The Brief

Sarah Monroe once had a relatively comfortable middle-class life.

She and her family lived in a neatly landscaped neighborhood near Cleveland. They had a six-figure income and health insurance through her job. Then, four years ago, when Monroe was pregnant with twin girls, something started to feel off.

"I kept having to come into the emergency room for fainting and other symptoms," recalled Monroe, 43, who works for an insurance company.

The babies were fine. But after months of tests and hospital trips, Monroe was diagnosed with a potentially dangerous heart condition.

It would be costly. Within a year, as she juggled a serious illness and a pair of newborns, Monroe was buried under more than $13,000 in medical debt.

Part of the reason: Like tens of millions of Americans, she had a high-deductible health plan. People with these plans typically pay thousands of dollars out of their own pockets before coverage kicks in.

The plans, which have become common over the past two decades, are getting renewed attention thanks to President Donald Trump and his GOP allies in Congress.

Many Republicans are reluctant to extend government subsidies that help cover patients' medical bills and insurance premiums through the Affordable Care Act.

And although GOP leaders have yet to coalesce around an alternative, several leading Republican lawmakers have proposed Americans who don't get insurance through an employer should get cash in a special health care account, paired with a high-deductible health plan.

In such an arrangement, someone could choose a plan on an ACA marketplace that costs less per month but comes with an annual deductible that can top $7,000 for an individual plan.

"A patient makes the decision," Sen. Bill Cassidy, R-La., said at a recent hearing. "It empowers the patient to lower the cost."

In a post on Truth Social last month, Trump said: "The only healthcare I will support or approve is sending the money directly back to the people."

"Skin in the game"

Conservative economists and GOP lawmakers have been making similar arguments since high-deductible health plans started to catch on two decades ago.

Back then, a backlash against the limitations of HMOs, or health maintenance organizations, propelled many employers to move workers into these plans, which were supposed to empower patients and control costs. A change in tax law allowed patients in these plans to put away money in tax-free health savings accounts to cover medical bills.

"The notion was that if a consumer has 'skin in the game,' they will be more likely to seek higher-quality, lower-cost care," said Shawn Gremminger, who leads the National Alliance of Healthcare Purchaser Coalitions, a nonprofit that works with employers that offer their workers health benefits.

"The unfortunate reality is that largely has not been the case," Gremminger said.

Today, nearly all health plans comes with a deductible, with the average for a single worker with job-based coverage approaching $1,700, up from around $300 in 2006.

Plans with deductibles that exceed $1,650 can be paired with a tax-free health savings account.

But even as deductibles became widespread over the last 20 years, medical prices in the U.S. skyrocketed. The average price of a knee replacement, for example, increased 74% from 2003 to 2016, more than double the rate of overall inflation.

At the same time, patients have been left with thousands of dollars of medical bills they can't pay, despite having health insurance.

About 100 million people in the U.S. have some form of health care debt, a 2022 survey showed.

Most, like Monroe, are insured.

Medical price shopping isn't easy

Although Monroe had a health savings account paired with her high-deductible plan, she was never able to save more than a few thousand dollars, she said. That wasn't nearly enough to cover the big bills when her twins were born and when she got really ill.

"It's impossible, I will tell you, impossible to pay medical bills," she said.

There was another problem with her high-deductible plan. Although these plans are supposed to encourage patients to shop around for medical care to find the lowest prices, Monroe found this impractical when she had a complex pregnancy and heart troubles.

Instead, Monroe chose the largest health system in her area.

"I went with that one as far as medical risk," she said. "If anything were to happen, I could then be transferred within that system."

Federal rules that require hospitals to post more of their prices can make comparing institutions easier than it used to be.

But unlike a car or a computer, most medical services remain difficult to shop for, in part because they stem from an emergency or are complex and can stretch over numerous years.

Researchers at the nonprofit Health Care Cost Institute, for example, estimated that just 7% of total health care spending for Americans with job-based coverage was for services that realistically could be shopped for.

