MMN Editor

With more than $14 trillion in assets under management, BlackRock is the largest asset manager in the world. Passive strategies make up about two-thirds of those assets. In particular, the firm’s well-known iShares exchange-traded funds are low-cost solutions for both advisors and individual investors building well-diversified portfolios. Morningstar’s list of the best iShares ETFs to buy and hold for US equity exposure features top-rated passive funds that we expect to outperform their competitors over a full market cycle. Investors can confidently buy and hold these funds in a long-term portfolio.The 21 Best iShares ETFs to Buy that Invest in US StocksTo find the best iShares ETFs to buy that focus on US stocks, we screened for those earning a Morningstar Medalist Rating of Silver or Gold with 100% analyst coverage. All the ETFs on the list fall into Morningstar’s US equity category group and practice passive strategies. All data is as of March 13, 2026.iShares Core S&P 500 ETF IVViShares Core S&P Mid-Cap ETF IJHiShares Core S&P Small-Cap ETF IJRiShares Core S&P Total US Stock Market ETF ITOTiShares Core S&P US Growth ETF IUSGiShares Core S&P US Value ETF IUSViShares ESG Aware MSCI USA ETF ESGUiShares ESG Aware MSCI USA Small-Cap ETF ESMLiShares ESG MSCI USA Leaders ETF SUSLiShares MSCI USA Min Vol Factor ETF USMViShares MSCI USA Momentum Factor ETF MTUMiShares MSCI USA Quality Factor ETF QUALiShares MSCI USA Value Factor ETF VLUEiShares Russell 1000 ETF IWBiShares Russell 1000 Growth ETF IWFiShares Russell 1000 Value ETF IWDiShares Russell 3000 ETF IWViShares Russell Mid-Cap ETF IWRiShares S&P 500 Growth ETF IVWiShares S&P 500 Value ETF IVEiShares S&P Mid-Cap 400 Growth ETF IJKMorningstar expects the highly rated US equity iShares ETFs on this list to outperform their peers over a full market cycle. But even though all the funds on our list invest in US stocks, they practice different strategies and therefore behave differently from each other. Investors need to do some homework to understand exactly what a particular ETF invests in before buying.Here’s a quick look at the two Gold-rated picks from the list of the best iShares US equity ETFs. Be sure to review a fund’s complete report for more details.iShares Core S&P 500 ETFMorningstar Category: US Fund Large BlendMorningstar Medalist Rating: GoldIShares Core S&P 500 ETF provides exposure to US large-cap stocks at a low cost. The ETF replicates the S&P 500, which is a market-cap-weighted index of 500 of the largest US stocks that are chosen by an index committee based on liquidity and profitability standards. Management has done a good job of tracking its index, using derivatives to manage its cash, and employing securities lending to generate additional income to help keep the ETF’s expense ratio low.IShares S&P 500 accurately represents the large-cap US stock market, allowing its low fee and efficient portfolio to carve out a long-term edge.The fund tracks the S&P 500. A committee selects 500 of the largest US stocks, or roughly 80% of the US stock market, and weights them by the market cap. The index committee has discretion over selecting companies that meet its liquidity and profitability standards. While a committee-based approach may lack clarity, it adds flexibility to reduce unnecessary changes during reconstitution, taming transaction costs compared with more rigid rules-based indexes.Assigning position sizes based on a stock’s market cap is a simple and efficient method to weight the portfolio. Since US stocks are highly traded, they quickly reflect new information, and carving an edge is difficult. Market-cap weighting naturally adjusts to price changes without frequent rebalancing, generating lower trading costs. That, and lower fees, give large-blend index funds a long-term performance advantage over most actively managed peers.The fund holds a broad, well-diversified portfolio. It typically includes around 500 stocks, and the top 10 represented around 40% of the portfolio at year-end 2025. Still, market-cap weighting can contribute to portfolio concentration when a few stocks dominate the market. This has been the case lately with a handful of mega-cap technology stocks growing to prominence and commanding a greater share of the portfolio.When a few richly valued companies or sectors power most of the market gains, market-cap weighting may overexpose the strategy to the fluctuations of one stock or sector. But this is not a fault in design, as it simply reflects the market’s composition. Its low turnover, low fee, and broad diversification