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COLUMBIA FALLS, Mont. — Over two years ago, Kim Hilton and his partner walked out of their home for the final time. The house had sold, and the new landlord raised the rent.

They couldn’t afford it. Their Social Security payments couldn’t cover the cost of any apartments in northwestern Montana’s Flathead Valley.

Hilton’s partner was able to move into her daughter’s studio apartment. There wasn’t enough space for Hilton, so they reluctantly split up.

At 68 years old, he moved into his truck — a forest-green Chevy Avalanche.

Hilton quickly found out how hard it would be to survive. Hilton has diabetes. That first night, his insulin froze, rendering it useless.

Things didn’t get any easier that winter. On the coldest nights, temperatures dropped to about minus 20 degrees. Hilton kept the truck running, but eventually his fuel pump failed. He was on his own in the cold.

Hilton is incredibly optimistic, but in that moment, he said, his spirit broke.

“I just said I want to go to sleep and not wake up and I won’t have to worry about anything. I’ll just sit here and be a little popsicle in the truck,” Hilton recalled.

Hilton was one of tens of thousands of seniors in the U.S. who became homeless for the first time in 2022. A dramatic increase in the number of homeless seniors nationwide is overwhelming services for unhoused people.

Older Montanans especially are struggling because housing costs have skyrocketed since 2021, in part because of the rise of remote work. The state has one of the nation’s fastest-growing homeless populations, according to federal data.

University of Pennsylvania researcher Dennis Culhane estimated that the number of homeless people age 65 and up in the U.S. would triple between 2019 and 2030. He recently updated that estimate using federal data for a recently published paper.

“We are on track to meet that prediction. In fact, the growth has been slightly higher than we predicted,” he said.

According to Culhane’s research, the number of people 65 and older jumped by a little over a third between 2019 and 2022 alone. By 2022, there were about 250,000 people over 55 who were unhoused. About half of this population are homeless for the first time.

What researchers and advocates call the “gray wave” of homeless seniors is overwhelming service providers trying to help.

Wendy Wilson is seeing the gray wave coming firsthand. She’s a case manager at Assist, a nonprofit that helps Flathead residents struggling to meet their medical needs. In the past, that meant helping them get free meals or finding a ride to the doctor’s office.

Increasingly, Wilson helps older people like Hilton find housing.

“They have medical issues. It’s not easy for them to be living in a truck or at the homeless shelter when you have medical issues going on,” she said.

Wilson found Hilton a spot in early 2023 at the Samaritan House in Kalispell, which has private rooms. But after five months of living in his truck, Hilton’s health had gone downhill fast. He had several fainting episodes at the shelter, then-manager Sona Blue said.

“It scared us because we have no medical care in this facility,” she said.

That’s not usual for shelters. Finally, Hilton took a bad fall, and shelter staff sent him to an emergency room.

The doctor who treated Hilton discovered he had developed pressure wounds from sitting for months in the same position in his truck. Because of the neuropathy in his limbs from his diabetes, Hilton couldn’t feel the pain. Those wounds never healed and became infected, another common complication of diabetes. 

Hilton had one leg amputated. Later, his other leg was amputated as well. Returning to the shelter in a wheelchair wasn’t an option: There were no shelter staffers or medical personnel available to help with his basic needs.

A handful of homeless service providers, including shelter staffers and other medical case workers, tried to help Hilton find another place to go. They put him on waiting lists for the limited supply of subsidized housing in the area.

Wilson secured one of the few slots in a Medicaid program that helps pay for assisted living for Hilton. But it can take a year or more for units to open. So Wilson crossed her fingers that Hilton would get lucky before he was released from the hospital after his second amputation.

Many seniors across the country are stuck playing the same dangerous waiting game, said Caitlyn Synovec with the National Health Care for the Homeless Council.

“Sometimes they can’t be safely served in a shelter because they have issues with incontinence or cognition. Then they’re more likely to be on the streets, and their conditions will worsen quite a bit,” she said.

Communities are looking for solutions.

To serve aging people with complex medical needs, homeless shelters for seniors are cropping up in such cities as Salt Lake City and Fort Lauderdale, Florida.

Montana recently got approval from federal health officials to use Medicaid funding to temporarily help people with medical conditions make rent.

But that’s not enough, according to Synovec. She said the real solution is building more affordable housing so older Americans don’t become homeless in the first place.

That housing will need to be accessible, too. Older homeless people like Hilton need homes they can safely navigate. Because of his new wheelchair, he needed a ground-floor apartment.

In the fall, Hilton finally got a spot in a facility that would take his Medicaid waiver. He also got an electric wheelchair to make it easier to get to doctor appointments in town.

Hilton said he hasn’t pushed his new wheelchair to its top speed yet. “It goes fast for a wheelchair. I’m going to find out when I go down to dinner. I’ll stretch it out, break it in,” he said with a laugh.

Hilton is grateful to finally have stable housing. Wilson is grateful too. She said it was one of the few times she’s been able to help a senior regain housing.

“It was a woo-hoo moment,” she said.

As long as the facility stays open and the Medicaid waiver program isn’t cut, she’s confident Hilton will have made it through homelessness.

This article is part of a partnership with NPR and Montana Public Radio.

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

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The new Trump administration could be coming for your snacks.

For years, the federal government has steered clear of regulating junk food, fast food, and ultra-processed food.

Now attitudes are changing. Some members of President-elect Donald Trump’s inner circle are gearing up to battle “Big Food,” or the companies that make most of the food and beverages consumed in the United States. Nominees for top health agencies are taking aim at ultra-processed foods that account for an estimated 70% of the nation’s food supply. Based on recent statements, a variety of potential politically charged policy options to regulate ultra-processed food may land on the Trump team menu, including warning labels, changes to agribusiness subsidies, and limits on which products consumers can buy with government food aid.

