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Rennie Glasgow, who has served 15 years at the Social Security Administration, is seeing something new on the job: dead people.

They’re not really dead, of course. In four instances over the past few weeks, he told KFF Health News, his Schenectady, New York, office has seen people come in for whom “there is no information on the record, just that they are dead.” So employees have to “resurrect” them — affirm that they’re living, so they can receive their benefits.

Revivals were “sporadic” before, and there’s been an uptick in such cases across upstate New York, said Glasgow. He is also an official with the American Federation of Government Employees, the union that represented 42,000 Social Security employees just before the start of President Donald Trump’s second term.

Martin O’Malley, who led the Social Security Administration toward the end of the Joe Biden administration, said in an interview that he had heard similar stories during a recent town hall in Racine, Wisconsin. “In that room of 200 people, two people raised their hands and said they each had a friend who was wrongly marked as deceased when they’re very much alive,” he said.

It’s more than just an inconvenience, because other institutions rely on Social Security numbers to do business, Glasgow said. Being declared dead “impacts their bank account. This impacts their insurance. This impacts their ability to work. This impacts their ability to get anything done in society.”

“They are terminating people’s financial lives,” O’Malley said.

Though it’s just one of the things advocates and lawyers worry about, these erroneous deaths come after a pair of initiatives from new leadership at the SSA to alter or update its databases of the living and the dead.

Holders of millions of Social Security numbers have been marked as deceased. Separately, according to The Washington Post and The New York Times, thousands of numbers belonging to immigrants have been purged, cutting them off from banks and commerce, in an effort to encourage these people to “self-deport.”

Glasgow said SSA employees received an agency email in April about the purge, instructing them how to resurrect beneficiaries wrongly marked dead. “Why don’t you just do due diligence to make sure what you’re doing in the first place is correct?” he said.

The incorrectly marked deaths are just a piece of the Trump administration’s crash program purporting to root out fraud, modernize technology, and secure the program’s future.

But KFF Health News’ interviews with more than a dozen beneficiaries, advocates, lawyers, current and former employees, and lawmakers suggest the overhaul is making the agency worse at its primary job: sending checks to seniors, orphans, widows, and those with disabilities.

Philadelphian Lisa Seda, who has cancer, has been struggling for weeks to sort out her 24-year-old niece’s difficulties with Social Security’s disability insurance program. There are two problems: first, trying to change her niece’s address; second, trying to figure out why the program is deducting roughly $400 a month for Medicare premiums, when her disability lawyer — whose firm has a policy against speaking on the record — believes they could be zero.

Since March, sometimes Social Security has direct-deposited payments to her niece’s bank account and other times mailed checks to her old address. Attempting to sort that out has been a morass of long phone calls on hold and in-person trips seeking an appointment.

Before 2025, getting the agency to process changes was usually straightforward, her lawyer said. Not anymore.

The need is dire. If the agency halts the niece’s disability payments, “then she will be homeless,” Seda recalled telling an agency employee. “I don’t know if I’m going to survive this cancer or not, but there is nobody else to help her.”

Some of the problems are technological. According to whistleblower information provided to Democrats on the House Oversight Committee, the agency’s efforts to process certain data have been failing more frequently. When that happens, “it can delay or even stop payments to Social Security recipients,” the committee recently told the agency’s inspector general.

While tech experts and former Social Security officials warn about the potential for a complete system crash, day-to-day decay can be an insidious and serious problem, said Kathleen Romig, formerly of the Social Security Administration and its advisory board and currently the director of Social Security and disability policy at the Center on Budget and Policy Priorities. Beneficiaries could struggle to get appointments or the money they’re owed, she said.

For its more than 70 million beneficiaries nationwide, Social Security is crucial. More than a third of recipients said they wouldn’t be able to afford necessities if the checks stopped coming, according to National Academy of Social Insurance survey results published in January.

Advocates and lawyers say lately Social Security is failing to deliver, to a degree that’s nearly unprecedented in their experience.

Carolyn Villers, executive director of the Massachusetts Senior Action Council, said two of her members’ March payments were several days late. “For one member that meant not being able to pay rent on time,” she said. “The delayed payment is not something I’ve heard in the last 20 years.”

When KFF Health News presented the agency with questions, Social Security officials passed them off to the White House. White House spokesperson Elizabeth Huston referred to Trump’s “resounding mandate” to make government more efficient.

“He has promised to protect social security, and every recipient will continue to receive their benefits,” Huston said in an email. She did not provide specific, on-the-record responses to questions.

Complaints about missed payments are mushrooming. The Arizona attorney general’s office had received approximately 40 complaints related to delayed or disrupted payments by early April, spokesperson Richie Taylor told KFF Health News.

A Connecticut agency assisting people on Medicare said complaints related to Social Security — which often helps administer payments and enroll patients in the government insurance program primarily for those over age 65 — had nearly doubled in March compared with last year.