across the US market more than offset these risks.The US exchange-traded fund returned 14.8% annualized over the past 10 years through year-end 2025. It holds little cash, which should help it outperform cash-saddled active peers during market rallies. Likewise, low cash drag could hurt this fund when the stock market declines, but long-term positive returns give this efficient approach a clear edge. Performance across share classes will vary on account of differences in fees and currency exchange rates for non-US investors.Brendan McCann, associate analystRead Morningstar’s full report on the iShares Core S&P 500 ETF.iShares Core S&P Total US Stock Market ETFMorningstar Category: US Fund Large BlendMorningstar Medalist Rating: GoldThis iShares ETF to buy and hold in 2026 offers exposure to the entire investable US stock market. It tracks the S&P Total Market Index, which includes all US-domiciled stocks that trade on a major US exchange and pass S&P’s minimum liquidity threshold. Although iShares Core S&P Total US Stock Market ETF lands in the large-blend Morningstar Category, it provides exposure to small and mid-size companies. That being said, the largest stocks in the US make up the bulk of this ETF’s portfolio due to the index’s market-cap weighting.IShares Core S&P Total Market accurately represents the US stock market, allowing its low fee and efficient portfolio to carve out a long-term edge.The fund tracks the S&P Total Market Index, which selects all investable US stocks and weights them by market cap. As a result, the index experiences little turnover because of the minuscule average size of additions or deletions to the existing portfolio. The fund holds a representative basket of stocks within the index, which further reduces unnecessary trading costs.Assigning position sizes based on a stock’s market cap is a simple and efficient method to weight the portfolio. Since US stocks are highly traded, they quickly reflect new information, and carving an edge is difficult. Market-cap weighting naturally adjusts to price changes without frequent rebalancing, lowering trading costs. That, and lower fees, give large-blend index funds a long-term performance advantage over most actively managed peers.The portfolio is broad and well-diversified. It typically holds around 2,500 stocks, and the top 10 represented 34% of the portfolio as of January 2026. Still, market-cap weighting can contribute to portfolio concentration when a few stocks dominate the market. This has been the case lately with a handful of mega-cap technology stocks growing to prominence and commanding a greater share of the portfolio.When a few richly valued companies or sectors power most of the market’s gains, market-cap weighting may overexpose the strategy to the fluctuations of one stock or sector. But this is not a fault in design, as it simply reflects the market’s composition. Its low turnover, low fee, and broad diversification across the US market more than offset these risks.The US exchange-traded fund share class returned 15.1% annualized over the past 10 years through January 2026. It holds little cash, which should help it outperform cash-saddled active peers during market rallies. Likewise, low cash drag could hurt this fund when the stock market declines, but long-term positive results for the US market have given this efficient approach an edge. Performance across share classes will vary owing to differences in fees and currency exchange rates for non-US investors.Brendan McCann, associate analystRead Morningstar’s full report on the iShares Core S&P Total US Stock Market ETF.What Are US Equity Funds?US equity funds exclusively invest in US stocks. These portfolios do not focus on a particular equity sector. Instead, they may target a particular market cap or equity style, such as value or growth. This group contains the following categories:Large blendLarge growthLarge valueLeveraged net longMid-cap blendMid-cap growthMid-cap valueSmall blendSmall growthSmall valueHow to Find More of the Best ETFs to Buy for the Long TermGiven their high Morningstar Medalist Ratings, we expect the top-rated funds on our list to outperform over a full market cycle. That being said, investors may want to expand their search beyond this list, using parameters that matter to them. Here are more ways to find more ETFs and mutual funds:Use the Morningstar Investor screener to create your own list of funds to investigate further.Explore Morningstar Medalist funds on our Best Investments page.Read our latest ETF insights and analysis on Morningstar.com.