The push to reform the American diet is being driven largely by conservatives who have taken up the cause that has long been a darling of the left. Trump supporters such as Robert F. Kennedy Jr., whose controversial nomination to lead the Department of Health and Human Services still faces Senate confirmation, are embracing a concept that champions natural foods and alternative medicine. It’s a movement they’ve dubbed “MAHA,” or Make America Healthy Again. Their interest has created momentum because their goals have fairly broad bipartisan support even amid a bitterly divided Congress in which lawmakers from both sides of the aisle focused on the issue last year.

It’s likely to be a pitched battle because the food industry wields immense political influence and has successfully thwarted previous efforts to regulate its products or marketing. The category of “food processing and sales companies,” which includes Tyson Foods and Nestle SA, tallied $26.7 million in spending on lobbying in 2024, according to OpenSecrets. That’s up from almost $10 million in 1998.

“They have been absolutely instrumental and highly, highly successful at delaying any regulatory effectiveness in America,” said Laura Schmidt, a health policy professor at the University of California-San Francisco. “It really does feel like there needs to be a moment of reckoning here where people start asking the question, ‘Why do we have to live like this?’”

“Ultra-processed food” is a widely used term that means different things to different people and is used to describe items ranging from sodas to many frozen meals. These products often contain added fats, starches, and sugars, among other things. Researchers say consumption of ultra-processed foods is linked — in varying levels of intensity — to chronic conditions like diabetes, cancer, mental health problems, and early death.

Nutrition and health leaders are optimistic that a reckoning is already underway. Kennedy has pledged to remove processed foods from school lunches, restrict certain food additives such as dyes in cereal, and shift federal agricultural subsidies away from commodity crops widely used in ultra-processed foods.

The intensifying focus in Washington has triggered a new level of interest on the legal front as lawyers explore cases to take on major foodmakers for selling products they say result in chronic disease.

Bryce Martinez, now 18, filed a lawsuit in December against almost a dozen foodmakers such as Kraft Heinz, The Coca-Cola Co., and Nestle USA. He developed diabetes and non-alcoholic fatty liver disease by age 16, and is seeking to hold them accountable for his illnesses. According to the suit, filed in the Philadelphia Court of Common Pleas, the companies knew or should have known ultra-processed foods were harmful and addictive.

The lawsuit noted that Martinez grew up eating heavily advertised, brand-name foods that are staples of the American diet — sugary soft drinks, Cheerios and Lucky Charms, Skittles and Snickers, frozen and packaged dinners, just to name a few.

Nestle, Coca-Cola, and Kraft Heinz didn’t return emails seeking comment for this article. The Consumer Brands Association, a trade association for makers of consumer packaged goods, disputed the allegations.

“Attempting to classify foods as unhealthy simply because they are processed, or demonizing food by ignoring its full nutrient content, misleads consumers and exacerbates health disparities,” said Sarah Gallo, senior vice president of product policy, in a statement.

Other law firms are on the hunt for children or adults who believe they were harmed by consuming ultra-processed foods, increasing the likelihood of lawsuits.

One Indiana personal injury firm says on its website that “we are actively investigating ultra processed food (UPF) cases.” Trial attorneys in Texas also are looking into possible legal action against the federal regulators they say have failed to police ultra-processed foods.

“If you or your child have suffered health problems that your doctor has linked directly to the consumption of ultra-processed foods, we want to hear your story,” they say on their website.

Meanwhile, the FDA on Jan. 14 announced it is proposing to require a front-of-package label to appear on most packaged foods to make information about a food’s saturated fat, sodium, and added sugar content easily visible to consumers.

And on Capitol Hill, Sens. Bernie Sanders (I-Vt.), Ron Johnson (R-Wis.), and Cory Booker (D-N.J.) are sounding the alarm over ultra-processed food. Sanders introduced legislation in 2024 that could lead to a federal ban on junk food advertising to children, a national education campaign, and labels on ultra-processed foods that say the products aren’t recommended for children. Booker cosigned the legislation along with Sens. Peter Welch (D-Vt.) and John Hickenlooper (D-Colo.).

The Senate Committee on Health, Education, Labor and Pensions held a December hearing examining links between ultra-processed food and chronic disease during which FDA Commissioner Robert Califf called for more funding for research.

Food companies have tapped into “the same neural circuits that are involved in opioid addiction,” Califf said at the hearing.

Sanders, who presided over the hearing, said there’s “growing evidence” that “these foods are deliberately designed to be addictive,” and he asserted that ultra-processed foods have driven epidemics of diabetes and obesity, and hundreds of billions of dollars in medical expenses.

Research on food and addiction “has accumulated to the point where it’s reached a critical mass,” said Kelly Brownell, an emeritus professor at Stanford who is one of the editors of a scholarly handbook on the subject.

Attacks from three sides — lawyers, Congress, and the incoming Trump administration, all seemingly interested in taking up the fight — could lead to enough pressure to challenge Big Food and possibly spur better health outcomes in the U.S., which has the lowest life expectancy among high-income countries.

“Maybe getting rid of highly processed foods in some things could actually flip the switch pretty quickly in changing the percentage of the American public that are obese,” said Robert Redfield, a virologist who led the Centers for Disease Control and Prevention during the previous Trump administration, in remarks at a December event hosted by the Heritage Foundation, a conservative think tank.

Claims that Big Food knowingly manufactured and sold addictive and harmful products resemble the claims leveled against Big Tobacco before the landmark $206 billion settlement was reached in 1998.

