After a patch of ice sent Marc Durocher hurtling to the ground, and doctors at UMass Memorial Medical Center repaired the broken hip that resulted, the 75-year-old electrician found himself at a crossroads.

He didn’t need to be in the hospital any longer. But he was still in pain, unsteady on his feet, unready for independence.

Patients nationwide often stall at this intersection, stuck in the hospital for days or weeks because nursing homes and physical rehabilitation facilities are full. Yet when Durocher was ready for discharge in late January, a clinician came by with a surprising path forward: Want to go home?

Specifically, he was invited to join a research study at UMass Chan Medical School in Worcester, Massachusetts, testing the concept of “SNF at home” or “subacute at home,” in which services typically provided at a skilled nursing facility are instead offered in the home, with visits from caregivers and remote monitoring technology.

Durocher hesitated, worried he might not get the care he needed, but he and his wife, Jeanne, ultimately decided to try it. What could be better than recovering at his home in Auburn with his dog, Buddy?

Such rehab at home is underway in various parts of the country — including New York, Pennsylvania, and Wisconsin — as a solution to a shortage of nursing home and rehab beds for patients too sick to go home but not sick enough to need hospitalization.

Staffing shortages at post-acute facilities around the country led to a 24% increase over three years in hospital length of stay among patients who need skilled nursing care, according to a 2022 analysis. With no place to go, these patients occupy expensive hospital beds they don’t need, while others wait in emergency rooms for those spots. In Massachusetts, for example, at least 1,995 patients were awaiting hospital discharge in December, according to a survey of hospitals by the Massachusetts Health & Hospital Association.

Offering intensive services and remote monitoring technology in the home can work as an alternative — especially in rural areas, where nursing homes are closing at a faster rate than in cities and patients’ relatives often must travel far to visit. For patients of the Marshfield Clinic Health System who live in rural parts of Wisconsin, the clinic’s six-year-old SNF-at-home program is often the only option, said Swetha Gudibanda, medical director of the hospital-at-home program.

“This is going to be the future of medicine,” Gudibanda said.

But the concept is new, an outgrowth of hospital-at-home services expanded by a covid-19 pandemic-inspired Medicare waiver. SNF-at-home care remains uncommon, lost in a fiscal and regulatory netherworld. No federal standards spell out how to run these programs, which patients should qualify, or what services to offer. No reimbursement mechanism exists, so fee-for-service Medicare and most insurance companies don’t cover such care at home.

The programs have emerged only at a few hospital systems with their own insurance companies (like the Marshfield Clinic) or those that arrange for “bundled payments,” in which providers receive a set fee to manage an episode of care, as can occur with Medicare Advantage plans.

In Durocher’s case, the care was available — at no cost to him or other patients — only through the clinical trial, funded by a grant from the state Medicaid program. State health officials supported two simultaneous studies at UMass and Mass General Brigham hoping to reduce costs, improve quality of care, and, crucially, make it easier to transition patients out of the hospital.

The American Health Care Association, the trade group of for-profit nursing homes, calls “SNF at home” a misnomer because, by law, such services must be provided in an institution and meet detailed requirements. And the association points out that skilled nursing facilities provide services and socialization that can never be replicated at home, such as daily activity programs, religious services, and access to social workers.

But patients at home tend to get up and move around more than those in a facility, speeding their recovery, said Wendy Mitchell, medical director of the UMass Chan clinical trial. Also, therapy is tailored to their home environment, teaching patients to navigate the exact stairs and bathrooms they’ll eventually use on their own.

A quarter of people who go into nursing homes suffer an “adverse event,” such as infection or bed sore, said David Levine, clinical director for research for Mass General Brigham’s Healthcare at Home program and leader of its study. “We cause a lot of harm in facility-based care,” he said.

By contrast, in 2024, not one patient in the Rehabilitation Care at Home program of Nashville-based Contessa Health developed a bed sore and only 0.3% came down with an infection while at home, according to internal company data. Contessa delivers care in the home through partnerships with five health systems, including Mount Sinai Health System in New York City, the Allegheny Health Network in Pennsylvania, and Wisconsin’s Marshfield Clinic.

Contessa’s program, which has been providing in-home post-hospital rehabilitation since 2019, depends on help from unpaid family caregivers. “Almost universally, our patients have somebody living with them,” said Robert Moskowitz, Contessa’s acting president and chief medical officer.