As Russia’s invasion of Ukraine moves into its second year, Peter and Eric welcome to The Drill Down the author Rebekah Koffler, a Russian-born U.S. intelligence expert who served as a Russian strategy specialist in the Defense Intelligence Agency and with the CIA’s National Clandestine Service to analyze the war’s likely outcome and ask questions about the Biden administration’s strategy for helping the Ukrainians.

The environmental catastrophe in East Palestine, Ohio had many causes. Government incompetence and neglect played a role, as did both excessive regulation and deregulation under different administrations. Corporate “efficiencies” as well as domestic politics created the conditions that caused a terrible accident. The response was to prevent one type of disaster by creating another type of disaster.

On this episode of The Drill Down, Eric Eggers takes over the pilot’s seat and welcomes Seamus Bruner, director of research here at the Government Accountability Institute. Seamus is an investigative journalist and the author of two books on corruption within the FBI and other parts of the federal government and has been one of GAI’s biggest investigative stars since our founding in 2012. His third book, “Controligarchs,” will hit stores soon. Seamus joins the podcast today to talk about his research on Chinese government money flowing to the “Biden Center” at the University of Pennsylvania and elsewhere.

There’s a huge balloon floating over the nation. Everyone wants it gone, and we all worry what it might do to us.It’s the national debt, currently about $30 trillion dollars. Your hosts Peter Schweizer and Eric Eggers tackle ways Congress might start to reduce the federal debt, much of which is the fault of spending on programs such as Medicare and Social Security, on the Drill Down with Peter Schweizer.”

When Peter and Eric open this week’s show by talking about balloons and popcorn, you might be imagining wide-eyed little children at the county fair, not a sneaky communist regime committing economic and military espionage on America. But that’s what popcorn and balloons mean here at The Drill Down with Peter Schweizer.Of course, the big story of the past week was Communist Chinese government’s spy balloon that floated across the US through Montana and 10 other states before being shot down by a missile fired by an F-22 fighter jet off the coast of Myrtle Beach, SC. Not since 1957, when the Soviet Union launched Sputnik, the first satellite shot into Earth’s orbit, has a foreign government’s flight activity so captured attention and rattled so many Americans.

The chain of investigations into the illegal investment scheme MBI International has continued to rattle Malaysia’s capital market,

by Ashley Hiruko, KUOW

This article was produced for ProPublica’s Local Reporting Network in partnership with KUOW public radio. Sign up for Dispatches to get our stories in your inbox every week.

When Brenna Poppe moved into the Civic Hotel off the damp streets of Seattle in late 2022, she cried with joy. During her next year at the city-sponsored homeless shelter, she’d meet other guests who felt the same way — overwhelmed by the sudden realization that tonight, they would not sleep outside.

The Civic got quieter last year, however. Rooms around her, their doors still painted bright yellow from when the hotel was a boutique property, started to empty out. A “deafening silence” crept in, she recalled.

The 53-room hotel was converted to a shelter in the early days of the pandemic, and the city of Seattle kept it going. After Poppe’s first year there, the city in February 2024 signed a $2.7 million lease extension to continue using rooms at the Civic and other buildings as shelter space through the end of the year. And yet, despite committing to pay the rent, the city stopped sending people there.

Existing residents moved on to permanent housing or elsewhere and no one took their place. Dozens of rooms went unfilled.

By December, Seattle taxpayers were paying a hefty $4,200 a month per empty room — at a time when thousands of Seattleites were without a roof over their heads.

City officials described their decision to leave the rooms vacant as simply a “pause” while they evaluated what to do about an anticipated budget deficit.

One-time federal funding was going away and, if the city eventually succeeded in securing long-term funding, officials wanted to find a cheaper location than the Civic. They said the uncertainty forced them to both hold onto the Civic and stop placing people there, to avoid later sending clients back to the street.

But internal records reveal more complicated motives. At the same time as the city was halting placements, it rejected a move to a cheaper shelter location, which the main advocate of the plan said would keep the program running without interruption. A top official in the office of Mayor Bruce Harrell, explaining the decision in private, voiced animosity toward the nonprofit leader who pitched the new location and signaled an end to city support for the leader’s program.

Regardless of the rationale, the outcome of the city’s decision was that for nearly a year, Seattle paid for just as many rooms as before yet helped fewer and fewer people off the street with them.

Seattle Mayor Bruce Harrell, whose plan to address homelessness promised to “better track shelter capacity and ensure beds do not go unfilled.”

(Megan Farmer/KUOW)

Placements resumed this year, in a new location, after a 16-month gap.

Many West Coast cities are struggling, as Seattle has, with a rise in homelessness in recent years. Before referrals were halted, the effort that placed people at the Civic had already moved hard-to-reach homeless people from the street to a shelter space and, in many cases, then on to long-term housing and stability.

Seattle’s decision to keep dollars flowing to an effort it had suspended comes as cities such as Los Angeles are facing criticism for failing to accurately track outcomes of their massive outlays on homelessness.