Lawyers representing beneficiaries say that, while the historically underfunded agency has always had its share of errors and inefficiencies, it’s getting worse as experienced employees have been let go.

“We’re seeing more mistakes being made,” said James Ratchford, a lawyer in West Virginia with 17 years’ experience representing Social Security beneficiaries. “We’re seeing more things get dropped.”

What gets dropped, sometimes, are records of basic transactions. Kim Beavers of Independence, Missouri, tried to complete a periodic ritual in February: filling out a disability update form saying she remains unable to work. But her scheduled payments in March and April didn’t show.

She got an in-person appointment to untangle the problem — only to be told there was no record of her submission, despite her showing printouts of the relevant documents to the agency representative. Beavers has a new appointment scheduled for May, she said.

Social Security employees frequently cite missing records to explain their inability to solve problems when they meet with lawyers and beneficiaries. A disability lawyer whose firm’s policy does not allow them to be named had a particularly puzzling case: One client, a longtime Social Security disability recipient, had her benefits reassessed. After winning on appeal, the lawyer went back to the agency to have the payments restored — the recipient had been going without since February. But there was nothing there.

“To be told they’ve never been paid benefits before is just chaos, right? Unconditional chaos,” the lawyer said.

Researchers and lawyers say they have a suspicion about what’s behind the problems at Social Security: the Elon Musk-led effort to revamp the agency.

Some 7,000 SSA employees have reportedly been let go; O’Malley has estimated that 3,000 more would leave the agency. “As the workloads go up, the demoralization becomes deeper, and people burn out and leave,” he predicted in an April hearing held by House Democrats. “It’s going to mean that if you go to a field office, you’re going to see a heck of a lot more empty, closed windows.”

The departures have hit the agency’s regional payment centers hard. These centers help process and adjudicate some cases. It’s the type of behind-the-scenes work in which “the problems surface first,” Romig said. But if the staff doesn’t have enough time, “those things languish.”

Languishing can mean, in some cases, getting dropped by important programs like Medicare. Social Security often automatically deducts premiums, or otherwise administers payments, for the health program.

Lately, Melanie Lambert, a senior advocate at the Center for Medicare Advocacy, has seen an increasing number of cases in which the agency determines beneficiaries owe money to Medicare. The cash is sent to the payment centers, she said. And the checks “just sit there.”

Beneficiaries lose Medicare, and “those terminations also tend to happen sooner than they should, based on Social Security’s own rules,” putting people into a bureaucratic maze, Lambert said.

Employees’ technology is more often on the fritz. “There’s issues every single day with our system. Every day, at a certain time, our system would go down automatically,” said Glasgow, of Social Security’s Schenectady office. Those problems began in mid-March, he said.

The new problems leave Glasgow suspecting the worst. “It’s more work for less bodies, which will eventually hype up the inefficiency of our job and make us, make the agency, look as though it’s underperforming, and then a closer step to the privatization of the agency,” he said.

Jodie Fleischer of Cox Media Group contributed to this report.

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

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JACKSON, Miss. — Storm clouds hung low above a community center in Jackson, where pastor Andre Devine invited people inside for lunch. Hoagies with smoked turkey and ham drew the crowd, but several people lingered for free preventive health care: tests for HIV and other diseases, flu shots, and blood pressure and glucose monitoring.

Between greetings, Devine, executive director of the nonprofit group Hearts for the Homeless, commiserated with his colleagues about the hundreds of thousands of dollars their groups had lost within a couple of weeks, swept up in the Trump administration’s termination of research dollars and clawback of more than $11 billion from health departments across the country.

Devine would have to scale back food distribution for people in need. And his colleagues at the nonprofit health care group My Brother’s Keeper were worried they’d have to shutter the group’s mobile clinic — an RV offering HIV tests, parked beside the community center that morning. Several employees had already been furloughed and the cuts kept coming, said June Gipson, CEO of My Brother’s Keeper.

“People can’t work without being paid,” she said.

The directors of other community-based groups in Mississippi, Alabama, Louisiana, and Tennessee told KFF Health News they too had reduced their spending on HIV testing and outreach because of delayed or slashed federal funds — or they were making plans to do so, anticipating cuts to come.

Scaling back these efforts could prove tragic, Gipson said. Without an extra boost of support to get tested or stay on treatment, many people living with HIV will grow sicker and stand a greater chance of infecting others.

President Donald Trump, in his first term, promised to end America’s HIV epidemic — and he put the resources of the federal government behind the effort. This time, he has deployed the powers of his office to gut funding, abandoning those communities at highest risk of HIV.

Trump’s earlier efforts targeted seven Southern states, including Mississippi, where funds went to community groups and health departments that tailor interventions to historically underserved communities that face discrimination and have less access to quality education, health care, stable income, and generational wealth. Such factors help explain why Black people accounted for 38% of HIV diagnoses in the United States in 2023, despite representing only 14% of the population, and also why half of the country’s new HIV infections occur in the South.