“These companies allegedly use the tobacco industry’s playbook to target children, especially Black and Hispanic children, with integrated marketing tie-ins with cartoons, toys, and games, along with social media advertising,” Rene Rocha, one of the lawyers at Morgan & Morgan representing Martinez, told KFF Health News.

The 148-page Martinez lawsuit against foodmakers draws from documents made public in litigation against tobacco companies that owned some of the biggest brands in the food industry.

Similar allegations were made against opioid manufacturers, distributors, and retailers before they agreed to pay tens of billions of dollars in a 2021 settlement with states.

The FDA ultimately put restrictions on the labeling and marketing of tobacco, and the opioid epidemic led to legislation that increased access to lifesaving medications to treat addiction.

But the Trump administration’s zeal in taking on Big Food may face unique challenges.

The ability of the FDA to impose regulation is hampered in part by funding. While the agency’s drug division collects industry user fees, its division of food relies on a more limited budget determined by Congress.

Change can take time because the agency moves at what some critics call a glacial pace. Last year, the FDA revoked a regulation allowing brominated vegetable oil in food products. The agency determined in 1970 that the additive was not generally recognized as safe.

Efforts to curtail the marketing of ultra-processed food could spur lawsuits alleging that any restrictions violate commercial speech protected by the First Amendment. And Kennedy — if he is confirmed as HHS secretary — may struggle to get support from a Republican-led Congress that champions less federal regulation and a president-elect who during his previous term served fast food in the White House.

“The question is, will RFK be able to make a difference?” said David L. Katz, a doctor who founded True Health Initiative, a nonprofit group that combats public health misinformation. “No prior administration has done much in this space, and RFK is linked to a particularly anti-regulatory administration.”

Meanwhile, the U.S. population is recognized as among the most obese in the world and has the highest rate of people with multiple chronic conditions among high-income countries.

“There is a big grassroots effort out there because of how sick we are,” said Jerold Mande, who served as deputy undersecretary for food safety at the Department of Agriculture from 2009 to 2011. “A big part of it is people shouldn’t be this sick this young in their lives. You’re lucky if you get to 18 without a chronic disease. It’s remarkable.”

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

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The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Incoming President Donald Trump’s inauguration is Monday, yet the new GOP-led Congress is already rushing to work his priorities into legislation, eyeing cuts to Medicaid to pay for new tax and immigration priorities. But even in its waning days, the Biden administration continues to make big policy moves, including a possible order for tobacco companies to dramatically decrease the amount of nicotine in cigarettes. 

Meanwhile, the fires in Los Angeles are drawing new attention to the health dangers of not just smoke from organic matter, but also toxic substances released by burning plastic and other man-made materials — as well as the threat posed to both air and water quality.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Sandhya Raman of CQ Roll Call.

Panelists Anna Edney Bloomberg @annaedney Read Anna's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen Read Joanne's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Republican lawmakers are weighing options to cut federal spending on Medicaid, the nearly $900-billion-a-year government program that covers 1 in 5 Americans. They could use the savings to bolster Trump priorities, such as extending the 2017 tax cuts. The GOP made splashy but unsuccessful attempts to cut Medicaid when Trump first took office and the party held a larger House majority — though the party seems more aligned with Trump today than it was then.
• Congress has gotten down to business on messaging bills: It advanced legislation this week that would ban trans athletes from girls’ school sports and, separately, a measure to detain and even deport immigrants who are living in the U.S. without legal status and have been charged with, though not convicted of, minor crimes such as shoplifting.
• The Supreme Court has agreed to hear a case later this year about the U.S. Preventive Services Task Force — an independent body of experts that issues recommendations in disease prevention and medicine. A ruling against its authority could strip coverage for key preventive health services from not just those with Affordable Care Act coverage, but also those on employer-sponsored health plans. The question stands: If not this task force, who would make the determinations about what preventive care should be covered?
• And the outgoing Biden administration issued a slew of health regulations this week, including a ban on the dye Red No. 3 in food and other ingested products, as well as an early regulation limiting the amount of nicotine in tobacco products. The incoming Trump administration could upend these and more regulations, though some do align with its policy interests.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the latest KFF Health News “Bill of the Month” feature, about a colonoscopy that came with a much larger price tag than estimated. If you have a mystifying or outrageous medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline?” by Felice J. Freyer.

Anna Edney: Bloomberg News’ “It’s Not Just Sunscreen. Toxic Products Line the Drugstore Aisles,” by Anna Edney.

Joanne Kenen: The Atlantic’s “A Secret Way To Fight Off Stomach Bugs,” by Daniel Engber.

Sandhya Raman: Nature’s “New Obesity Definition Sidelines BMI To Focus on Health,” by Giorgia Guglielmi.

Also mentioned in this week’s podcast:

• MedPage Today’s “ABIM Revokes Certification of Another Doctor Who Made Controversial COVID Claims,” by Kristina Fiore.
• The Atlantic’s “What Happens When a Plastic City Burns,” by Zoë Schlanger.
• ProPublica’s “The Second Trump White House Could Drastically Reshape Infectious Disease Research. Here’s What’s at Stake,” by Anna Maria Barry-Jester.
• The New York Times’ “Don’t Call Kennedy a Vaccine Skeptic. Call Him What He Is: A Cynic,” by Paul A. Offit.
• The Federal Trade Commission’s “Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies.”

Credits Taylor Cook Audio producer Lonnie Ro Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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HHS intends to provide $211 million to accelerate, enhance platform capability for emerging infectious diseases.

HHS Office for Civil Rights, Cedars-Sinai Enter Into Mutual Agreement to Advance Civil Rights and Improve Maternal Health for All

Jen Fisher solo puede hacer ciertas cosas para proteger a su hijo de las infecciones que los niños pueden contraer en la escuela. Dijo que el resto depende de otros estudiantes y padres en su ciudad natal de Franklin, en Tennessee.

