By Arielle Zionts, KFF Health News

EKALAKA, Mont. — There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.

There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy takes notes while treating a patient in the Ekalaka, Montana, hospital as nurse Willow Meyer works nearby. (Arielle Zionts/KFF Health News/TNS)

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

Nurse practitioner Alex Lovec examines Ben Bruski during a visit to the clinic at Dahl Memorial Healthcare Association in Ekalaka, Montana, for help with his allergies. (Arielle Zionts/KFF Health News/TNS)

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

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He pointed to Vermont, where a report recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.

The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

An Ekalaka ambulance meets a medevac plane from Billings Clinic— which offers the highest level of care in Montana— at the municipal airport. (Arielle Zionts/KFF Health News/TNS)

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

Mobile mammogram clinics make it easier for people in the Ekalaka, Montana, area to get care since their local facilities don’t offer the technology, which helps detect breast cancer. (Arielle Zionts/KFF Health News/TNS)

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told KFF Health News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

High-end credit cards are nothing new. American Express has been catering to a discerning crowd since the 1960s, while airlines began partnering with Visa and Mastercard in the 1980s to launch airline credit cards for loyal travelers.

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Cards with triple-digit annual fees are becoming more common, with even several “midmarket” cards upping fees to around $150. But that’s pocket change compared to premium card annual fees of $500 or more.

High annual fees get a mixed reaction from consumers. A NerdWallet survey, conducted online by The Harris Poll, found that 57% of Americans say no annual fee would be important to them if they were applying for a new credit card.

At the same time, the J.D. Power 2025 U.S. Credit Card Satisfaction Study found that cardholders paying an annual fee of $500 or higher are less satisfied with the reasonableness of that cost, but they’re more satisfied with the overall card experience than those paying an annual fee under $500.

“So much of the card perception and satisfaction is based on the return or the value that the consumer feels like they’re getting from the product,” says John Cabell, managing director, payments intelligence at J.D. Power.

Compared with cards with lower fees, premium cards offer many additional benefits that can help justify the cost. Depending on your needs and spending habits, high-fee cards may or may not be a better deal for you.

When to consider a high-fee card

You travel often

Premium credit cards typically offer travel-related perks, such as annual travel credits worth hundreds of dollars and free visits to airport lounges. You may also get a few travel-adjacent benefits, like the ability to book a reservation at a popular restaurant for a special dinner on vacation, or access to ticket presales for concerts and sporting events.

If you’re not a frequent traveler, other cards can be more rewarding for those close-to-home purchases — groceries, food delivery, gas or public transit for your daily commute, or streaming service subscriptions. If these expenses make up the bulk of your spending, a cash-back card could be a better fit.

The card’s other perks match your habits

Increasingly, premium cards are offering coupon book-style credits. You pay the annual fee, and then chip away at it by making certain purchases that earn statement credits.

These credits can be offered as one annual discount, or they may be divided into smaller semi-annual or monthly credits.

Often, they apply only for a purchase at a specific merchant, such as a discount on the membership fee for a certain fitness club. Or you may get a credit for something broader, such as a collection of participating restaurants in several cities.

If you were already spending money on an eligible purchase, your card is giving you a valuable discount. But if you buy something expensive just to get a little money back, you’re still spending a lot of money.

You get good value out of your points

You probably didn’t sign up for an expensive card just to save $10 a month on ridesharing. Let’s acknowledge the most compelling reason: the enormous welcome bonus that will knock hundreds of dollars off the cost of a future vacation.

In some cases, redeeming for travel is how you get the most value out of your points. Some cards allow you to transfer your points to one of their airline or hotel partners, which can be a highly valuable way to cash in your rewards.

But if you redeem in other ways — like for cash back, gift cards or merchandise — point values can vary and may be lower.

When to stick to a lower-fee card

You have credit card debt

As appealing as premium credit cards can be, if you have credit card debt, hold off on applying for one. The amount you’re paying in interest is going to wipe out the value of your rewards pretty quickly.

“Where that math works is best for people who are transacting and who are not paying interest on that credit card, because that’s a real drain,” Cabell says.

Let’s see how this math can play out. According to NerdWallet’s 2024 Household Credit Card Debt study, the average U.S. household with revolving credit card debt owed $10,815 as of June 2025. If you carried a debt of this amount and paid an interest rate of 22% (just under the average credit card interest rate of 22.25%, according to Federal Reserve data as of May 2025), you’d spend more than $2,300 in a year on interest payments.

It’s unlikely you’ll be able to recoup that cost with a card’s sign-up bonus and a few statement credits. (And, again, to earn those statement credits, you have to spend money just to get a portion of it back.)

