SALINAS, Calif. — This coastal valley made famous by the novelist John Steinbeck is sometimes known affectionately as “America’s salad bowl,” though the planting and harvesting is done mostly by immigrants from Mexico.

For Taylor Farms, a major global purveyor of packaged salads and cut vegetables, that’s made it a logical place to pioneer a novel type of health care for its workforce, one that could have broad utility in the smartphone era: cross-border medical consultations through an app.

The company is among the first customers of a startup called MiSalud, which connects Spanish-speaking Taylor Farms employees to physicians and mental health therapists in Mexico. Providers aren’t licensed in the U.S. and can’t prescribe medications but instead serve as health coaches who can dispense advice and work with a U.S.-based doctor if needed.

Amy Taylor, who has led the company’s wellness initiative since 2014 and is the daughter-in-law of company founder Bruce Taylor, said about 5,600 of Taylor Farms’ 6,400 employees who work where MiSalud is currently available have signed up for the app, and 2,300 have used the app at least once. The service is free for employees and up to three family members.

Amy Taylor said the company hopes the app, which is part of a broader wellness program, can help employees stay healthier while keeping health care and other labor costs in check. She plans a full evaluation once the program has been in place for two years.

The health of farmworkers is a major concern for the state’s agricultural economy. A 2022 study led by researchers from the University of California-Merced evaluated the health of more than 1,200 farmworkers and found that 37% of men and 47% of women reported having at least one chronic condition, including common conditions such as diabetes, high blood pressure, and anxiety.

Taylor said her company’s employees, ranging from fieldworkers and drivers to retail packaging and office staff, mirror the study’s findings. She said predominant health concerns among workers include obesity, high blood pressure, diabetes, and mental health.

“These are the people who are feeding America healthy food,” Taylor said of the company’s employees. “They should also be healthy.”

MiSalud — or “My Health” — was the inspiration of Bismarck Lepe, a serial entrepreneur and Stanford graduate, who hails from a migrant farmworker family. Until age 6, when his family settled in Oxnard, California, they would travel between Mexico, California, and Washington state to harvest fruit. He saw that family and friends often delayed health care until they could return to Mexico because the U.S. system was too difficult to navigate, and insurance coverage too expensive or hard to find.

“My mother still prefers to get her health care in Mexico,” Lepe said. “It’s easier for her.”

Lepe and co-founders Wendy Johansson and Cindy Blanco Ochoa launched MiSalud Health in 2021 with $5 million from a venture capital fund backed by Melinda French Gates’ Pivotal Ventures, which focuses on social-impact investing. It has since added Samsung Next and Ulu Ventures as investors.

MiSalud started out by offering consultations with Mexican physicians for individuals who downloaded the app, Johansson said. But people keen enough to find the app, download it, and sign up for the program themselves weren’t ultimately those who needed it most, and in 2023 the company pivoted to offering its service to companies as an employee benefit. (Individuals can still use it too.)

Besides Taylor Farms, the company counts the California city of Lynwood among about a dozen other clients, according to Johansson. MiSalud touted that nearly 40% of employees served by its platform say that without the app they would either have ignored their health concerns or waited until they could travel to Mexico to see a doctor.

Paul Brown, a UC-Merced professor of health economics who contributed to the university’s farmworker health study, warned that telehealth consultations aren’t adequate substitutes for in-person care by a primary care physician or a specialist. However, “to the extent that these types of programs can kind of link people into more standard care, that’s good,” he added.

Brown said MiSalud’s approach could be more effective if policies changed to allow Mexican doctors to more easily treat patients in the U.S. A California program begun in 2002 allows Mexican doctors to travel to the Salinas Valley and other heavily Latino communities and treat patients, but cross-border telemedicine, even between states, remains limited.

Even so, Taylor Farms employees say the app has been helpful. Rosa “Rosita” Flores, a line supervisor with the company’s retail operations, said she decided to give MiSalud a try after co-workers raved about it.

A recent company wellness fair, partly sponsored by MiSalud, had alerted her to the importance of monitoring her blood sugar and blood pressure levels, so she booked an appointment on the app to discuss it. “The app is very easy to use,” she said in Spanish. When she had to cancel a video chat after her daughter got sick, the health coaches followed up by text.

Proponents of cross-border medicine say the approach helps bridge linguistic and cultural barriers in health care. Almost half of all U.S. immigrants — about two-thirds of whom are native Spanish speakers — have limited proficiency in English, and research has repeatedly shown that language barriers often discourage people from seeking care.

For example, Alfredo Alvarez, a MiSalud health coach who is a licensed physician in Mexico, pointed to belief in el mal de ojo, or the “evil eye” — the idea that a jealous or envious glance by someone can cause harm, especially to children. An American doctor might be dismissive of the notion, but he understands.

“This isn’t uncommon here,” he said of Mexico. “It’s a belief in traditional medicine.”

It’s not that Alvarez encourages his socios, or members, to pass an egg over the child or make the child wear a special bracelet — traditional ways of diagnosing and treating el mal de ojo. Rather, he acknowledges their traditions and steers them to evidence-based medicine.

MiSalud’s coaches can try to break stereotypes as well. For example, Alvarez said, a Mexican reverence for machismo can translate to the idea that “men don’t do doctor visits.” Meanwhile, he said, women may overlook their health in prioritizing other family members’ needs.

Coaches also try to remove the stigma around seeking mental health treatment. “A lot of our socios have been extremely uncomfortable with or wary of mental health professionals,” said Rubén Benavides Crespo, a MiSalud mental health coach who is a licensed psychologist in Mexico.

The app tries to break through by making it easy to book counseling appointments and asking questions such as whether someone has trouble sleeping, rather than invoking more worrisome or potentially stigmatizing terms like anxiety or depression.

MiSalud representatives say the app saw a 50% increase in requests for mental health support following the November presidential election. A more common request, however, is grief counseling, often following the loss of a loved one.

“Loss requires adaptation,” Benavides said.

For Sam Chaidez, director of operations for a Taylor Farms location in Gonzales, MiSalud is a welcome addition for weight management. The son of fieldworkers, Chaidez graduated from UC-Davis and returned to the Salinas Valley to work for the company in 2007.

In 2019, Chaidez, a new parent at the time, began to understand his risk for diabetes and other health problems because of Taylor Farms’ wellness program. Through diet and exercise and, more recently, coaching by MiSalud, Chaidez has shed 150 pounds.

Chaidez encourages co-workers to walk with him at lunch, and he credits MiSalud coaches for helping him keep the weight off and stay healthy. “It’s been a great help,” he said.

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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Gloria Sachdev has spent years challenging the health care industry, trying to bring down the high cost of care.

It’s working, even in an unlikely place: Indiana, which has had some of the nation’s highest hospital prices. Over the past few years, Indiana lawmakers have passed bills pushed by Sachdev that target complex and sometimes wonky health policy issues.

Sachdev, 55, trained as a pharmacist and for years led a coalition of Indiana businesses. In her quest to shake up the status quo, she sparked the creation of a national report on hospital pricing. She won over powerful Republican donor Al Hubbard, who has championed her proposals. She’s convened health care experts from across the country to tackle cost transparency. In turn, all this has elevated her profile in Indiana and beyond.

Now, this disruptor has ascended to a position of power in the Hoosier State. Indiana’s new Republican governor, Mike Braun, appointed her to a newly created Cabinet position overseeing the state’s health care agencies.

Republican leaders in Indiana have been receptive to Sachdev’s work, persuaded by her argument that the free-market approach of limited government intervention, long favored by the GOP, doesn’t work with health care.

“I believe in a free market, too,” she said.

But health care isn’t like a grocery store where shoppers have lots of options in the cereal aisle and can see the prices. Too often, Indiana patients are left with few choices and no price transparency, Sachdev said. That messaging has resonated with Indiana Republicans, she said, because they see it in their own communities.

A decade ago, when she began representing frustrated employers as chief executive of the Employers’ Forum of Indiana, she asked the businesses within that coalition to identify their biggest pain point: “They unanimously said health care affordability.”

Sachdev had spent years training as a pharmacist, pursuing a career in health care like her father. He was a researcher at the University of Oklahoma who made advances in decoding cystic fibrosis, a life-threatening genetic disorder that damages the lungs.

In her own career, Sachdev said, she has always sought answers to seemingly simple questions, driven by data and her belief that sound policy stems from rigorous analysis of the available evidence. So to examine the employers’ concerns, she sought to find out how health care prices in Indiana compared with those in other states. No such data existed at the time.

She cold-called Chapin White, then an economist at the Rand Corp. research organization, and persuaded him to help her find the answer. After some initial studies of Indiana, Rand published a study in 2019 that analyzed the prices paid by private health plans to more than 1,500 hospitals across the nation.

The results shocked her: Indiana landed at the top of the list, with the highest hospital prices among the 25 states initially studied. Sachdev was incredulous that her adopted state had earned such a dubious distinction. “We’re not New York City,” she said.

The results emboldened her — and state lawmakers — to take action. “When we’re highlighted like that, it certainly requires our attention,” said Chris Garten, the majority floor leader in the Indiana Senate and a former chair of the General Assembly’s oversight task force on health care costs.

The push for transparency also gained momentum nationally, leading President Donald Trump to issue an executive order in his first term that required hospitals to publicly disclose prices.

“Gloria was the catalyst for getting this started,” said Brown University economist Christopher Whaley, one of the other authors of the price transparency report while at Rand.

Consolidation has fueled higher prices in medical care. But Indiana is an outlier in how it chose to respond to consolidation, at least among red states, said Katie Gudiksen, executive editor of The Source on Healthcare Price and Competition, an online resource from the University of California Law-San Francisco.

Over the past few years, Indiana legislators have enacted laws to combat consolidation, banning large hospital systems from tacking on extra fees, restricting employers from imposing non-compete contracts on primary care physicians, and requiring health care companies to report pending mergers to the state’s attorney general.

Sachdev called the move to ban extra fees in some hospitals a major victory. Across the U.S., hospitals may add an extra charge to a bill, known as a facility fee, even when the visit happens outside the hospital at an affiliated doctor’s office. Indiana’s law not only lowers prices, she said, but also removes an incentive for hospitals to buy up physician practices for the purpose of tacking on a facility fee.

“All of our efforts are really in this space of increasing competition,” she said.

Last spring, Sachdev drew national medical pricing experts to Indianapolis for a conference on health care transparency. Celebrity entrepreneur Mark Cuban, a critic of high prices in the industry, was a keynote speaker.

At the conference, the latest installment of the Rand report was unveiled. Indiana had fallen from the top spot to the state with the ninth-highest prices.

Last fall, however, a hospital merger threatened to undo some of Sachdev’s wins in Indiana. Rival hospitals in Terre Haute were seeking to merge. The deal would have left the city and those in the surrounding rural areas with a hospital monopoly, and such consolidations elsewhere have been shown to raise medical prices.

Under the state’s Certificate of Public Advantage law, the deal would have been shielded from federal anti-monopoly restrictions. Two dozen states have had COPA laws on their books at some point, despite warnings from the Federal Trade Commission that such hospital mergers can become difficult to control and may decrease the overall quality of care.

The deal faced immense pushback. Doctors, health economists, and the FTC called on the Indiana Department of Health to deny Union Health’s application to merge with HCA Healthcare-owned Terre Haute Regional Hospital.

In an opinion piece in The Indianapolis Star, Sachdev urged regulators to consider the harm that came after similar mergers elsewhere.

“The evidence shows how deals, like the one in Terre Haute, can crush communities,” Sachdev wrote with Zack Cooper, a health economist and associate professor at Yale University.

In November, just days before the state was due to rule on the deal, Union Health withdrew its merger application.

“I was thrilled,” Sachdev said. “The writing was on the wall that it would have been denied.”

Now, Indiana state Sen. Ed Charbonneau, a Republican and chair of the Senate health committee, has introduced a bill to repeal the state’s COPA law. Indiana would become the sixth state to roll back such a law.

Describing Sachdev as aggressive and analytical, Charbonneau said she regularly shares her thoughts about the COPA law and other health care issues. “Gloria is not at all reluctant to come and talk to me or call me or text me,” he said.

When Braun appointed her as secretary of health and family services, he said in a statement that her “proven track record of transforming healthcare delivery and costs makes her the ideal choice to lead Indiana’s health initiatives.”

Braun’s health care agenda targets prices that “are robbing Hoosiers’ paychecks,” according to his campaign platform, which adds, “Without intervention, the strain will only get worse.”

In his second week as governor, Braun signed multiple executive orders seeking to increase transparency, directing state agencies to review the practices of pharmacy benefit managers and evaluate pricing. He also has said he plans to build on the legislature’s “ambitious work” of tackling affordability. With Republicans in control of the legislature, Braun is unlikely to encounter political gridlock, a reality that excites Sachdev.

“I’ve been working from the ground up, and we’ve made progress,” she said. “If I’m helping Gov. Braun from the top down, we can make faster, greater progress.”

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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SALINAS, California. — Este valle costero, que se hizo famoso gracias al novelista John Steinbeck, a veces se conoce cariñosamente como “la ensaladera de Estados Unidos”, aunque la siembra y la cosecha las realizan principalmente inmigrantes de México.

Para Taylor Farms, que es uno de los principales proveedores mundiales de ensaladas envasadas y verduras cortadas, esto lo ha convertido en un lugar ideal para implementar un innovador modelo de atención médica para sus empleados.

Este método, que podría llegar a tener gran utilidad en la era de los teléfonos inteligentes, es una aplicación que permite efectuar consultas médicas transfronterizas.

Taylor Farms es uno de los principales clientes de una startup llamada MiSalud, que pone en contacto a los empleados hispanohablantes de la empresa con médicos y terapeutas de salud mental en México.

Estos profesionales no tienen licencia en Estados Unidos y no pueden recetar medicamentos, pero actúan como consejeros de salud, colaborando, si es necesario, con un médico estadounidense.

Amy Taylor, que dirige esta iniciativa de promoción de la salud de la empresa desde 2014 y es la nuera de su fundador, Bruce Taylor, dijo que unos 5.600 de los 6.400 empleados de Taylor Farms se han registrado en MiSalud y 2.300 han utilizado la aplicación por lo menos una vez.

El servicio es gratuito para los empleados y hasta tres miembros de su familia.

Amy Taylor explicó que la empresa espera que la aplicación, que forma parte de un programa de bienestar más amplio, pueda ayudar a los empleados a mantenerse saludables y, al mismo tiempo, controlar tanto los gastos de la atención médica como otros costos laborales.

Está previsto realizar una evaluación completa de este programa una vez que haya estado en funcionamiento dos años.

La salud de estos trabajadores es una de las principales preocupaciones de la economía agrícola del estado.

Un estudio de 2022, dirigido por investigadores de la Universidad de California-Merced, evaluó la salud de más de 1.200 trabajadores agrícolas y descubrió que el 37% de los hombres y el 47% de las mujeres informaron que padecían al menos una enfermedad crónica, incluidas afecciones comunes como diabetes, hipertensión y ansiedad.

Taylor explicó que los empleados de la empresa, que abarcan desde trabajadores del campo y choferes hasta personal de empaque y empleados de oficina, tienen los mismos problemas que los participantes del estudio. Destacó que las principales preocupaciones de salud entre los trabajadores incluyen la obesidad, la hipertensión, la diabetes y la salud mental.

“Estas son las personas que alimentan a Estados Unidos con comida saludable”, dijo Taylor refiriéndose a los trabajadores de la compañía: “También deberían estar sanos”.

MiSalud fue resultado de la inspiración de Bismarck Lepe, un emprendedor de múltiples proyectos, graduado de la Universidad de Stanford, que proviene de una familia de trabajadores agrícolas migrantes.

Hasta los 6 años, cuando finalmente se estableció en Oxnard, California, toda la familia Lepe viajaba entre México, California y el estado de Washington para cosechar fruta.

Lepe observó que tanto su familia como los amigos a menudo retrasaban la atención médica hasta que podían regresar a México. El sistema de salud estadounidense les resultaba demasiado complicado y el seguro demasiado costoso o de difícil acceso.

“Mi madre sigue prefiriendo recibir atención médica en México”, dijo Lepe. “Para ella es más sencillo”.

Lepe y las cofundadoras Wendy Johansson y Cindy Blanco Ochoa lanzaron MiSalud Health en 2021 con $5 millones de un fondo de capital de riesgo respaldado por Pivotal Ventures, la firma de Melinda French Gates que se enfoca en inversiones de impacto social. Desde entonces, han sumado dos nuevos inversores, Samsung Next y Ulu Ventures.