El hijo de Fisher, Raleigh, de 12 años, vive con una afección cardíaca congénita que ha debilitado su sistema inmune. Ha recibido todas las vacunas recomendadas a su edad, para su protección. Pero incluso con estas vacunas, un virus que para otro niño significaría estar en cama un par de días, para Raleigh podría transformarse en una enfermedad grave, terminando en una sala de emergencias, explicó Fisher.

“Queremos que todos estén vacunados para que enfermedades como el sarampión y cosas que básicamente han sido erradicadas no regresen”, dijo Fisher. “Esas pueden definitivamente tener un efecto muy adverso en Raleigh”.

Durante gran parte de la vida de Raleigh, Fisher podía estar tranquila gracias a la alta tasa de vacunación infantil en Tennessee, un punto positivo de salud pública en un estado conservador con resultados de salud deficientes y una de las expectativas de vida más cortas del país.

Mississippi y West Virginia, dos estados también conservadores, con malos resultados de salud y baja expectativa de vida, también tienen algunas de las tasas de vacunación más altas para niños de kinder en el país.

Esta aparente contradicción se debe a que los requisitos de vacunación infantil no siempre se alinean con otras características de los estados, dijo James Colgrove, profesor de la Universidad Columbia que estudia los factores que influyen en la salud pública.

“Los tipos de políticas que tienen los estados no encajan perfectamente en la categoría de ‘rojo’ o ‘azul’ o en una región u otra”, dijo Colgrove.

Defensores, médicos, investigadores, y funcionarios de salud pública temen que estos puntos positivos de salud pública en algunos estados estén desapareciendo: muchos han informado recientemente un aumento en las personas que optan por no vacunar a sus hijos, a medida que cambian las opiniones de los estadounidenses.

Durante el año escolar 2023-24, el porcentaje de niños de kinder exentos de una o más vacunas aumentó al 3.3%, el más alto jamás reportado, con aumentos en 40 estados y Washington, DC, según datos de los Centros para el Control y Prevención de Enfermedades (CDC). Tennessee y Mississippi estuvieron entre los estados con aumentos. Casi todas las exenciones a nivel nacional fueron por razones no médicas.

Los defensores de la vacunación temen que los mensajes antivacunas puedan acelerar un creciente movimiento de “libertad sanitaria” impulsado por líderes en estados como Florida.

Este impulso contra las vacunas probablemente continuará creciendo con la elección de Donald Trump como presidente y su propuesta de nominar al activista antivacunas Robert F. Kennedy Jr. como secretario del Departamento de Salud y Servicios Humanos (HHS).

Pediatras en estados con altas tasas de exenciones, como Florida y Georgia, dicen estar preocupados por lo que observan: niveles decrecientes de inmunización entre niños de kinder, lo que podría llevar a un resurgimiento de enfermedades prevenibles por vacunación, como el sarampión. En algunas áreas, el Departamento de Salud de Florida reportó tasas de exenciones no médicas de hasta un 50% para niños.

“La exención religiosa es enorme”, dijo Brandon Chatani, especialista en enfermedades infecciosas pediátricas en Orlando. “Eso ha permitido una forma fácil para que estos niños vayan a las escuelas sin vacunas”.

En muchos estados, es más fácil obtener una exención religiosa que una médica, que a menudo requiere la aprobación de un médico.

En la última década, California, Connecticut, Maine y Nueva York han eliminado las exenciones religiosas y filosóficas de los requisitos de vacunación escolar. West Virginia no las ha tenido.

Idaho, Alaska y Utah tuvieron las tasas de exención más altas durante el año escolar 2023-24, según los CDC. Estos estados permiten que los padres o tutores legales eximan a sus hijos por razones religiosas presentando un formulario notarizado o una declaración firmada.

Florida y Georgia, con algunas de las tasas reportadas más bajas de vacunación para niños de kinder, permiten que los padres eximan a sus hijos presentando un formulario en la escuela o guardería.

Ambos estados han informado disminuciones en la aplicación de la vacuna contra el sarampión, las paperas y la rubéola (conocida como MMR), una de las vacunas infantiles más comunes. En Georgia, la cobertura de la MMR para niños de kinder cayó de 93.1% en el año escolar 2019-20 al 88.4% en el año escolar 2023-24, según los CDC. En Florida, en el mismo período, bajó de 93.5% al 88.1%.

Andi Shane, especialista en enfermedades infecciosas pediátricas en Atlanta, atribuye las tasas decrecientes en Georgia a familias que no tienen acceso a un pediatra. Las políticas estatales sobre exenciones también son clave, dijo.

“Hay muchos datos que respaldan el hecho de que cuando no se permiten exenciones por creencias personales, las tasas de vacunación son más altas”, aseguró Shane.

En diciembre, funcionarios de salud pública de Georgia lanzaron un aviso diciendo que el estado había registrado significativamente más casos de tos ferina que el año anterior. Según datos de los CDC, Georgia reportó 280 casos en 2024 en comparación con 96 el año anterior.

Hasta 2023, Mississippi era uno de los pocos estados que permitía a los padres optar por no vacunar a sus hijos solo por razones médicas, y únicamente con la aprobación de un médico. Eso hizo que tuviera una de las tasas de vacunación más altas del país hasta el año escolar 2023-24.

“Es una de las pocas cosas que Mississippi ha hecho bien”, dijo Anita Henderson, pediatra que ha ejercido en la parte sur del estado durante casi 30 años. Aseguró que, en términos de salud, las tasas de vacunación infantil eran el único “rayo de luz” del estado.