Allowing vacancies to grow at city-leased shelter space also seems to be at odds with a commitment by Harrell, whose 2022 plan to address homelessness promised efforts to “better track shelter capacity and ensure beds do not go unfilled.”

(A spokesperson for Harrell responded that it’s important to note city-funded shelters had 2,850 units in all last year, 87% of which were full on any given night. The city declined a request to interview Harrell.)

Poppe, who lived at the Civic through 2024, viewed its empty rooms as a squandered opportunity, and she told the shelter staff as much.

“Multiple times,” Poppe said, “I spoke to staff about this egregious amount of open rooms.”

After Initial Ramp-Up, Occupancy in City-Funded Rooms Plummets

Notes: Data unavailable for June 2024. “City-funded rooms” are defined as rooms reserved for the city of Seattle. Each bar represents a count taken on one day of the month.

(Source: CoLEAD, a nonprofit-led program that partnered with Seattle to fill city-funded rooms as shelter space)

The Blade
On any given day in a section of Third Avenue between Pike and Pine streets known as The Blade, disorder is commonplace. Some people are screaming at the air, their pants falling off their frail frames. Others are sleeping, huddled in doorways to keep warm and safe. This human suffering stands in contrast with neighboring symbols of Seattle’s affluence: Pike Place Market, Benaroya Hall and the downtown shopping district are within a five-minute stroll.

A walk-up-only McDonald’s on the corner has been dubbed “McStabby’s,” referencing violent crimes that have taken place nearby over the years.

In 2022, nonprofits and downtown businesses came up with a plan that would ultimately involve the Civic Hotel.

The Third Avenue Project was designed to reduce the violence and open drug use through extensive outreach and the deescalation of conflicts between people on the street. But housing was also on the minds of the organizers.

Many believed in a modified version of the “housing-first” approach, which is predicated on the idea that any issues people struggle with on the streets are best addressed if they first find shelter, with no requirements for sobriety. Despite Seattle’s shortage of shelter beds and affordable permanent housing, the nonprofit leaders involved with Third Avenue hoped to help at least some clients move indoors.

The concept seemed to line up with the priorities of Harrell, who on his campaign website the year before had promised “an accountable, ambitious plan with transparency and benchmarks to expand and provide housing and services on demand to every unsheltered neighbor.”

Third Avenue Project organizers got to work after Harrell took office, with significant funding from the city.

“Safety ambassadors” were the first step. They would reverse overdoses and intervene when scuffles broke out, but also develop relationships with people in the street and then connect them with shelter and services.

“The hardest thing that we do is seeing people in the dire straits that they live in daily,” said Stephenie Wheeler-Smith, CEO of the company that hires the ambassadors, We Deliver Care. “This is not easy work. People don’t want to come out and touch these people or look at them or see their wounds or help them get health care.”

Safety ambassadors Trey Kendall, left, and Dee Stokes hand out water and snacks in July in Seattle’s Chinatown-International District.

(Megan Farmer/KUOW)

Importantly, safety ambassadors wouldn’t just move people along. They also could be a first point of contact on a path to permanent housing.

As one element of their $2.1 million contract with the city, the safety ambassadors referred homeless people on Third Avenue to housing and emergency shelter providers. The main one they’d use was a nonprofit-led program called CoLEAD, which had a $4.6 million contract with the city in 2023 that included placing people in temporary lodging and providing support services they needed.

The next step was the Civic Hotel. City officials signed a $1.1 million six-month lease with the Civic’s owners for its 53 guest rooms. CoLEAD would also let Third Avenue clients use rooms in any of the other shelters it managed, and at the same time the program would send clients from other referral sources to the Civic.

Unlike with some other shelters, these clients did not have to stop using drugs or alcohol, and they had access to their own space, which was ideal for people who may have struggled at traditional shelters.

The plan got results.

By November 2023, city-funded rooms at the Civic and other buildings were packed.

Marco Brydolf-Horwitz, who studied CoLEAD for nearly two years as part of a doctoral program, said he saw people transformed by the stability of temporary lodging.

“You can’t do much when people are on the street,” he said. “Once people are inside, then you can figure out what level of housing resources are needed.”

People shelter themselves along Third Avenue.

(Megan Farmer/KUOW)

The Halt
For all the success stories, the problem with the Civic was cost. The county had snapped it up as a temporary measure during the frenzy of the pandemic, and the city inherited it. After the initial lease, rent had risen to the equivalent of $2.6 million a year in 2023.