MiSalud comenzó ofreciendo consultas con médicos mexicanos para las personas que descargaban la aplicación, contó Johansson.

Pero los que podían bajar la aplicación y registrarse por sí mismos no eran, en última instancia, los que más la necesitaban. Por eso, en 2023, la compañía dio un giro para ofrecer su servicio a las empresas como beneficio para los empleados. (Aunque los individuos también pueden seguir utilizándolo).

Además de Taylor Farms, MiSalud tiene entre sus clientes a la ciudad de Lynwood, en California, y a otra docena de empresas. La compañía asegura que casi el 40% de los empleados atendidos por su plataforma admiten que, sin la aplicación, hubieran ignorado sus problemas de salud o hubieran esperado hasta viajar a México para buscar atención médica.

Paul Brown, profesor de economía de la salud de la UC-Merced, colaboró en la investigación sobre el estado físico y  mental de los trabajadores agrícolas que efectuó la universidad. Advirtió que las consultas de telemedicina no sustituyen adecuadamente la atención presencial de un médico de atención primaria o un especialista.

Sin embargo, agregó: “En la medida en que este tipo de programas puedan conectar a las personas con una atención más estándar, son beneficiosos”.

Brown comentó que el enfoque de MiSalud podría ser más eficaz si se modificaran las políticas para permitir que los médicos mexicanos puedan atender a pacientes en Estados Unidos con más facilidad.

Un programa de California iniciado en 2002 permite que los médicos mexicanos viajen al Valle de Salinas y a otras comunidades con gran presencia de población latina para atender pacientes, pero la telemedicina transfronteriza, incluso entre estados, sigue siendo limitada.

Aun así, los empleados de Taylor Farms afirman que la aplicación ha sido útil. Rosa “Rosita” Flores, supervisora de línea de las operaciones minoristas de la empresa, dijo que decidió probar MiSalud después que sus compañeros de trabajo le hablaran bien de la aplicación.

En una reciente feria de bienestar de la empresa, patrocinada en parte por MiSalud, le hicieron notar la importancia de monitorear sus niveles de azúcar en sangre y la presión arterial, por lo que reservó una cita en la aplicación para hablar del tema.

“La aplicación es muy fácil de usar”, dijo. Cuando tuvo que cancelar una videollamada porque su hija se enfermó, los asesores de salud hicieron el seguimiento por mensaje de texto.

Los defensores de la medicina transfronteriza afirman que este enfoque ayuda a salvar las barreras lingüísticas y culturales en la atención médica.

En el país, casi la mitad de los inmigrantes —de los cuales aproximadamente dos tercios son hispanohablantes nativos— tienen un dominio limitado del inglés, y las investigaciones han demostrado muchas veces que las barreras lingüísticas a menudo disuaden a las personas de buscar atención médica.

Por ejemplo, Alfredo Álvarez, asesor de salud de MiSalud que es médico certificado en México, mencionó la creencia en el “mal de ojo”, la idea de que una mirada envidiosa o celosa de una persona puede causar daño, especialmente a los niños.

Un médico estadounidense podría descartar esa idea, pero Álvarez la comprende.

“Esto no es raro aquí”, dijo refiriéndose a  México. “Es una creencia de la medicina tradicional”.

No es que Álvarez anime a sus los usuarios de la aplicación a pasar un huevo por encima del niño o a hacer que el niño lleve una pulsera especial, formas tradicionales de “diagnosticar” y tratar el mal de ojo. Más bien, reconoce sus tradiciones y los orienta hacia la medicina basada en la evidencia.

Los asesores de MiSalud también pueden intentar romper con estereotipos.

Por ejemplo, Álvarez dijo que la arraigada cultura machista de México puede traducirse en la idea de que “los hombres no van al médico”. Mientras tanto, agregó, las mujeres pueden descuidar su salud porque priorizan las necesidades de otros miembros de la familia.

Los asesores también intentan eliminar al estigma que rodea a la búsqueda de tratamiento de salud mental. “Muchos de nuestros ‘socios’ se han sentido extremadamente incómodos o recelosos ante los profesionales de salud mental”, dijo Rubén Benavides Crespo, asesor de MiSalud en este campo y psicólogo titulado en México.

La aplicación intenta romper el hielo facilitando la reserva de las consultas de asesoramiento y haciendo preguntas del estilo de si alguien tiene problemas para dormir, en lugar de invocar términos más preocupantes o potencialmente estigmatizantes como ansiedad o depresión.

Los representantes de MiSalud informaron que la aplicación experimentó un aumento del 50% en las solicitudes de apoyo para la salud mental tras las elecciones presidenciales de noviembre. Sin embargo, una solicitud más común es el asesoramiento para el duelo, a menudo tras la pérdida de un ser querido.

“La pérdida requiere adaptación”, señaló Benavides.

Para Sam Chaidez, director de operaciones de una planta de Taylor Farms en Gonzales, California, MiSalud es un apoyo adicional para el control de peso.

Hijo de trabajadores del campo, Chaidez se graduó en la Universidad de California en Davis y regresó al Valle de Salinas para trabajar en la empresa en 2007.

En 2019, Chaidez, que acababa de ser padre, empezó a comprender el riesgo de padecer diabetes y otros problemas de salud gracias al programa de bienestar de Taylor Farms. A partir de la dieta y el ejercicio y, más recientemente, al asesoramiento de MiSalud, Chaidez ha perdido 150 libras (68 kilos).

Ahora anima a sus compañeros de trabajo a caminar con él a la hora de comer, y atribuye a los asesores de MiSalud el mérito de haberlo ayudado a no recuperar el peso perdido y a mantenerse sano. “Ha sido una gran ayuda”, señaló.

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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OCR Opens Compliance Reviews of Four Medical Schools over Protests Taking Place during Their 2024 Commencement Ceremonies.

Max Schachter wanted to be close to his son Alex on his birthday, July 9, so he watched old videos of him.

“It put a smile on my face to see him so happy,” Schachter said.

Alex would have turned 21 that day, six years after he and 16 other children and staff at Marjory Stoneman Douglas High School in Parkland, Florida, were shot and killed by a former student in 2018. In the years before the shooting, that former student had displayed concerning behavior that elicited dozens of calls to 911 and at least two tips to the FBI.

“Alex should still be here today. It’s not fair,” Schachter said.

After two weeks of grieving Alex’s death, Schachter, propelled by anger and pain, began advocating for school safety. In part, he wanted to ensure his three other children would never be harmed in the same way. He joined the newly formed Marjory Stoneman Douglas High School Public Safety Commission to improve the safety and security of Florida’s students. And he launched a nonprofit bearing Alex’s name, which advocates for school safety.

Doing that work, he learned about threat assessment teams, groups of law enforcement and school officials who try to identify potentially dangerous or distressed kids, intervene, and prevent the next school shooting. Florida is one of about 18 states that require schools to have threat assessment and intervention teams; a national survey estimates 85% of public schools have a team assigned to the task.

The teams, whose mission and operational strategies often are based on research from the FBI and the Secret Service’s National Threat Assessment Center, or NTAC, have become more common as the number of school shootings has increased. Despite their prevalence for almost 25 years, some of the teams have developed systemic problems that put them at risk of unfairly labeling and vilifying children.

States vary widely in their requirements of threat assessment teams and there isn’t a nationwide archetype. Few school districts and states collect data about the teams, little is known about their operations, and research on their effectiveness at thwarting mass shootings and other threats is limited. But a 2021 analysis by the NTAC of 67 plots against K-12 schools found that people “contemplating violence often exhibit observable behaviors, and when community members report these behaviors, the next tragedy can be averted.”

“School shooters have a long thought process. They don’t just snap. They have concerning behavior over time. If we can identify them early, we can intervene,” said Karie Gibson, chief of the FBI’s Behavioral Analysis Unit.

Yet, Dewey Cornell, a forensic clinical psychologist who in 2001 developed one of the first sets of guidelines for school threat assessment teams, said there have been problems. In many cases, he said, threats have been deemed not serious “but parents and teachers are so alarmed that it is difficult to assuage their fears. The school community gets in an uproar and the school administrators feel pressured to expel the student.”

And in other cases, a school doesn’t do a threat assessment and assumes a student is dangerous when somebody else reports them as a threat, and they may take a zero tolerance approach and remove them from the school, said Cornell, the Virgil S. Ward professor of education at the University of Virginia.

A task force convened by the American Psychological Association found little evidence that zero tolerance policies have improved school climate or school safety and said they may create negative mental health outcomes for students. The task force cited examples of students who were expelled for incidents or school rule violations as minor as having a knife in their lunch box for cutting an apple.

Marisa Randazzo, a research psychologist and the director of threat assessment for Georgetown University, said she has also seen “hyperreactions,” especially among school communities that have experienced a mass killing.

“It’s understandable. People who have been close to an event like this are on higher alert than other people,” said Randazzo, who previously worked for the Secret Service and co-founded Sigma Threat Management Associates.

Threat assessments are supposed to be a graduated process calibrated to the seriousness of a problem, since the majority of student threats are not credible and can be resolved through supportive interventions, according to research from the Secret Service.

Stephanie Crawford-Goetz, a school psychologist and the director of mental health for student support services in the Douglas County School District in Colorado, where a shooting occurred at a charter school in 2019, said her district’s threat assessment process emphasizes a proactive, rehabilitative approach to managing potential threats, as the NTAC suggests.

Crawford-Goetz said her district interviews students before convening the team to assess whether a threat is a misguided expression of anger or frustration and if the student has a plan and means to carry out violence.

Students whose threats are deemed transient receive support, such as help with coping skills, and they may meet with a mental health provider.

If the threat is credible, a student may be temporarily removed from the classroom or school.

Randazzo said the vast majority of kids who make threats are suicidal or despondent: “The process is designed primarily to figure out if someone is in crisis and how we can help. It is not designed to be punitive.”

Crawford-Goetz tells parents about her district’s threat assessment team at the beginning of the school year. Some districts report keeping their teams a secret from parents, which is not how they were designed to operate, said Lina Alathari, chief of the NTAC. Her team encourages schools to educate the whole community about the threat assessment process.

Some advocacy groups contend that threat assessment teams have perpetuated inequities. There has also been widespread concern that children with disabilities can easily get swept into a threat assessment.

In a 2022 report, the National Disability Rights Network, a nonprofit based in Washington, D.C., said some threat assessment teams have become “judge, jury, and executioner,” going beyond assessing risk of serious, imminent harm to determining guilt and punishment.

Expanding their scope allows threat assessment teams to get around civil rights protections, the report says.

Cornell disputed the disability rights group’s conclusion. “This has not been corroborated by scientific studies and is speculative,” he said.

Some states, such as Florida, mandate that threat assessment teams determine whether a student’s disability played a role in their behavior and recommend they include special education teachers and other professionals in their evaluation.

In Texas, which has mandated threat assessment teams, a third of students subjected to threat assessments in the Dallas Independent School District receive special education services.

Yet, the district doesn’t have a special education staff representative on its threat assessment team, according to a March 2023 report by Texas Appleseed, a nonprofit public interest justice center.

Many school districts are developing their own models in the absence of national standards for threat assessments.

Florida revamped its threat assessment system in January 2024 to improve response times, provide consistent data collection, and build in more checks and balances and oversight, said Pinellas County Sheriff Bob Gualtieri, who is also chair of the Marjory Stoneman Douglas High School Public Safety Commission.

The new model requires the teams to work quickly and file uniform, electronic summary reports of threat assessment findings. Those results follow students throughout their school years.

The adjustments are intended to eliminate the risk of not knowing about a student’s past troubling behavior if they change schools, as occurred with the Parkland shooter and a student who shot and killed classmates at a high school near Winder, Georgia, in September, said Gualtieri.

“As parents, you never stop worrying about your kids,” Schachter said.

Virginia mandates that all public schools and higher education institutions, including colleges, have threat assessment teams. In Florida, where one of Schachter’s daughters attends college, threat assessment teams are mandated in all public schools, including charter schools.

“There’s more work to be done,” Schachter said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management 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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WALHALLA, S.C. — Nestled in the foothills of the Blue Ridge Mountains, a small primary care clinic run by Clemson University draws patients from across the region. Many are Hispanic and uninsured, and some are willing to travel from other counties, bypassing closer health care providers, just to be seen by Michelle Deem, the clinic’s bilingual nurse practitioner.

“Patients who speak Spanish really prefer a Spanish-speaking provider,” Deem said. “I’ve gotten to know this community pretty well.”

Clemson doesn’t operate an academic medical center, nor does it run a medical school. Arguably, the public university is best known for its football program. Yet, with millions of dollars earmarked from the state legislature, it has expanded into delivering health care, with clinics in Walhalla and beyond. School leaders are attempting to address gaps in rural and underserved parts of a state where health outcomes routinely rank among the worst in the country.

“Some of these communities have such high need,” said Ron Gimbel, director of Clemson Rural Health, which operates four clinics and a fleet of mobile health units as part of the university’s College of Behavioral, Social and Health Sciences. “They have so many barriers that impact their ability to be healthy.”

Clemson Rural Health is one of several programs attempting to meet this need in the state.

“Rural health is trendy,” said Graham Adams, CEO of the South Carolina Office of Rural Health.

State lawmakers nationwide are spending millions of dollars to address a rural health care crisis long in the making. For more than a decade, though, Republican-controlled legislatures in most Southern states have refused billions in federal funds that would provide public health insurance coverage to more low-income adults. These are the same states where racial health disparities and health outcomes are often worse than in other regions.

Nearly every state has extended Medicaid coverage for women in the months after they give birth. But 10 states haven’t fully expanded Medicaid coverage with federal money made available under the 2010 Affordable Care Act. Seven of these states — Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas — are in the South. With few exceptions, adults without children in these states don’t qualify for Medicaid coverage, regardless of their income level.

Georgia Gov. Brian Kemp and South Carolina Gov. Henry McMaster, both Republicans, recently announced plans to expand Medicaid in limited ways to include some parents. The South Carolina plan would impose work requirements on some of these newly eligible Medicaid beneficiaries, while the Georgia plan would allow some parents of young children to skirt the state’s existing Medicaid work rules. Both plans require federal approval.

Jonathan Oberlander, a professor and health policy scholar at the University of North Carolina, said he doesn’t expect to see any of the remaining states rushing to fully expand Medicaid. Before Donald Trump took office on Jan. 20, Republicans in Washington had already expressed their intention to dramatically cut spending for Medicaid, which covers 72 million people at a cost of nearly $900 billion.

“There’s a large gray cloud hanging over Medicaid expansion right now, and that’s because there’s so much uncertainty about what the Trump administration and congressional Republicans are going to do,” Oberlander said.

Even so, in South Carolina this year the advocacy group CoverSC plans to lobby the General Assembly to pass a bill to adopt Medicaid expansion, said Beth Johnson, regional government relations director for the American Cancer Society Cancer Action Network and a CoverSC board member. The state’s legislative session began Jan. 14.

If such a measure were approved, the federal government would cover 90% of the state’s Medicaid expansion costs and South Carolina would be expected to pay 10%, or an estimated $270 million during the first year, according to a 2024 report by the Milken Institute School of Public Health at George Washington University.

Across all 10 non-expansion states — which, outside the South, also include Kansas, Wisconsin, and Wyoming — about 1.5 million people fall into a coverage gap, according to 2024 estimates from KFF, the health information nonprofit that includes KFF Health News. That means they do not qualify for Medicaid coverage or financial assistance to buy insurance through the federal marketplace.

Many of the people who would qualify for Medicaid if these states were to expand eligibility are gig workers, Johnson said. They play music, drive for Uber, or deliver pizza, and they typically don’t qualify for health insurance through their jobs.

“They are providing services that we all appreciate,” she said. “And they simply can’t afford health insurance.”

In some South Carolina communities, Clemson Rural Health attempts to fill this gap by providing primary care, cancer screenings, nutrition education, and diabetes management for uninsured patients free of charge or at reduced rates. Only about half of the patients seen by Clemson Rural Health have health insurance, Gimbel said, compared with 92% of the U.S. population.

During the current state fiscal year, Clemson Rural Health has been underwritten by a $2.5 million contract, its largest source of funding, from the state Department of Health and Human Services, which administers Medicaid in South Carolina and operates with a budget approved by state lawmakers.

That’s a relatively small amount of money compared with the $47.5 million the state legislature has given to the Medical University of South Carolina in recent years to move into rural communities. MUSC has served Charleston for most of its 200-year history, but since 2019 it has expanded across the state by purchasing, building, or partnering with seven rural hospitals — some on the brink of closure — and one freestanding emergency department. MUSC is set to open an additional rural hospital this year.