Pero eso cambió en abril de 2023 cuando un juez federal ordenó a los funcionarios estatales comenzar a permitir exenciones religiosas. Según Henderson, el fallo ha alentado a muchas familias.

“Estamos viendo cada vez más escepticismo, más dudas sobre las vacunas y una falta de confianza debido a este fallo”, dijo.

Desde la orden judicial que permite las exenciones religiosas, los funcionarios estatales han otorgado más de 5.000, según el departamento de salud estatal. Daniel Edney, oficial de salud del estado, dijo que la mayoría de las solicitudes provienen de residentes “más pudientes” en bolsones de riqueza del estado.

“La mayoría de las personas escuchan las opiniones de los expertos, como sus pediatras y médicos de familia, para mantenerse al día con el calendario de vacunación porque es lo mejor para proteger a sus hijos”, dijo.

La ley de vacunación de West Virginia —que no permite exenciones no médicas— también podría cambiar pronto, dijo Matthew Christiansen, quien fue oficial de salud del estado hasta que renunció en diciembre.

El año pasado, un proyecto de ley que habría ampliado las exenciones avanzó en la Legislatura, pero fue vetado por el gobernador saliente republicano Jim Justice. El gobernador entrante, el republicano Pat Morrisey, ha sido un crítico abierto de los mandatos de vacunación: emitió una orden ejecutiva vigente a partir del 1 de febrero para proponer disposiciones que permitan las exenciones de vacunación por motivos religiosos y de conciencia.

“Quiero enviar un mensaje de que si tienes una creencia religiosa, entonces vamos a tener una excepción”, dijo en una conferencia de prensa el 14 de enero. “No vamos a ser la excepción.

Las personas que usan como argumento sus libertades personales para rechazar vacunas para sus hijos pueden, en última instancia, limitar la capacidad de otros para vivir plenamente, dijo Christiansen. “Que los niños contraigan sarampión, paperas y polio, y queden paralizados de por vida, es un impedimento para la libertad y autonomía personal de esos niños”, enfatizó.

Desde la pandemia de covid, el sentimiento antivacunas ha ido en aumento en Tennessee. La organización Stand for Health Freedom redactó una carta para que los ciudadanos enviaran a sus legisladores estatales pidiendo la renuncia de la directora médica del Programa de Vacunas y Enfermedades Prevenibles por Vacunación de Tennessee. El grupo dijo que la directora había demostrado una “falta de respeto por los derechos de consentimiento informado” de las personas.

“Se sienten empoderados por la idea de que esta administración presidencial parece creer firmemente que muchos de estos temas deberían ser devueltos a los estados”, dijo Emily Delikat, directora de Tennessee Families for Vaccines, un grupo pro-vacunación.

En última instancia, como muchas intervenciones efectivas de salud pública, las vacunas son víctimas de su propio éxito, dijo Henderson, la pediatra de Mississippi. La mayoría de las personas no han presenciado brotes de sarampión o polio, por lo que olvidan lo peligrosas que son estas enfermedades, agregó.

“Desafortunadamente, puede que se necesite un resurgimiento de esas enfermedades para crear conciencia sobre el hecho de que son mortales y prevenibles”, dijo. “Espero que no se tenga que llegar a eso”.

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Jen Fisher can do only so much to keep her son safe from the types of infections that children can encounter at school. The rest, she said, is up to other students and parents in their hometown of Franklin, Tennessee.

Fisher’s son Raleigh, 12, lives with a congenital heart condition, which has left him with a weakened immune system. For his protection, Raleigh has received all the recommended vaccines for a child his age. But even with his vaccinations, a virus that might only sideline another child could sicken him and land him in the emergency room, Fisher said.

“We want everyone to be vaccinated so that illnesses like measles and things that have basically been eradicated don’t come back,” Fisher said. “Those can certainly have a very adverse effect on Raleigh.”

For much of Raleigh’s life, Fisher could take comfort in the high childhood vaccination rate in Tennessee — a public health bright spot in a conservative state with poor health outcomes and one of the shortest life expectancies in the nation.

Mississippi and West Virginia, two similarly conservative states with poor health outcomes and short life expectancies, also have some of the highest vaccination rates for kindergartners in the nation — a seeming contradiction that stems from the fact that childhood vaccination requirements don’t always align with states’ other characteristics, said James Colgrove, a Columbia University professor who studies factors that influence public health.

“The kinds of policies that states have don’t map neatly on to ‘red’ versus ‘blue’ or one region or another,” Colgrove said.

Advocates, doctors, public health officials, and researchers worry such public health bright spots in some states are fading: Many states have recently reported an increase in people opting out of vaccines for their kids as Americans’ views shift.

During the 2023-24 school year, the percentage of kindergartners exempted from one or more vaccinations rose to 3.3%, the highest ever reported, with increases in 40 states and Washington, D.C., according to Centers for Disease Control and Prevention data. Tennessee and Mississippi were among those with increases. Nearly all exemptions nationally were for nonmedical reasons.

Vaccine proponents worry anti-vaccine messaging could accelerate a growing “health freedom” movement that has been pushed by leaders in states such as Florida. Momentum against vaccines is likely to continue to grow with the election of Donald Trump as president and his proposed nomination of anti-vaccine activist Robert F. Kennedy Jr. as secretary of the Department of Health and Human Services.

Pediatricians in states with high exemption rates, such as Florida and Georgia, say they’re concerned by what they see — declining immunization levels for kindergartners, which could lead to a resurgence in vaccine-preventable diseases such as measles. The Florida Department of Health reported nonmedical exemption rates as high as 50% for children in some areas.

“The religious exemption is huge,” said Brandon Chatani, a pediatric infectious disease doctor in Orlando. “That has allowed for an easy way for these kids to enter schools without vaccines.”

