By Lauren Sausser, KFF Health News

BRIDGEPORT, W.Va. — By the time Eric Tennant was diagnosed in 2023 with a rare cancer of the bile ducts, the disease had spread to his bones. He weighed 97 pounds and wasn’t expected to survive a year with stage 4 cancer.

Two years later, grueling rounds of chemotherapy have slowed the cancer’s progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant’s body and his quality of life.

Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.

Early this year, Tennant’s oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that’s when his family began fighting another adversary: their health insurer, which decided the treatment was “not medically necessary,” according to insurance paperwork.

Eric and Rebecca Tennant of Bridgeport, West Virginia, fought for months to get Eric’s cancer treatment approved by his insurer. When West Virginia’s Public Employees Insurance Agency eventually decided to reverse the denial in May, Eric had become too sick for the procedure. (NBC News/TNS)

Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they’ve never met who may lack relevant training.

Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by KFF Health News and NBC News found.

When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn’t cover it, they appealed the denial four times.

“It’s a big mess,” said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.

“There’s literally nothing we can do to get them to change,” she said in an April interview with KFF Health News. “They’re, like, not accountable to anyone.”

Eric Tennant (left) and his wife, Rebecca, of Bridgeport, West Virginia. Eric was diagnosed with cancer in 2023. Since then, he has undergone several rounds of chemotherapy, which have ravaged his body and quality of life. (NBC News/TNS)

While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.

“You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment,” Pickern said. Yet, once the news cycle died down, “everything went back to the status quo.”

An unintended consequence of health reform?

Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.

The practice isn’t new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a 2024 U.S. Senate report. By denying costly care, companies pay less for health care expenses while still collecting premiums.

“At the end of the day, they’re a business and they exist to make money,” said Pickern, who wrote about the negative impacts of prior authorization on patient care for The American Journal of Managed Care.

For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.

But the use of prior authorization has also increased in recent years. That’s partly due to the growth of enrollment in Medicare Advantage plans, which rely heavily on prior authorization compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.

“But we can’t really prove this,” said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes KFF Health News. Health insurers haven’t been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.

Meanwhile, many states are looking to overhaul the prior authorization process.

In March, Virginia passed a law that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient’s provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.

And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.

Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.

These changes were supported by AHIP, a trade group that represents health insurers.

‘Sick with little recourse’

But the new federal rules won’t prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.

For some patients, the stakes couldn’t be higher.

Related Articles

FDA vaccine official restricted COVID vaccine approvals against the advice of agency staff

Strike to start Tuesday for health care workers at Stillwater clinic

RSV vaccine access expanded to some people in their 50s, according to CDC website

Gun suicides in US reached record high in 2023

Here’s how millions of people could lose health insurance if Trump’s tax bill becomes law

On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It’s used to treat breast cancer but has shown promise in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.

But Schrift’s insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.

In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.

Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer’s decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.

“Never in a million years did I think I’d end up here,” Ekirch said, “sick with little recourse.”

Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, introduced a bill that would eliminate prior authorization altogether. But history suggests that would create new problems.

When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department’s costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General’s Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.

What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.

On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.

On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.

Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.

Hall said that after he was forced to “step down” to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company’s coverage limits set his recovery back by months — and, ironically, cost the insurer more. His wife, Julie, estimated Jeff’s medical bills have exceeded $5 million, and most of his care has been covered by his insurer.

“Getting better is not always the goal of an insurance company. It’s a business,” Jeff Hall said. “They don’t care.”

In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands “it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment.” He encouraged members affected by coverage limits to contact their health care providers to “explore service and treatment options.”

A ‘rare and exceptional’ reversal

Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric’s prognosis.

They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.

As a safety instructor with the West Virginia Office of Miners’ Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia’s Public Employees Insurance Agency.

As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer’s decision in March, citing that histotripsy is “unproven in this case and is not medically necessary.”