On Jan. 2, 2024, Lisa Daugaard, one of the nonprofit leaders managing the Third Avenue Project, pitched the city on a cheaper alternative: an apartment building in North Seattle with 11 more rooms the city could use for $1 million less.

The city’s obligations with the Civic had ended when its lease expired the month before. Daugaard could get the city’s clients moved by February. Daugaard simply needed some assurance the city would keep backing the project because she was considering a three-year lease on the new location.

Internal chat messages between Chief Deputy Mayor Tiffany Washington and other staff in the mayor’s office. “DM Burgess” is Deputy Mayor Tim Burgess, who did not respond to a request for comment from KUOW and ProPublica.

(Obtained by KUOW)

A few weeks later, Daugaard had her answer: Stop placing Third Avenue clients in city-funded beds, cycle existing ones into permanent housing and “ramp down” the Civic Hotel shelter. It was couched as a “pause” in placements through CoLEAD, records show.

In emails to Daugaard — and, in at least one case, internally — city officials cited uncertainty created by a looming budget deficit as one of the main reasons for the new marching orders. They reiterated this explanation, along with an expected loss in one-time funding, in interviews and emails with KUOW and ProPublica.

The mayor’s press secretary, Callie Craighead, said the city was “committed to maintaining shelter investments” but had “no way to provide such confirmation” to Daugaard until the city developed its next budget. She said the North Seattle apartment building was also not move-in ready at the time. Extending the lease at the Civic was a stopgap to avoid sending clients back to homelessness.

Chief Deputy Mayor Tiffany Washington described the halt in referrals as a way of “winding down” operations at the Civic in anticipation of a move to a new spot, a “best practice” among social services managers.

But a chat message from Washington to a colleague, released to KUOW and ProPublica last week through a public records request, spells out additional reasons for turning down Daugaard’s proposal. It says, in part: “because I want her out of the homelessness business. She is not good at it.”

Washington stated in the message, incorrectly, that the proposed North Seattle location was another hotel, “which is not cheap” and concluded, “This means we would be leasing hotels forever.”

She also asserted that CoLEAD had a high rate of returns to homelessness and a low rate of placements in permanent housing.

Data provided by the mayor’s office and the King County Regional Homelessness Authority shows otherwise. The year before, CoLEAD moved a far bigger share of its clients from its city-funded beds into permanent housing than emergency shelter operators as a whole: 65%, compared with 26%.

Contacted by KUOW and ProPublica last week, Washington said she’d known Daugaard for 10 years and that “I have nothing but respect for her work.” She said of her chat message about ending CoLEAD’s role in the city’s response to homelessness: “Discussions are different than decisions.” She noted that the city’s relationship with CoLEAD continues today.

Daugaard declined to comment on Washington’s private message naming her. The nonprofit that employs Daugaard and oversees CoLEAD issued a statement defending the program’s track record at placing people in permanent housing as “exceptional.”

The mayor’s proposed budget for next year supports programs that follow CoLEAD’s approach, the statement said, “and we greatly appreciate that, in the end, the City has backed this model which has proven to serve the interests of Seattle neighborhoods and chronically unsheltered individuals alike.”

As of February 2024, the North Seattle plan was formally off the table. The city extended its lease with the Civic.

Officials committed to spending $225,000 a month for 53 rooms through year’s end — despite having just told nonprofit shelter managers to ensure those rooms emptied out.

The Fallout
The disruption to the flow of clients off Third Avenue and into the city-funded rooms gradually became noticeable.

The kind of shelter that the Civic Hotel provided — individual rooms that came with services such as help in accessing health care — is a valuable resource, especially when it comes to people who may be struggling with mental illness or addiction, like many of those on Third Avenue. Traditional shelters lack privacy and personal space.

A typical guest room in the Civic Hotel, first image, and the building’s lobby area, pictured in 2019.

(Civic Hotel via TripAdvisor)

With the ending of placements at the Civic and city-funded rooms in other CoLEAD shelters, safety ambassadors who were paid to quell the violence on Third Avenue turned to other shelter organizations. But it wasn’t enough to fully offset the loss of CoLEAD’s buildings.

KUOW and ProPublica examined data from We Deliver Care for placements to organizations that provide shelter or housing, including the nonprofit that operates CoLEAD. The number went from 47 in 2023 to 30 in 2024.