Other states have made similar investments. The University of Georgia, for example, has established a new medical school, partly to send more physicians into underserved and rural areas. The Georgia General Assembly kicked in half the cost of a new $100 million building for medical education and research in Athens.

Meanwhile, the Tennessee General Assembly passed a budget last year that included $81 million for a variety of rural health initiatives.

Outside the South, state legislatures in Colorado, Nevada, West Virginia, and elsewhere have made recent investments in rural health, in addition to expanding Medicaid eligibility.

Some of this spending has been prompted by a wave of rural hospital closures — more than 100 since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

It’s not yet clear what long-term impact some of these initiatives will have — for instance, whether the Clemson program will “reduce premature mortality, decrease preventable hospitalizations, and improve overall quality of life,” as it aims to do, according to its website. Some public health experts point out that bolstering the number of rural clinics, hospitals, and doctors in the South won’t matter much if patients can’t afford to make an appointment.

“Lack of ability to pay is one of the greatest barriers,” said Adams, the Office of Rural Health chief.

Oberlander said conservative lawmakers often consider projects such as building new rural clinics more politically palatable than expanding Medicaid coverage.

“The further away you get from the ACA, the less polarized the politics of health care,” he said.

South Carolina Senate President Thomas Alexander, a Republican who lives in Walhalla, said the General Assembly is willing to invest in some rural health initiatives to improve health care access.

“Just because you expand Medicaid doesn’t mean you’ve expanded access to the services,” Alexander said. “I want to focus on expanding access to the services.”

Gimbel would not comment on Medicaid expansion in South Carolina, and he said it’s too soon to know how federal Medicaid changes under the Trump administration might affect funding for Clemson Rural Health, which currently receives money from the state’s Medicaid agency. But making the Clemson program financially solvent might take several more years, he said.“If rural health was profitable,” he said, “we wouldn’t have a rural health problem.”

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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KFF Health News senior correspondent Arthur Allen discussed what to watch for in Robert F. Kennedy Jr.’s confirmation hearings for secretary of Health and Human Services on CBS News Chicago on Jan. 29.

• Click here to watch Allen on CBS News Chicago
• Read Allen’s “What RFK Jr. Might Face in His Nomination Hearings This Week”

KFF Health News editor-at-large for public health Céline Gounder discussed why the CIA has “low confidence” in its assessment of the origins of the covid-19 virus on CBS News 24/7 on Jan. 27.

• Click here to watch Gounder on CBS News 24/7

KFF Health News senior correspondent Noam N. Levey discussed the Consumer Financial Protection Bureau’s final rule to remove medical debt from consumer credit reports on PBS’ “PBS News Weekend” on Jan. 25.

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• Read the KFF Health News series “Diagnosis: Debt”

KFF Health News contributor Sue O’Connell discussed Montana’s mental health facilities on Billings’ KTVQ on Jan. 24.

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• Read O’Connell’s “Montana Eyes $30M Revamp of Mental Health, Developmental Disability Facilities,” co-reported with Mike Dennison

KFF Health News senior correspondent Renuka Rayasam discussed bird flu in Georgia on WUGA’s “The Georgia Health Report” on Jan. 24.

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• Read Amy Maxmen’s “How America Lost Control of the Bird Flu, Setting the Stage for Another Pandemic”

KFF Health News chief Washington correspondent Julie Rovner discussed the nomination of Robert F. Kennedy Jr. for secretary of Health and Human Services on CBS News on Jan. 22.

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KFF Health News correspondent Molly Castle Work discussed mental health specialists’ role in the Los Angeles wildfire response on America’s Heroes Group on Jan. 22.

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• Read Work’s “Amid Wildfire Trauma, L.A. County Dispatches Mental Health Workers to Evacuees”

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President Donald Trump ratcheted up his administration’s reversal of transgender rights on Tuesday with an executive order that seeks to intervene in parents’ medical decisions by prohibiting government-funded insurance coverage of puberty blockers or surgery for people under 19.

Trump’s order, titled “Protecting Children From Chemical and Surgical Mutilation,” is certain to face legal challenges and would require congressional or regulatory actions to be fully enacted. But transgender people and their advocates are concerned it will nonetheless discourage prescriptions and medical procedures they consider to be lifesaving in some cases, while complicating insurance coverage for gender-affirming care.

“It can’t be understated how harmful this executive order is, even though it doesn’t do anything on its own,” said Andrew Ortiz, a senior policy attorney at the Transgender Law Center. “It shows where the administration wants to go, where it wants the agencies to put their efforts and energies.”

The order is one of several Trump has issued, less than two weeks since taking office, that target the trans community. He has directed his administration to recognize only the male and female sex — and to abandon the term “gender” altogether. He ordered the State Department to issue passports identifying Americans only by their genders assigned at birth. He has encouraged the Justice Department to prosecute teachers and other school officials who help trans children transition, including by using their preferred names. And he signed an order that’s expected to lead to transgender people being banned from military service.

“We’re terrified. We cry every day. Hurting my family and my kid is winning politics for Republicans right now,” said the parent of a transgender child who lives in Missouri and asked not to be identified for fear of being targeted. “Every bone in my body is telling me I can’t keep my child safe from my government anymore, I can’t keep my family safe.”

About 300,000 American children ages 13-17 identify as transgender, according to the Williams Institute at the UCLA School of Law, which researches sexual orientation and gender identity law and public policy. But the number who seek gender-affirming care is believed to be far fewer. An examination by Reuters and Komodo Health of about 330 million health insurance claims filed from 2017 to 2021 found that fewer than 15,000 patients ages 6 to 17 with a diagnosis of gender dysphoria had received gender-affirming hormone therapy and fewer than 5,000 had started puberty-blocking medications — though the annual number of such patients more than doubled over the five-year span.

Trump’s order seeking to disrupt insurance coverage for young people, the Williams Institute said in a brief, “will likely at least limit the availability of gender-affirming care or make it more difficult to access in the short term and could increase risk for both providers and recipients of the care.”

Much of what the order calls for would require rule changes or other federal guidance, which can take weeks to months. Though it is mostly directed toward government health insurance programs, the order could have private-sector implications, too, and is likely to face litigation from states or advocacy organizations.

Specifically, the directive intends to limit insurance coverage for hormonal or surgical treatments that help young people transition.

It directs the secretary of the Department of Health and Human Services to “take all appropriate steps” to end insurance coverage of such treatments. It specifically names several government programs such as Tricare, which serves the military and its dependents; Medicare and Medicaid; federal and postal health benefit programs; and the Foreign Service Benefit Plan.

“The aim here is clearly targeted at federally funded plans, such as Medicare and Medicaid, but there’s a lack of clarity as to whether it would impact other plans, such as exchange plans, where essential health benefits are required,” said Lindsey Dawson, director of LGBTQ Health Policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

State Medicaid programs vary widely in their rules around transgender care, with a variety of limits or restrictions on what types of care can be covered for minors in just over half the states, according to a map provided by the Colorado-based Movement Advancement Project, a nonprofit think tank.

While little is likely to happen immediately from the order — one of more than 100 issued by the president since his inauguration last week — it could, nonetheless, have a chilling effect on medical professionals.

The order directs the Department of Justice to work with Congress to promote legislation that would allow children and parents a “private right of action” — the ability to file a lawsuit — against medical professionals who provide transgender care.

And the Justice Department was also directed to consider the application of existing laws to those who provide or promote access to gender care.

In addition, one section of the order directs agencies to “take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children,” a move that could affect hospitals or medical schools.

Julian Polaris, a partner at the consulting firm Manatt, said the order “displays the federal government’s willingness to use federal programs to restrict access to disfavored services even to providers and patients outside those federal programs.”

The move drew immediate criticism from groups supporting LBGTQ+ people’s rights.

“It is unconscionable that less than 24 hours after trying to take away Head Start programs and school meals for kids, President Trump issued an order demonizing transgender youth and spreading dangerous lies about gender-affirming care,” Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America, wrote in a press release.

Because it defines “youths” as those under age 19, the order would apply the directives to medical treatments provided to 18-year-olds, who otherwise are considered adults in making legal choices, voting, or serving in the military.

“There’s also just a problem with not seeing young people as capable in making decisions around their health and their futures, and so blurring that line and trying to move it up and taking more control over more people is obviously concerning,” Ortiz said. “But having the line hard at 18 also doesn’t make it any better.”

Ortiz noted that the order contains misinformation about medical care for young people who are transitioning and targets a small subset of U.S. residents: transgender youths in families that can access and afford gender-affirming care.

“That should be concerning to everybody,” he said, “that they are pulling out populations to target, to say that, ‘We don’t think that you deserve access to best-practice medical care.’”

Trump’s order explained that the action was necessary because such medical treatment could cause young people to regret the move later, once they “grasp the horrifying tragedy that they will never be able to conceive children of their own or nurture their children through breastfeeding.”

KFF Health News Midwest correspondent Bram Sable-Smith contributed to this report.

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Montana lawmakers are grappling with what they can do to improve patient care and operations at the state’s psychiatric hospital since realizing that the efforts underway to restore the troubled facility’s good standing could take more time.

The nearly 150-year-old Montana State Hospital has recently struggled to care for patients and retain staff. The problems came to a head in 2022, when federal investigators yanked the hospital’s federal certification — and funding — from the Centers for Medicare & Medicaid Services because of a pattern of patient deaths found to be preventable, as well as injuries and falls.

Since then, Republican Gov. Greg Gianforte’s administration has launched a complex and expensive overhaul of the Montana State Hospital’s operations with the goal of regaining certification. That outcome may require years more work and tens of millions in additional funding from the Republican-majority legislature.

At least some lawmakers begrudgingly acknowledge the protracted scenario, reflecting on the time spent trying to pressure the state health department to move at a faster pace.

“I think it’s going to be done when it’s done,” said Republican Sen. Dennis Lenz, a longtime lawmaker who sits on the health department’s budget committee in the state legislature. “It’s like telling your teenager, ‘Come on, get your act together. Come on, put your clothes away.’”

Lawmakers in this session have the power to add or restrict money for Gianforte’s health department and write laws related to state hospital oversight, admissions, and discharge processes.

Health officials in the Gianforte administration are neck-deep in efforts to renovate the facility, slow its revolving door of leaders, and increase staff retention. Lawmakers are instead turning their attention toward ways to strengthen mental health services outside the hospital — an effort urged on by other mental health care advocates.

“I think the future of the hospital, and whether or not it will improve enough to be considered meeting the minimum federal standards for a hospital, rests on whether or not Montana can build up its community-based services,” said David Carlson, executive director of Disability Rights Montana, a federally appointed watchdog group that advocates for patients in state facilities. “They’re so interlinked. And we’re putting too much pressure on a singular hospital in Warm Springs.”

The state hospital’s campus, located in southwestern Montana near Butte, treats criminally and civilly committed patients. Inspectors decided to decertify the hospital after identifying numerous violations of patient care standards, including deaths, infection control issues related to covid-19, repeated falls, and medication mismanagement that amounted to “chemical restraints.”

In the wake of that loss, the hospital’s top-level leadership has rotated through five administrators. Medical staffers have strongly criticized new mandates and changing protocols. The facility relies on expensive contracted health professionals, and, until this month, a consulting firm to oversee the hospital’s operations. Waitlists for the unit of criminally charged patients are persistently long, bogging down court cases and leaving suspects incarcerated in jails throughout the state.

In mid-January presentations to lawmakers, state health officials gave mixed reviews about how the hospital is improving.

The facility has discontinued the use of chemical restraints entirely, officials said, and recently hired a permanent CEO and chief medical officer. Doug Harrington, Montana’s state medical officer, said the facility is also seeing more interest from prospective employees applying for open positions.

“The short answer is yes, things are changing. And it will take time; it’s not going to happen overnight. But the seeds have already been planted, and we’re seeing some of the fruit growing up,” Harrington told lawmakers on the health department’s budget subcommittee.

Harrington also acknowledged that the timeline for regaining certification from CMS was pushed back to 2026 due to physical repairs at the central hospital.

“When you start tearing the wall out, you frequently find fungus, black mold, infectious agents in the water of the cooling systems,” he said. “We need to shut down an entire wing and move those patients somewhere else so that that can be sealed off and worked on.”

Last fall, the state began moving patients to a 20-bed space in Helena leased from Shodair Children’s Hospital to allow for the renovation of one of the hospital’s wings.

In total, the Gianforte administration has requested that the legislature greenlight a one-time allocation of almost $61.5 million to continue to cover the cost of contracting clinical and nursing staff at the state hospital. The facility’s two-year budget, including that request, is more than $167 million.

Another high-priority upgrade for the hospital is the creation of a comprehensive electronic health records system.

Funding for that project — approximately $27.6 million to cover all state facilities — was originally approved by the legislature in 2023. But state officials have yet to ink a contract for the electronic system, and they say the cost could change during negotiations with a future vendor.

The state estimated in January that the electronic records project, from development to implementation, would take three years. A spokesperson for the hospital said the department expects to have a contract signed and to begin that timeline in March.

Previous efforts to legislate change at the hospital are still in motion. Lawmakers passed a bill with bipartisan support in 2023 that directed the state to move patients with a primary diagnosis of dementia, such as Alzheimer’s disease, or a traumatic brain injury out of the hospital and into community-based facilities better equipped to care for patients with memory issues and other cognitive disabilities.

The bill set a deadline for those patients to be moved by the end of this June. Jennifer Carlson, a former Republican lawmaker who chairs a committee to oversee that transition, said the department still has patients in residence who are subject to the legislation, but she’s feeling optimistic about meeting that target.

Another bill from 2023 required the state health department to share unredacted abuse and neglect reports with Disability Rights Montana, the designated federal civil rights inspector. But since the law took effect, staff turnover and changing protocols at the hospital made for inconsistent application of the law, officials with the advocacy group said.

David Carlson of Disability Rights Montana, who is not related to Jennifer Carlson, said lawmakers’ and advocates’ time may be better spent this session on trying to reduce the number of patients that hospital staffers are struggling to care for. One strategy is to finalize the transfer of memory-care patients targeted by the 2023 law to community-based facilities, he said, and help grow local mental health crisis services.

Even with those changes, he added, the responsibility for high-quality patient care rests with the Gianforte administration and the hospital’s leadership team.

Ultimately, if medical standards and internal protocols don’t improve, David Carlson said, the last branch of government that can put a check on the hospital’s operations is the judiciary. Disability Rights Montana has previously represented patients suing state institutions over civil rights violations and errors in patient care.

“That’s not a threat. That’s just a description of how this all works,” Carlson said. “Accountability will come from some branch of government. The administration can embrace it themselves and get ahead of it. The legislature can lay it on there, or we can have the courts do it.”

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During her annual OB-GYN visit, Callie Anderson asked about getting off the birth control pill.

“We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered to retired state police.

“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson said.

She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well.

“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus.

Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs. Last year, federal health officials recommended doctors discuss pain management with patients beforehand, including options such as lidocaine shots and topical anesthetics.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

It’s unclear how many Americans have such coverage. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of covered workers were still on “grandfathered” plans.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she said.

Mike McMullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

The Pennsylvania State Troopers Association, which offers some retirees the plan that covered Anderson, did not respond to requests for comment. Highmark Blue Cross Blue Shield, the insurer, referred questions to the state.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”

A benefit handbook for the plan identifies it as grandfathered and lists a variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, said Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

She said most insurers cover the devices, but coverage can vary, too. For instance, some cover only certain types or brands of contraceptives. Generally, an IUD insertion costs $500 to $1,500, she added.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she said.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income.

“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she said. The billing office, she said, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”

Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

With birth control, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn said. “It’s incredibly hard to be an advocate for yourself.”

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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.

Robert F. Kennedy Jr., President Donald Trump’s nominee to lead the Department of Health and Human Services, came under sharp questioning from Democrats and some Republicans at his confirmation hearings this week before two Senate committees. Of particular interest were the doubts about Kennedy’s qualifications and past anti-vaccination positions raised by Sen. Bill Cassidy (R-La.), who is a physician — and, notably, a member of the Senate Finance Committee, which is expected to vote next week on whether to advance Kennedy’s nomination to the Senate floor.