Fumiko Chino, an oncologist at the MD Anderson Cancer Center in Houston, said it makes no sense to expect patients with cancer or another chronic disease to go out and compare prices for complicated medical care such as surgeries, radiation, or chemotherapy after they've been diagnosed with a potentially deadly illness.

"You're not going be able to actually do that effectively," Chino said, "and certainly not within the time frame that you would need to when facing a cancer diagnosis and the imminent need to start treatment."

Drowning in bills

Chino said patients with high deductibles are often instead slammed with a flood of huge medical bills that lead to debt and a cascade of other problems.

She and other researchers found in a study of more than 8,000 cancer patients presented last year at the American Society of Clinical Oncology that cancer patients who had high-deductible health insurance were more likely to die than similar patients without that kind of coverage.

For her part, Monroe and her family were forced to move out of their house and into a 1,100-square-foot apartment.

She drained her savings. Her credit score sank. And her car was repossessed.

There have been other sacrifices, too. "When families get to have nice Christmases or get to go on spring break," Monroe said, hers often does not.

She is thankful that her children are healthy. And she continues to have a job. But Monroe said she can't imagine why anyone would want to double down on the high-deductible model for health care.

"We owe it to ourselves to do it a different way," she said. "We can't treat people like this."

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.
Copyright 2025 KFF Health News

Big Bear’s famous bald eagle couple, Jackie and Shadow, now have a pair of eggs to look after.

Jackie welcomed the second egg of the season around 5:10 p.m. Monday, according to Friends of Big Bear Valley, the nonprofit that runs a popular YouTube livestream centered on the nest overlooking Big Bear Lake.

More than 22,000 people were watching the livestream when Jackie welcomed the new addition, up from more than 14,000 viewers when the first egg arrived Friday afternoon.

The season so far

Jackie laid the first egg around 4:30 p.m. Friday, with Shadow stopping by to see it for the first time about 10 minutes later, according to Friends of Big Bear Valley records.

It was almost exactly a year after the feathered duo welcomed the first egg of the 2025 season.

Jackie tends to lay eggs three days apart, and the second egg arrived right on schedule.

Jackie could be seen rousing and puffing up her feathers about a half-hour before laying the second egg. She made a high-pitched whistling tea kettle noise a little before 5 p.m. Monday.

Officials from Friends of Big Bear Valley have told LAist those behaviors are signs an egg is imminent.

“She looks almost royal, because all of her feathers are out and it's just — I cry,” Jenny Voisard, the organization’s media and website manager, said with a laugh last week. “It's usually pretty amazing.”

The eagle pair typically takes turns caring for their eggs. Shadow visited the nest for nearly three hours across nine incubation “daddy duty” sessions on Sunday, according to organization records.

What’s ahead for the nest

Jackie has laid up to three eggs in a clutch, including in each of the past two seasons, so fans could see another egg arrive this week.

A clutch refers to the group of eggs laid in each nesting attempt. Bald eagles generally have one clutch per season, according to Friends of Big Bear Valley. A second clutch is possible if the eggs don’t make it through the early incubation process.

For example, Jackie laid a second clutch in February 2021 after the first round of eggs was broken or destroyed by ravens the month before.

The Big Bear eagles also practice delayed incubation, which is when Jackie and Shadow don’t apply their full body heat to the eggs until the whole clutch is laid.

Waiting to incubate full time helps the eggs hatch closer together, making the chicks more similar in size and age, which the organization says gives them a better chance of survival.

Jackie and Shadow successfully delayed incubation for their trio of eggs last season, according to Friends of Big Bear Valley. Sunny and Gizmo hatched and later went on to fledge, or fly away from the nest for the first time, last summer.

Chicks? Chicks soon??

Once egg-laying is over, the chick countdown is on.

Jackie and Shadow's usual incubation time is around 35 to 39 days, starting when the eagles begin to fully incubate their clutch, according to Friends of Big Bear Valley.

Last season, the first egg hatched at around 40 days old, the second egg hatched around 38 days old and the third egg around 39 days old.

“Pip Watch” — short for pipping, which is the first hole an eaglet makes as it emerges from its egg — is typically announced by Friends of Big Bear Valley before chicks break through each season.

