NORRISTOWN, Pa. – What was intended to be a presentation recognizing Emergency Medical Services in Montgomery County became a plea for help from Ken Davidson, a paramedic and assistant chief of Second Alarmers Rescue Squad and president of the Montgomery Ambulance Association and vice-president of the Ambulance Association of Pennsylvania.

He told the commissioners that since his last appearance a year ago the 17 EMS services in the county had responded to over 97,000 calls. Davidson went on to say that there is an EMS crisis at the local, state and national level “due to two issues above all others – staffing and funding.”

He explained that staffing is a challenge because the work “is physically and emotionally challenging with a lack of sleep and consistent stress.” Davidson told the commissioners that since his appearance a year ago “things have gotten worse.” There are more and more times, he said, that his EMS company must downgrade from advanced life support to basic coverage or, worse, he noted, decrease the number of staff on a particular shift.

“The number of times you must rely on and provide mutual aid is at an all-time high,” Davidson commented. Response times are gradually increasing across Montgomery County.” He went on to explain, “It is a public safety issue affecting the care our citizens receive when they call 911.”

In most parts of the county, Davidson told the commissioners, responses are backed up eight deep, however, in the past the dispatchers rarely had to go beyond the second or third back-up. “There have been multiple instances in the past year, he commented, “when the system was out of resources and juggling had to occur because even the eight-deep unit was not available.”

Davidson continued, “This year I again ask for your help working with all 62 municipalities in the county to establish proper support and sustainable funding for EMS as an essential public safety service. We also need your help in engaging state officials with advancing legislation that would require insurance agencies to reimburse EMS agencies directly.” This is important, he explained, because when payment is made directly to the patient, they often do not know what the check is for and the EMS agency can have difficulty collecting what they are owed for the ambulance service.

“I hope when I stand before you the next EMS week, I can thank you not only for recognizing the work of our providers but also for helping to turn concern into action,” Davidson concluded.

Commission chair Jamila Winder suggested that the commissioners meet with Davidson to discuss how they can facilitate meetings with other elected officials to find more financial support. She also commented that for her EMS work is personal because for five years EMS staff helped her care for her bed-ridden parents.

Commissioner Thomas DiBello remarked that the state makes the laws and the townships provide the services, but the county sits in the middle of everything. He noted that when the current commissioners started their terms in 2024 a study was started on EMS services in Montgomery County, but he’s frustrated because he doesn’t know where the study stands. As county commissioner DiBello observed, they need to get more actively involved and push the recommendations that are in the study.

During the commissioner’s comments Winder recognized Leon Smith for being named National Teacher of the Year. Although Smith teaches in the Haverford School District in Delaware County, he is a Montgomery County resident, living in Upper Dublin. Also, commissioner Neil Makhija reported that in the election on Tuesday, 85,000 Montgomery County residents voted at the polls and 61,000 absentee ballots were received.

In the coming weeks, the federal audit of Medicaid programs across the country will enter its next steps to root out fraud following investigations in other states. But Pennsylvania’s leaders say that the commonwealth is already proactive when it comes to protecting programs from abuse.

“The Shapiro Administration takes fraud prevention extremely seriously, and we are proud of procedures we use to vet provider enrollment and monitor service provision on a regular basis — processes that the federal government has approved and that have helped Pennsylvania be recognized as a national leader in Medicaid fraud identification and prosecution,” Gov. Josh Shapiro’s office told the Capital-Star in a joint statement with the Department of Human Services.

A federal report from last year identified Pennsylvania’s Medicaid Fraud Control Unit under state Attorney General Dave Sunday as the top-ranking state for the number of criminal convictions and third overall for charges filed against those defrauding Medicaid. The commonwealth’s Office of State Inspector General reported earlier this month that it charged 310 people with public benefits fraud totaling more than $3 million in 2025.