Meanwhile, 35 rooms at the Civic and other shelters that CoLEAD managed sat empty as of December 2024.

Among the people who would have said yes to one of the rooms the city had left unused was Tiffany Fields, who at the time was struggling to stay safe outdoors.

“It ain’t no joke,” Fields said of life on the street. “It’s not fun. It’s not for play.”

Fields slept at downtown bus stops, often gathering with groups or pretending to have a firearm in her coat to stay safe. She spoke to herself out loud when she felt at risk in the hopes that feigning mental illness would ward others off.

“I’ve seen a lot of weird things,” Fields said. “They tend to prey on women by themselves, but I know how to hold my own.”

A 2023 University of Washington study of the Third Avenue Project found that of the 980 people contacted by We Deliver Care’s safety ambassadors through October 2023, 90% were unhoused.

“From a human perspective, people want to be inside and they want to be sheltered,” said Wheeler-Smith, leader of the outreach efforts to connect people on Third Avenue with services. “And unfortunately, we don’t have a lot of places to send people to be sheltered, period.”

Daugaard, whose group works alongside Wheeler-Smith’s safety ambassadors, said it was demoralizing for the outreach workers to keep talking to people on Third Avenue about their struggles with limited chances to fundamentally change the path they’re on.

Losing the rooms that the Civic provided meant that “all they’re doing is kind of keeping a lid on the level of disorder and its impact on other people,” Daugaard said.

(The University of Washington report, based on time spent on the street with the safety ambassadors, described reversed overdoses and defused conflicts.)

The kind of shelter that the Civic Hotel provided — individual rooms with supportive services such as help with healthcare and job training — is a hot commodity, especially when it comes to people who may be struggling with mental illness or addiction, like many of those on Third Avenue.

(Megan Farmer/KUOW)

Of the estimated 5,000 shelter beds available in Seattle’s city limits and on nearby Vashon Island during early 2024, only 3% were free, according to an annual point-in-time count. Another 4,600 people lived without shelter at the time.

Rachel Fyall, associate professor at the University of Washington Evans School of Public Policy & Governance, said the cost of not housing people includes emergency room care, jail cells and police on the street.

“Philosophically,” Fyall said, “any room that is unused is too many rooms.”

But when organizers know a shelter is likely to close soon, does it then make sense to leave rooms unused so newcomers won’t have to relocate shortly after they arrive?

Noah Fay, senior director of housing programs at another nonprofit that runs homeless shelters, said the desire to avoid disruptions for residents has to be balanced against the desire to keep beds full when unmet demand in Seattle is enormous.

He said his organization recently prepared for a shelter shutdown by halting referrals two months ahead of time. The city did so 11 months before its lease ended.

A crowd of people gathers in Seattle’s Little Saigon neighborhood in March.

(Megan Farmer/KUOW)

“Pause” Lifted
In July, Fields was strolling through the Third Avenue area.

A safety ambassador called out to her and said Fields’ caseworker had been looking for her. The caseworker had good news. She was getting shelter.

“I said, ‘Are you kidding?’” Fields recalled. “‘Please tell me it’s not a sick joke.’”

The city had recently ended the “pause” on placing CoLEAD clients in temporary shelters.

The new venue was the North Seattle apartment building Daugaard had proposed more than a year earlier. The nonprofit running CoLEAD named it the Turina James.

Washington told KUOW and ProPublica CoLEAD had “significantly improved” its record of moving people to permanent housing since the pause, proving it was a good decision. (Data show CoLEAD’s success rate with city-funded clients declined from 65% in 2023 to 56% last year, while its success for all clients improved marginally, from 69% in 2023 to 71% last year. The city did not address the apparent discrepancy.)

Tiffany Fields

(Illustration by Shoshana Gordon/ProPublica. Source image: courtesy of Tiffany Fields.)

Fields’ intake was done over the phone, and an Uber was sent to pick her up and take her to her new temporary home. When she arrived, she said, she was welcomed with open arms. She was given gifts and a key.

“God, he works in mysterious ways,” Fields said. “Sometimes when you call on him, he may not come right then and there, but when he does come, when he does show up, he shows out.”

Fields said she’s felt much more stable since making it indoors.

“I’m happy. I’m in a very, very, very good place,” Fields said. “So I can, you know, get my life back on track, get my life back in order.”