Now, Trump is undermining HIV efforts by barring funds from programs built around diversity, equity, and inclusion. A Day One executive order said they represent “immense public waste and shameful discrimination.”

Since then, his administration has cut millions of dollars in federal grants to health departments, universities, and nonprofit organizations that do HIV work. And in April, it eliminated half of the Centers for Disease Control and Prevention’s 10 HIV branch offices, according to an email to grant recipients, reviewed by KFF Health News, from the director of the CDC’s Division of HIV Prevention. The layoffs included staff who had overseen the rollout of HIV grants to health departments and community-based groups, like My Brother’s Keeper.

The CDC provides more than 90% of all federal funding for HIV prevention — about $1 billion annually. The Trump administration’s May 2 budget proposal for fiscal 2026 takes aim at DEI initiatives, including in its explanation for cutting $3.59 billion from the CDC. Although the proposal doesn’t mention HIV prevention specifically, the administration’s drafted plan for HHS, released mid-April, eliminates all prevention funding at the CDC, as well as funding for Trump’s initiative to end the epidemic.

Eliminating federal funds for HIV prevention would lead to more than 143,000 additional people in the U.S. becoming infected with HIV within five years, and about 127,000 additional people who die of AIDS-related causes, according to estimates from the Foundation for AIDS Research, a nonprofit known as amfAR. Excess medical costs would exceed $60 billion, it said.

Eldridge Dwayne Ellis, the coordinator of the mobile testing clinic at My Brother’s Keeper, said curbing the group’s services goes beyond HIV.

“People see us as their only outlet, not just for testing but for confidential conversations, for a shoulder to cry on,” he said. “I don’t understand how someone, with the stroke of a pen, could just haphazardly write off the health of millions.”

Quiet Tears

Ellis came into his role in the mobile clinic haphazardly, when he worked as a construction worker. Suddenly dizzy and unwell on a job, a co-worker suggested he visit the organization’s brick-and-mortar clinic nearby. He later applied for a position with My Brother’s Keeper, inspired by its efforts to give people support to help themselves.

For example, Ellis described a young man who visited the mobile clinic recently who had been kicked out of his home and was sleeping on couches or on the street. Ellis thought of friends he’d known in similar situations that put them at risk of HIV by increasing the likelihood of transactional sex or substance use disorders.

When a rapid test revealed HIV, the young man fell silent. “The quiet tears hurt worse — it’s the dread of mortality,” Ellis said. “I tried to be as strong as possible to let him know his life is not over, that this wasn’t a death sentence.”

Ellis and his team enrolled the man into HIV care that day and stayed in touch. Otherwise, Ellis said, he might not have had the means or fortitude to seek treatment on his own and adhere to daily HIV pills. Not only is that deadly for people with HIV, it’s bad for public health. HIV experts use the phrase “treatment as prevention” because most new infections derive from people who aren’t adhering to treatment well enough to be considered virally suppressed — which keeps the disease from spreading.

Only a third of people living with HIV in Mississippi were virally suppressed in 2022. Nationally, that number is about 65%. That’s worse than in eastern and southern Africa, where 78% of people with HIV aren’t spreading the virus because they’re on steady treatment.

My Brother’s Keeper is one of many groups improving such numbers by helping people get tested and stay on medication. But the funding cuts in Washington have curtailed their work. The first loss was a $12 million grant from the National Institutes of Health, not even two years into a 10-year project. “Programs based primarily on artificial and non-scientific categories, including amorphous equity objectives, are antithetical to the scientific inquiry,” the NIH said in a letter reviewed by KFF Health News.

My Brother’s Keeper then lost a CDC award to reduce health disparities — a grant channeled through the Mississippi state health department — that began with the group’s work during the covid pandemic but had broadened to screening and care for HIV, heart disease, and diabetes. These are some of the maladies that account for why low-income Black people in the Deep South die sooner, on average, than those who are white. According to a recent study, the former’s life expectancy was just 68 years in 2021, on par with the average in impoverished nations like Rwanda and Myanmar.

The group then lost CDC funding that covered the cost of laboratory work to detect HIV, chlamydia, gonorrhea, and syphilis in patients’ blood samples. Mississippi has the highest rate of sexually transmitted diseases among states, in part because people spread infections when they aren’t tested and treated.

“The labs are $200 to $600 per person,” Gipson said, “so now we can’t do that without passing the cost to the patient, and some can’t pay.”

Two other CDC grants on HIV prevention, together worth $841,000, were unusually delayed.

Public health specialists close to the CDC, who spoke on condition of anonymity because they fear retaliation, said they were aware of delays in HIV prevention funding, despite court orders to unfreeze payments for federal grants in January and February. “The faucet was being turned off at a higher level than at the CDC,” one specialist said. The delays have now been compounded, they said, by the gutting of that agency’s HIV workforce in April.