State Secretary of the Department of Human Services Val Arkoosh said last week the state was committed to protecting Medicaid and food assistance benefits for eligible Pennsylvanians while combatting misuse. She spoke before a panel of state House Democrats in Philadelphia on Thursday.

“The phrase ‘fraud, waste and abuse’ is one we hear frequently now in public discourse. It is typically framed as an accusation of either social service program mismanagement or misuse by individual public benefit recipients, and there are suggestions that states are inattentive to these concerns,” Arkoosh continued. “These accusations bear absolutely no relationship to the reality of the work that the Pennsylvania Department of Human Services does every single day.”

Most fraud, she emphasized, came from providers, rather than enrolled individuals.

Inspector General Michelle Henry expanded, adding that combatting provider-specific fraud “is not a hypothetical concern.”

“These are healthcare providers who bill medicaid for services never rendered, vendors who misrepresent the nature of their work and contractors who falsify records to obtain government payments,” said Henry.

Long-discussed tools to prevent fraud get little traction

Letters from Centers for Medicare and Medicaid Services to the state shared with the Capital-Star show that the agency was particularly concerned about claims filed by “high-risk” providers, or those without a National Provider Identification (NPI) number.

Arkoosh revealed last week that the state will now require everyone to have an NPI within the next two or three years. Direct Care Workers employed with an agency traditionally used their employer’s number, rather than their own, meaning hundreds of thousands of people will need to register, she added as an example.

“We have to literally expand our system to accommodate that amount of volume. So we are acquiring and in the process of implementing new provider modules that will accommodate that amount of volume,” Arkoosh said. “We will really be able to have a close eye on this work.”

The nationally managed registry doesn’t require all Medicaid providers to have NPIs, though states can make that a rule. Arkoosh said newly added providers would need to register.

In regard to the timeline for full implementation, her agency alluded to staffing shortages in several healthcare fields.

“Many providers have indicated that it is costly to enroll in the Medicaid program, and that additional requirements could delay filling vacant spots and exacerbate ongoing workforce issues. This transition is occurring in a way that does not overwhelm providers and create access issues for recipients,” said a spokesperson.

The state “revalidates” — or checks — all providers every five years to meet federal requirements, but the federal government now calls for a “swift revalidation” in a tighter timeframe.

The state has talked for years about requiring NPIs or a state-level version, though a previous bill requiring it failed to muster support after its champion left office. Shapiro, when he previously served as state Attorney General, oversaw a grand jury that recommended such an anti-fraud measure and personally pushed for a “False Claims Act.”

Despite longstanding bipartisan support, the state hasn’t joined the 30 states with their own False Claims Act, which incentivizes whistleblowers to report fraud by offering a sliver of the recovered assets as a reward. Most programs explicitly focus on Medicaid, though some states like New York also have laws focused on tax compliance.

The state Senate version — which has both a Republican and Democrat sponsor — hasn’t yet had a committee hearing. The House bill, which only has Democrat sponsors, passed the chamber in July on a 136-67 vote over Republican opposition. It also hasn’t been heard in the Senate.

Henry, the state inspector general who previously worked with Shapiro at the attorney general’s office, said Pennsylvania was the largest state without such protection.

“(At the attorney general’s office), I saw firsthand what Pennsylvania lacks without a False Claims Act. The gap was not theoretical,” said Henry. “It was a recurring, frustrating constraint on what we could do for the people of Pennsylvania.”

Shapiro renewed his push for the bill in a February speech and a Republican senator quizzed Arkoosh about it in March, meaning it’s still at the forefront of some members’ minds, despite the lack of movement.

What it takes to combat fraud

Arkoosh said that individual applications are screened against 15 databases to check accuracy and screen for flags, looking at income, citizenship, residency, household composition, disability status and more every six to 12 months.

Names and information are compared to death records as well.

Of the 3.3 million applications or redeterminations, roughly 20,000 are forwarded to the Office of State Inspector General, typically. In the last year, the office pursued 674 cases worth $179 million.