In many states, it’s easier to get a religious exemption than a medical one, which often requires signoff from a doctor.

Over the past decade, California, Connecticut, Maine, and New York have removed religious and philosophical exemptions from school vaccination requirements. West Virginia has not had them.

Idaho, Alaska, and Utah had the highest exemption rates for the 2023-24 school year, according to the CDC. Those states allow parents or legal guardians to exempt their children for religious reasons by submitting a notarized form or a signed statement.

Florida and Georgia, with some of the lowest reported minimum vaccination rates for kindergartners, allow parents to exempt their children by submitting a form with the child’s school or day care.

Both states have reported declines in uptake of the measles, mumps, and rubella vaccine, which is one of the most common childhood shots. In Georgia, MMR coverage for kindergartners dropped to 88.4% in the 2023-24 school year from 93.1% in 2019-20, according to the CDC. Florida dropped to 88.1% from 93.5% during the same period.

Andi Shane, a pediatric infectious disease specialist in Atlanta, traces Georgia’s declining rates to families who lack access to a pediatrician. State policies on exemptions are also key, she said.

“There’s lots of data to support the fact that when personal belief exemptions are not permitted, that vaccination rates are higher,” she said.

In December, Georgia public health officials put out an advisory saying the state had recorded significantly more whooping cough cases than in the prior year. According to CDC data, Georgia reported 280 cases in 2024 compared with 96 the year before.

Until 2023, Mississippi was one of the few states that allowed parents to opt out of vaccinating their kids only for medical reasons — and only with the approval of a doctor. That gave it among the highest vaccination rates in the nation as of the 2023-24 school year.

“It’s one of the few things Mississippi has done well,” said Anita Henderson, a pediatrician who has practiced in the southern part of the state for nearly 30 years. In terms of health, she said, childhood vaccination rates were the state’s one “shining star.”

But that changed in April 2023 when a federal judge ordered state officials to start allowing religious exemptions. The ruling has emboldened many families, Henderson said.

“We are seeing more and more skepticism, more and more vaccine hesitancy, and a lack of confidence because of this ruling,” she said.

State officials have granted more than 5,000 religious exemptions since the court order allowing them, according to the state health department. Daniel Edney, the state health officer, said most of the requests have come from “more affluent” residents in “pockets” of the state.

“Most people listen to the expert opinions of their pediatricians and family medicine doctors to stay on the vaccine schedule, because it’s what is best to protect their children,” he said.

West Virginia’s vaccine law — which hasn’t allowed nonmedical exemptions — also could soon change, Matthew Christiansen said in December before he resigned as the state’s health officer.

A bill that would have broadened exemptions made it through the legislature last year but was vetoed by outgoing Republican Gov. Jim Justice. The new governor, Republican Pat Morrisey, has been a vocal critic of vaccine mandates. And just a day after being inaugurated, he issued an executive order to propose provisions by Feb. 1 that could allow religious and conscientious exemptions.

“I want to send a message that if you have a religious belief, then we’re going to have an exception,” he said at a Jan. 14 press conference. “We’re not going to be the outlier.”

People asserting their personal freedoms to decline vaccines for their kids can ultimately curtail the ability of others to live full lives, Christiansen said. “Kids getting measles and mumps and polio and being paralyzed for their whole life is an impediment on personal freedom and autonomy for those kids,” he said.

Since the covid pandemic, anti-vaccine sentiment has been growing in Tennessee. One organization, Stand for Health Freedom, drafted a letter for constituents to send to their state lawmakers calling for the resignation of the medical director of Tennessee’s Vaccine-Preventable Diseases and Immunization Program. The group said she demonstrated a “lack of respect for the informed consent rights” of the people.

“They feel emboldened by the idea that this presidential administration seems to feel very strongly that a lot of these issues should be taken back to the states,” said Emily Delikat, director of Tennessee Families for Vaccines, a pro-vaccine group.

Ultimately, like many effective public health interventions, vaccines are a victim of their own success, said Henderson, the Mississippi pediatrician. Most people haven’t seen outbreaks of measles or polio, so they forget how dangerous the diseases are, she said.

“It may unfortunately take a resurgence of those diseases to raise awareness to the fact that these are dangerous, these are deadly, these are preventable,” she said. “I hope it doesn’t come to that.”

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

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SACRAMENTO, Calif. — As the nation braces for potential policy shifts under President-elect Donald Trump’s “Make America Healthy Again” mantra, the nation’s most populous state and largest health care market is preparing for a few changes of its own.

With supermajorities in both houses, Democrats in the California Legislature passed — and Democratic Gov. Gavin Newsom signed — laws taking effect this year that will erase medical debt from credit reports, allow public health officials to inspect immigrant detention centers, and require health insurance companies to cover fertility services such as in vitro fertilization.

Still, industry experts say it was a relatively quiet year for health policy in the Golden State, with more attention on a divisive presidential election and with several state legislators seeking to avoid controversial issues as they ran for Congress in competitive swing districts.

Newsom shot down some of legislators’ most ambitious health care policies, including proposals that would have regulated pharmaceutical industry middlemen and given the state more power to stop private equity deals in health care.

Health policy experts say advocates and legislators are now focused on how to defend progressive California policies such as sweeping abortion access in the state and health coverage for immigrants living in the U.S. without authorization.

“I think everyone’s just thinking about how we’re going to enter 2025,” said Rachel Linn Gish, a spokesperson with the consumer health advocacy group Health Access California. “We’re figuring out what is vulnerable, what we are exposed to on the federal side, and what do budget changes mean for our work. That’s kind of putting a cloud over everything.”