None of their appeals worked. After KFF Health News and NBC News reached out to West Virginia’s Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.

“This decision reflects a rare and exceptional situation” and does not represent a change in the Public Employees Insurance Agency’s overall coverage policies,” Director Brent Wolfingbarger said in a prepared statement to KFF Health News.

In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with “anyone navigating through life-threatening care decisions.”

“Currently, there is no evidence that histotripsy is as effective as alternative treatment options available,” he said in late May, after the earlier insurance denials were reversed, “and its impact on survival or cancer recurrence is unknown.”

MES Peer Review Services did not respond to a request for an interview.

Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.

Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband’s insurance plan for wasting months of their time.

“Time is precious,” she said. “They know he has stage 4 cancer, and it’s almost like they don’t care if he lives or dies.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

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

By CURT ANDERSON and KATE PAYNE, Associated Press

The first group of immigrants has arrived at a new detention center deep in the Florida Everglades that officials have dubbed “Alligator Alcatraz,” a spokesperson for Republican state Attorney General James Uthmeier told The Associated Press.

“People are there,” Press Secretary Jae Williams said, though he didn’t immediately provide further details on the number of detainees or when they arrived.

“Next stop: back to where they came from,” Uthmeier said on the X social media platform Wednesday. He’s been credited as the architect behind the Everglades proposal. Requests for additional information from the office of Republican Gov. Ron DeSantis and the Florida Division of Emergency Management, which is building the site, had not been returned early Thursday afternoon.

A Sysco truck arrives at the “Alligator Alcatraz,” a new migrant detention facility at the Dade-Collier Training and Transition facility, Wednesday, July 2, 2025, in Ochopee, Fla. (AP Photo/Marta Lavandier)

The facility, at an airport used for training, will have an initial capacity of about 3,000 detainees, DeSantis said. The center was built in eight days and features more than 200 security cameras, 28,000-plus feet of barbed wire and 400 security personnel.

Immigrants who are arrested by Florida law enforcement officers under the federal government’s 287(g) program will be taken to the facility, according to a Trump administration official. The program is led by Immigration and Customs Enforcement and allows police officers to interrogate immigrants in their custody and detain them for potential deportation.

The facility is expected to be expanded in 500 bed increments until it has an estimated 5,000 beds by early July.

Environmental groups and Native American tribes have protested against the center, contending it is a threat to the fragile Everglades system, would be cruel to detainees because of heat and mosquitoes, and is on land the tribes consider sacred.

Related Articles

Melania Trump meets with patients, visits garden at Washington children’s hospital

Has ICE ‘gone too far’ in enforcing immigration laws? Here’s what a poll found

Trump will kick off a yearlong celebration of America’s 250th anniversary with event in Iowa

Who flies the American flag? Poll finds major partisan divide ahead of July 4

Putin and Trump discuss Iran and Ukraine in phone call, Kremlin official says

It’s also located at a place prone to frequent heavy rains, which caused some flooding in the tents Tuesday during a visit by President Donald Trump to mark its opening. State officials say the complex can withstand a Category 2 hurricane, which packs winds of between 96 and 110 mph, and that contractors worked overnight to shore up areas where flooding occurred.

DeSantis and other state officials say locating the facility in the rugged and remote Florida Everglades is meant as a deterrent — and naming it after the notorious federal prison of Alcatraz, an island fortress known for its brutal conditions, is meant to send a message. It’s another sign of how the Trump administration and its allies are relying on scare tactics to try to persuade people in the country illegally to leave voluntarily.

State and federal officials have touted the plans on social media and conservative airwaves, sharing a meme of a compound ringed with barbed wire and “guarded” by alligators wearing hats labeled “ICE” for Immigration and Customs Enforcement. The Republican Party of Florida has taken to fundraising off the detention center, selling branded T-shirts and beer koozies emblazoned with the facility’s name.

Anderson reported from St. Petersburg, Florida. Payne reported from Tallahassee, Florida. Associated Press reporters Gisela Salomon in Miami contributed.