Henry said that such a proactive relationship with vetting applications before paying out benefits was “unique” based on her discussions with other states’ leaders.

Courtesy of the Office of State Inspector General

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“I do think Pennsylvania is ahead of the game in a lot of ways,” she said. “The prevention piece is a really big component of that. A lot of states are looking at it, and it’s usually after the fact. After the benefits have gone out the door, after the taxpayer’s dollars have been lost.”

Providers are also compared to death records, though these investigations are referred to the attorney general’s office or other agencies, depending on the case.

Some workers in more flexible arrangements, such as those working in a Medicaid member’s home, must log their activities with Electronic Visit Verification — either by calling a number or using an app. In the fiscal year 2024-2025, the state identified 657 cases of fraud because of this requirement, recovering $584,000, according to Arkoosh.

“We are also exploring innovative practices like leveraging data analytics, predictive monitoring, and AI assistance to review billing patterns for anomalies or concerning trends, and additional attention is given to services that are historically frequently subjects of fraud,” a spokesperson for the Department of Human Services told the Capital-Star.

Arkoosh warned that 2027 would make the agency’s work more difficult, when the federal “One Big, Beautiful Bill Act” would take effect. Under the Trump-led effort, the 750,000 low- to middle-income Pennsylvanians covered under Medicaid “expansion” will need to submit paperwork every six months, rather than annually, and meet community engagement requirements.

“Adding this level of complexity onto these programs is only going to make them more vulnerable to misuse, just simply by the volume and complexity of the work,” said Arkoosh.

States will need to log whether each member worked, volunteered or went to school on a part-time basis for at least 80 hours each month, though the law includes exceptions for certain medical conditions, full-time caretakers and others.

“The totality of that really is going to stress all of our systems, and I can imagine that (Henry’s office) is going to get a lot more than 20,000 referrals as we start to have to apply now these additional layers of scrutiny onto individuals,” Arkoosh continued. “It’s going to be quite difficult.”

Previous attempts to introduce work requirements have increased the number of uninsured residents without an increase to the number of those working. Arkoosh estimated the state would spend $50 million on technology upgrades alone, not counting the 250 people who would need to be hired to conduct that work.

Read more from our partners, the Pennsylvania Capital-Star.

Control of the House of Representatives could come down to four pivotal battleground races in Pennsylvania.

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With an increasingly limited map of competitive seats, both Democrats and Republicans are emphasizing the importance of these campaigns, which are about to see a flood of money and investment from both sides.

Some of that has already started, including from Gov. Josh Shapiro, who is on a party-building kick while facing a re-election bid that, as of yet, is not expected to be particularly competitive. A potential 2028 presidential contender, Shapiro has emphasized these four races, making primary endorsements in each contest and signaling he will be deeply involved in them as November nears. Help the battleground Democrats win, and Shapiro will be able to tell Democratic presidential voters about how he helped the party re-take the House and defeat a broad spectrum of Republican House members. Fall short, and his political strength will come under further scrutiny.

And there’s the Donald Trump factor, too. Pennsylvania — a state critical to his 2016 and 2024 presidential victories — is one of his most-trafficked campaign stops. Republican victories, including by one of his closest congressional allies, would bolster his own political strength amid what is shaping up as a difficult election cycle for the GOP. Unlike Shapiro, though, Trump has yet to signal how big a role he will play in these contests.

Tuesday’s primaries locked in the cast of characters in these districts, though most of the matchups were virtually assured beforehand.

In Pennsylvania’s 1st District, Rep. Brian Fitzpatrick — one of the only congressional Republicans who won a district carried by then-Vice President Kamala Harris in 2024 — will face Bucks County Commissioner Bob Harvie. In the 7th District, first-term Rep. Ryan Mackenzie will face state firefighters union head Bob Brooks in the state’s swingiest district.