The two Massachusetts-based studies, however, do enroll patients who live alone. In the UMass trial, an overnight home health aide can stay for a day or two if needed. And while alone, patients “have a single-button access to a live person from our command center,” said Apurv Soni, an assistant professor of medicine at UMass Chan and the leader of its study.

But SNF at home is not without hazards, and choosing the right patients to enroll is critical. The UMass research team learned an important lesson when a patient with mild dementia became alarmed by unfamiliar caregivers coming to her home. She was readmitted to the hospital, according to Mitchell.

The Mass General Brigham study relies heavily on technology intended to reduce the need for highly skilled staff. A nurse and physician each conducts an in-home visit, but the patient is otherwise monitored remotely. Medical assistants visit the home to gather data with a portable ultrasound, portable X-ray, and a device that can analyze blood tests on-site. A machine the size of a toaster oven dispenses medication, with a robotic arm that drops the pills into a dispensing unit.

The UMass trial, the one Durocher enrolled in, instead chose a “light touch” with technology, using only a few devices, Soni said.

The day Durocher went home, he said, a nurse met him there and showed him how to use a wireless blood pressure cuff, wireless pulse oximeter, and digital tablet that would transmit his vital signs twice a day. Over the next few days, he said, nurses came by to take blood samples and check on him. Physical and occupational therapists provided several hours of treatment every day, and a home health aide came a few hours a day. To his delight, the program even sent three meals a day.

Durocher learned to use the walker and how to get up the stairs to his bedroom with one crutch and support from his wife. After just one week, he transitioned to less-frequent, in-home physical therapy, covered by his insurance.

“The recovery is amazing because you’re in your own setting,” Durocher said. “To be relegated to a chair and a walker, and at first somebody helping you get up, or into bed, showering you — it’s very humbling. But it’s comfortable. It’s home, right?”

A year ago, a new head of Social Security set out to stop the agency from financially devastating many of the people it was meant to help.

The agency had long made it a practice to reduce or halt benefit checks to recoup billions of dollars in payments it sent recipients but later said they never should have received.

Martin O’Malley, then the Social Security Administration commissioner, announced in March 2024 the agency would no longer cut off people’s monthly old-age, survivors, and disability checks to recoup money they had allegedly been overpaid — a pattern he called “clawback cruelty.” Instead, it would default to withholding 10% of monthly benefits. The new policy allowed people who already live on little to pay their rent and keep food on the table.

Last Friday, the Trump administration reversed that policy.

Beginning March 27, to recover new overpayments, the Social Security Administration will automatically withhold 100% of recipients’ monthly benefits, the agency announced.

The agency said it was acting in the interest of fiscal responsibility and that the reversal would save the government about $7 billion over a decade.

“It is our duty to revise the overpayment repayment policy back to full withholding, as it was during the Obama administration and first Trump administration, to properly safeguard taxpayer funds,” acting Commissioner Lee Dudek said in a news release.

Advocates for Social Security beneficiaries described the action as cruel and harmful.

“The results are predictable: more unnecessary suffering,” said Kathleen Romig, who worked at the Social Security Administration under O’Malley and is now director of Social Security and disability policy at the Center on Budget and Policy Priorities.

Kate Lang of the advocacy group Justice in Aging said she was heartbroken.

“Those who are most vulnerable, with the fewest resources, are the ones who will feel the harsh impacts of this change,” she said. Many “are going to be unable to buy food or keep the roof over their head,” she said.

In 2023, after an investigation by KFF Health News and Cox Media Group cast a spotlight on overpayments and clawbacks, lawmakers from both parties called on the Social Security Administration to change its approach.

The policy change a year ago was inspired in part by the plight of people such as Denise Woods, who was sleeping in her Chevy in Savannah, Georgia, in December 2023 while contending with lupus and congestive heart failure after the government cut off her disability benefits. The government was demanding she repay almost $58,000.

Many overpayments are the result of government error. It can take the government years to figure out it has been paying someone too much, and by then, the amount the government says it is owed can grow far beyond a beneficiary’s ability to repay. And it has often demanded that recipients repay the full amount within 30 days.

As of October, the SSA was withholding at least a portion of monthly benefit payments from hundreds of thousands of people, according to data the SSA provided last fall to KFF Health News and Cox Media Group. The agency said it was withholding up to 10% from 669,903 people to recoup an overpayment. Asked whether those numbers covered all types of benefits administered by the SSA, the agency’s press office didn’t say.