“I know of many organizations reliant on subcontracted federal funds who have not been paid for the work they’ve done, or whose funding has been terminated,” said Dafina Ward, executive director of the Southern AIDS Coalition.

To reach the underserved, these groups offer food, housing assistance, bus passes, disease screening, and a sense of community. A network of the groups was fostered, in part, by Trump’s initiative to end the epidemic. And it showed promise: From 2017 to 2022, new HIV infections decreased by 21% in the cities and the Southern states it targeted.

Disparities in infections were still massive, with the rate of HIV diagnoses about eight times as high for Black people as white people, and the South remained hardest hit. Ward was hopeful at the start of this year, however, as testing became more widespread and HIV prevention drugs — called preexposure prophylaxis, or PrEP — slowly gained popularity. But her outlook has shifted and she fears that grassroots organizations might not weather the funding turmoil.

“We’re seeing an about-face of what it means to truly work towards ending HIV in this country,” she said.

A Closed Clinic

Southeast of Jackson, in Hattiesburg, Sean Fortenberry tears up as he walks into a small room used until recently for HIV testing. He has kept his job at Mississippi’s AIDS Services Coalition by shifting his role but agonizes about the outcome. When Fortenberry tested positive for HIV in 2007, he said, his family and doctor saved his life.

“I never felt that I was alone, and that was really, really important,” he said. “Other people don’t have that, so when I came across this position, I was gung-ho. I wanted to help.”

But the coalition froze its HIV testing clinic and paused mobile testing at homeless shelters, colleges, and churches late last year. Kathy Garner, the group’s executive director, said the Mississippi health department — which funds the coalition with CDC’s HIV prevention dollars — told her to pause outreach in October before the state renewed the group’s annual HIV prevention contract.

Kendra Johnson, communicable diseases director at Mississippi’s health department, said that delays in HIV prevention funds were initially on the department’s end because it was short on administrative staff. Then Trump took office. “We were working with our federal partners to ensure that our new objectives were in line with new HIV prevention activities,” Johnson said. “And we ran into additional delays due to paused communications at the federal level.”

The AIDS coalition remains afloat largely because of federal money from the Ryan White HIV/AIDS Program for treatment and from the Department of Housing and Urban Development. “If most of these federal dollars are cut, we would have to close,” Garner said.

The group provides housing or housing assistance to roughly 400 people each year. Research shows that people in stable housing adhere much better to HIV treatment and are far less likely to die than unhoused people with HIV.

Funding cuts have shaken every state, but the South is acutely vulnerable when it comes to HIV, said Gregorio Millett, director of public policy at amfAR. Southern states have the highest level of poverty and a severe shortage of rural clinics, and several haven’t expanded Medicaid so that more low-income adults have health insurance.

Further, Southern states aren’t poised to make up the difference. Alabama, Louisiana, Kentucky, Mississippi, and Missouri put zero state funds into HIV prevention last year, according to NASTAD, an association of public health officials who administer HIV and hepatitis programs. In contrast, about 40% of Michigan’s HIV prevention budget is provided by the state, 50% of Colorado’s HIV prevention budget, and 88% of New York’s.

“When you are in the South, you need the federal government,” said Gipson, from My Brother’s Keeper. “When we had slavery, we needed the federal government. When we had the push for civil rights, we needed the federal government. And we still need the federal government for health care,” she said. “The red states are going to suffer, and we’re going to start suffering sooner than anyone else.”

‘So Goes Mississippi’

When asked about cuts and delays to HIV prevention funding, the CDC directed queries to HHS. The department’s director of communications, Andrew Nixon, replied in an email: “Critical HIV/AIDS programs will continue under the Administration for a Healthy America (AHA) as a part of Secretary [Robert F.] Kennedy’s vision to streamline HHS to better serve the American people.”

Nixon did not reply to a follow-up question on whether the Trump administration considers HIV prevention critical.

On April 4, Gipson received a fraction of her delayed HIV prevention funds from the CDC. But Gipson said she was afraid to hire back staff amid the turmoil.

Like the directors of many other community organizations, Gipson is going after grants from foundations and companies. Pharmaceutical firms such as Gilead and GSK that produce HIV drugs are among the largest contributors of non-governmental funds for HIV testing, prevention, and care, but private funding for HIV has never come close to the roughly $40 billion that the federal government allocated to HIV annually.

“If the federal government withdraws some or all of its support, the whole thing will collapse,” said Alice Riener, CEO of the community-based organization CrescentCare in Louisiana. “What you see in Mississippi is the beginning of that, and what’s so concerning is the infrastructure we’ve built will collapse quickly but take decades to rebuild.”

Southern health officials are reeling from cuts because state budgets are already tight. Mississippi’s state health officer, Daniel Edney, spoke with KFF Health News on the day the Trump administration terminated $11 billion in covid-era funds intended to help states improve their public health operations. “There’s not a lot of fat, and we’re cutting it to the bone right now,” Edney said.