Last year’s Pip Watch kicked off in March, a few days before the first chick hatched in the nest.

The Coalition for Humane Immigrant Rights announced a new lawsuit Monday against federal immigration agencies for claims of inhumane conditions at the Adelanto ICE Processing Center in San Bernardino County.

The organization claims people detained in the Adelanto facility lack drinkable water, healthy food, clean clothes, places to sleep and access to medical care. Failing to provide these basic necessities, CHIRLA says in court documents, amounts to punishment — violating detainees rights to due process.

“ We are really at a moment where we are seeing a human rights crisis right before our eyes,” CHIRLA policy director Jeanette Zanipatin said at a news conference Monday. “And the detention centers, especially the one at Adelanto, is where we are seeing it unfold in real time.”

Immigrant Defenders Law Center, Willkie Farr & Gallagher LLP and Public Counsel are assisting in the case against Immigration and Customs Enforcement and the Department of Homeland Security.

 ”We're asking both that the judge force Adelanto, the detention facility, to ensure that basic medical care is being provided, that basic hygiene and sanitary conditions, food and water are provided, and that oversight is conducted over the facility,” said Alvaro Huerta, director of litigation and advocacy at Immigrant Defenders Law Center.

ICE and Homeland Security have not responded to LAist about the case or claims in this article.

A question of constitutional rights

When CHIRLA announced the lawsuit on Monday, Zanipatin said there has been “a long history of unsafe and abusive conditions” at the Adelanto facility. She referenced a July 2025 report from the nonprofit Disability Rights California that found conditions at the facility were “dangerous and inadequate for all people, especially for those with disabilities.”

Court documents filed by CHIRLA also reference previous reports that found issues at the facility, including a 2018 report from the DHS Office of Inspector General that found “a number of serious issues that violate ICE’s 2011 Performance-Based National Detention Standards and pose significant health and safety risks at the facility.”

Those issues included findings of nooses in detainees’ cells, improper use of disciplinary segregation and inadequate medical care.

“Based on interviews with detainees and medical staff and a review of independent reports,” the report states, “we concluded that detainees do not have timely access to proper medical care.”

CHIRLA claims in their lawsuit that Adelanto leadership rejected the findings of the inspector general report and took no corrective action.

The concerns raised by CHIRLA as they announced the lawsuit closely resemble the findings of Disability Rights California, which also claimed detainees were not provided adequate medical care, food, water or clean clothing. The organization also reported that some people had limited access to communication with their loved ones.

Huerta claimed that the conditions in the Adelanto facility are poor by design.

“ Adelanto, like most ICE prisons, is engineered to be so punishing, so relentlessly soul crushing, that people abandon their rights and accept deportation even when they have strong asylum claims or a clear pathway to legal status,” Huerta said.

He said 32 people died while detained by ICE nationwide in 2025, and at least 6 more have died in January. Two people died at Adelanto last fall, Huerta said.

Family members speak out

Mariel Garcia told LAist she would call her father, Gabriel Garcia-Aviles, nearly every day. That ended when he was detained by immigration agents in Costa Mesa on Oct. 14.

Garcia-Aviles had a work permit, his daughter said, but he was detained and taken to Adelanto. She said she tried many times to ask the facility staff to allow her to call her father, or even to get an update on his condition, but she was never able to talk to him again.

Worried, she said she got a call from the staff at Adelanto.

“ They called me the day he was passing away,” Garcia told LAist, “They're like, go tell your family and friends to come and say their last goodbyes because your father's in critical condition.”

Her brother, Gabriel Garcia, said that when they arrived at the hospital their father was intubated and “lifeless." Still, he said, there were law enforcement officers standing outside the hospital room.

Garcia-Aviles died Oct. 23 at age 56.

Jose Ayala also talked about the loss of his brother, Ismael Ayala-Uribe, while he was detained in the Adelanto facility.

“ He was there for about a month and we knew nothing of his condition,” Ayala said at Monday’s press conference, “just that he was sick and that he wasn't getting any help when he asked.”