“Under Trump’s leadership, Social Security has reinstated a cruel policy of clawing back Social Security overpayments with no regard for an American’s ability to pay or whether the overpayment was an error by the agency,” said Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee.

The new plan to completely withhold monthly benefits from recipients who were allegedly overpaid does not extend to the Supplemental Security Income program, one of two Social Security programs for people with disabilities. SSI, as the agency explains, covers “people with disabilities and older adults who have little or no income or resources.”

The government’s estimate that cutting people off completely will save $7 billion over a decade implies it expects many more overpayments in the years ahead.

The SSA’s March 7 announcement was part of a broader dismantling of Biden-era policies under President Donald Trump. It was also part of a broader upheaval at the Social Security Administration, which announced In February that it would cut its staff from about 57,000 to 50,000.

In an interview Monday, O’Malley predicted that the public will experience much longer wait times trying to get through to the agency by phone and longer waits for disability determinations.

Social Security runs on a very old computer system, he said, and driving people out of the agency who understand it “can only result in system collapse.”

“The risk of totally shutting down the agency is greatly increased by people mucking around that don’t know what they’re doing,” O’Malley said.

On the PBS NewsHour last week, he advised recipients to save money to prepare for an interruption of benefits.

Trump deputy Elon Musk has boasted of taking a chainsaw to the federal government and has called Social Security a Ponzi scheme. In a signed declaration filed in federal court last week, a recently retired SSA official, Tiffany Flick, said she “witnessed a disregard for critical processes” as members of DOGE — the Department of Government Efficiency, which Trump established by executive order — demanded access to sensitive Social Security systems, including files that contain beneficiaries’ banking information.

New management at the SSA called its workforce “bloated.” But, under the previous administration, the agency was telling a starkly different story.

A year ago, O’Malley told lawmakers that, as the number of people receiving benefits increased, “historic underfunding and understaffing” at the agency had created a “service delivery crisis.”

Late last year, the agency provided data to KFF Health News showing that in September its workforce was near a 50-year low. As of last month, applicants for disability benefits were waiting an average of more than seven months for a decision, according to the SSA website.

The staffing cuts will lead to more overpayments than ever and will make it harder for the people affected to clear up mistakes, said Jen Burdick, an attorney at Community Legal Services of Philadelphia.

As KFF Health News and Cox Media Group revealed in 2023, about 2 million people a year were receiving notices from the SSA that they were overpaid and owed money back.

People can appeal overpayment notices, request a lower withholding rate, or ask the SSA to waive collection altogether, the agency said. The SSA does not pursue recoveries while an initial appeal or waiver request is pending, it said.

Shortly before O’Malley left the SSA in November, the agency implemented changes that made it easier for beneficiaries to get overpayments waived. The agency spelled out grounds for determining the beneficiary was not at fault — for instance, if the agency continued to issue overpayments after the beneficiary reported a change in their financial circumstances that should have led to a reduction in benefits. Those policy changes remain intact.

Several Republicans who expressed concern about clawbacks in the aftermath of 2023 news coverage did not respond to inquiries for this article or declined to comment. One of them was Sen. Rick Scott (R-Fla.), who is now chair of the Senate’s Special Committee on Aging.

“Hardworking American taxpayers pay into Social Security all of their lives so that they can depend on it in the time they need it most,” Scott said in a 2023 letter to the agency. “The fact that the SSA’s actions are leaving some of them worse off, through no fault of their own, is absolutely unacceptable.”

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The Trump administration issued its first major set of proposed changes to the Affordable Care Act on Monday that federal officials said are intended to crack down on fraud in the program. Policy experts said they will make it harder for consumers to sign up for coverage, potentially reducing enrollment.

Details were released Monday after a draft press release was inadvertently posted earlier.

About 24 million Americans signed up for insurance plans sold under the ACA, known popularly as Obamacare, for 2025. The Biden administration achieved record enrollment levels after increasing premium subsidies for many lower-income people, which resulted in reducing the monthly cost of some plans to $0. It also made it easier for some very low-income people to sign up at any time of year, instead of waiting for an enrollment period each fall. But the program became plagued by fraudulent enrollment last year, generating about 274,000 consumer complaints through August, most focused on rogue insurance agents and other bad actors, to the Centers for Medicare & Medicaid Services.