Others on Third Avenue are still waiting for housing. But the paths available to them look much different now, even with referrals resuming, than they did in 2022 and 2023. When making placements at the Turina James, unlike at the Civic and other CoLEAD shelters, the city is no longer emphasizing Third Avenue clients but instead people from Seattle’s Chinatown-International District.

Brenna Poppe, the woman who lived in the Civic as it emptied out, was still sleeping indoors as of July. She was staying at the North Seattle property, still thankful to have a roof over her head.

Around her, the rooms were starting to fill up.

by Duaa Eldeib

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

When a health insurance company refuses to pay for treatment, most people begrudgingly accept the decision.

Few patients appeal; some don’t trust the insurer to reverse its own decision.

But a little-known process that requires insurers and plans to seek an independent opinion outside their walls can force insurers to pay for what can be lifesaving treatment. External reviews are one of the industry’s best-kept secrets, and only a tiny fraction of those eligible actually use them.

ProPublica recently reported the story of a North Carolina couple, Teressa Sutton-Schulman and her husband, who we identified in the story by his middle initial, L, to protect his privacy. Last year, L suffered escalating mental health issues and needed intensive psychiatric care. Highmark Blue Cross Blue Shield issued the couple multiple denials in their case, even after Sutton-Schulman’s husband attempted suicide twice in the span of 11 days.

The instructions for an external review were buried on page seven of one of the denial letters.

“You can now request that your case be reviewed by a health care provider who is totally independent of your health plan or insurance carrier,” read the letter from the state insurance department in Texas, where the treatment occurred.

Skeptical but hopeful, Sutton-Schulman submitted the request for the external review. Their case was assigned to Dr. Neal Goldenberg, an Ohio doctor who works for a third-party review company as a side job. After reading the extensive appeal, Goldenberg overturned Highmark’s denial to cover treatment that had cost Sutton-Schulman and L more than $70,000.

Highmark previously said in a statement that the company was “passionate about providing appropriate and timely care” to its members. It acknowledged that “small errors made by physicians and/or members can lead to delays and initial denials” but said that those are corrected on appeals.

The lesson is simple, explained Kaye Pestaina, a vice president at the nonprofit health policy think tank KFF, who has studied external appeals.

“Appeal, appeal, appeal, appeal,” she said. “That’s all you have.”

External appeals have been around for decades at the state level, but in 2010, the Affordable Care Act expanded access to the reviews for the majority of people who get their health insurance through work. The details around the external review process vary depending on whether an insurance plan is regulated by state or federal laws.

Karen Pollitz helped draft the federal regulations around external reviews during the Obama administration, but she said an extensive lobbying effort on behalf of insurance companies and employers weakened the initial protections. Now, only a fraction of denials are eligible for an external review, and the health insurance plan gets to hire the reviewers.

Transparency requirements that called for insurers to report data around denials and other metrics, she said, also were largely not implemented.

“There are all kinds of ways they could strengthen the laws and the regulations to hold health plans more accountable,” said Pollitz, who left the administration after the rollbacks and worked at KFF before retiring.

But for now, Pollitz said, filing external appeals is sometimes the only recourse patients have. An advantage of the Affordable Care Act, she added, was that it established state consumer assistance programs to help people get the coverage they were promised.

Federal funding for those programs dried up a couple of years later, but about 30 states decided to find other ways to pay for the programs. (Want to find out if your state has one? Here’s a list from federal officials.) If the remaining 20 or so states — including Wisconsin and Ohio — established programs, families would reap the benefits, according to Cheryl Fish-Parcham, director of private coverage at the consumer health care advocacy organization Families USA.

“Every state needs one of these programs,” she said. “Health care is so complicated, and people really need experts to turn to.”

Fish-Parcham meets with representatives from consumer assistance programs across the country every month. The models differ from state to state. Programs are housed in state attorney general offices, in nonprofits and even as independent agencies. Helping patients or their providers with external appeals is a key part of the programs’ role. The first step often is simply letting them know that appeals — both internal and external — are options.

“The numbers are low because some people just give up. They’re frustrated. They’re tired. They’re battling cancer,” said Kimberly Cammarata, director of Maryland’s Health Education and Advocacy Unit, the state’s consumer assistance program. “And sometimes the information about why the claim was denied or about how to appeal is terribly unclear. A lot of these outcome letters will say you have a right to an external appeal, but they don’t exactly tell you where to go.”