Ayala said his family learned of his brother’s death when the police came and knocked at their door. He said staff at Adelanto did not tell them Ayala-Uribe had been hospitalized or that he needed a surgery, which ICE said in a news release was for an abscess.

Ayala told LAist that he was able to talk with his brother over the phone a couple of times when he was detained, and Ayala-Uribe was joking with him about the poor conditions of the facility causing him to lose weight.

“ One of the last things he told me,” Ayala recalled, “was, ‘We'll see who comes out skinnier.’”

He said his brother was 39 when he died on Sept. 22, 2025.

CHIRLA alleges in court documents that staff at Adelanto were aware Ayala-Uribe was having a potentially life-threatening medical emergency three days before his death, but he was taken back to his cell after being seen by the facility’s medical team.

An ICE news release said Ayala-Uribe “was evaluated by an on-call medical provider Sept. 18, provided medication, and returned to his dormitory,” but did not mention the severity of his condition.

The cause of both deaths remain under investigation, CHIRLA said in an accompanying news release.

The second deadly shooting of a U.S. citizen by federal immigration officers in Minneapolis is raising the prospect of a partial government shutdown at the end of the week.

Senate Democrats say they will not vote to fund the Department of Homeland Security without new guardrails for immigration enforcement.

But that opposition may also torpedo the larger $1.3 trillion spending package needed to keep large swaths of the federal government operational past Friday night.

"The appalling murders of Renee Good and Alex Pretti on the streets of Minneapolis must lead Republicans to join Democrats in overhauling ICE and CBP to protect the public," Senate Minority Leader Chuck Schumer, D-N.Y., wrote on Sunday. "People should be safe from abuse by their own government."

Democrats were already raising alarms about the conduct of immigration officers before the latest killing in Minneapolis on Saturday.

Last week, all but seven House Democrats voted against the funding bill covering homeland security, which includes money for Immigration and Customs Enforcement and Customs and Border Protection.

At the time, a few Senate Democrats also pledged to vote against the funding when it reached them this week, though the response across the Capitol was far from the near-unified opposition in the House.

That is because the House sent the DHS funding over to the Senate tied together with billions in spending for defense, health, transportation and other federal agencies, in part to expedite the process as Congress races to meet a Friday deadline to keep the government fully open.

"The hard truth is that Democrats must win political power to enact the kind of accountability we need," Sen. Patty Murray, D-Wash., the top Democrat on the Senate appropriations committee, wrote in a statement last week saying she would vote for the total package.

After Pretti's shooting on Saturday by a Border Patrol agent, Murray said she would join her Democratic colleagues in opposing the funding.

Congress faces Friday deadline to avert a partial shutdown

The timeline was already tight once a winter storm delayed the first Senate votes of the week until Tuesday night. But the renewed debate over immigration enforcement is complicating the task more.

Schumer wants to cleave the DHS measure from everything else. The other remaining spending measures have overwhelming bipartisan support. Democrats want to continue negotiating the DHS funding bill without shutting down large parts of the government.

The funding measure needs to reach a 60-vote threshold to pass, meaning some Democratic support is needed for it to clear the Senate. But disentangling different parts of the legislation requires buy-in from Republicans, and so far, GOP leadership has not indicated that they are willing to separate the funding bills.

Flowers, signs and mementos are seen Monday at a makeshift memorial in the area where Alex Pretti was shot dead by federal immigration agents in Minneapolis. On January 24, federal agents shot and killed Pretti, a 37-year-old ICU nurse, while scuffling with him on an icy roadway.

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Senate Majority Leader John Thune's communications director, Ryan Wrasse, wrote on X on Monday that the Senate will proceed as planned to consider all the funding bills together.

"A government shutdown, even a partial one, does not serve the American people well," he wrote. "Hopefully Senate Democrats, who are actively engaged in conversations, can find a path forward to join us before this week's funding deadline hits."

Sen. Susan Collins, R-Maine, the appropriations committee chair, told The New York Times over the weekend, "I'm exploring all options. We have five other bills that are really vital, and I'm relatively confident they would pass."

