabling communication by people with diseases making it hard or impossible to speak.

The hospital system announced it would close the Home Health Augmentative and Alternative Communication-Speech Language Pathology program next month. People who are involved and have benefited from the service said it would be a devastating decision.

Kara Hayden, one of three speech language pathologists with the program, talked about the ramifications for people with diseases like ALS and certain types of autism.

"They won't be able to communicate with their family and friends," Hayden outlined. "They won't be able to participate in social engagements and interactions. They'll be more socially isolated, which we know: loneliness kills. They won't be able to participate and direct their own medical care. They won't be able to communicate with their doctors."

The speech pathologists are represented by the Oregon Nurses Association, which opposes the layoffs and said Providence is prioritizing profits over patients and employees. Providence said it is restructuring some of its programs to focus on core services. The hospital system also said it is reevaluating whether to close this program based on feedback from the community.

Lois Rosenbaum's husband Richard is a former Providence neurologist who has ALS. She said his only means of communication as been through this program's speech therapist, who has come to their home almost every week for the past year.

"It is a life-changing program for people with ALS who can't communicate any other way," Rosenbaum stressed. "It enables them to communicate in the only way they can, through a computer and through a system that is especially designed for people who can no longer speak."

Hayden added the program provides a unique service.

"We tailor their interventions to their home environment," Hayden explained. "To the people who are coming and going from their homes, to the physical environment to their homes and to their specific communication needs."