 Meanwhile, a federal government memo temporarily freezing a lot of federal grant and loan funding touched off confusion and recriminations at the new Trump administration for its sudden, sweeping actions.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, and Sarah Karlin-Smith of the Pink Sheet.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

• During appearances before two Senate committees, Kennedy assured lawmakers he would follow science and defer to Trump’s policy preferences. But he also made mistakes that are notable for someone vying to lead the nation’s top health agency, such as confusing the Medicaid and Medicare programs.
• As Kennedy’s second hearing concluded, it was not immediately clear whether he would earn the votes needed to be confirmed by the full Senate — especially as at least one key Republican, Cassidy, seemed less than convinced. If every Democrat and independent votes against him, Kennedy could lose just a few GOP votes and still be confirmed.
• Much of the nation’s health system — alongside many, many other entities that rely on federal funding — experienced a kind of whiplash early this week, as the Trump administration’s Office of Management and Budget issued a memo freezing federal grants and loans until they could be reviewed for adherence to Trump’s priorities. A federal judge temporarily blocked the freeze from taking effect, and OMB revoked the memo — but the White House said Trump’s recent executive orders affecting funding “remain in full force and effect, and will be rigorously implemented.”
• In other Trump administration news, Trump fired a slew of inspectors general late last week — including the one who oversees HHS and the nation’s health system. And an executive order affecting health care for trans children has many parents and advocates on edge.

Also this week, Rovner interviews Nicholas Bagley, a University of Michigan law professor, who explains how the federal regulatory system is supposed to operate to make health policy.

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

Julie Rovner: 404 Media’s “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Costs Six Figures,” by Jason Koebler.

Sandhya Raman: ProPublica’s “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” by Mary Hudetz and Hannah Bassett.

Sarah Karlin-Smith: CBS News’ “Wind-Blown Bird Poop May Help Transmit Bird Flu, Minnesota’s Infectious Disease Expert Warns,” by Mackenzie Lofgren.

Also mentioned in this week’s podcast:

KFF Health News’ “Trump’s Funding ‘Pause’ Throws States, Health Industry Into Chaos,” by Phil Galewitz.

Click to open the transcript Transcript: RFK Jr. in the Hot Seat

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 30, at 1:30 p.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sandhya Raman of CQ Roll call. 

Sandhya Raman: Hi, everyone. 

Rovner: And Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi there. 

Rovner: Later in this episode, we’ll have my interview with University of Michigan law professor Nicholas Bagley, who will break down for us how the federal regulatory system is supposed to work when it comes to health. But first, how is it still January? 

We are coming to you a little later than usual today because we have been watching hearings on Capitol Hill, where Health and Human Services Secretary-designate Robert F. Kennedy Jr., who was called a “predator” in a video earlier this week posted by his cousin Caroline Kennedy, appeared for his confirmation hearings. On Wednesday, he was at the Senate Finance Committee. Earlier today, he was at the Senate Health, Education, Labor, and Pensions Committee. A reminder, only the Finance Committee actually gets to vote on whether to send this nomination to the floor. I think it’s safe to say there was a lot to chew over in these two days of hearings. But first, do we have any idea how likely he is to be confirmed by the full Senate? 

Karlin-Smith: It seems like it’s going to be close. Yesterday, I didn’t hear any notable concerns necessarily from Republicans. It seemed like all the Senate Finance Republicans didn’t have any huge issues with his nomination, although I guess I should say one of the people on that committee is the chair of the one we saw today, and he didn’t quite make his opinion known. 

And then today the Senate health committee chair, Bill Cassidy, who is a doctor, made it very clear that he is not happy with Kennedy’s views on vaccines, and that he talks about some very personal moments in his career where he experienced the death of a particular young woman who was unvaccinated and it could have been prevented if she was. And Cassidy didn’t quite indicate where he’s going, but it seems like it may be hard for Kennedy to get him to a yes, because it seemed like Cassidy was giving him a lot of chances today, and oftentimes Kennedy was kind of saying the wrong answer of what Cassidy wanted to hear on vaccinations. And there’s a few other Republicans, I think, in a similar boat there, so it’s probably going to be close, but— 

Rovner: Yeah, and of course Cassidy, who’s the chairman of the health committee, is one of the Republican votes on the Finance Committee, too. There are several members who are on both committees. It was interesting, sort of, to watch what they said yesterday compared to what they said today in terms of questioning. But certainly there don’t seem to be any Democrats who are leaning his way, which is, I mean, we saw when he was officially nominated there were a lot of Democrats, not necessarily in the Senate but around the country, who agree with some of the things he says about regulatory capture by the drug industry and the food industry and ultra-processed foods. He does say a lot of things that are of interest and agreed to by Democrats, right? 

Karlin-Smith: Yeah, there were a few people I was watching because there were some inklings again that maybe they would vote to confirm him. One was Sen. [Raphael] Warnock from Georgia, who there was no indication, again, in his remark that he had interest in supporting him. The other was [Sen.] Sheldon Whitehouse, who apparently was Kennedy’s law school roommate and friend. And again, there was no indication of support or openness, not that we actually know how he was going to vote. And then the third person actually was Sen. Bernie Sanders, who at the hearings, both days, he did express some of his interest in some of the ideas that Kennedy has espoused. But yet again, I think the things they disagree on sort of outweigh the things where they can see agreement. And I think they’re seen as so problematic that they just totally cancel out any place where they could work together. 

Rovner: Just a reminder, Cassidy is super important here because RFK Jr. can’t afford to lose more than three Republican votes, assuming all the Democrats and independents vote against him, which is not necessarily what we know. And we assume but don’t know that the three senators who voted against [now-Defense Secretary] Pete Hegseth — Sen. Lisa Murkowski, [Sen.] Susan Collins of Maine, and Sen. Mitch McConnell, who’s a polio survivor and has said things about Kennedy’s vaccine statements — we assume those are likely to be no votes. So Cassidy would be the fourth and therefore decisive one. And I think that’s why everybody’s been watching him so closely. Sandhya, I see you nodding. 

Raman: I think even if [the] health [committee] is not voting on this, he’s the head of health, he’s a doctor, and if he votes no, that gives other Republicans who might be saying yes or leaning yes cover to kind of switch if they want to. Once you have one fall, then it’s easier for others in a lot of cases. So I think that after this weekend we’ll have more information. Cassidy’d said he wanted to ask additional questions, whatever those might be, and if those, where the cards may fall. 

Rovner: Yes. I believe Cassidy’s parting words in the hearing were, You might be hearing from me this weekend. Of course, if I were Cassidy and I were thinking about voting no, I don’t think I would blast it out right now to give time for everybody to come back at him, so you could see how he might want to play his cards a little bit closer to the chest. 

Well, for those who did not sit through the hearings like we did, I will say — I went back and counted — this is my 11th HHS secretary confirmation set of hearings that I have watched. And I could say that RFK Jr. is easily the least knowledgeable nominee that I have ever seen, at least in how the Department of Health and Human Services works. At both committees he was asked pretty easy questions about Medicare and Medicaid and showed that he does not understand either program, which together cover more than a hundred million Americans. What stood out to each of you? 

Raman: I think those, definitely, especially given that he’d fumbled on that the first hearing, the fact that that comes up again from Sen. [Maggie] Hassan asking questions on that in both hearings, that he stumbles again on the issues within the CMS [Centers for Medicare & Medicaid Services] umbrella. And I think yesterday he’d had some questions about EMTALA [the Emergency Medical Treatment and Active Labor Act] and emergency pregnancies, and again he— 

Rovner: Yeah, going to ask about abortion separately in a second. 

Raman: Yeah, so I think the fact that there have been major issues within the HHS umbrella that seemed new to him doesn’t bode well for what I saw. 

Karlin-Smith: One of the things that stood out to me was that he often got caught in lies or semi-lies and stuff around some of his past statements. And again, that just seems like a failure of the various staff in the Trump organization to really prepare him to know how to handle this. Because if you have such a public record like that, you know these things are going to come up. And even there was one exchange that happened yesterday, and the same comment was brought up today with Warnock, about comments he made comparing the effects of giving people vaccines to actions of the Nazis or abusive priests. And he says, I didn’t say it. And then he sort of says, But this is what I said, which is basically the same thing. 

And then the other thing I was going to say is I’ve noticed sort of a shift, since [Donald] Trump officially won the election and was getting closer to being in office, of the drug industry, some head CEOs really being like, You know, actually, we think [President] Trump will be positive for the industry. And they seem to be kind of ignoring some of the anti-vaccine sentiment and other things, including Trump’s populist appeal on drug pricing. 

Just some of the comments of Kennedy actually surprised me. We sort of know he’s skeptical of a lot of drugs, prescription drugs, being overused in the U.S. But again, both days he made a comment suggesting there’s a study that says prescription drugs are the third-leading cause of death in the U.S., which is not correct, and having a hard time finding what study he was referencing. But the CDC [Centers for Disease Control and Prevention] does have sort of accidental and unintentional injuries as the third-leading cause of death. But that includes a lot of stuff beyond just things that may impact prescription drugs, like opioid overdose deaths. So that’s going to include every car crash in the U.S. that causes a fatality. It’s going to include drownings, a lot of things that have nothing to do with prescription drugs. And that just seems like a big thing to both get wrong as an HHS nominee and also, again, something that’s kind of concerning for people that are interested in medical research and believe there is a positive benefit to pharmaceuticals. 

Rovner: One of the things that he said a lot, which is a safe thing for a nominee to say when being questioned by senators on both sides, is that he would be in line with what the president wants. Of course, in this case, there’s a lot about Trump that we don’t know what he wants, particularly on issues that are not his very top priorities like immigration. So on health care — on Will you continue the drug negotiations that were started under the Biden administration? — he’s like, I’m going to carry out President Trump’s policies. And this is where, Sandhya, I was going to ask about abortion, because he’s obviously, and we’ve talked about this a lot, a lot of anti-abortion groups who are very suspect of him because he was a Democrat until last year and he was very much pro-abortion-rights, and now he says that he will basically do what he is told. Is that essentially how you took it? 

Raman: Yeah. And I think the interesting thing was when in some of that questioning, the way he answered wasn’t I’d had a change of heart or I had a conversation with someone that shifted my perspective or anything like that. He just said: I will do what the president says. But yes, I made those statements. There was no bridge between those. And kind of like you said, if we don’t have clarity on some of those things from Trump, it’s hard to know which way he might go, how high that could be a priority for him. 

I mean, there were certain things that we can kind of expect if he’s confirmed that he might do, just because they have been happening throughout the years under Republican administrations and some of those commitments that were kind of made. But I think this has not really been a top issue for him in general. Like what we were saying before, he wasn’t familiar with EMTALA. That has been a huge thing over the past couple years. The federal government is involved with lawsuits and into kind of upholding that law and making sure that hospitals give emergency care to pregnant women that might need an abortion. 

Rovner: And there’s a Supreme Court case pending on this. 

Raman: It’s surprising that that would be unfamiliar for him given how big of an issue that is. And I think him not being familiar is not even just an issue for Democrats. For Republicans that want that assurance, they would likely want him to be familiar so that when we have HHS implementing guidance later on, that it would go in line with how they would want to interpret EMTALA. So that was one that just really stood out to me. 

Rovner: Yeah, I think I was taken aback, just the idea that he didn’t know what it was and he didn’t even know that the Medicare program basically has the ability to enforce rules for hospitals because it gives so much money to hospitals. Of the many things that made me kind of raise my eyebrows, that made me raise my eyebrows a little bit. I think I put this on social media. Whoever prepped him for these hearings did not do a very good job, because there was some really, really basic stuff any nominee for this job should have known, for much lower jobs should have known, that he appeared not to. 

Well, that was hardly the only news this week. It’s been pretty crazy. It is still Thursday, I think. We’re going to go back a little bit to what I’m calling the “funding freeze fiasco.” When we left off last week, much of science at the Department of Health and Human Services had been “paused,” she puts in air quotes, to use the administration’s word. Meaning no outside communication, no official travel, not much purchasing, and lots of panicked scientists at National Institutes of Health, the FDA [Food and Drug Administration] and the CDC, just to name a few of the agencies. 

Well, it turns out that was just a preview. Monday night, the Office of Management and Budget, whose nominated leader, Russell Vought, has not been confirmed by the Senate yet, issued a memo calling for a halt to all federal grants and loans, with the named exceptions of Social Security and Medicare, starting at 5 p.m. Tuesday. On Tuesday morning, the White House tried to say that the freeze wasn’t supposed to affect programs that provide benefits to individuals, things like food stamps or welfare. But by midday, reports were coming out from around the country about state officials shut out of Medicare payment portals and grantees of various other health programs, including community health centers and federal family planning clinics, unable to access payment systems as well. 

Tuesday afternoon, a federal judge delayed the freeze until Monday, meaning a few days from now. But on Wednesday morning, OMB issued a memo repealing the earlier memo. Shortly after that, White House press secretary Karoline Leavitt said the freeze was actually still on for programs that may violate Trump’s executive orders trying to stop diversity, equity, and inclusion programs, as well as many programs created by the Inflation Reduction Act. A judge cited that confusion and Leavitt’s tweet and blocked the entire effort Wednesday afternoon. So where are we now? And bigger question, does the president really have the authority to just stop payment of so many federal programs? 

Raman: It’s confusing to every single person that I have talked to in different swaths of health care in that this is very unprecedented. They don’t know how to react. And that has been on different days of the week depending on which part of the timeline that we’ve been in. And a concern that I’ve heard from multiple folks has been that despite whatever is kind of written at the time, there’s the chilling effect of the confusion making something sort of overimplemented, even if it only applies to some pocket of funding or some programming. It’s just people being scared and avoiding it just so that their whole program or whole whatever doesn’t get targeted in something. And I’m not a lawyer. I can’t tell you what falls as legal or not legal. But I think that the legal experts that I’ve heard from have really questioned that they have the authority to do all of this. 

Rovner: I have a friend who works for a nongovernmental organization that works with many governmental organizations, and she said last night, “We have 13 different stop-work orders.” 

Karlin-Smith: I was going to say the other thing about the situation besides the legality of it was when they put out the initial order, it was unclear whether Medicaid was a part of it. It wasn’t specifically exempted as Medicare and Social Security were. And then the next day, all these state Medicaid portals were down and they issued this other memo that says, No, no, sorry, we didn’t mean to not accept Medicaid and SNAP [the Supplemental Nutrition Assistance Program] and these other programs that provide critical health food benefits. And it seems like part of what might have been going on is that they just don’t understand how all of this funding works and that Medicaid sort of operates through grants, right? The states get the money, and then it goes to people. And similarly with a lot of other programs, it’s not a direct payment to a person or a direct distribution of goods. 

And again, I think it’s similar to the experience of listening to RFK. It does make you wonder how much of the people that are running the government understand what the government is, what it entails, and how to operate a government appropriately and think about the consequences ahead of time. And now again, I think as Sandhya mentioned initially, maybe I think some of this confusion and chaos is just the point. They don’t care. But if they break things, it is concerning that when they’re making policy, they don’t seem to know what they’re doing. And then that federal workers feel like they have to follow these unclear policies and maybe doing almost too much because of it. And we’ve seen that maybe with some of the rollbacks of NIH spending after they froze certain spending, and they’ve allowed some of the HIV treatment distribution to go on worldwide. But the fact that people felt like they had to freeze it initially signals the policy wasn’t appropriately written or communicated or something like that. 

Rovner: Yeah, and I also saw some arguments that it was just a coincidence that all these portals were down, that they were literally down for maintenance, not because the funding was being frozen, that was just sort of an accidental thing. Although it seems very odd to take them down for maintenance in the first week of the administration. There’s a lot. So whatever happens with the broader order, and we still don’t really know, at HHS, there is still lots of upheaval going on even without any Senate-confirmed officials installed yet. Sarah, we talked a lot about what’s happening at NIH last week. What’s happening at the FDA? 

Karlin-Smith: So, in some ways, I think, from what I’ve heard, the FDA is like a little bit more protected. And I’m going to say it’s a relative thing, but drug approvals are still happening because drug approvals come from user fee funding. They’re still able to have meetings related to that. They’re still doing inspections of food facilities, manufacturing facilities, things like that that help keep people safe, even though there’s travel bans. The things that I’ve seen that seem most impactful and concerning at this point, besides just, I think, a lot of federal government workers are just a little bit nervous about their jobs and stability and so forth. 

Rovner: A little bit. 

Karlin-Smith: Yes. Right now as part of Trump’s diversity, equity, and inclusion executive order, which seemed to my read to be about really how those issues are handled in hiring and staffing, but it seems like it’s being applied very broadly, including at FDA. So a big thing is the FDA took down a lot of webpages and a key guidance document around increasing diversity in clinical trials. And that’s really important. And it’s important for minorities. It’s important for women. It wasn’t very long ago that we didn’t know a lot about how drugs worked in women vs. men because we didn’t include women. And it turns out that is a big difference sometimes. It’s things like that where key programs that I think are seen as scientifically important are in question over, again, an order that is not clear whether it’s supposed to impact that type of stuff. 