Collins, who is up for reelection and whose state is also a target of immigration raids by the Trump administration, is among the Republicans who have expressed fresh concerns about the tactics, calling for an investigation.

A handful of Republicans have called for congressional hearings or offered sharper criticism.

"My support for funding ICE remains the same," Sen. Pete Ricketts, R-Neb., wrote in a statement. "But we must also maintain our core values as a nation, including the right to protest and assemble."

Even if Democrats could convince Republicans to agree to separate DHS funding from the rest, that would mean the legislation needs approval again in the House, which is on recess until Feb. 2. It is unlikely that House Speaker Mike Johnson, R-La., would call members back to Washington early, increasing the risk of a partial shutdown.

Why Democrats are willing to risk another shutdown

Before this weekend, few lawmakers expressed appetite for another shutdown after a record 43-day one this fall. For weeks, Democrats withheld their votes from a short-term funding measure to reopen the government without a deal to extend expiring health insurance subsidies.

Eventually, a handful of Democrats joined with Republicans to reopen the government, with the promise of a vote on the subsidies. That vote failed in December. The deal included the passage of three bipartisan spending packages for veterans, agriculture and other areas through the end of September 2026 and a short-term extension for everything else through Jan. 30.

Congress has already passed several more full-year funding bills through September, but the measures still awaiting final passage in the Senate account for 75% of annual federal discretionary spending.

But even Democrats who ultimately voted with Republicans to end the last funding stalemate now say they will vote against the DHS funding despite the risk of another shutdown.

"We have bipartisan agreement on 96% of the budget," Sen. Catherine Cortez-Masto, D-Nev., wrote in a statement. "We've already passed six funding bills. Let's pass the remaining five bipartisan bills and fund essential agencies while we continue to fight for a Department of Homeland Security that respects Americans' constitutional rights and preserves federal law enforcement's essential role to keep us safe."

Federal agents look on as demonstrators gather near the site of where Alex Pretti was fatally shot by.

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Holding up the DHS funding bill would not halt the administration's immigration crackdown. Last summer, Congressional Republicans allocated $75 billion for ICE over four years in President Donald Trump's "One Big Beautiful Bill."

Democrats say they do not want to give ICE the roughly $10 billion base funding that is on the line now. But more so, Democrats see this as rare leverage in the minority to extract policy changes.

Democrats already negotiated to include $20 million in funding for officer-worn body cameras, plus more funding for oversight and a reduction in funding for enforcement and removal operations and detention bed capacity. But most Democrats said this did not go far enough.

Democrats want more sweeping reforms to reign in the tactics, such as prohibiting ICE from deploying excessive force and explicitly preventing them from raiding places of worship, hospitals and schools. Republicans previously rejected these demands.

The DHS funding bill also includes funding for the Transportation Security Administration, the U.S. Coast Guard and the Federal Emergency Management Agency.

But Democrats are betting that the American public is on their side. A recent New York Times poll found that a majority of respondents said the federal immigration tactics have gone too far.

Nearly $1.3 trillion in federal funding is at stake

The funding fight over DHS is the latest dispute over funding in Congress. Last year, the Trump administration moved to rescind billions in federal funding appropriated by Congress for foreign aid and public broadcasting — and proposed a budget slashing nondiscretionary funding by some 20%.

Instead, the final legislation keeps federal nondiscretionary spending essentially flat. For example, the administration called for cutting the Centers for Disease Control and Prevention budget by 50%. Under the bipartisan health spending bill, the agency's funding would remain roughly unchanged.

Bill Hoagland, senior vice president of the Bipartisan Policy Center and a former longtime appropriations committee staffer, said this is striking considering Congress has mostly followed Trump's lead.

"Congress is starting to show a little bit of backbone," Hoagland said. "I think there is increasing recognition of the need to have Congress exert its power of the purse."

Hoagland also notes that Congress is nearly a quarter of the way into the fiscal year, so once lawmakers greenlight the remaining funding, it will not be too long before the appropriations process begins again.
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