A balance transfer credit card, or a lower-interest personal loan, could help you save on interest as you pay down credit card debt.

You’re not the card’s target audience

If you’re not loyal to a specific airline, that airline’s card likely isn’t for you. If you’re not a luxury traveler, you won’t use a credit toward stays at five-star hotels. If you live in a small or midsize city, credits for merchants located in a major city a two-hour drive away are going to be difficult to benefit from.

Many of these perks are aspirational in nature. Who doesn’t imagine a stay in an overwater bungalow in French Polynesia, while they book two nights at a midrange hotel next to a strip mall for a friend’s wedding?

It’s OK to dream, but don’t let fantasy get in the way of whether a card fits your reality.

You want simple benefits

Perhaps what you’re looking for in a card is straightforward: a solid welcome bonus, rewards categories that align with your spending, and points you can redeem easily. No struggling to remember which card to use for what purchase, and no lengthy lists of statement credits you’ll forget to use.

If you want a card that’s a tool and not a homework assignment, some premium cards are just not for you. There are options where using just one or two annual credits will wipe out the fee, which could be doable. But if a card’s features overwhelm you, you’re not going to get value out of them.

Sara Rathner writes for NerdWallet. Email: srathner@nerdwallet.com.

The article Annual Fees Over $500? Here’s When They Make Sense originally appeared on NerdWallet.

By STAN CHOE, Associated Press Business Writer

NEW YORK (AP) — Wall Street is holding a bit steadier on Wednesday following the prior day’s swoon for Nvidia, Palantir and other darlings swept up in the mania around artificial-intelligence technology.

The S&P 500 edged down by 0.1%, coming off its third straight loss after setting an all-time high last week. The Dow Jones Industrial Average was up 83 points, or 0.2%, as of 9:35 a.m. Eastern time, and the Nasdaq composite was down 0.4%.

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Mixed profit reports from big U.S. retailers helped keep the market in check. Lowe’s rose 2.8% after the home-improvement retailer delivered a profit for the latest quarter that topped analysts’ expectations. It also said it agreed to buy Foundation Building Materials, a distributor of drywall, ceiling systems and other interior building products, for about $8.8 billion.

TJX, the company behind the TJ Maxx and Marshalls stores, climbed 6.2% after beating analysts’ forecasts for profit and revenue. It also raised its forecast for profit over its full fiscal year, while CEO Ernie Herrman said TJX is seeing “strong demand at each of our U.S. and international businesses” and that its current quarter is off to a strong start.

Target, meanwhile, tumbled 10.1% even though it edged past analysts’ expectations for profit in the spring. The struggling retailer said that CEO Brian Cornell plans to step down Feb. 1 and that an insider, 20-year veteran Michael Fiddelke, will replace him. He helped reenergize the company, but it has struggled to turn around weak sales in a more competitive post-COVID retail landscape.

Estee Lauder dropped 2.3% after offering a forecast for profit this upcoming fiscal year that fell short of Wall Street’s estimates. The beauty company said it expects tariffs to shave roughly $100 million off its upcoming earnings.

La-Z-Boy sank 14.4% after the furniture maker’s profit and revenue for the spring came up shy of analysts’ expectations. CEO Melinda Whittington said it’s contending with “soft industry demand” and that it’s looking at potential alternatives “to address financial pressure from non-core’ parts” of its business.

Tech stocks were feeling pressure again, but not to the same degree as a day before. Nvidia slipped 0.9%, following its 3.5% drop on Tuesday. Palantir Technologies fell 2.1% to add to its 9.4% loss from the day before.

They’ve been facing increasing criticism that their stock prices had shot too high, too fast amid the furor around AI and had become too expensive.

The week’s biggest news for Wall Street is likely arriving on Friday, when Federal Reserve Chair Jerome Powell will give a highly anticipated speech in Jackson Hole, Wyoming. The setting has been home to big policy announcements from the Fed in the past, and the hope on Wall Street is that Powell will hint that an interest rate cut is coming soon.

The Fed has kept its main interest rate steady this year, primarily because of the fear of the possibility that President Donald Trump’s tariffs could push inflation higher. But a surprisingly weak report on job growth across the country may be superseding that.

Treasury yields have come down sharply on expectations for coming cuts to interest rates, and the yield on the 10-year Treasury remained at 4.30%, where it was late Tuesday.

In stock markets abroad, indexes were mixed across Europe and Asia.

London’s FTSE 100 rose 0.7% despite a report that said inflation in the U.K. rose more than expected through July, in part due to soaring airfares and food prices.