Mississippi needed this boost, Edney said, because the state ranks among the lowest in health metrics including premature death, access to clinical care, and teen births. But Edney noted hopeful trends: The state had recently moved from 50th to 49th worst in health rankings, and its rate of new HIV cases was dropping.

“The science tells us what we need to do to identify and care for patients, and we’re improving,” he said. “But trends can change very quickly on us, so we can’t take our foot off the gas pedal.”

If that happens, researchers say, the comeback of HIV will go unnoticed at first, as people at the margins of society are infected silently before they’re hospitalized. As untreated infections spread, the rise will eventually grow large enough to make a dent in national statistics, a resurgence that will cost lives and take years, if not decades, to reverse.

Outside the community center on that stormy March morning, pastor Devine lamented not just the loss of his grant from the health department, but a $1 billion cut to food distribution programs at the U.S. Department of Agriculture. He rattled off consequences he feared: People relying on food assistance would be forced to decide between buying groceries, paying bills, or seeing a doctor, driving them further into poverty, into emergency rooms, into crime.

Deja Abdul-Haqq, a program director at My Brother’s Keeper, nodded along as he spoke. “So goes Mississippi, so goes the rest of the United States,” Abdul-Haqq said. “Struggles may start here, but they spread.”

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

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People who work in real-life emergency rooms have raved about how the new TV drama “The Pitt” accurately captures the complex dynamics of their workplaces and the medical details of their cases.

Host Dan Weissmann talks with Alex Janke, an emergency medicine doctor and health policy researcher, about how the show stacks up against his experiences in the ER. They also discuss its depictions of the financial forces that shape day-to-day problems inside ERs.

Dan Weissmann

@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: Why ‘The Pitt’ Is Our Fave New Drama

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. I’ve got a new favorite TV show: “The Pitt.” I signed up for HBO — Max, whatever –thats what my editor says I’m supposed to call it. The show takes place in a Pittsburgh emergency room, and the first season follows the staff through a single, jam-packed day, hour by hour. It’s riveting. Noah Wyle, who got famous playing a young doctor on the show ER in the 1990s, stars here as the senior doc on duty. And people who work in emergency rooms say it gets a lot of things right, including medical details that fly past most of us in scenes like this… 

Doctor 1: Bring me up to speed? 

Doctor 2: Intubated for agonal respirations. GCS five, probably anticoagulated. Doctor 1: With what? 

Doctor 3: First time here. There’s no medical records. 

Doctor 1: Call for FFP. 

Doctor 2: No, we got four factors… 

Dan: And yeah, I basically did not catch any of that. But when I played it for an actual ER doctor, Alex Janke, he kept smiling and nodding along. In any case, those were not the kinds of scenes I called Alex Janke to talk about. Because what drew me to the Pitt — for professional purposes at least — are scenes that show the bigger-picture forces — the financial forces — that MAKE this day, and every day, so difficult for the people who work in big-city ERs, and for the people who show up needing care. Forces that make ERs more crowded, and more chaotic. Less safe, and more expensive. I called Alex Janke because on top of working shifts at ERs, he does research on those forces as a professor at the University of Michigan. 

Alex Janke: I care a lot about. Emergency medicine. Like I think that what we do is really, really special. And I also think that if you want to understand the problems in the world, you should come to the emergency department,’cause that’s where people go when they have problems. 

Dan: Problems like gun violence, homelessness, sex trafficking,drug addiction, and a likely hate crime bring patients to The Pitt throughout the season. The Pitt also looks at questions that Alex studies: Why do people have to wait so long to get seen at ERs? How badly can those long wait-times affect our health? So, we watched some scenes that address those questions together and Alex was like… 

Alex Janke: I’ve gotta find the people that made this show. This is so crazy. They, they’ve gotta have some docs working for them. 

Dan: There’s a whole team. There’s a whole team. 

Dan: Alex Janke thinks the producers picked the right team… because, he says: This is too real. So here comes a debrief. Basically free of spoilers — in terms of the MEDICAL drama. And I’ll tell you right now: The financial problems? Those storylines do not get wrapped up on The Pitt, or in real life. But the show does help us understand them, and what they cost all of us– doctors, patients, everybody– in money, in our health, and in our emotional well-being. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. 

The folks who made “The Pitt” made a super-canny choice: The show follows a single day in this ER — and it happens to be the first day for a crew of new residents and interns. So while we watch them get shown around, we get a tour. First stop, the waiting room. It’s PACKED. A second-year resident explains how patients register, get a quick assessment… 

Doctor: And then they come back to waiting room till bed opens up Doctor 2: For how long? 

Doctor: Eight hours if they’re lucky. A lot of times 12. 

Doctor 3: Ah, is it always this busy? 

Doctor: Uh, no. It gets a lot busier. 

Dan: Here’s Alex’s take on that snapshot.