Some states have enacted legislation to combat that confusion. For example, insurers in Maryland are no longer able to bury information on appeals deep in their denial letters. Beginning this month, a new state law requires insurers to include information at the top of all denial letters in “prominent bold print” that states the member has the right to appeal or file a complaint to the insurance commissioner. That declaration advises consumers that the letter contains information on how to file an appeal and reach the Health Education and Advocacy Unit. The unit’s address, phone number, fax and email must also be included in the body of the notice.

Connecticut added similar information at the top of denial letters in a box on the front page in 2023. The office saw an almost immediate effect. In the two years that followed, more than 40% of referrals to the state’s Office of the Healthcare Advocate came from people who received denial letters with the new language.

The office isn’t funded through taxpayer money. It’s paid for entirely by state assessments on insurance companies.

“We want to help people,” said Kathleen Holt, who was nominated in 2024 by Connecticut’s governor to lead the office as the state health care advocate. “The insurance companies know that people don’t appeal, and in some ways I think they can be more aggressive with their denials. They don’t expect people to come back, and when they do that very small percentage of the time, it’s the cost of doing business for them.”

Connecticut’s data shows that the health care advocate office has been able to resolve or overturn denials in the patient’s favor about 80% of the time, Holt said. Some plans may charge up to $25 per external appeal, but Connecticut did away with that fee several years ago. Some states, including New York, have been tracking the outcomes of their external appeals online, which the public can review.

“We can help people write their appeals,” Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, said of New York residents. “We write appeals for them, sometimes going through thousands of pages of medical records and writing 15- to 20-page appeals.”

Experts say these six things can help patients and providers after a denial. Since we are journalists and not lawyers, we are unable to provide any legal advice about this process.

Gather your information: Experts suggest not throwing out any letters or notices from your insurer, including denial notices, explanation of benefits, correspondence and plan documents. If you’ve misplaced them, they said you can contact your insurer for additional copies. They also recommend downloading or requesting your medical records. You can request your claim file, which most people have a right to under federal regulations.
Does your state have a consumer assistance program? Not all states have consumer assistance programs. Here’s a list of those that do. Advocates recommend reaching out and asking them to explain the denial. It might be as simple as a missing or incorrect code. Their job is to use their time, experience and resources to explain the process. Their services are free. Other programs and nonprofits also offer assistance.
Why were you denied, and what are your timelines to appeal? Are you being denied because the insurer determined the treatment was not medically necessary or because your plan didn’t cover it? Does your plan follow federal or state regulations? Experts say these distinctions may determine if and how you appeal your denial. Most plans give you about 180 days from the date of the denial notice to appeal internally, but experts say not to wait. If you’re not sure about the answers to any of these questions, you can call your insurer and ask. They are required to provide you the reason for denial.
Can your health care provider help? Experts suggest reaching out to your doctor or therapist. They said some providers will file the appeal on your behalf. Others will write a letter of support. At the very least, advocates agree, most should help you understand why your treatment was denied and what additional steps you can take.
Filing an internal appeal: Before you can file an external appeal, you typically have to attempt to resolve the dispute internally with the insurance company. This step may involve one or two levels of internal appeals.
How to request an external appeal: This is your last shot before considering a lawsuit. After you’ve exhausted your internal appeals, you can contact your insurer to request an external appeal. When you file a request for a federal external review, your plan usually has five days to consider your request.

If the insurer agrees that your denial is eligible, it will provide directions on where to file the appeal. Experts say to make sure to read the notice all the way through.

Remember that only certain denials are eligible for external appeals. These denials typically involve medical judgment, surprise medical bills, or an insurer deciding to retroactively cancel coverage or determining that a treatment was experimental. Denials based on the terms of the plan or because the service was out of network generally are not eligible.

Under federal rules, third-party review companies typically have between 45 and 60 days to decide the outcome of an external review. You may ask for an expedited appeal if the situation is urgent. In those situations, you may also be eligible to request an external review without exhausting your internal appeals or even file both internal and external appeals at the same time. Federal requirements typically call for expedited external appeals to occur as quickly as your condition requires but not take longer than 72 hours.

If the external reviewer decides to overturn your denial, the determination is binding. Your insurer is required by law to accept the decision and pay for treatment. If the reviewer rules against you, you may be able to file a lawsuit.