In the neighboring 8th District, another first-term Republican, Rep. Rob Bresnahan, will face-off with Scranton Mayor Paige Cognetti. And in the state’s 10th District, Rep. Scott Perry, the one-time head of the House Freedom Caucus, will face former newscaster Janelle Stelson in a rematch of a 2024 contest Perry narrowly won.

NBC News spoke with more than a dozen Pennsylvania political operatives, national strategists working on the races, and candidates running in them. The picture that emerged was of a Democratic Party eager to zoom in on a tightly clustered group of pick-up opportunities and tag-team the races with Shapiro, while Republicans, aware of the challenges that lie ahead, hope that their battle-tested incumbents can withstand the onslaught. And the candidates from both sides, meanwhile, are portraying themselves as above Washington, D.C., partisanship and in-touch with working-class concerns.

“The math is simple: Democrats can win back the House by flipping four seats in Pennsylvania,” Democratic Congressional Campaign Committee spokesperson Eli Cousin said in a statement, calling the four Republicans “uniquely vulnerable” and touting Shapiro as “a political juggernaut at the top of the ticket.”

A Democratic operative close to multiple potential 2028 contenders told NBC News they are “feeling very confident” about the handful of battleground House races in Pennsylvania. But should Democrats fall short in any number of these contests, this person said “what a problem that would be.”

“Not just for Democrats, because we need Congress, but because this was supposed to be the shining example of candidate selection and the governor getting in early and all that stuff,” this person, who requested anonymity because they are not allowed to speak with the media, said.

Republicans who spoke with NBC News acknowledged the challenge of facing Shapiro’s ticket in a state where he enjoys high approval ratings and defeated his 2022 opponent, state Sen. Doug Mastriano, by 15 points. And that is in addition to a tough national environment where Trump’s approval numbers are sagging and voters have expressed dissatisfaction with the economy and his handling of the war in Iran.

“In addition to facing uphill national tides against them, they also have to deal with the fact that Josh Shapiro is going to have unlimited money,” a former Trump campaign official with ties to the state said, adding: “Which means that instead of spending money on his own re-election, he’s going to be spending money targeting” Perry, Mackenzie and Bresnahan.

The former Trump campaign official said the candidate most likely to feel the most heat from Shapiro is Perry, who was closely involved with Trump’s effort to overturn the 2020 election and defeated Stelson in 2024 by a few thousand votes. This person said if Shapiro makes it “his mission” to defeat Perry as outside spending floods the district, it will be difficult for the congressman to prevail.

“My guess is the number one thing he talks about is getting Scott Perry so that he can call up any national donor and say, not only did I flip two freshman districts, but also the former head of the Freedom Caucus is gone,” the person said.

In a primary night address to supporters on Tuesday, Shapiro noted Pennsylvanians “have a lot of power and a lot of responsibility this year.”

“You also deserve leaders in Congress who will focus on getting stuff done for you — not going to D.C. to say yes to whatever they’re told, no matter how much it hurts Pennsylvanians,” he said, adding, “Think about what it will look like, after we flip four seats here in Pennsylvania and win all across this country in November, to have a Congress that actually fights for us.”

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The districts cover the Lehigh Valley, Wilkes-Barre/Scranton through the Poconos, south-central Pennsylvania and a slice of suburban Philadelphia. The candidates have stressed bipartisanship in their messaging — and even some Republicans Shapiro is targeting have refrained from criticizing the governor.

In interviews, Harvie said one of the facts he was most proud of in his time as commissioner was the high rate of bipartisan votes he has taken. Cognetti, who ran for mayor as an independent, discussed the electorate in her city and district favoring leaders who “don’t govern in a partisan way.”

Stelson said she was “the nonpartisan voice of this area for more than 30 years” in local TV news, adding, “for me, it doesn’t matter which party, Democrat, Republican, you will represent everyone, the independents, and I want them to know I’m listening, and I’m going to be doing the work.”