Rovner: Yeah, I noticed at the Finance Committee hearing for Kennedy yesterday, one of the senators asked him about clinical trials including more Native Americans, and he said, Oh yes, absolutely. And I thought: “Oh, I don’t think you’re supposed to say that right now. I think that’s all part of what the Trump administration is trying to get rid of.” But obviously, Sarah, as you said, Trump seems to be taking the tech phrase “Move fast and break things” very much to heart, basically doing whatever he wants and daring someone to stop him, which so far nobody really has except maybe that one judge. 

Another example of where this is happening is the World Health Organization, which Trump ordered the U.S. to leave as one of his Day 1 executive orders. But leaving the WHO is supposed to be a year-long process, and this year’s funding is supposed to be honored, yet already officials at the CDC have been ordered to stop all work with the WHO on things like Ebola and Marburg and mpox, as well as bird flu. That includes virtual as well as in-person work. Is anybody pushing back on these things? 

Raman: In a sense, if you looked at earlier this week when we were getting a lot of the pushback on the foreign-aid aspect and not for things like PEPFAR [the President’s Emergency Plan for AIDS Relief], we had even the WHO put out a statement critiquing the U.S. saying this is a bad idea. So even coming from them critiquing the actions that the U.S. is taking, even if the U.S. is kind of withdrawn. But I think this was one of the things that we kind of saw coming a lot more than some of the others, just because in the latter half of the first Trump administration there was gaining animosity towards WHO and just different things there. You could see it in Congress. It was not unexpected for them to want to amp up calls for that. 

Rovner: But my bigger question is, just throwing away some of the things that Congress has said that, Yes, if you want to pull out of the WHO, here’s how you do it, and he’s like, Nope, we’re just doing it. 

Karlin-Smith: Well, I think, and there’s sort of technicalities in how they wrote the order, but Congress does have to actually approve that or at least sign off on that. But in terms of pushback, I guess I think the sentiment I’ve seen from people is: Where are Democrats? Why are they not making a big deal about some of this stuff? Because it is so unprecedented. This is not a kind of what you typically expect in a transition. Which obviously, again, right? We transitioned from a Democratic to Republican president. There are differences in policy ideas and so forth, and they’re putting their people in charge. You sometimes maybe expect a little bit of changes, even certain types of pauses. But the scope and the potential harm and even questionable legality of some of this is different. And Democrats have been fairly quiet, and I think people are looking for that, like, Well, how do we react? And if you don’t have the leadership reacting and helping guide you, then you end up in a kind of quiet space. 

Rovner: I feel like Democrats were trying to, and they said this, that, We don’t want to be like the last Trump administration, where they reacted to every little thing. But now there seems to be the, Why are they not reacting at all? 

So I’m going to add another thing to this along some of these same lines. Trump late Friday night fired about a dozen and a half inspectors general from most of the executive departments, including several he himself had installed. Included in that group was a Health and Human Services inspector general, Christi Grimm, a career employee who had been in the IG’s office since 1999 and was in fact the acting IG during the last year of Trump’s first term in 2020. These firings of what are supposed to be nonpartisan fraud and abuse watchdogs are irregular, shall we say, because Congress passed a law requiring that a president give Congress 30 days’ notice of any IG firing and to state a cause, neither of which has happened. In fact, the Agriculture Department’s IG, Phyllis Fong, was marched out of her office after refusing to leave quietly, pointing out her termination did not follow protocol, which it did not. Is this Trump thumbing his nose at Congress or just trying to do so much so fast that nobody has time to react? 

Raman: To me, I think it’s trying to do so much so fast that people don’t have to react. Because even if you think of the HHS inspector general, what does the HHS inspector general do? A lot of oversight on Medicare and Medicaid to reduce fraud there. And that is such a big, I think, talking point for Republicans, every year in Congress, just, what are different guardrails we can add to reduce fraud. That is such a big thing for them. And to just strip that without having something else set up, it doesn’t seem in line with — I mean, I don’t know. I think that it really is part of the causing chaos. 

Rovner: Yeah. 

Karlin-Smith: I think I read last night they usually recover something in the not quite $10 billion a year or something like that. So that’s a lot of money. And we think of, again, a party, and Trump in particular, has been really focused on creating a more efficient government and reducing waste, particularly in HHS, where the primary role I think of the OIG [Office of Inspector General] and where they spend most of their time is recovering money that wasn’t properly spent. It doesn’t seem to line up with their political positions and views, and it’s just creating a lot of concern in spaces about that he’s sort of pushing the limits of the law to put his people in charge. 

Rovner: Right, because he wouldn’t want an IG who’s nonpartisan to call out fraud and waste and potential corruption from people within HHS, which is part of what the IG’s job is in all of these departments, not just HHS. So we’re going to have to watch how that plays out. Well, one thing that is pretty common to see early in a new administration is lots of executive orders, because the departments haven’t been fully staffed up yet. A lot of those executive orders this week have been aimed at transgender people. Executive orders directed an end to trans people serving in the military, seek to bar doctors from treating minors even with reversible treatments like puberty blockers, and threatened to pull federal funding from schools where teachers call students by their preferred names. Is it just me or does this feel pretty far-reaching? 

Raman: I think what part of this is, we’ve seen them kind of messaging on this issue for a while. This has been a big social issue that has been brought up. So I wouldn’t say that it is surprising that this comes up now. I think it’s part of that flood. We’re not used to having Monday, the executive order, Tuesday and Wednesday that are so broad in scope. And I think that is part of it, that it’s hard to go through it all and kind of see what are the ramifications that this could all have. I would say that the one Tuesday, the one that’s health-based, is pretty broad in that we’re seeing things that we haven’t really seen before, just because I think a lot of the expansions of gender-affirming care on the state level have been happening within the last four years, so there hasn’t really been an opportunity for if they were able to do that. 

But I think the thing that kind of sticks out is that with a lot of the trans health stuff geared at children, the age is not necessarily 18. The executive order is 19 and below, and it’s sometimes older than that in some of the states. But I think for something that’s national and just kind of what, all the rulemaking that he’s directing to not cover gender-affirming care for youth under Tricare, and just changing the provisions in the Postal Service and federal employee plans, it’s pretty wide-ranging. And I think the part that I would definitely be most curious about are the things related to the Justice Department and what they can enforce on other states, just because we do have states that have pretty progressive policies for gender-affirming care, and that folks that live in more restrictive states have kind of moved there to be able to access that for their kids, and just what they’ll be able to do on that level to tamp down on that. I think that will be a big thing to watch. 

Rovner: Well, moving on to reproductive health. Last week at this time, we were talking about how the first flurry of executive actions did not include anything about abortion. The anniversary of Roe v. Wade came and went on Wednesday, and the annual March for Life by anti-abortion forces came and went with both the president and the vice president speaking on Friday, and still nothing. And then Friday night, Trump issued the orders we’d been kind of expecting all along since Monday. Sandhya, this was kind of a return to Republican administrations past, right? 

Raman: Yeah. So he reinstated the Mexico City policy, which we’ve had every Republican administration since [President Ronald] Reagan, and it restricts the funding that we can give to foreign organizations that even if they with their other funds do anything in the abortion realms. Similar to what we’ve done with Title X in the U.S. but for foreign aid. And then I think another important piece is they in a separate document rejoined us into this document known as the Geneva Consensus Declaration, where countries kind of pledge that they’re going to be against abortion and advance women and children’s health efforts. And I think those things were pretty expected. I wasn’t expecting it to come that much later after the March for Life rather than kind of timed with that. And then the other important thing was that he rescinded two of the executive orders under [President Joe] Biden to be more in line with Hyde-level restrictions, so not using federal funding for abortion in most circumstances. 

Rovner: So then on Monday we saw things go even a little bit further. Acting Health and Human Services Secretary Dorothy Fink put out a document that looked pretty routine, except it quietly said that not only could HHS programs not pay for abortion, which they haven’t been able to because of the Hyde Amendment, but also that they could not, quote, “promote” abortion, which has been interpreted to mean talk about the procedure in anything except the most negative terms. Now, this is a big change. For decades, the Hyde Amendment that bars funding coexisted side by side with a requirement in the Title X family planning program that women with unintended pregnancies be counseled on all their options, including abortion, and be referred for abortion if they ask. This is most definitely not current law, but I guess if you’ve been following the rest of this week’s theme, that seems not to matter to this administration, right? 

Raman: Yeah. And I think also, within that same statement, she kind of said they were going to reevaluate their guidance about conscience and religious protections within the Office of Civil Rights. And that also kind of brought me back to we had a lot of rulemaking in Trump 1 related to that. And I think some of those were more directly related to abortion, gender-affirming care, things like that within that umbrella. So I would expect more on that front to also kind of come back. But yeah, I think this is another one where it’s another step more, another step more. 

Rovner: Another flood the zone and dare everybody to keep up with it. All right, one final thing this week, one of the big administration priorities we haven’t talked about is immigration. And yes, immigration is a health care issue. One of the changes the Trump administration is making is allowing ICE [Immigration and Customs Enforcement] officers to raid hospitals and other health care facilities. The reason that’s always been taboo is that you don’t want people with potentially contagious diseases to shy away from seeking medical care because they’re afraid of encountering immigration authorities, and then they end up spreading those diseases far and wide instead. Are we just going to have to learn this lesson the hard way again? 

Karlin-Smith: It seems potentially likely, and it’s at a concerning time with bird flu, avian flu circulating, and a lot of farmworkers in this country being immigrants and migrants who may or may not have legal status officially, because we need to know to actively protect everybody and figure out where the disease is spreading, what we need to do in reaction to that and keep everybody safe. We need to know if people have bird flu or don’t have bird flu. And so you want people to be comfortable getting medical care and treatment and getting tested and not feel like they’re risking being separated from their family, their livelihood, and all of that stuff. 

The other thing I thought, again, some of the rhetoric that’s used around this is sort of people are taking services from Americans and they’re not giving anything in return, and a lot of these people contribute to our tax system and stuff and don’t actually get any benefits back from that. So again, I think some of the logic around that. But it’s certainly been interesting to see hospitals figure out how they can deal with this or what they need to do to train their staff to kind of protect their patients and figure out how they comply with these policies. 

Rovner: And encourage sick people to come forward and get medical care. All right, well, that’s as much news as we have time for this week. Now we will play my interview with Nick Bagley, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Nicholas Bagley, the Thomas G. Long professor of law at the University of Michigan Law School. In addition to being an expert on all things health-law-related, in his day job Nick teaches administrative law. So I’ve asked him here to give us a refresher on how the federal regulatory process is supposed to work. Nick, thank you so much for joining us. 

Nicholas Bagley: I am thrilled to be here, and go blue. 

Rovner: Before we get to our main topic, this administration is off to a bit of a different start, if I can call it that, in terms of go fast and break things. Just how different has the start of this Trump administration been? 

Bagley: Well, in one respect, I think it’s pretty different. They’re coming out, rhetorically at least, extremely strong in a whole flurry of executive orders that say that they’re going to make enormous changes to the regulatory state. They’ve promoted this “Department of Governmental Efficiency” that Elon Musk heads. They’re making lots of claims that they’re going to cut back on all the red tape that makes it hard for Americans to get stuff done. So in that sense, it is a little bit different, a kind of shock-and-awe offensive. 

But when you drill down to details, there’s a little less there than meets the eye. So an executive order, they sound really fancy, but they’re really just gussied-up internal memoranda telling one of your subordinates to do something. And so they make big promises, and then when you drill down to the details they say, And follow through as practicable and consistent with law and make sure you take your time and talk to all the relevant stakeholders, etc., etc., etc. And so for a lot of the initiatives, we’re still waiting on details, and that’s very consistent with past administrations, because it takes a long time to make big regulatory changes. 

Rovner: So at her first briefing earlier this week, presidential press secretary Karoline Leavitt said that Trump had already repealed a number of President Biden’s regulations, and reporters I have seen use similar language. But that hasn’t really happened yet, right? 

Bagley: It hasn’t happened. And I’ve spent a lot of time trying to get across just how little these executive orders do on their own. They’re important in that they set a tone, they offer instructions, they tell us about where the president would like to go, and his subordinates will take that seriously. But the president can’t undo a regulation just by waving his pen around. There’s a process, and that process takes time. 

Rovner: What’s the difference between congressional power and executive power? I mean, President Trump seems to think that he can pretty much do anything he wants with the executive branch. That’s not really the case, right? 

Bagley: No, it’s a big misunderstanding. The executive branch is really dependent for all of its authority and all of its funding on Congress. The core of Article 2 power under the U.S. Constitution says that the president “shall take Care” that the laws are faithfully executed. That’s the president’s responsibility. And if he hasn’t been given power by Congress, he has precious few powers on his own. There’s really not much conferred in the Constitution itself. So all of the president’s awesome powers, they derive from laws that Congress can adopt and that Congress can amend and that Congress can repeal. And so this claim that he’s going to go it alone is really a claim that he’s going to work with the statutes that are on the books. And some of those statutes give him a lot of authority, and he’s going to have a lot of room to run. And others of those statutes are going to constrain him quite a bit. And we’ve seen his claims about what he wants to do, and now we’re going to have to test how much he’s going to be allowed to do. 

Rovner: Can you talk very broadly about what power the president has through rulemaking authority and what he, at least in theory, can’t do? 

Bagley: Yeah. When an agency moves to adopt a rule, a rule is something that says to the regulated community, these are the kinds of things you have to do in order to continue an operation. So if you’re a power plant, you’ve got to install this scrubber. If you’re a meat processing facility, you’ve got to abide by these safety regulations. And on and on and on. When agencies adopt those rules, there’s a law that requires them to work through a pretty intensive process. So what they’ve got to do is they’ve got to offer notice about the rule that they’re thinking of adopting. They’ve got to allow the public to comment on that rule. And then the agency has got to respond in detail to all of those comments. 

And that’s a process. It doesn’t sound that intensive, but it takes usually in the order of somewhere between one and three years to get a regulation through that process. And you can do it quicker if you really have to, but of course that takes some resources, too. So when President Trump’s press secretary says he’s gotten rid of a bunch of regulations, she’s just misstating the law. That’s not true. Now, the processes will start and many of those rules will eventually be undone, but it will take time. 

Rovner: And the same thing in terms of his doing rules. These are all about, what can he do as compared to Congress? He can’t just make up rules, right? 

Bagley: Yeah, he can’t just make up rules. There are a bunch of really important legislative constraints that are easy to forget about. The first one, and really the most important one, is the appropriations power. He can’t mint money. But the second is when he exercises power, he’s got to abide by the rules that Congress has laid out on how he exercises that power. And it turns out that Congress has never been comfortable telling the president, Go be the lord of the manner in this particular space and just rule by decree. Congress says: There’s got to be a process to make sure that all stakeholders are heard and to make sure that we get these right. And if you don’t go through the requisite process, we’ve told the courts to come in and stop you. 

And sometimes President Trump assumes that because the judiciary leans to the right, they’re going to be passive when it comes to his abuses of regulatory power, and I think is misreading how the courts think about this problem. In the first Trump administration, we saw a lot of Republican judges push back hard on sloppy regulatory choices, and I expect to see the same pattern emerge here. 

Rovner: So where do things like guidance and executive orders fit into this? He’s got power there, but not as much power as he does through the regulatory process, right? 

Bagley: That’s exactly right. So when you adopt a rule, that rule has what they call the “force of law.” It’s basically like a law even though it’s adopted by the executive branch. And that means that if you violate the rule, you can be punished for violating the rule. When you’re talking about executive orders or guidance documents, they’re kind of easy come, easy go. You can adopt them with a stroke of a pen, but they can’t actually create any new binding legal obligations. So for example, a guidance document, might hear about these sometimes, they’re just telling the world how the agency thinks about a particular rule or a particular law. It says, This is how we understand what this rule or what this law means. But that’s not binding on the courts. It’s not binding on adjudicators. It’s just the agency’s opinion. And because it’s just the agency’s opinion, it doesn’t carry that kind of weight. So if you really want to make big regulatory changes, there’s really no substitute to going through the full dress process. 

Rovner: So to add one more level of confusion to this, last year there was a very important Supreme Court case that we talked about a lot on the podcast that threw out a 40-year-old precedent known as Chevron deference that basically instructed judges to trust the expertise of federal agencies, at least in most cases. Will the elimination of Chevron make it easier or harder for the Trump administration to carry out its agenda through the regulatory process? 