By SHEIKH SAALIQ

DHARAMSHALA, India (AP) — The Dalai Lama has announced that he intends to reincarnate, paving the way for a successor to take on a mantle stretching back 500 years after his death.

But as he approaches his 90th birthday, that news hasn’t eased the worries of Tibetan Buddhists who wonder: What will happen when this Dalai Lama is gone?

For decades, the 14th Dalai Lama has been more than a spiritual leader. He has sustained a nation in exile and managed to build a community that’s kept the Tibetan culture and identity alive. He is the China -reviled spokesperson for a Tibetan homeland that many, like him, can see only from afar. He has received a Nobel Peace Prize and been courted by royalty, politicians and Hollywood stars, helping him draw global attention and support for Tibet.

When his death comes, it will pitch the global Tibetan community into uncertainty, perhaps for years. His successor will have to be found through the traditional process of reincarnation. China, whose troops took control of Tibet in 1950, says it will reject anyone chosen without Beijing’s consent.

Tibetans in India’s Himalayan town of Dharamshala, the Dalai Lama’s home in exile, and scattered around the world fear a new onslaught on their cultural and religious identity.

“The absence of His Holiness would be a huge setback for the Tibetans,” said Penpa Tsering, the head of the democratically elected Tibetan government-in-exile. “The responsibility lies on us as to how we carry forward the legacy of His Holiness.”

A long gap

The Dalai Lama has become one of the world’s most recognizable figures while leading a Tibetan diaspora through their struggle for autonomy and opposition of China’s control of Tibet. He has not named a successor, but he says they will be born in the “free world” — outside China.

Previous Dalai Lamas have been identified by senior monastic disciples, under strict religious rituals meant to identify their predecessor’s reincarnation. Monks interpret signs, consult oracles and send search committees to Tibetan households looking for a child who exhibits the qualities of the Dalai Lama.

All of this takes years of effort, leaving a leadership vacuum. Years of religious education and training are needed before the identified successor grows up and takes up full responsibilities as spiritual leader.

China has already sought to elevate other spiritual figures, particularly Tibetan Buddhism’s No. 2 figure, the Panchen Lama, whose legitimacy is highly contested by many Tibetans at home and in exile.

Gyaltsen Norbu was installed by Beijing as the 11th Panchen Lama in 1995 after followers of the Dalai Lama recognized a different boy as the Panchen’s incarnation. That boy disappeared soon after.

Joy and stubbornness

And there’s no guarantee the successor will have the current Dalai Lama’s charisma, or his ability to balance a sense of joy with the stubbornness needed to counter China.

“He is a fulcrum, he’s the epitome of the Tibetan movement,” said writer and activist Tenzin Tsundue, who was born in India.

Tsundue for years has advocated for Tibet’s autonomy. To him, the current Dalai Lama’s absence will be hugely felt.

Like many other Tibetans, however, his hopes are pinned on the government in exile. “How is home not anything but a genuine human demand?” he added.

Such concerns are most prevalent in Dharamshala, where a Tibetan community of over 20,000 administers its own schools, hospitals and monasteries and elects its own lawmakers and president. The Dalai Lama handed over his political powers to a democratically elected government in 2011.

Beijing is likely to appoint its own candidate

China doesn’t recognize the Tibetan government-in-exile and brands the Dalai Lama a dangerous separatist. It has shunned direct contact with his representatives for more than a decade.

It has insisted that the Dalai Lama’s successor will be from inside China and must be approved by its government.

Tibetans in exile have long been wary of the officially atheist Chinese government’s attempts to meddle with the Tibetan Buddhism reincarnation system. They see it as part of Beijing’s plan to tighten its control over Tibet.

“If they do it, they are actually making a mockery of themselves among the free countries,” said Geshe Lhakdor, a Tibetan Buddhist scholar, calling Beijing’s stance “hypocrisy.”