On the Republican side, Bresnahan talked up his work on constituent services and membership in the Problem Solvers’ Caucus. He touted bipartisan work on his website and, in a working-class district, was particularly proud of being one of a small handful of Republicans to win the backing of the American Federation of Government Employees, the largest federal employee union.

“I’m one of only two Republicans in the Commonwealth of Pennsylvania that they’ve endorsed, because I’m willing to work across the aisle,” he said.

Republicans see Bresnahan’s work on labor issues as one of his best calling cards in what will be a difficult race. They’re hopeful that a bruising primary in the neighboring district can boost Mackenzie’s chances, while Fitzpatrick’s proven ability to win in a tough political environment will serve him well.

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“I don’t think anyone’s under any illusions that it’s gonna be easy,” a national Republican strategist working on the races said. “Everyone’s very clear about the fact that we’re looking to defy history here.”

Democrats in Pennsylvania are coalescing around a midterm message focused on the economy and, more recently, corruption. In his primary night address, Shapiro mentioned “corruption” in Washington at least a dozen times. Both Stelson and Cognetti have framed themselves as corruption-fighters in their runs.

Cognetti targeted Bresnahan for a series of stock trades he made in office, including when he sold up to $130,000 in stocks in companies that manage nearly half of all Medicaid enrollees before voting to make cuts to the program. Bresnahan said financial advisers manage his portfolio and he gave them no instructions on what to buy, sell or hold.

“Part of his platform was on banning congressional stock trading, and he immediately became one of the most active stock traders in Congress,” Cognetti said. “I know from conversations throughout the district, even before we decided to run, that folks know him as the stock trader. … Folks don’t want to see their local elected officials personally profit off of their public office.

Bresnahan said he is “actually excited for the legislation, any piece of legislation that provides some kind of guidance for people that had careers before coming to Congress.”

“Personally, I don’t think that the mayor of Scranton can run on her record,” he said. “They can’t assault me on my actual voting record, so they’ve resorted to character assassination.”

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On Trump’s role in the races, Republicans said most are of the mindset that it’s better to accept Trump’s help and gain the benefits of his appearance and support, since most will be tagged with any downside of an alignment with Trump regardless of if he is involved.

“President Trump and House Republicans have been successful in Pennsylvania by being laser-focused on lowering costs, improving community safety, and strengthening American manufacturing,” National Republican Congressional Committee spokesperson Reilly Richardson said in a statement, adding, “Republicans are united and ready to win this November.”

Asked if he would like to see the president campaign for him, Bresnahan said, “what’s so important is that we have a relationship with the administration and Cabinet officials.”

“So regardless of who is in power in the state Legislature or in the presidency, the member of Congress needs to work with everyone, and we’re certainly going to continue to work with the president,” he said. “And should the president choose to come back to Northeastern Pennsylvania, we’re absolutely going to welcome him.

On the other hand, Democrats are excited about Shapiro’s personal involvement.

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“We’re so excited to be working with him, and honored that we were his first of the cycle in terms of endorsements,” Stelson said, adding that Shapiro introduced her at her campaign launch.

Republicans though have held their fire and even praised Shapiro, as Fitzpatrick did ahead of the governor endorsing Harvie.

“I honestly haven’t given much thought into the implications of what Josh Shapiro may or may not do,” Bresnahan said, adding that he has a good relationship with Shapiro’s federal legislative affairs team. “The governor is well entitled to endorse whoever he thinks is right for his fit, but we’re still going to work together, and I’m going to work with this team, because at the end of the day, the people of Northeastern Pennsylvania deserve representation at the federal level that aligns with their ideological beliefs.”

Both sides are gearing up for the political world to zero in on these races. This fall marks the first election cycle since Trump’s 2016 bid for the presidency that Pennsylvania won’t feature a competitive Senate race or presidential contest on the ballot.

“If we protect Pennsylvania, I think that we feel we are well on our way to protecting our House majority,” the national Republican strategist added. “A lot of people are going to be looking to Pennsylvania on election night.”

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