Here are some of the biggest new health care laws Californians should know about:

Medical debt

California becomes the eighth state in which medical debt will no longer affect patients’ credit reports or credit scores. SB 1061 bars health care providers and debt collectors from reporting unpaid medical bills to credit bureaus, a practice that supporters of the law say penalizes people for seeking critical care and can make it harder for patients to get a job, buy a car, or secure a mortgage.

Critics including the California Association of Collectors called the measure from Sen. Monique Limón (D-Santa Barbara) a “tremendous overreach” and successfully lobbied for amendments that limited the scope of the bill, including an exemption for any medical debt incurred on credit cards.

The Biden administration has finalized federal rules that would stop unpaid medical bills from affecting patients’ credit scores, but the fate of those changes remains unclear as Trump takes office.

Psychiatric hospital stays for violent offenders

Violent offenders with severe mental illness can now be held longer after a judge orders them released from a state mental hospital.

State officials and local law enforcement will now have 30 days to coordinate housing, medication, and behavioral health treatment for those parolees, giving them far more time than the five-day deadline previously in effect.

The bill drew overwhelming bipartisan support after a high-profile case in San Francisco in which a 61-year-old man was charged in the repeated stabbing of a bakery employee just days after his release from a state mental hospital. The bill’s author, Assembly member Matt Haney (D-San Francisco), called the previous five-day timeline “dangerously short.”

Cosmetics and ‘forever chemicals’

California was the first state to ban PFAS chemicals, also known as “forever chemicals,” in all cosmetics sold and manufactured within its borders. The synthetic compounds, found in everyday products including rain jackets, food packaging, lipstick, and shaving cream, have been linked to cancer, birth defects, and diminished immune function and have been increasingly detected in drinking water.

Industry representatives have argued that use of PFAS — perfluoroalkyl and polyfluoroalkyl substances — is critical in some products and that some can be safely used at certain levels.

Immigration detention facilities

After covid-19 outbreaks, contaminated water, and moldy food became the subjects of detainee complaints and lawsuits, state legislators gave local county health officials the authority to enter and inspect privately run immigrant detention centers. SB 1132, from Sen. María Elena Durazo (D-Los Angeles), gives public health officials the ability to evaluate whether privately run facilities are complying with state and local public health regulations regarding proper ventilation, basic mental and physical health care, and food safety.

Although the federal government regulates immigration, six federal detention centers in California are operated by the GEO Group. One of the country’s largest private prison contractors, GEO has faced a litany of complaints related to health and safety. Unlike public prisons and jails, which are inspected annually, these facilities would be inspected only as deemed necessary.

The contractor filed suit in October to stop implementation of the law, saying it unconstitutionally oversteps the federal government’s authority to regulate immigration detention centers. A hearing in the case is set for March 3, said Bethany Lesser, a spokesperson for California Attorney General Rob Bonta. The law took effect Jan. 1.

Doctors vs. insurance companies using AI

As major insurance companies increasingly use artificial intelligence as a tool to analyze patient claims and authorize some treatment, trade groups representing doctors are concerned that AI algorithms are driving an increase in denials for necessary care. Legislators unanimously agreed.

SB 1120 states that decisions about whether a treatment is medically necessary can be made only by licensed, qualified physicians or other health care providers who review a patient’s medical history and other records.

Sick leave and protected time off

Two new laws expand the circumstances under which California workers may use sick days and other leave. SB 1105 entitles farmworkers who work outdoors to take paid sick leave to avoid heat, smoke, or flooding when local or state officials declare an emergency.

AB 2499 expands the list of reasons employees may take paid sick days or use protected unpaid leave to include assisting a family member who is experiencing domestic violence or other violent crimes.

Prescription labels for the visually impaired

Starting this year, pharmacies will be required to provide drug labels and use instructions in Braille, large print, or audio for blind patients.

Advocates of the move said state law, which already required translated instructions in five languages for non-English speakers, has overlooked blind patients, making it difficult for them to monitor prescriptions and take the correct dosage.

Maternal mental health screenings

Health insurers will be required to bolster maternal mental health programs by mandating additional screenings to better detect perinatal depression, which affects 1 in 5 people who give birth in California, according to state data. Pregnant people will now undergo screenings at least once during pregnancy and then six weeks postpartum, with further screenings as providers deem necessary.

Penalties for threatening health care workers (abortion clinics)

With abortion care at the center of national policy fights, California is cracking down on those who threaten, post personal information about, or otherwise target providers or patients at clinics that perform abortions. Penalties for such behavior will increase under AB 2099, and offenders can face felony charges, up to three years in jail, and $50,000 in fines for repeat or violent offenses. Previously, state law classified many of those offenses as misdemeanors.

Insurance coverage for IVF

Starting in July, state-regulated health plans covering 50 employees or more would be required to cover fertility services under SB 729, passed and signed last year. Advocates have long fought for this benefit, which they say is essential care for many families who have trouble getting pregnant and would ensure LGBTQ+ couples aren’t required to pay more out-of-pocket costs than straight couples when starting a family.

In a signing statement, Newsom asked legislators to delay implementation of the law until 2026 as state officials consider whether to add infertility treatments to the list of benefits that insurance plans are required to cover.

It’s unclear whether legislators intend to address that this session, but a spokesperson for the governor said that Newsom “clearly stated his position on the need for an extension” and that he “will continue to work with the legislature” on the matter.

Plans under CalPERS, the California Public Employees’ Retirement System, would have to comply by July 2027.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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It takes a lot of courage to grow old.

I’ve come to appreciate this after conversations with hundreds of older adults over the past eight years for nearly 200 “Navigating Aging” columns.

Time and again, people have described what it’s like to let go of certainties they once lived with and adjust to new circumstances.

These older adults’ lives are filled with change. They don’t know what the future holds except that the end is nearer than it’s ever been.

