The Biden administration plans to push states to boost oversight of the number of doctors, hospitals, and other health providers insurers cover in Obamacare plans, under rules proposed in November.

The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It’s likely one of the last major ACA policy efforts of President Joe Biden’s first term — and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.

Biden has been a staunch supporter of Obamacare and has taken steps during his own first term in the White House to expand the program through rules and legislation, including measures that increased premium subsidies. In part because of those subsidies, enrollment has increased steadily and hit records under his watch.

The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run their own ACA marketplaces.

The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.

So expect some controversy.

Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA “a low point for the Republican Party.”

Trump also said he was “seriously” considering alternatives, which harked back to his presidency when he frequently promised an Obamacare replacement was soon to be revealed. It never was.

Biden quickly seized on Trump’s comments, saying on Nov. 27 that “my predecessor has once again — God love him — called for cuts that could rip away health insurance for tens of millions of Americans.”

Many of the changes made during Biden’s term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House — just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.

When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program’s namesake, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period, and allowing less expensive but less protective short-term plans to cover longer periods of time. Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don’t cover many of the benefits included in ACA plans and are often called “junk insurance” by critics.

“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Politics may be one reason the administration’s latest proposal doesn’t include larger changes to the ACA. Doing anything more aggressive in an election year “might disrupt a program that Biden fully supports,” said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.

But the proposal from the Department of Health and Human Services does respond to concerns about “network adequacy,” or whether insurers’ doctor and hospital networks are large enough to meet demand. The rules would require states to set numerical standards, such as a maximum “time and distance” that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.

The proposal would affect the 18 states, plus the District of Columbia, that run their own ACA marketplaces.

While many of them already set some network parameters, the standards vary. The administration’s latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.

Requiring standards at least as tough as federal exchange rules across all states “would enhance consumer access to quality, affordable care,” the document says.

Some states “may not be doing enough to ensure compliance,” said Corlette. “States will have to step up their game.”

States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients’ wait times for appointments, especially for primary care and behavioral health, state marketplaces won’t yet have to impose similar standards.

More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.

“On the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet,” said Condeluci. But he said there’s support for the idea that state marketplaces were not “to be nationally run or overly prescriptive from a federal government regulatory perspective.”

The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an “essential health benefit” in their benchmark plans. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho’s period currently begins Oct. 15 and ends Dec. 15, and New York’s begins Nov. 16 and ends Jan. 31.

The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.

The ACA marketplaces “cover millions of people and it’s very important to make sure they are working and people understand what they are buying,” said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.

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A recent Federal Trade Commission civil lawsuit accusing one of the nation’s largest anesthesiology groups of monopolistic practices that sharply drove up prices is a warning to private equity investors that could temper their big push to snap up physician groups.

Over the past three years, FTC and Department of Justice officials have signaled they would apply more scrutiny to private equity acquisitions in health care, including roll-up deals in which larger provider groups buy smaller groups in a local market.

Nothing happened until September, when the FTC sued U.S. Anesthesia Partners and the private equity firm Welsh, Carson, Anderson & Stowe in federal court in Houston, alleging they had rolled up nearly all large anesthesiology practices in Texas. In the first FTC legal challenge against a private equity purchase of medical practices, the federal agency targeted one of the most aggressive private equity firms involved in building large, market-dominating medical groups.

In an interview, FTC Chair Lina Khan confirmed that her agency wants to send a message with this suit. Welsh Carson and USAP “bought up the largest anesthesiology practices, then jacked up prices and entered into price-setting and market-allocation schemes,” said Khan, who was appointed by President Joe Biden in 2021 to head the antitrust enforcement agency, with a mandate to combat health care consolidation. “This action puts the market on notice that we will scrutinize roll-up schemes.”

The large and growing volume of private equity acquisitions of physician groups in recent years has raised mounting concerns about the impact on health costs, quality of care, and providers’ clinical autonomy. A JAMA Internal Medicine study published last year found that prices charged by anesthesiology groups increased 26% after they were acquired by private equity firms.

“Now we’re seeing that scrutiny with this suit,” said Ambar La Forgia, an assistant professor of business management at the University of California-Berkeley, who co-authored the JAMA article. “This suit will cause companies to be more careful not to create too much local market power.”

The FTC’s lawsuit alleges that USAP and Welsh Carson engaged in an anti-competitive scheme to gain market power and drive up prices for hospital anesthesiology services. The FTC also accuses USAP and Welsh Carson — which established the medical group in 2012 and has expanded it to eight states — of cutting deals with competing anesthesiology groups to raise prices and stay out of one another’s markets.

USAP now controls 60% of Texas’ hospital anesthesia market, and its prices are double the median rates of other anesthesia providers in the state, according to the lawsuit. Learning that USAP would boost rates following one acquisition, a USAP executive wrote, “Awesome! Cha-ching,” the civil complaint said.