Bagley: Yeah. Well, if you ask the Trump administration, they think this is great. They think it’s going to make their job easier because the United States Supreme Court is clipping the wings of these left-leaning agencies that are imposing rules willy-nilly. But actually, the truth is that losing Chevron deference is a real blow to the Trump administration’s priorities. And the reason is really simple. Chevron doctrine gave the executive branch flexibility in how it interpreted statutes. It allowed them to interpret those statutes kind of how they thought best, so long as what they offered was a reasonable interpretation. But now the courts are going to get to decide what the statutes mean. And if the Trump administration likes a particular interpretation, and the courts say, That’s not the best reading of the statute. We think the best reading of the statute is a different one, the Trump administration might have won under Chevron, but it’s going to lose under Loper Bright. And so I think they’re going to find themselves handcuffed to a much greater extent than I think they appreciate. 

Rovner: So basically, it’s going to cut both ways. 

Bagley: It’s going to cut both ways. These big changes to administrative law often have that effect. The Supreme Court, when it issues Loper Bright, what it’s saying is, We want the courts to be more important in this regulatory process. But the courts being more important means that the executive branch is a little less important, and that’s true for Democratic presidents and it’s true for Republican presidents. 

Rovner: We’re going to have to learn a lot more about health law in this coming four years. Nick Bagley, thank you so much. 

Bagley: Very happy to do it. Thank you. 

Rovner: OK, we are back. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Sandhya, you were first to choose this week, so why don’t you go first? 

Raman: So I chose “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” and it’s by Mary Hudetz of ProPublica and Hannah Bassett of the Arizona Center for Investigative Reporting. So the story is about how at least 40 Native American residents in some sober living homes in Phoenix died when state Medicaid officials weren’t able to respond to the fraud scheme targeting Native Americans. And their investigation found that half of the deaths were happening when officials were ignoring the calls about the oversight issues that were getting reported. And the Medicaid agency even found that the fraud cost taxpayers up to like $2.5 billion. It’s a really sobering story. 

Rovner: Sarah. 

Karlin-Smith: So I took a look at a piece this week from CBS News, “Wind-blown bird poop may help transmit bird flu.” It’s about a possibility that Michael Osterholm talked about this week on his podcast, which is we have some reason to believe that bird flu may be spreading in bird poop, and it sort of can basically transmit in the air into a point where somebody, a human being including, may end up getting infected with bird flu and they didn’t have any direct contact with an animal or something like that. And so it raises concerns about the ability for it to spread much more differently. 

And also, he mentioned it raises concerns just for control of the virus, because of the way chickens are sort of housed. If they’re on farms and so forth, it would be very difficult to sort of refit their homes, if you will, to sort of prevent them from getting bird flu from outside wild birds. So if they can show this is happening, this would be kind of a big complication in our ability to track, control, and contain the virus, and of course, as they were talking about in this story, get the price of eggs down, which everyone’s very focused on. 

Rovner: That’s right. Well, my extra credit this week is from an independent news outlet called 404 Media. It’s called “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Cost Six Figures” by Jason Koebler. It’s about a machine used in open-heart surgeries and a company that used to offer hospital maintenance staff certification classes to teach workers how to maintain and repair the machines. But now the company has decided instead to require those hospitals to purchase maintenance contracts. Hospitals are now considering not only that it’s going to cost them more but that they may have to wait longer for an authorized repair person rather than rely on their own personnel. This is part of the broader right-to-repair debate, except this one could have life-or-death consequences. 

OK, that’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our ace producer and editor, Francis Ying, also to our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and increasingly at Bluesky, @julierovner. Where are you guys these days? 

Karlin-Smith: I’m mostly at Bluesky at @sarahkarlin-smith but still hanging around X a little bit and trying to post on LinkedIn, too. 

Rovner: Sandhya? 

Raman: On Bluesky and on X, @SandhyaWrites. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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The Trump administration has intervened in the release of important studies on the bird flu, as an outbreak escalates across the United States.

One of the studies would reveal whether veterinarians who treat cattle have been unknowingly infected by the bird flu virus. Another report documents cases in which people carrying the virus might have infected their pet cats.

The studies were slated to appear in the official journal of the Centers for Disease Control and Prevention, the Morbidity and Mortality Weekly Report. The distinguished journal has been published without interruption since 1952.

Its scientific reports have been swept up in an “immediate pause” on communications by federal health agencies ordered by Dorothy Fink, the acting secretary of the Department of Health and Human Services. Fink’s memo covers “any document intended for publication,” she wrote, “until it has been reviewed and approved by a presidential appointee.” It was sent on President Donald Trump’s first full day in office.

That’s concerning, former CDC officials said, because a firewall has long existed between the agency’s scientific reports and political appointees.

“MMWR is the voice of science,” said Tom Frieden, a former CDC director and the CEO of the nonprofit organization Resolve to Save Lives.

“This idea that science cannot continue until there’s a political lens over it is unprecedented,” said Anne Schuchat, a former principal deputy director at the CDC. “I hope it’s going to be very short-lived, but if it’s not short-lived, it’s censorship.”

White House officials meddled with scientific studies on covid-19 during the first Trump administration, according to interviews and emails collected in a 2022 report from congressional investigators. Still, the MMWR came out as scheduled.

“What’s happening now is quite different than what we experienced in covid, because there wasn’t a stop in the MMWR and other scientific manuscripts,” Schuchat said.

Neither the White House nor HHS officials responded to requests for comment. CDC spokesperson Melissa Dibble said, “This is a short pause to allow the new team to set up a process for review and prioritization.”

News of the interruption hit suddenly last week, just as Fred Gingrich, executive director of the American Association of Bovine Practitioners, a group for veterinarians specializing in cattle medicine, was preparing to hold a webinar with members. He planned to disclose the results of a study he helped lead, slated for publication in the MMWR later that week. Back in September, about 150 members had answered questions and donated blood for the study. Researchers at the CDC analyzed the samples for antibodies against the bird flu virus, to learn whether the veterinarians had been unknowingly infected earlier last year.

Although it would be too late to treat prior cases, the study promised to help scientists understand how the virus spreads from cows to people, what symptoms it causes, and how to prevent infection. “Our members were very excited to hear the results,” Gingrich said.

Like farmworkers, livestock veterinarians are at risk of bird flu infections. The study results could help protect them. And having fewer infections would lessen the chance of the H5N1 bird flu virus evolving within a person to spread efficiently between people — the gateway to a bird flu pandemic.

At least 67 people have tested positive for the bird flu in the U.S., with the majority getting the virus from cows or poultry. But studies and reporting suggest many cases have gone undetected, because testing has been patchy.

Just before the webinar, Gingrich said, the CDC informed him that because of an HHS order, the agency was unable to publish the report last week or communicate its findings. “We had to cancel,” he said.

Another bird flu study slated to be published in the MMWR last week concerns the possibility that people working in Michigan’s dairy industry infected their pet cats. These cases were partly revealed last year in emails obtained by KFF Health News. In one email from July 22, an epidemiologist pushed to publish the group’s investigation to “inform others about the potential for indirect transmission to companion animals.”

Jennifer Morse, medical director at the Mid-Michigan District Health Department and a scientist on the pending study, said she got a note from a colleague last week saying that “there are delays in our publication — outside of our control.”

A person close to the CDC, speaking on the condition of anonymity because of concerns about reprisal, expected the MMWR to be on hold at least until Feb. 6. The journal typically posts on Thursdays, and the HHS memo says the pause will last through Feb. 1.

“It’s startling,” Frieden said. He added that it would become dangerous if the reports aren’t restored. “It would be the equivalent of finding out that your local fire department has been told not to sound any fire alarms,” he said.

In addition to publishing studies, the MMWR keeps the country updated on outbreaks, poisonings, and maternal mortality, and provides surveillance data on cancer, heart disease, HIV, and other maladies. Delaying or manipulating the reports could harm Americans by stunting the ability of the U.S. government to detect and curb health threats, Frieden said.

The freeze is also a reminder of how the first Trump administration interfered with the CDC’s reports on covid, revealed in emails detailed in 2022 by congressional investigators with the House Select Subcommittee on the Coronavirus Crisis. That investigation found that political appointees at HHS altered or delayed the release of five reports and attempted to control several others in 2020.

In one instance, Paul Alexander, then a scientific adviser to HHS, criticized a July 2020 report on a coronavirus outbreak at a Georgia summer camp in an email to MMWR editors, which was disclosed in the congressional investigation. “It just sends the wrong message as written and actually reads as if to send a message of NOT to re-open,” he wrote. Although the report’s data remained the same, the CDC removed remarks on the implications of the findings for schools.

Later that year, Alexander sent an email to then-HHS spokesperson Michael Caputo citing this and another example of his sway over the reports: “Small victory but a victory nonetheless and yippee!!!”

Schuchat, who was at the CDC at the time, said she had never experienced such attempts to spin or influence the agency’s scientific reports in more than three decades with the agency. She hopes it won’t happen again. “The MMWR cannot become a political instrument,” she said.

Gingrich remains hopeful that the veterinary study will come out soon. “We’re an apolitical organization,” he said. “Maintaining open lines of communication and continuing research with our federal partners is critical as we fight this outbreak.”

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Shannon Sharpe was having one of those 15-minutes-of-internet-infamy moments. Social media blew up in September after the retired Denver Broncos tight end — accidentally, he later said — broadcast some of his intimate activities online.

One of his sponsors took advantage of the moment: the telehealth company Ro, which sells a variety of prescription medicines for erectile dysfunction and hair and weight loss. The company revved up a social media campaign on the social platform X for an ad in which Sharpe boasted about his experience with the company’s erectile dysfunction medications, a company spokesperson confirmed.

The ads were more than just a passing attempt to hitch a corporate caboose to a runaway social media locomotive. A group of direct-to-consumer telehealth companies have become omnipresent across just about all media formats, seeking patients interested in their low-stigma, low-fuss, low-touch, high-convenience health products.

They’re on your favorite podcasts and in the background on the cable TV in your gym. Thirteen telehealth entities spent a combined $111 million in 2023 on television ads, more than double the sum in 2019, according to an analysis from iSpot.tv, a television ad-tracking company, provided to KFF Health News.

The ads feature high-wattage celebrities such as Jennifer Lopez as well as lesser-known influencers who are paid four figures to post a snapshot or short video to Instagram, according to interviews with marketers. Three publicly traded telehealth companies spent a total of more than $1.4 billion on advertising, sales, and marketing in 2023, according to financial reports filed with the Securities and Exchange Commission, categories that reflect the extent of their online efforts.

The companies’ advertising typically emphasizes convenience in a health care system that’s often just the opposite. They promise judgment-free birth control or care for conditions like erectile dysfunction and hair loss that have traditionally been stigmatized. As the companies expand, they’re venturing into more complex kinds of medicine, such as care for mental health conditions and obesity.

Services that telehealth companies offer, critics warn, may shortchange patients in need of close, sensitive attention. Researchers differ on telehealth services’ quality, with some saying telehealth companies offer little follow-up and inconsistent care from a revolving cast of doctors.

Still, they agree the care is fundamentally different from the traditional style. A company’s model can “kind of flip what you’re taught at medical school on its head,” said Ateev Mehrotra, a Brown University professor of public health who studies telehealth.

Typically, he said, a patient goes to the doctor with a complaint; there, the parties figure out a diagnosis and, if appropriate, a medication. By contrast, he said, telehealth companies’ advertising invites patients to make their own diagnoses, while pairing them with clinicians who, if they confirm their conditions, prescribe medicines the patients already think they want.

Under this style of medicine, the clinician is “now a screener, and you just want to make sure that that medication is safe for that patient,” Mehrotra said.

The model may work for certain kinds of care, Mehrotra said, such as birth control. He and some colleagues conducted a study in which they recruited patients with standardized backstories to patronize startups offering contraceptive medicines over the internet. Generally, the study found, the services performed well.

Harley Diamond, a patient at Nurx, a startup offering birth control prescriptions and other services, offers an example of how these companies can work well in some circumstances. After she saw an Instagram ad, she signed up to get birth control. She lives in Tennessee, a red state where it can be difficult to access contraception: Local clinics have closed and an arsonist burned down a Planned Parenthood. (The facility recently reopened.)

But when she turned to Nurx for her mental health, she found the service confounding and its convenience lacking.

The company’s app sends her frequent questionnaires about symptoms and reactions to drugs, she said. “There is no comforting face to validate you,” she wrote in an email to KFF Health News. The questions were the same each time, and she said she spoke with a new doctor in every interaction.

“It can feel like you’re having to start from scratch explaining yourself to someone new every month,” she said.

When she expressed concerns — for example, about side effects of an antidepressant she was taking — it would take “days, generally,” to hear back, with no change in her protocol, she said. Often, she said, her messages would get no response at all.

Rajani Rao, senior vice president at Nurx, said the company is “constantly working” to improve response times, “especially as we experience a high volume of patient care requests.” In mental health, the majority of Nurx’s patients experience elimination of symptoms after six months of treatment, she said.

Rao also referred to Nurx as providing an “integrated care team,” using language echoed across the industry. Ro, for example, says its care is available in the time and format of its patient’s preference and that it audits the quality of its services.

Continuous care is crucial to make sure mental health patients are on the right doses of medications and that they’re not experiencing side effects, said Reshma Ramachandran, an assistant professor of medicine at Yale who has conducted her own secret-shopper study of telehealth sites.

What’s more, research shows many mental health medications are best paired with therapy, Ramachandran said.

Ramachandran thinks frustrations like Diamond’s might be widespread, based on her team’s research. She said she’s frustrated at the “very groovy, glossy” picture painted by telehealth ads.

Ramachandran said her study is still under consideration for publication in medical journals. But she provided preliminary results to congressional offices examining the telehealth sector.

Last year, Sen. Dick Durbin, an Illinois Democrat, and former Sen. Mike Braun, an Indiana Republican, introduced legislation to regulate some telehealth advertising practices. A spokesperson for Durbin said he intends to reintroduce the bill this year.

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Listen as senior producer Zach Dyer reports on the public health concerns over online sports betting and a fund in Missouri that might help with addiction treatment and prevention. 

The parking lot at the Super One Stop in Granite City, Illinois, is full. The convenience store just across the Mississippi River from Missouri sells liquor, cigarettes, and some groceries. But not all the cars belong to customers. It’s a Sunday morning in the middle of football season, and the people sitting in their vehicles are mostly looking down at their smartphones.

Nick Krumwiede is sure the people parked around him are betting on the day’s NFL games. That’s why he’s there. Krumwiede drove 15 minutes across the state line from his home in St. Louis to place three bets, including one on his beloved Chicago Bears.

Krumwiede could have driven to a casino in East St. Louis, Illinois, to bet on the games in person. But with apps like DraftKings and FanDuel on his smartphone, he doesn’t need to make the trip. He can place his bets in this parking lot.

“This is Sunday football, everybody,” Krumwiede said. “I guarantee you that’s what they’re doing.”

“You see them all sitting in there staring at their phones?” he said.

Public health experts say smartphone-based betting makes it easier for people to get into deep gambling trouble fast. But it takes effort to drive to a parking lot across state lines to bet on an NFL game. Soon, Missouri gamblers will be able to place those bets from their couches. Voters approved sports betting in Missouri in a November ballot initiative, and the state could start issuing sports betting licenses as soon as this summer.

The ballot measure requires the state to dedicate at least $5 million a year from its sports betting tax revenue to combat compulsive gambling. Supporters of the measure said that increase in resources could help the state address harms associated with gambling addiction. In other states, the introduction of online sports betting has been linked to increased calls to hotlines for problem gambling.

Estimates of the state’s revenue from sports betting range from $12.8 million to $20.5 million, according to a fiscal note for a previous bill to legalize sports betting.

Carolyn Hawley is a professor at Virginia Commonwealth University who researches problem-gambling addiction, treatment, and harm reduction. She has tracked Virginia’s experience since sports betting started there four years ago.

“ We don’t even have to leave our homes anymore,” she said. “We now have them on our smartphones. We can do it anytime, anyplace.”

In Virginia, some primary care providers have started asking their patients about their gambling habits, Hawley said. Doctors have shared reports of stress-related ailments, she said, especially in young men who had been betting on sports.

“They’re coming in with GI issues. They’re coming in with heart issues. They’re coming in with depression,” she said.

Sports bettors tend to be younger and male. In a recent poll of registered voters, Fairleigh Dickinson University found that a quarter of men under 30 bet on sports online. Problem gamblers make up 10% of that group, compared with 3% of the overall U.S. population.