Tibetans say they were effectively independent for centuries and accuse China of trying to wipe out Tibet’s Buddhist culture and language. Many of the more than 7 million Tibetans living under Chinese rule accuse Beijing of stifling religious freedoms, changing its ethnic makeup by moving millions of Han Chinese into the region and torturing political prisoners.

The Chinese government denies these allegations.

Waning global attention

For years, governments across the world have feted the Dalai Lama for advocating for Tibetan rights and spreading a message of nonviolence. They have also helped him raise tens of millions of dollars to build Tibetan cultural and religious institutions.

But Tsundue said that global powers have become more unreliable in their support of the Tibetan cause as China’s influence grows.

“Everybody has benefited at our cost because they have been trading with China,” Tsundue said. “We are, in a way, a victim of geopolitics.”

Some countries, including the United States, view Beijing’s attempts to control the reincarnation of the Dalai Lama as a violation of religious freedom and Tibetan cultural tradition. Others, like the European Union and India, have maintained a cautious stance to avoid friction with China.

Related Articles

94 Palestinians killed in Gaza, including 45 people waiting for aid, authorities say

Today in History: July 3, Union wins Battle of Gettysburg

US contractors say their colleagues are firing live ammo as Palestinians seek food in Gaza

Russia ramps up offensives on 2 fronts in Ukraine as both sides seek an advantage before the fall

Ukraine looks to jointly produce weapons with allies as the US halts some shipments

Tsering, the president of the government-in-exile, acknowledged this, calling Tibetans’ efforts to keep the issue of Tibet alive “a miracle.”

He also cautioned that the future depends on the Tibetan people at large.

Under the Dalai Lama’s “Middle Way” policy, the movement for Tibet’s autonomy has largely been nonviolent. It espouses autonomy under Chinese sovereignty.

The newly announced succession plan, however, can prompt a reckoning of that policy, and it is unclear how the Dalai Lama’s successor might approach dialogue with Beijing.

Tsering cautioned that much could change in the coming years. His biggest worry is that the Dalai Lama’s death in exile could trigger a violent response inside Tibet, where in recent years hundreds of monks and others reportedly set themselves on fire in protest against Chinese rule.

“I hope the Tibetans won’t get radicalized,” he said.

By MICHELLE L. PRICE, Associated Press

WASHINGTON (AP) — First lady Melania Trump was set to visit with sick patients at Children’s National hospital in Washington on Thursday as the children made Fourth of July arts and crafts ahead of the holiday.

Trump, continuing a tradition of support by first ladies for the pediatric care center, was also expected during her visit to visit a rooftop “healing” garden she dedicated during the first Trump administration to first ladies of the United States.

Related Articles

Has ICE ‘gone too far’ in enforcing immigration laws? Here’s what a poll found

Trump will kick off a yearlong celebration of America’s 250th anniversary with event in Iowa

Who flies the American flag? Poll finds major partisan divide ahead of July 4

Putin and Trump to speak by phone in their 6th conversation this year

How a GOP rift over tech regulation doomed a ban on state AI laws in Trump’s tax bill

The Bunny Mellon Healing Garden, set to be decked out in decorations for Independence Day on Friday, was named to honor Rachel “Bunny” Mellon, a friend of first lady Jacqueline Kennedy.

Mellon was a philanthropist and avid gardener who designed the Rose Garden and other White House gardens during the Kennedy administration.

The garden was dedicated to America’s first ladies because of their decades-long support for the hospital and its patients, including a traditional first lady visit at Christmastime that dates back to Bess Truman.

Trump, along with chief White House groundskeeper Dale Haney, is set to inspect the planting of a new yellow rose bush donated by the White House and planted earlier in the week at the hospital garden.

After, the first lady is scheduled to visit the heart and kidney unit at the hospital.

Later Thursday, the first lady was expected to join President Donald Trump in the Oval Office where they set to meet with Edan Alexander, the last living American hostage in Gaza, who was released in May.