Alex Janke: I think this is entirely real. And we can really expect this to be true going into the future that, uh, you know, eight hour waits, 12 hour waits, very high rates of left without being seen are just gonna keep happening all over the country. And it’s not gonna be every day that you walk in the door. but it’s gonna keep happening. 

Dan: Why? 

Alex Janke: That’s a great question. 

Dan: Alex has a couple of answers. One is about demographics: We’ve got more folks now who are old, with complex medical issues than ever before, and that’s only gonna get more true for a long time to come. The other basically gets dramatized in the next couple scenes we watch. First, Noah Wyle’s character, the senior MD on this shift, Dr. Michael Rabinovich — everybody calls him Doctor Robby – gives the newbies his briefing. Here’s the first thing he tells them. 

Robby: As you can see, our house is always packed and our department is mostly clogged up with borders. Those are admitted patients waiting for a room upstairs sometimes for days. 

Dan: OK, that went by quick, but Dr Robby basically just described WHY people wait eight hours, twelve hours, why this ER and its waiting room is so full. I’ll let Alex explain. 

Alex Janke: The emergency department is not full because folks with the sniffles came in when they could have gone to an urgent care. That is not the reason that the ER is crowded. Those patients are so easy, we see ’em out in triage. I love seeing those patients ’cause that’s somebody that I can 

get in and out. I can take really good care of that patient sometimes just from the waiting room. The ER is full because there are folks that need to be in the hospital or folks that need to be in skilled nursing facilities or in rehab and we can’t get them to that next step. 

Dan: So those patients become “boarders” — get stuck: they can’t get moved to the next step, but of course they can’t go home either. 

Alex Janke: And so they wait in the ER and that creates crowding all around all the other patients.

Dan: The “boarders” fill up the ER beds. So everybody else piles up in the waiting room. Things get super-crowded. That sucks for those of us who show up as patients — a lot of us wait a super-long time. And that crowding — and the chaos that comes with it — creates burnout for people who work in ERs. 

Alex Janke: The thing that burns you out is feeling like you’re not able to do a good job or you’re not in control of your working environment. And this is the reason. It is because it is crowded. Like an old lady comes in with belly pain. I can’t take care of that patient in the waiting room that I need that lady back in the department. I wanna get a CAT scan on that lady. I need some time with her. And it’s just, it’s, it’s dangerous and unpleasant all around. 

Dan: Because you, because you don’t have space to see her. You don’t have a bed, you don’t have capacity to see her. And so she’s in danger. 

Alex Janke: Absolutely. Without a doubt. And, you know, there’s a deep, there’s a deep literature on this, crowding impacts the quality of care along every possible dimension. It makes you more likely to screw up. I’m an ER doctor. My whole job is to not screw up. I’m like playing this game and the game is to not miss something really bad. And the faster you make me go with fewer resources, your ER doctor’s just a little more likely to screw up and not handle that correctly. I have gray hairs from a couple of cases. 

Dan: He tells me about one of them. A woman who came in with a rash. When he finally examined her, twelve hours later, it turned out that rash was from flesh-eating bacteria. Those twelve hours meant that bacteria did a lot of damage. Alex says that woman spent a long time in the ICU, and took months to fully recover. 

Alex Janke: I mean, those are the, you know, that’s one of the cases I know about, like how many patients have I been on shift and I don’t even know what happened,’cause there’s so much chaos going on that I don’t have insight into what might have missed or what we might not have done very well? 

Dan: So the ER doesn’t work because it’s too crowded. And it’s crowded because of “boarders” — patients waiting for beds elsewhere. And in the next scene, we get Dr. Robbie’s perspective on WHY that’s happening. That’s when a hospital administrator, Gloria, shows up to give him a hard time. She says, WE NEED TO TALK ABOUT YOUR NUMBERS. Meaning, patient satisfaction numbers.

Gloria: Do you know how likely patients are to recommend this hospital? Robby: Um, this is an emergency department, not a Taco Bell. Gloria: 11%. 

Robby: Well, if you want people to be happier, don’t make ’em wait for 12 hours. 

Gloria: There’s a nursing shortage across the country. 

Robby: Most of our patients are boarders who are waiting for a bed upstairs. 

Gloria: We don’t have the beds. 

Robby: That’s bullshit. The beds are up there. You just don’t want to hire the staff. You need to care for ‘em. 

Dan: Alex has one little problem with this scene. He’s like, these conversations definitely happen, but not on shift, on the ER floor. But you know, OK it’s a TV show, and the whole premise is that we’re on the floor the whole time. And Alex has a second problem. Dr. Robby maybe does too good a job keeping his cool. 

Alex Janke: You know, Dr. Robby is rushing from one dying patient to another, and someone shows up in a suit and says, you know, your patients aren’t very satisfied with your care. I think he handles it like an angel. If it were me, I think I would lose my job that day. 

Dan: Otherwise, Alex is like: This is dead on. 