After the legalization of sports betting in Virginia, Hawley observed a spike in calls to her state’s gambling helpline: 1,000% more from 2019 to 2023.

Hawley, who is also the president of the Virginia Council on Problem Gambling, said 200% more people were looking for resources to quit gambling.  Other states have seen similar trends.

Dozens of states have legalized sports betting after a Supreme Court decision cleared the way in 2018, including every state that borders Missouri save one, Oklahoma.

Supporters who pushed for sports betting in Missouri say people already cross into other states to gamble. They argue that Missouri has missed out on valuable tax dollars that could, in part, help fund gambling treatment and prevention efforts in the state.

“The beautiful thing about being the 39th state to do something is you are able to take a look at what has worked and what hasn’t worked in other states,” said Jack Cardetti, spokesperson for Winning for Missouri Education, a group made up of Missouri professional sports teams and sports betting companies that supported the ballot initiative.  “If we’re going to have an expansion of gaming here in the state of Missouri,” he said, “we also need to expand the resources.”

Missouri spent just $100,000 on problem gambling in 2023 and zero dollars the year before that. The state is still developing a plan to spend the money earmarked from the ballot initiative.

In Illinois at the Super One Stop, store owner Himang Patel said he doesn’t mind sports bettors using his parking lot to gamble on their phones. Some people sit up to an hour, and Patel said that can be an opportunity to sell a pack of cigarettes or bag of chips. He guessed that the extra foot traffic will die off when sports betting becomes legal in Missouri.

Krumwiede said he’s looking forward to not having to make the drive across the state line, but he’s also mindful that easier access could come with risks. He knows gambling can be addictive.

“Sometimes I have bad days where I go out and put out a hundred bucks and I lose almost all of it,” he said. “It’s kind of like a sinking feeling. You don’t talk about it.”

Krumwiede tries to set rules for himself so he doesn’t lose too much money at any one time.

He said he is looking forward to not having to make the drive to Illinois after sports betting starts in Missouri. But he’s worried, too. He said there were periods in the past when he lost too much money.

“It’s a little scary, but I’m just going to have to make new rules,” Krumwiede said.

He has a few more months to figure it out.

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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In summertime, cows wait under a canopy to be milked at Mark McAfee’s farm in Fresno, California. From his Cessna 210 Centurion propeller plane, the 63-year-old can view grazing lands of the dairy company he runs that produces products such as unpasteurized milk and cheese for almost 2,000 stores.

Federal regulators say it’s risky business. Samples of raw milk can contain bird flu virus and other pathogens linked to kidney disease, miscarriages, and death.

McAfee, founder and CEO of the Raw Farm, who also leads the Raw Milk Institute, says he plans to soon be in a position to change that message.

Robert F. Kennedy Jr., the anti-vaccine activist President Donald Trump has tapped to run the Department of Health and Human Services, recruited McAfee to apply for a job as the FDA’s raw milk standards and policy adviser, McAfee said. McAfee has already written draft proposals for possible federal certification of raw dairy farms, he said.

Virologists are alarmed. The Centers for Disease Control and Prevention recommends against unpasteurized dairy that hasn’t been heated to kill pathogens such as bird flu. Interstate raw milk sales for human consumption are banned by the FDA. A Trump administration that weakens the ban or extols raw milk, the scientists say, could lead to more foodborne illness. It could also, they say, raise the risk of the highly pathogenic H5N1 bird flu virus evolving to spread more efficiently, including between people, possibly fueling a pandemic.

“If the FDA says raw milk is now legal and the CDC comes through and says it advises drinking raw milk, that’s a recipe for mass infection,” said Angela Rasmussen, a virologist and co-editor-in-chief of the medical journal Vaccine and an adjunct professor at Stony Brook University in New York.

The raw milk controversy reflects the broader tensions President Donald Trump will confront when pursuing his second-administration agenda of rolling back regulations and injecting more consumer choice into health care.

Many policies Kennedy has said he wants to revisit — from the fluoridation of tap water to nutrition guidance to childhood vaccine requirements — are backed by scientific research and were established to protect public health. Some physician groups and Democrats are gearing up to fight initiatives they say would put people at risk.

Raw milk has gained a following among anti-regulatory conservatives who are part of a burgeoning health freedom movement.

“The health freedom movement was adopted by the tea party, and conspiracy websites gave it momentum,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, who has studied the history of the anti-vaccine movement.

Once-fringe ideas are edging into the mainstream. Vaccine hesitancy is growing.

Arkansas, Utah, and Kentucky are weighing legislation that would relax or end requirements for fluoride in public water. And 30 states now allow for the sale of raw milk in some form within their borders.

While only an estimated 3% of the U.S. population consumes raw milk or cheese, efforts to try to restrict its sales have riled Republicans and provided grist for conservative podcasts.

Many conservatives denounced last year’s execution of a search warrant when Pennsylvania agriculture officials and state troopers arrived at an organic farm tucked off a two-lane road on Jan. 4, 2024. State inspectors were investigating cases of two children sickened by E. coli bacteria and sales of raw dairy from the operation owned by Amish farmer Amos Miller, according to a complaint filed by the state’s agricultural department.

Bundled in flannel shirts and winter jackets, the inspectors put orange stickers on products detaining them from sale, and they left toting product samples in large blue-and-white coolers, online videos show. The 2024 complaint against Miller alleged that he and his wife sold dairy products in violation of state law.

The farm was well known to regulators. They say in the complaint that a Florida consumer died after being sickened in 2014 with listeria bacteria found in raw dairy from Miller’s farm. The FDA said a raw milk sample from the farm indicates it was the “likely source” of the infection, based on the complaint.

Neither Miller’s farm nor his lawyer returned calls seeking comment.

The Millers’ attorney filed a preliminary objection that said “shutting down Defendants would cause inequitable harm, exceed the authority of the agency, constitute an excessive fine as well as disparate, discriminatory punishment, and contravene every essential Constitutional protection and powers reserved to the people of Pennsylvania.”

Regulators in Pennsylvania said in a press release they must protect the public, and especially children, from harm. “We cannot ignore the illnesses and further potential harm posed by distribution of these unregulated products,” the Pennsylvania agricultural department and attorney general said in a joint statement.

Unpasteurized dairy products are responsible for almost all the estimated 761 illnesses and 22 hospitalizations in the U.S. that occur annually because of dairy-related illness, according to a study published in the June 2017 issue of Emerging Infectious Diseases.

But conservatives say raiding an Amish farm is government overreach. They’re “harassing him and trying to make an example of him. Our government is really out of control,” Pennsylvania Republican Sen. Doug Mastriano said in a video he posted to Facebook.

Videos show protesters at a February 2024 hearing on Miller’s case included Amish men dressed in black with straw hats and locals waving homemade signs with slogans such as “FDA Go Away.” A court in March issued a preliminary injunction that barred Miller from marketing and selling raw dairy products within the commonwealth pending appeal, but the order did not preclude sales of raw milk to customers out of state. The case is ongoing.

With Kennedy, the raw milk debate is poised to go national. Kennedy wrote on X in October that the “FDA’s war on public health is about to end.” In the post, he pointed to the agency’s “aggressive suppression” of raw milk, as one example.

McAfee is ready. He wants to see a national raw milk ordinance, similar to one that exists for pasteurized milk, that would set minimal national standards. Farmers could attain certification through training, continuing education, and on-site pathogen testing, with one standard for farms that sell to consumers and another for retail sales.

The Trump administration didn’t return emails seeking comment.

McAfee has detailed the system he developed to ensure his raw dairy products are safe. He confirmed the process for KFF Health News: cows with yellow-tagged ears graze on grass pastures and are cleansed in washing pens before milking. The raw dairy is held back from consumer sale until it’s been tested and found clear of pathogens.

His raw dairy products, such as cheese and milk, are sold by a variety of stores, including health, organic, and natural grocery chains, according to the company website, as well as raw dairy pet products, which are not for human consumption.

He said he doesn’t believe the raw milk he sells could contain or transmit viable bird flu virus. He also said he doesn’t believe regulators’ warnings about raw milk and the virus.

“The pharmaceutical industry is trying to create a new pandemic from bird flu to get their stock back up,” said McAfee, who says he counts Kennedy as a customer. His view is not shared by leading virologists.

In December, the state of California secured a voluntary recall of all his company’s raw milk and cream products due to possible bird flu contamination.

Five indoor cats in the same household died or were euthanized in December after drinking raw milk from McAfee’s farm, and tests on four of the animals found they were infected with bird flu, according to the Los Angeles County Department of Health.

In an unrelated case, Joseph Journell, 56, said three of his four indoor cats drank McAfee’s raw milk. Two fell sick and died, he said. His third cat, a large tabby rescue named Big Boy, temporarily lost the use of his hind legs and had to use a specialized wheelchair device, he said. Urine samples from Big Boy were positive for bird flu, according to a copy of the results from Cornell University and the U.S. Department of Agriculture.

McAfee dismissed connections between the cats’ illnesses and his products, saying any potential bird flu virus would no longer be viable by the time his raw milk gets to stores. He also said he believes that any sick cats got bird flu from recalled pet food.

Journell said he has hired a lawyer to try to recover his veterinary costs but remains a staunch proponent of raw milk.

“Raw milk is good for you, just not if it has bird flu in it,” he said. “I do believe in its healing powers.”

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States and the nation’s health industry were thrown into disarray after the Trump administration ordered Monday that the government freeze nearly all federal grants at 5 p.m. ET Tuesday, a sweeping directive that at least initially appeared to include funding for Medicaid, the state-federal health insurance program that covers more than 70 million Americans.

By midmorning Tuesday, state officials around the country reported they had been shut out of a critical online portal that allows states to access federal Medicaid funding.

Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee, said on the social media site Bluesky that the portals were down in all 50 states following the Trump administration’s order.

“This is a blatant attempt to rip away health care from millions of Americans overnight and will get people killed,” he wrote.

Around midday Tuesday, as state health officials pressed the federal government for clarity, the White House Office of Management and Budget — which issued the Monday memo — put out new guidance clarifying that “mandatory programs like Medicaid” were not included in the freeze.

Karoline Leavitt, the White House press secretary, declined to confirm that Medicaid was exempt when pressed by reporters during an early afternoon briefing.

But she later said in a post on the social platform X that “no payments have been affected” by what she described as a “portal outage.”

The possibility that federal Medicaid funding would be shut off overnight spooked advocates already on edge about the program’s future. President Donald Trump vowed on the campaign trail not to seek cuts for Medicare or Social Security, the nation’s major entitlement programs serving mostly retired people. But he did not make the same promise about Medicaid, which pays for health care for primarily low-income and disabled people — approximately 1 in 5 Americans.

Separate from the freeze, congressional Republicans are discussing cutting the nearly $900 billion program, arguing costs have ballooned with enrollment, notably including the program’s expansion to cover more low-income adults. Lawmakers are also eyeing ways to save money for Trump’s other legislative priorities — in particular, extending the tax cuts from his first term that expire at the end of this year.

The federal government pays most costs for Medicaid, which is operated by states. Medicaid pays for most long-term care for Americans and for about 40% of all U.S. births, and together with the related Children’s Health Insurance Program covers about 38 million children.

Federal funding for Medicaid does not go directly to individual enrollees but to the states, which then distribute it to providers, health plans, and other entities that serve Medicaid enrollees.

State officials can access that funding through internet portals.

Joan Alker, who is executive director of the Center for Children and Families at the Georgetown McCourt School of Public Policy, said on X Tuesday that the portal lockout is “a major crisis.”

She pointed out that many states access their federal funding at the end of the month — “i.e. this week,” she wrote.

The original freeze order came in the form of a vaguely worded two-page memo from the Office of Management and Budget to all federal agencies directing them to “temporarily pause all activities related to obligation or disbursement of all Federal financial assistance.”

“This temporary pause will provide the Administration time to review agency programs and determine the best uses of the funding for those programs consistent with the law and the President’s priorities,” the memo said. The only programs explicitly noted as exceptions were Medicare and Social Security, which left it unclear how states would continue to pay doctors, hospitals, nursing homes, and private health plans to manage Medicaid.

Around the nation, health officials scrambled to make sense of the order, which was scheduled to take effect at 5 p.m. ET Tuesday. A federal judge halted the freeze shortly before its implementation, blocking the change until next week.

Even as OMB clarified that Medicaid was not included, the immediate impacts to other critical health programs were becoming clear, especially for community health centers and medical research centers.

Democrats in Congress expressed outrage at the Trump administration for pausing federal funding not only to Medicaid but also to numerous other programs, including the Supplemental Nutrition Assistance Program, also known as food stamps, the WIC nutrition program for pregnant and postpartum women and infants, and school meal programs for low-income students.

“The Trump Administration’s action last night to suspend all federal grants and loans will have a devastating impact on the health and well-being of millions of children, seniors on fixed incomes, and the most vulnerable people in our country,” Sen. Bernie Sanders (I-Vt.) said in a statement Tuesday. “It is a dangerous move towards authoritarianism and it is blatantly unconstitutional.”

The National Association of Medicaid Directors and the major nursing home associations were among those seeking clarification from the White House on Tuesday about the order’s impact on Medicaid funding.

Numerous state officials and groups said they were considering or had already filed litigation challenging the order. One lawsuit was filed Tuesday against OMB in federal court in Washington, D.C., by the National Council of Nonprofits and the American Public Health Association, seeking a temporary restraining order to “maintain the status quo until the Court has an opportunity to more fully consider the illegality of OMB’s actions.”

Attorneys general in California, New York, and four other states announced Tuesday afternoon a joint lawsuit against the Trump administration over the order, which they said had already frozen systems for Medicaid, Head Start, and even child support enforcement across multiple states.

“There is no question this policy is reckless, dangerous, illegal, and unconstitutional,” said New York Attorney General Letitia James. She added that she and other Democratic attorneys general would seek a temporary restraining order to halt the OMB policy from going into effect.

Leavitt defended the freeze during her White House briefing — the first of the new administration — saying it was critical to ensuring that federal funding was being used appropriately.

“This is a very responsible measure,” she said.

Reporting contributed by Bram Sable-Smith, Jordan Rau, Renuka Rayasam, Brett Kelman, and Christine Mai-Duc.

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Just a few years ago, children with Type 1 diabetes reported to the school nurse several times a day to get a finger pricked to check whether their blood sugar was dangerously high or low.

The introduction of the continuous glucose monitor (CGM) made that unnecessary. The small device, typically attached to the arm, has a sensor under the skin that sends readings to an app on a phone or other wireless device. The app shows blood sugar levels at a glance and sounds an alarm when they move out of a normal range.

Blood sugar that’s too high could call for a dose of insulin — delivered by injection or the touch of a button on an insulin pump — to stave off potentially life-threatening complications including loss of consciousness, while a sip of juice could remedy blood sugar that’s too low, preventing problems such as dizziness and seizures.

Schools around the country say teachers listen for CGM alarms from students’ phones in the classroom. Yet many parents say that there’s no guarantee a teacher will hear an alarm in a busy classroom and that it falls to them to ensure their child is safe when out of a teacher’s earshot by monitoring the app themselves, though they may not be able to quickly contact their child.

Parents say school nurses or administrative staff should remotely monitor CGM apps, making sure someone is paying attention even when a student is outside the classroom — such as at recess, in a noisy lunchroom, or on a field trip.

But many schools have resisted, citing staff shortages and concerns about internet reliability and technical problems with the devices. About one-third of schools do not have a full-time nurse, according to a 2021 survey by the National Association of School Nurses, though other staffers can be trained to monitor CGMs.

Caring for children with Type 1 diabetes is nothing new for schools. Before CGMs, there was no alarm that signaled a problem; instead, it was caught with a time-consuming finger-prick test, or when the problem had progressed and the child showed symptoms of complications.

With the proliferation of insulin pumps, many kids can respond to problems themselves, reducing the need for schools to provide injections as well.

Parents say they are not asking schools to continuously monitor their child’s readings, but rather to ensure that an adult at the school checks that the child responds appropriately.

“People at the [school] district don’t understand the illness, and they don’t understand the urgency,” said Julie Calidonio of Lutz, Florida.

Calidonio’s son Luke, 12, uses a CGM but has received little support from his school, she said. Relying on school staff to hear the alarms led to instances in which no one was nearby to intervene if his blood sugar dropped to critical levels.

“Why have this technology that is meant to prevent harms, and we are not acting on it,” she said.

Corey Dierdorff, a spokesperson for the Pasco County School District, where Luke attends school, said in a statement to KFF Health News that staff members react when they hear a student’s CGM sound an alert. Asked why the district won’t agree to have staff remotely monitor the alarms, he noted concerns about internet reliability.