The Trump administration said in a statement Monday that the new regulations include “critical and necessary steps to protect people from being enrolled in Marketplace coverage without their knowledge or consent, promote stable and affordable health insurance markets, and ensure taxpayer dollars fund financial assistance only for the people the ACA set out to support.”

Policy experts said the changes, though, will impose new paperwork burdens likely to hamper enrollment.

“Under this banner of trying to crack down on the bad actions of some insurance brokers, they are penalizing consumers, particularly low-income consumers, with more burdensome requirements and more limits on their access to coverage,” said Sabrina Corlette, a research professor and the co-director of the Center on Health Insurance Reforms at Georgetown University.

Among other new requirements, consumers would have to provide more information proving their eligibility for special enrollment periods and for premium subsidies when they enroll. The regulation would also shorten the annual enrollment period by a month. And it touches on social issues, limiting eligibility for “Dreamers” — a nickname for immigrants in the country illegally who were brought here as children, based on never-passed proposals in Congress called the DREAM Act.

The proposal would eliminate the year-round opportunity for a special enrollment period for people with very low incomes. But it would also set new requirements for the remaining special enrollment periods, which allow people to sign up after major life events, such as when their income changes, they lose their job-based coverage, or they get divorced, marry, or move. They would now have to provide evidence of their eligibility when applying under those special situations.

People auto-reenrolled into zero-premium plans during the regular enrollment period would be charged a small monthly payment until they confirm or update their information.

The ACA marketplaces, according to the proposal, would have to seek additional data from consumers, including the self-employed or gig workers, who estimate their income for the coming year but don’t have tax return data filed with the IRS for previous years.

The Biden administration made changes to reduce fraudulent enrollment last year including requiring three-way calls among insurance brokers, their clients, and the federal insurance marketplace, healthcare.gov, when certain sign-ups or coverage changes were made.

Some of the Trump administration’s proposed changes could help warn certain consumers that they’ve been unknowingly enrolled in an ACA plan, such as a requirement that some customers on even the least expensive plans receive a small, monthly premium bill.

However, the additional paperwork and other eligibility requirements “will probably have a downward effect on enrollment,” said Cynthia Cox, a vice president and the director of the Program on the ACA at KFF, a health information nonprofit that includes KFF Health News. “Some of that could be protecting enrollees who were fraudulently signed up or don’t realize they’re still signed up.”

Still, it could prove difficult for some people if they’re not able to document an expected change in income. “They might have a legitimate claim but have a hard time demonstrating it,” Cox said.

The annual open enrollment period would end Dec. 15, a month earlier than this year. The designated period is when most people sign up and is intended to prevent people from waiting until they get sick to enroll, a move that helps slow premium growth.

The Trump proposal also touches on social issues.

It would reverse the Biden administration policy that allows Dreamers to qualify for subsidized ACA coverage. That decision is already the subject of a court challenge brought by 19 states seeking to overturn it.

Also under the Trump proposal, gender-affirming care would not be considered part of the “essential health benefits” that all plans must cover.

According to an FAQ that accompanied the initial press release of the proposed regulations, the provision could “lead to increased out-of-pocket costs for individuals requiring sex-trait modification services, as they may need to seek plans that offer this coverage as a non-EHB or pay for services out-of-pocket.”

As a proposed rule, the measures now face a public comment period and potential revision before being finalized.

“None of it will go into effect right away,” said Katie Keith, director of the Center for Health Policy and the Law at Georgetown University. “The question is how much will apply in 2025 versus 2026.”

The FAQ acknowledged that some of the proposed changes, including ending year-round enrollment for very low-income people, “may increase the administrative burden for consumers associated with enrollment and verification processes or could deter some eligible low-income individuals from enrolling.”

But, it continued, “we believe that enhancing program integrity and reducing improper enrollments outweighs these potential impacts on access to coverage.”

Some lawmakers and conservative groups have pointed to the concerns about unauthorized enrollment and the role, if any, that ACA subsidies or enrollment periods have in fueling the problem.

The right-leaning Paragon Health Institute, for example, released a report in June that, among other things, called for the Biden administration’s expansion of the special enrollment period for low-income people to be reversed.

“There is substantial amounts of fraud and waste in the ACA exchanges and the Biden administration pursued the enrollment-at-all costs strategy, and was tolerant of the waste, fraud and abuse,” said Brian Blase, a former health aide during Trump’s first presidency who is president of the Paragon Health Institute and influential within the current Trump administration. “Clearly a different approach to protect legitimate enrollees and taxpayers is needed.”