And yet, they find ways to adapt. To move forward. To find meaning in their lives. And I find myself resolving to follow this path as I ready myself for retirement.

Patricia Estess, 85, of the Brooklyn borough of New York City spoke eloquently about the unpredictability of later life when I reached out to her as I reported a series of columns on older adults who live alone, sometimes known as “solo agers.”

Estess had taken a course on solo aging. “You realize that other people are in the same boat as you are,” she said when I asked what she had learned. “We’re all dealing with uncertainty.”

Consider the questions that older adults — whether living with others or by themselves — deal with year in and out: Will my bones break? Will my thinking skills and memory endure? Will I be able to make it up the stairs of my home, where I’m trying to age in place?

Will beloved friends and family members remain an ongoing source of support? If not, who will be around to provide help when it’s needed?

Will I have enough money to support a long and healthy life, if that’s in the cards? Will community and government resources be available, if needed?

It takes courage to face these uncertainties and advance into the unknown with a measure of equanimity.

“It’s a question of attitude,” Estess told me. “I have honed an attitude of: ‘I am getting older. Things will happen. I will do what I can to plan in advance. I will be more careful. But I will deal with things as they come up.’”

For many people, becoming old alters their sense of identity. They feel like strangers to themselves. Their bodies and minds aren’t working as they used to. They don’t feel the sense of control they once felt.

That requires a different type of courage — the courage to embrace and accept their older selves.

Marna Clarke, a photographer, spent more than a dozen years documenting her changing body and her life with her partner as they grew older. Along the way, she learned to view aging with new eyes.

“Now, I think there’s a beauty that comes out of people when they accept who they are,” she told me in 2022, when she was 70, just before her 93-year-old husband died.

Arthur Kleinman, a Harvard professor who’s now 83, gained a deeper sense of soulfulness after caring for his beloved wife, who had dementia and eventually died, leaving him grief-stricken.

“We endure, we learn how to endure, how to keep going. We’re marked, we’re injured, we’re wounded. We’re changed, in my case for the better,” he told me when I interviewed him in 2019. He was referring to a newfound sense of vulnerability and empathy he gained as a caregiver.

Herbert Brown, 68, who lives in one of Chicago’s poorest neighborhoods, was philosophical when I met him at his apartment building’s annual barbecue in June.

“I was a very wild person in my youth. I’m surprised I’ve lived this long,” he said. “I never planned on being a senior. I thought I’d die before that happened.”

Truthfully, no one is ever prepared to grow old, including me. (I’m turning 70 in February.)

Chalk it up to denial or the limits of imagination. As May Sarton, a writer who thought deeply about aging, put it so well: Old age is “a foreign country with an unknown language.” I, along with all my similarly aged friends, are surprised we’ve arrived at this destination.

For me, 2025 is a turning point. I’m retiring after four decades as a journalist. Most of that time, I’ve written about our nation’s enormously complex health care system. For the past eight years, I’ve focused on the unprecedented growth of the older population — the most significant demographic trend of our time — and its many implications.

In some ways, I’m ready for the challenges that lie ahead. In many ways, I’m not.

The biggest unknown is what will happen to my vision. I have moderate macular degeneration in both eyes. Last year, I lost central vision in my right eye. How long will my left eye pick up the slack? What will happen when that eye deteriorates?

Like many people, I’m hoping scientific advances outpace the progression of my condition. But I’m not counting on it. Realistically, I have to plan for a future in which I might become partially blind.

It’ll take courage to deal with that.

Then, there’s the matter of my four-story Denver house, where I’ve lived for 33 years. Climbing the stairs has helped keep me in shape. But that won’t be possible if my vision becomes worse.

So my husband and I are taking a leap into the unknown. We’re renovating the house, installing an elevator, and inviting our son, daughter-in-law, and grandson to move in with us. Going intergenerational. Giving up privacy. In exchange, we hope our home will be full of mutual assistance and love.

There are no guarantees this will work. But we’re giving it a shot.

Without all the conversations I’ve had over all these years, I might not have been up for it. But I’ve come to see that “no guarantees” isn’t a reason to dig in my heels and resist change.

Thank you to everyone who has taken time to share your experiences and insights about aging. Thank you for your openness, honesty, and courage. These conversations will become even more important in the years ahead, as baby boomers like me make their way through their 70s, 80s, and beyond. May the conversations continue.

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

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Jessie Mazar squeezed the grab handle in her husband’s pickup and groaned as contractions struck her during the 90-minute drive from her home in rural northeastern California to the closest hospital with a maternity unit.

She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.

Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.

That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.

Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.

Declining birth rates, staffing shortages, and financial pressures have led 56 California hospitals — about 1 in 6 — to shutter maternity units over the past dozen years.

But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.

“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife Bethany Sasaki. “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”

Last month, state Assembly member Mia Bonta introduced legislation to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.

“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.

The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.

“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.

For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.

Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.

The first-of-its-kind “Plumas model” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.

But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDPH spokesperson said only that it was under review.

The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.

Numerous other regulations have made it difficult for birth centers to keep their doors open.

Since August, birth centers in Sacramento and Monterey have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state Department of Health Care Access and Information regulations as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.

She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.

“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.

She blamed her closure on “regulatory dysfunction.”

Legislation signed by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.

The state has taken two to four years to issue birth center licenses, according to a brief by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.

Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.

The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”

Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is considerably lower than in the U.S. More than 98% of American babies are born in hospitals.

Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the California Maternal Quality Care Collaborative has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of about $36,000 for a vaginal birth in a California hospital.

If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program, which covers low-income residents, paid for about 40% of the state’s births in 2022.

Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.

Lori Link, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.

“That would be convenient,” she said. “We’re not holding our breath.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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