In September, Calidonio filed a complaint with the U.S. Justice Department against the district, saying its inability to monitor the devices violates the Americans with Disabilities Act, which requires schools to make accommodations for students with diabetes, among other conditions. She is still awaiting a decision.

The complaint comes about four years after the Connecticut U.S. attorney’s office determined that having school staffers monitor a student’s CGM was a “reasonable accommodation” under the ADA. That determination was made after four students filed complaints against four Connecticut school districts.

“We fought this fight and won this fight,” said Jonathan Chappell, one of two attorneys who filed the complaints in Connecticut. But the decision has yet to affect students outside the state, he said.

Chappell and Bonnie Roswig, an attorney and director of the nonprofit Center for Children’s Advocacy Disability Rights Project, both said they have heard from parents in 40 states having trouble getting their children’s CGMs remotely monitored in school. Parents in 10 states have filed similar complaints, they said.

CGMs today are used by most of the estimated 300,000 people in the U.S. with Type 1 diabetes under age 20, health experts say. Also known as juvenile diabetes, it is an autoimmune disease typically diagnosed in early childhood and treated with daily insulin to help regulate blood sugar. It affects about 1 in 400 people under 20, according to the American Academy of Pediatrics.

(CGMs are also used by those with Type 2 diabetes, a different disease tied to risk factors such as diet and exercise that affects tens of millions of people — including a growing number of children, though it is usually not diagnosed until the early teens. Most people with Type 2 diabetes do not take insulin.)

Students with diabetes or another disease or disability typically have a health care plan, developed by their doctor, that works with a school-approved plan to get the support they need. It details necessary accommodations to attend school, such as allowing a child to eat in class or ensuring staff members are trained to check blood glucose or give a shot of insulin.

For children with Type 1 diabetes, the plan usually includes monitoring CGMs several times a day and responding to alarms, Roswig said.

Lynn Nelson, president-elect of the National Association of School Nurses, said when doctors and parents deem a student needs their CGM remotely monitored, the school is obligated under the ADA to meet that need. “It is legally required and the right thing to do.”

Nelson, who also manages school nurse programs in Washington state, said schools often must balance the students’ needs with having enough administrative staff.

“There are real workforce challenges, but that means schools have to go above and beyond for an individual student,” she said.

Henry Rodriguez, a pediatric endocrinologist at the University of South Florida and a spokesperson for the American Diabetes Association, said remote monitoring can be challenging for schools. While they advocate for giving every child what they need to manage their diabetes at school, he said, schools can be limited by a lack of support staff, including nurses.

The association last year updated its policy around CGMs, stating: “School districts should remove barriers to remote monitoring by school nurses or trained school staff if this is medically necessary for the student.”

In San Diego, Taylor Inman, a pediatric pulmonologist, said her daughter, Ruby, 8, received little help from her public school after being diagnosed with Type 1 diabetes and starting to use a CGM.

She said alerts from Ruby’s phone often went unheard outside the classroom, and she could not always reach someone at the school to make sure Ruby was reacting when her blood sugar levels moved into the abnormal range.

“We kept asking for the school to follow my daughter’s CGM and were told they were not allowed to,” she said.

In a 2020 memo to school nurses that remains in effect, Howard Taras, the San Diego Unified School District’s medical adviser, said if a student’s doctor recommends remote monitoring, it should be done by their parents or doctor’s office staff.

CGM alarms can be “disruptive to the student’s education, to classmates and to staff members with other responsibilities,” Taras wrote.

“Alarms are closely monitored, even those that occur outside of the classroom,” Susan Barndollar, the district’s executive director of nursing and wellness, said in a statement. Trained adults, including teachers and aides, listen for the alarms when in class, at recess, at gym class, or during a field trip, she said.

She said the problem with remote monitoring is that staff in the school office doing the monitoring may not know where the student is to tend to them quickly.

Inman said last year they paid $20,000 for a diabetes support dog trained to detect high or low blood sugar and later transferred Ruby to a private school that remotely tracks her CGM.

“Her blood sugar is better controlled, and she is not scared and stressed anymore and can focus on learning,” she said. “She is happy to go to school and is thriving.”

Some schools have changed their policies. For more than a year, several parents lobbied Loudoun County Public Schools in Northern Virginia to have school nurses follow CGM alerts from their own wireless devices.

The district board approved the change, which took effect in August and affects about 100 of the district’s more than 80,000 students.

Before, Lauren Valentine would get alerts from 8-year-old son Leo’s CGM and call the school he attends in Loudoun County, not knowing if anyone was taking action. Valentine said the school nurse now tracks Leo’s blood sugar from an iPad in the clinic.

“It takes the responsibility off my son and the pressure off the teacher,” she said. “And it gives us peace of mind that the school clinic nurses know what is happening.”

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President Donald Trump has nominated Robert F. Kennedy Jr., an environmental lawyer with no formal medical or public health expertise, as secretary of Health and Human Sciences. Two Senate committees will question Kennedy this week on how his disproven views of science and medicine qualify him to run the $1.7 trillion, 80,000-employee federal health system.

Here are four considerations for lawmakers on the Senate Finance and Senate Health, Education, Labor and Pensions committees, which will host Kennedy for questioning on Wednesday and Thursday, respectively:

1) Kennedy’s unconventional health claims.

For decades, Kennedy has advocated for health-related ideas that are scientifically disproven or controversial. He created and was paid hundreds of thousands of dollars by Children’s Health Defense, a group that champions the false idea that vaccines cause autism and other chronic diseases and has sued to take vaccines off the market. Kennedy has said covid vaccines are the deadliest in history, antidepressants lead children to commit mass shootings, environmental contaminants may cause people to become trans, and HIV is not the only cause of AIDS. He also pushes the use of products that regulators consider dangerous, such as raw milk, and for broader use of some medicines, such as ivermectin and hydroxychloroquine, to treat conditions without FDA approval. He says public health agencies oppose their use only because of regulatory capture by big drug and food interests.

“He believes you can avoid disease if you have a healthy immune system. He sees vaccines and antibiotics as toxins,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia. Top Trump health nominees — Kennedy, Marty Makary for FDA commissioner, Jay Bhattacharya for National Institutes of Health director, and former U.S. Rep. Dave Weldon for Centers for Disease Control and Prevention director — are generally disdainful of the agencies they’ll be leading, Offit said.

“They think they are going to go into office, pull back the curtain, find all this bad stuff, and reveal it to the American public,” he said.

During a measles epidemic in 2019 and 2020 that killed 83 people, mostly children, in Samoa, Kennedy, as chairman of Children’s Health Defense, warned the country’s prime minister against measles vaccination. This behavior alone “is disqualifying” for an HHS nominee, said Georges Benjamin, executive director of the American Public Health Association.

Equally problematic, in Benjamin’s view, was Kennedy’s legal effort in 2021 to get the covid vaccine pulled from the market. “He can’t say he’s not anti-vax,” Benjamin said. “He wasn’t following the evidence.”

A Kennedy spokesperson did not respond to a request for comment.

2) Kennedy’s chances appear good, despite opposition.

Kennedy’s nomination has emerged in a moment when Trump is on a roll and mistrust of public health and medical authority in the wake of the pandemic has created an opening for people with unorthodox views of science to seize the reins of the country’s health system.

After former Fox News personality Pete Hegseth was confirmed as Defense secretary last week despite his controversial qualifications for the job and stark warnings from former top military brass, many Washington observers think RFK Jr. is going to be hard to defeat. In a meeting on the Hill with Democratic senators and their aides last week, Offit said, “the feeling was that he would likely be confirmed.”

Trump has demanded that Republican senators line up behind his nominees and has so far succeeded. It’s thought that Sens. Lisa Murkowski of Alaska and Susan Collins of Maine could oppose Kennedy, based on their opposition to Hegseth. Sen. Mitch McConnell (R-Ky.), the other Hegseth “nay” vote, is a polio survivor who has not spoken publicly about Kennedy but said in December that opposing “proven cures” was dangerous. Other senators whose Kennedy votes are said to be in question include Sen. Bill Cassidy (R-La.), the HELP Committee chair, a physician who gave a lukewarm response after meeting Kennedy.

Others have reported that Sens. Cory Booker (D-N.J.), who shares Kennedy’s concern with the spread of obesity and chronic illness, and Sheldon Whitehouse (D-R.I.), who attended law school with Kennedy, might vote for him. Neither senator’s office responded to a request for comment. Advancing American Freedom, a conservative advocacy group founded by former Vice President Mike Pence, has fought Kennedy’s nomination with a major ad buy.

3) The hearings are going to be heated.

Democratic senators are coming with plenty of ammunition. Sen. Elizabeth Warren (D-Mass.) sent Kennedy a 34-page letter containing 175 questions on everything from his anti-vaccine statements and actions to his waffling positions on abortion to his stances on Medicare, drug prices, and the cause of AIDS.

While public health and medical groups did not coordinate with Pence’s conservative organization, questions about Kennedy’s earlier stance in support of abortion rights could raise hackles on the GOP side of the aisle. Although his group is far from Pence on reproductive rights, Benjamin said, “if it helps derail him, I hope some senators are listening to Pence. Any shelter in a storm.”

“The hearings are going to be very difficult for him because he’s told a web of untruths as he’s marched across the offices,” said Leslie Dach, executive chair of Protect Our Care, a Democratic-aligned advocacy group.

Public opinion reflects leeriness of Kennedy on health, though not excessively. In a poll released Tuesday by KFF, 43% of respondents said they trusted him to make the right health recommendations. About 81% of Republicans in the poll said they trusted Kennedy — almost as many as trust their own doctor.

4) What happens if Kennedy takes office.

At the NIH, FDA, and other federal health agencies, nervous scientists speak of early retirement or jumping to industry should Kennedy and his agency heads take office.

The pharmaceutical industry has kept quiet on the nomination, as has the American Medical Association. Many patient advocacy groups are worried, but wary of creating friction with an administration they can’t ignore or defeat.

Kennedy’s comments on AIDS — suggesting that gay men’s use of stimulants, rather than the HIV virus, were its cause — are troubling to Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. But “I don’t know if he’s going to get confirmed or not,” he said. “If he does, we look forward to working with him and educating him.”

At the J.P. Morgan Healthcare conference earlier this month, Emma Walmsley, CEO of GSK, a leading vaccine maker, said she’d “wait and see what the facts are” before predicting what Kennedy would do. Vaccines, she noted, are “not our biggest business.”

GSK is one of a handful of vaccine makers remaining on the U.S. market. That number could shrink further if the Trump administration and Congress undo a 1986 law that provided legal protection for vaccine makers — as Kennedy has advocated.

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HHS, through the Office for Civil Rights, will reevaluate its regulations and guidance pertaining to Federal laws on conscience and religious exercise.

HELENA, Mont. — As part of a proposed revamping of the state’s behavioral health system, Republican Gov. Greg Gianforte’s administration is looking into moving a facility for people with developmental disabilities, beefing up renovations at the Montana State Hospital, and creating a Helena unit of that psychiatric hospital.

The changes, backers say, would fill gaps in services and help people better prepare for life outside of the locked, secure setting of the two state facilities before they reenter their own communities.

“I think part of the theme is responsibly moving people in and out of the state facilities so that we create capacity and have people in the appropriate places,” state Sen. Dave Fern (D-Whitefish) said of the proposed capital projects during a recent interview.

Fern served on the Behavioral Health System for Future Generations Commission, a panel created by a 2023 law to suggest how to spend $300 million to revamp the system. The law set aside the $300 million for improving state services for people with mental illness, substance abuse disorders, and developmental disabilities.

Gianforte’s proposed budget for the next two years would spend about $100 million of that fund on 10 other recommendations from the commission. The capital projects are separate ideas for using up to $32.5 million of the $75 million earmarked within the $300 million pool of funds for building new infrastructure or remodeling existing buildings.

The state Department of Public Health and Human Services and consultants for the behavioral health commission presented commission members with areas for capital investments in October. In December, the commission authorized state health department director Charlie Brereton to recommend the following projects to Gianforte:

• Move the 12-bed Intensive Behavior Center for people with developmental disabilities out of Boulder, possibly to either Helena or Butte, at an estimated cost of up to $13.3 million.
• Establish a “step-down” facility of about 16 beds, possibly on the campus of Shodair Children’s Hospital in Helena, to serve adults who have been committed to the Montana State Hospital but no longer need the hospital’s intensive psychiatric services.
• Invest $19.2 million to upgrade the Montana State Hospital’s infrastructure and buildings at Warm Springs, on top of nearly $16 million appropriated in 2023 for renovations already underway there in an effort to regain federal certification of the facility.

The state Architecture & Engineering Division is reviewing the health department’s cost estimates and developing a timeline for the projects so the information can be sent to the governor. Gianforte ultimately must approve the projects.

Health department officials have said they plan to take the proposals to legislative committees as needed. “With Commission recommendation and approval from the governor, the Department believes that it has the authority to proceed with capital project expenditures but must secure additional authority from the Legislature to fund operations into future biennia,” said department spokesperson Jon Ebelt.

The department outlined its facility plans to the legislature’s health and human services budget subcommittee on Jan. 22 as part of a larger presentation on the commission’s work and the 10 noncapital proposals in the governor’s budget. Time limits prevented in-depth discussion and public comment on the facility-related ideas.

One change the commission didn’t consider: moving the Montana State Hospital to a more populated area from its rural and relatively remote location near Anaconda, in southwestern Montana, in an attempt to alleviate staffing shortages.

“The administration is committed to continuing to invest in MSH as it exists today,” Brereton told the commission in October, referring to the Montana State Hospital.

The hospital provides treatment to people with mental illness who have been committed to the state’s custody through a civil or criminal proceeding. It’s been beset by problems, including the loss of federal Medicaid and Medicare funding due to decertification by the federal government in April 2022, staffing issues that have led to high use of expensive traveling health care providers, and turnover in leadership.

State Sen. Chris Pope (D-Bozeman) was vice chair of a separate committee that met between the 2023 and 2025 legislative sessions and monitored progress toward a 2023 legislative mandate to transition patients with dementia out of the state hospital. He agreed in a recent interview that improving — not moving — MSH is a top priority for the system right now.

“Right now, we have an institution that is failing and needs to be brought back into the modern age, where it is located right now,” he said after ticking off a list of challenges facing the hospital.

State Sen. John Esp (R-Big Timber) also noted at the October commission meeting that moving the hospital was likely to run into resistance in any community considered for a new facility.

Fern, the Whitefish senator, questioned in October whether similar concerns might exist for moving the Intensive Behavior Center out of Boulder. For more than 130 years, the town 30 miles south of Helena has been home, in one form or another, to a state facility for people with developmental disabilities. But Brereton said he believes relocation could succeed with community and stakeholder involvement.

The 12-bed center in Boulder serves people who have been committed by a court because their behaviors pose an immediate risk of serious harm to themselves or others. It’s the last residential building for people with developmental disabilities on the campus of the former Montana Developmental Center, which the legislature voted in 2015 to close.

Drew Smith, a consultant with the firm Alvarez & Marsal, told the commission in October that moving the facility from the town of 1,300 to a bigger city such as Helena or Butte would provide access to a larger labor pool, possibly allow a more homelike setting for residents, and open more opportunities for residents to interact with the community and develop skills for returning to their own communities.

Ideally, Brereton said, the center would be colocated with a new facility included in the governor’s proposed budget, for crisis stabilization services to people with developmental disabilities who are experiencing significant behavioral health issues.

Meanwhile, the proposed subacute facility with up to 16 beds for state hospital patients would provide a still secure but less structured setting for people who no longer need intensive treatment at Warm Springs but aren’t yet ready to be discharged from the hospital’s care. Brereton told the commission in October the facility would essentially serve as a less restrictive “extension” of the state hospital. He also said the agency would like to contract with a company to staff the subacute facility.

Health department officials don’t expect the new facility to involve any construction costs. Brereton has said the agency believes an existing building on the Shodair campus would be a good spot for it.

The state began leasing the building Nov. 1 for use by about 20 state hospital patients displaced by the current remodeling at Warm Springs — a different purpose than the proposed subacute facility.

Shodair CEO Craig Aasved said Shodair hasn’t committed to having the state permanently use the building as the step-down facility envisioned by the agency and the commission.

But Brereton said the option is attractive to the health department now that the building has been set up and licensed to serve adults.

“It seems like a natural place to start,” he told the commission in December, “and we don’t mind that it’s in our backyard here in Helena.”

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