Tokyo’s Nikkei 225 dropped 1.5% after Japan reported that its exports fell slightly more than expected in July, pressured by higher tariffs on goods shipped to the U.S. Imports also fell from a year ago.

Hong Kong’s Hang Seng added 0.2%. Shares that trade there of Chinese toy company Pop Mart International Group soared 12.5% after its CEO said its annual revenue could top $4 billion this year and announced the release of a mini version of its popular Labubu dolls.

AP Business Writers Yuri Kageyama and Matt Ott contributed.

By MICHAEL LIEDTKE, Associated Press Technology Writer

SAN FRANCISCO (AP) — President Donald Trump wants the U.S. government to own a piece of Intel, less than two weeks after demanding the Silicon Valley pioneer dump the CEO that was hired to turn around the slumping chipmaker. If the goal is realized, the investment would deepen the Trump administration’s involvement in the computer industry as the president ramps up the pressure for more U.S. companies to manufacture products domestically instead of relying on overseas suppliers.

What’s happening?

FILE – The Intel logo is displayed on the exterior of Intel headquarters in Santa Clara, Calif., Jan. 12, 2011. (AP Photo/Paul Sakuma, File)

The Trump administration is in talks to secure a 10% stake in Intel in exchange for converting government grants that were pledged to Intel under President Joe Biden. If the deal is completed, the U.S. government would become one of Intel’s largest shareholders and blur the traditional lines separating the public sector and private sector in a country that remains the world’s largest economy.

Why would Trump do this?

In his second term, Trump has been leveraging his power to reprogram the operations of major computer chip companies. The administration is requiring Nvidia and Advanced Micro Devices, two companies whose chips are helping to power the craze around artificial intelligence, to pay a 15% commission on their sales of chips in China in exchange for export licenses.

Trump’s interest in Intel is also being driven by his desire to boost chip production in the U.S., which has been a focal point of the trade war that he has been waging throughout the world. By lessening the country’s dependence on chips manufactured overseas, the president believes the U.S. will be better positioned to maintain its technological lead on China in the race to create artificial intelligence.

Didn’t Trump want Intel’s CEO to quit?

FILE – Intel CEO Lip-Bu Tan delivers a speech during the Computex 2025 exhibition in Taipei, Taiwan, Monday, May 19, 2025. (AP Photo/Chiang Ying-ying, File)

That’s what the president said August 7 in an unequivocal post calling for Intel CEO Lip-Bu Tan to resign less than five months after the Santa Clara, California, company hired him. The demand was triggered by reports raising national security concerns about Tan’s past investments in Chinese tech companies while he was a venture capitalist. But Trump backed off after Tan professed his allegiance to the U.S. in a public letter to Intel employees and went to the White House to meet with the president, who applauded the Intel CEO for having an “amazing story.”

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Why would Intel do a deal?

The company isn’t commenting about the possibility of the U.S. government becoming a major shareholder, but Intel may have little choice because it is currently dealing from a position of weakness. After enjoying decades of growth while its processors powered the personal computer boom, the company fell into a slump after missing the shift to the mobile computing era unleashed by the iPhone’s 2007 debut.

Intel has fallen even farther behind in recent years during an artificial intelligence craze that has been a boon for Nvidia and AMD. The company lost nearly $19 billion last year and another $3.7 billion in the first six months of this year, prompting Tan to undertake a cost-cutting spree. By the end of this year, Tan expects Intel to have about 75,000 workers, a 25% reduction from the end of last year.

Would this deal be unusual?

Although rare, it’s not unprecedented for the U.S. government to become a significant shareholder in a prominent company. One of the most notable instances occurred during the Great Recession in 2008 when the government injected nearly $50 billion into General Motors in return for a roughly 60% stake in the automaker at a time it was on the verge of bankruptcy. The government ended up with a roughly $10 billion loss after it sold its stock in GM.

Would the government run Intel?

U.S. Commerce Secretary Howard Lutnick told CNBC during a Tuesday interview that the government has no intention of meddling in Intel’s business, and will have its hands tied by holding non-voting shares in the company. But some analysts wonder if the Trump administration’s financial ties to Intel might prod more companies looking to curry favor with the president to increase their orders for the company’s chips.

What government grants does Intel receive?

Intel was among the biggest beneficiaries of the Biden administration’s CHIPS and Science Act, but it hasn’t been able to revive its fortunes while falling behind on construction projects spawned by the program.

The company has received about $2.2 billion of the $7.8 billion pledged under the incentives program — money that Lutnick derided as a “giveaway” that would better serve U.S. taxpayers if it’s turned into Intel stock. “We think America should get the benefit of the bargain,” Lutnick told CNBC. “It’s obvious that it’s the right move to make.”