Alex Janke: There’s so much going on here. This is wild. It’s so wild. 

Dan: And he unpacks it. Yes, there’s a nursing shortage. Yes, there’s an actual shortage of hospital beds. And to a degree, these shortages are … business decisions. 

Alex Janke: There’s some real truth, there’s a real hook to the idea that the emergency department waiting room and the emergency department beds as a place to keep folks waiting for a bed upstairs in the hospital — it is an optimization problem.

Dan: An optimization problem. That’s what Alex says people who study hospital administration have called this situation. The question is, what are you optimizing for? If you’re a hospital administrator, Alex says, you’re trying to optimize … your budget. You’re asking yourself: How do you get the most return for what you spend? You don’t do it by paying nurses to staff beds with no patients in them. Nobody’s paying you for empty beds. 

Alex Janke: I mean, we want our hospital beds full. we’ve gotta pay these enormous costs for inputs, like, uh, nurses and, every single hour of nursing care that you pay for, you wanna make sure that, uh, it’s getting used. Every hospital bed day that you have staffed, you better fill up that bed. 

Dan: So, now you’ve got a new equation to balance. Here’s how Alex describes the question: 

Alex Janke: How do you maximize your patient bed days —that’s how you get paid — without ever having to turn away business? 

Dan: OK, let’s unpack that: You want to maximize patient bed days. The number of beds that actually have patients in them, beds you’re getting paid for, on any given day. But you’ve limited the supply of beds upstairs. You don’t want to pay for something you might not be able to sell. And yet: You don’t want to turn away business.You’ve got a patient who needs a hospital room — a potential paying customer –you don’t wanna tell ‘em, hey we don’t have room for you on our cardiac ward. You gotta go somewhere else. So, how do you make room for patients — for customers — when there’s more demand? 

Alex Janke: Well, one way to do that is to queue those patients, put them in a in a slot so that they’re ready to fill up that bed as soon as that bed becomes available. Where does that happen? The emergency department. 

Dan: So this is why Alex is so enthusiastic about this scene: It dramatizes this whole analysis — and Dr. Robby’s perspective– the boarders who crowd up the ER and the waiting room: They’re the results of the hospital’s financial strategy. No wonder Dr. Robby’s mad. 

Coming up: How doctors get caught in the processes that end up with awful bills for patients. 

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their reporters win all kinds of awards every year. We are honored to work with them.

We’re gonna skip ahead to episode six of The Pitt. No spoilers here. This scene stands alone, and it’s all business. Robby stops by a computer terminal where one of the newbies is charting– writing up her notes after seeing a patient. Listen for a key term right up top: Medical Decision Making. A little later we’ll hear Robby use its initials: MDM. 

Dr. Robby: Four-year-old with a fever. Your medical decision making says otitis media. 

Dr. Javadi: Yeah, she had an ear infection. 

Robby: Did you also consider and rule out meningitis, mastoiditis, malignant otitis external? 

Dr. Javadi: I did. 

Dr. Robby: Then you should document your cognitive work in the MDM. Dr. Javadi: You want me to pad my chart? 

Dr. Robby: No. I want you to show your work. Billing is the side effect of that. 

Dan: “Billing is a ‘side effect’ of adding details” to the chart. When I watched that scene with Alex, he was like, Yup: charting is where our work turns into medical bills. 

Alex Janke: So when we bill for care, we bill an insurer for care, we bill the chart, right? 

Dan: The billing department translates the work described in the chart into 5-digit codes, and each one has a price tag. MDM, medical decision-making, contributes to codes for “evaluation and management” like 99281 or 99285. 

Alex Janke: And if you bill for 99285, you get a whole bunch of money. And if you bill for, uh, 99281, then you get a little bit of money. 

Dan: The only difference is that last number. It reflects a scale — 1 to 5 — how much work went into this visit. Was this straightforward? That’s a one. Was it high-level? Really complex? That could be a five. Researchers have found that “upcoding” — like billing a level four for something that’s really probably a two — is one reason why, as a country, we spend more on ER bills every year. I tell Alex: In one of the very first episodes of this podcast, we heard from a listener who had brought his son to the local ER — only place open at night — for what turned out to be …and ear infection. The hospital coded the visit a “4” out of 

five. Pretty expensive. Our listener said, if that’s a four, what is it when you bring your leg in a bag? Alex was like, Yeah. 

Alex Janke: There’s this fight between like physician groups on the one hand, and insurers on the other hand about like how hard our job is and how much they should pay us, and the only one who consistently loses in that fight is the patient. 

Dan: Yeah. Well said. Well said. 

Alex Janke: You’re absolutely right. It’s definitely true in emergency medicine. And you know, like I, I’ve written on this topic our patients are more medically complex than they have ever been. The complexity of the evaluation management that happens in the emergency department is higher than it has ever been. But that’s no excuse for, you know, leaving the patient with an absurd bill that’s out of proportion to what she did for them. This is one of the ways in which you’re like, put in all of these like little situations where like you’re in a lose-lose situation. 

Dan: Lose-lose situation. Alex tells me a story. He was working in triage one day, and a guy came in with a bug bite. 

Alex Janke: …and his buddy had convinced him that he might have like a really bad problem. He was like, this is a black widow spider bite. And it was a crazy day and I’m just like floating around at triage, slinging orders. And, he like stopped me in the hallway as he was like thinking about leaving. And he was like, do I really need to be seen for this? Do I really need to be seen for this? And I’m like, well, you have been seen. I am a doctor. And, and he walked out the door and I had this moment where I was like, do I go write a note on this guy? If I write a note, then we’ll bill him. 

Dan: And Alex says he knew: That guy didn’t have insurance. Whatever that bill was, he could get stuck paying for it. 

Alex Janke: I don’t know what that bill looks like. I don’t have insight into that. I don’t know how the place that I work at operates on that end. I’m almost never involved in it at all.

Dan: What’d you do? 

Alex Janke: Nah, I didn’t write a note. 

Dan: I said to Alex: Geez, some hospitals have folks who help people in these situations, who go: “Hey, let’s see if we can sign you up for Medicaid. Or a super-subsidized Obamacare plan. Or maybe you qualify for charity care here.” But of course not every hospital has those folks. Alex was like, oh yeah, for sure. 

Alex Janke: One of the places where I currently work, our registration staff know like a ton of stuff about insurance and patients will like ask me, and I’m like, oh, no, no, no. This is the person you gotta talk to. They actually know how to enroll whether it’s Medicaid or something else. Yeah. 

Dan: It’s great that there’s somebody , and you know, who the somebody is, for them to talk to,’cause that is not everybody’s experience. 

Alex Janke: Yeah. And also, I’ve worked at other places where you look around in the department and no one knows. And like, that’s always a bummer. Like there was a little while where I was handing out a phone number ’cause I didn’t like really know what I was supposed to be doing. And so I would, I would give people this phone number. I’d be like, what you’re telling me makes it sound like you qualify for Medicaid. But like, I don’t really know anything about Medicaid. This is the website, this is the phone number. It’s so bad. 

Dan: Alex says he hopes people who don’t work in ER’s watch The Pitt. 

Alex Janke: This show is good for people like me because it like humanizes us in a lot of ways and the show definitely makes us out —at least the first two episodes — they make us out in lots of heroic ways, and I think that’s great. And I think lots of emergency physicians are heroes. Lots of us are not heroes. You know, we’re just people. 

Dan: He thinks it’ll help people like him — in his role as a researcher and advocates — make a case for policies that’ll help ERs. And he’s not mad about seeing the business questions get dramatized. 

Alex Janke: We need to have those conversations way out in the open with bright lights and that’s the only way that they won’t ultimately have the patient be the only one who loses in the exchange. So, yeah.

Dan: As if we know a little bit more about the whole, about the game that we’re in the middle of. Yeah. 

Alex Janke: Exactly. Yeah. 

Dan: But as happy as he is that The Pitt is out there — having watched the first two episodes so we could have this conversation– he’s not inclined to watch more of it. 

Alex Janke: I think a lot of people, a lot of, like my friends, we don’t, we don’t have to watch it. I just go to work. It’s so spot on, so often, it feels like you’re at work. I’m like, well, I do this. I’ll tell you, I’m watching Abbott Elementary. 

Dan: The network sitcom about a Philadelphia grade school. 

Alex Janke: It’s pretty good. It’s pretty good. There’s some strong dialogue, there’s some really strong characters. 

Dan: Teacher friends of mine love that show. And it’s another, I mean, it’s interesting ’cause that’s another show about people who, part of their job is it like they’re in the path of suffering that other people are headed for and doing their best. 

Alex Janke: I sometimes say this to residents, but like you can go give as much as you want in the job of emergency medicine. You can give everything to the people who come in the door. It’s the same thing with teachers, right? If you’re a teacher, you can just keep giving. They’ll never stop asking for more, and a lot of ’em do. It seems like a hard gig to me and considerably less remunerative than my job, so… 

Dan: I will let my teacher friends know Alex said that. Meanwhile, about fifteen hours after we release this episode, HBO — I mean, Max — will release the last episode of The Pitt. For now. The show has been renewed for a second season, starting January 2026. Producers said recently that season two is gonna take place over a Fourth of July weekend… which, a study from Pew Research shows, means the busiest days of the year, by far, for emergency rooms. 

We’ll be back with a new episode in a few weeks. Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport, edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. Lynne Johnson is our operations manager. An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America – and a core program at KFF: an independent source of health policy research, polling, and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. An Arm and a Leg is Distributed by KUOW– Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thank you to everybody who supports this show financially. You can join in any time at arm and a leg show, dot com, slash: support. Thanks! And thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

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