In a written statement, Welsh Carson, which also holds sizable ownership shares in radiology, orthopedic, and primary care groups, called the FTC lawsuit “without merit in fact or law.” It said USAP’s commercial rates “have not exceeded the rate of medical cost inflation for close to 10 years.”

The New York firm also said its investment in USAP “has allowed independent anesthesiologists to deliver superior clinical outcomes to underserved populations” and that the FTC’s action will harm clinicians and patients. Welsh Carson declined a request for interviews with its executives.

“This is a pretty common roll-up strategy, and some of the big private equity companies must be wondering if more FTC complaints are coming,” said Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. “If the FTC is successful in court, it will have a chilling effect.”

Since the FTC filed the USAP lawsuit, Khan said, the agency has received information from people in other health fields about roll-ups it should scrutinize. “We have limited resources, but it’s an area we are interested in,” she said. “We want to focus on where we see the most significant harm.”

In physician acquisition deals, PE firms typically use mostly borrowed money to acquire a controlling interest in a large medical group, pay the physician owners a substantial upfront sum in exchange for sharply cutting their future compensation, and install a management team. Then they seek to acquire smaller groups in the same geographic market and bolt them onto the original medical group for more bargaining clout and operating efficiencies.

The PE firm’s goal is to garner at least 20% dividends a year and then sell the group to another investor for at least three times the purchase price in three to seven years. Critics say this short-term investment model spurs the investors and medical groups to boost prices and cut staffing to generate large profits as fast as possible.

“Private equity is trying to extract value quickly and sell the company for a profit, so there’s a lot more incentive to increase prices quickly and extract higher revenue,” La Forgia said.

In the two years after a sale, PE-owned practices in dermatology, gastroenterology, and ophthalmology charged insurers 20% more per claim on average than did practices not owned by private equity, according to a JAMA study published last year.

There are similar concerns about hospital systems acquiring physician practices, which also have raised prices. “The evidence shows that both private equity and hospital acquisitions of physician practices are bad for consumers, and scrutiny should be applied to all acquirers,” Adler said.

Critics warn that private equity roll-ups of medical groups can jeopardize quality of care, too. Chris Strouse, a Denver anesthesiologist who served on USAP’s national board of directors but left the company’s Colorado group out of disapproval in 2020, cited patient safety issues arising from short staffing and mismanagement. He said USAP would schedule shifts so that three or four providers would hand off to each other a single surgical procedure, which he said is risky. In addition, USAP frequently asked anesthesiologists to work the day after working a 24-hour on-call shift, he said. “The literature shows that’s outside the safety range,” he said. As a result, many providers have left USAP, he added.

The FTC has long been lax in monitoring roll-ups of physician groups, in part because federal law does not require public reporting of these deals unless they exceed $111.4 million in value, a threshold adjusted over time. Lowering the threshold would require congressional action. As a result, regulators may be unaware of many deals that lead to gradual market concentration, which allows providers to demand higher prices from insurers and employer health plans.

Recognizing that problem, the FTC proposed in June to beef up its reporting requirements for companies planning mergers, in hopes of spotting previous acquisitions of smaller groups that could lead to excessive market power and higher prices. In addition, in a draft of their merger review guidelines, issued in July, the FTC and the Department of Justice said they would consider the cumulative effect of a series of smaller acquisitions.

“The ways PE firms are making serial acquisitions, each individual acquisition is under the radar, but in aggregate they roll up the whole market,” Khan said. “Between the merger reporting form and the new merger guidelines, we want to be able to better catch unlawful roll-up schemes. … This would enable us to stop roll-ups earlier.”

But Brian Concklin, a lawyer with the law firm Clifford Chance, whose clients include private equity firms, said the FTC’s proposed reporting requirements would hamper many legitimate mergers. “The notion that they need all that information to catch deals that lessen competition seems overblown and false, given that the vast majority of these deals do not lessen competition,” he said. “It will be a substantial burden on most if not all clients to comply.”

Researchers and employer groups, however, were encouraged by the FTC’s action, though they fear it’s too little, too late, because consolidation already has reduced competition sharply. Some even say the market has failed and price regulation is needed.

“Providers have been able to extort higher prices on services with no improvement in quality or value or access,” said Mike Thompson, CEO of the National Alliance of Healthcare Purchaser Coalitions. “The FTC stepping up its game is a good thing. But this horse is out of the barn. If we don’t have better enforcement, we won’t have a marketplace.”

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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Florida

Gov. Ron DeSantisAge: 45Florida population: 22.2 million

California

Gov. Gavin NewsomAge: 56California population: 39 million

Republican presidential candidate Ron DeSantis and Democratic Gov. Gavin Newsom — political rivals from opposite coasts and proxies for red and blue America — are set to square off for a first-of-its-kind debate Nov. 30 in Georgia.

Newsom, a liberal firebrand in his second term as governor of California, isn’t running for president in 2024. But he goaded DeSantis, in his second term as governor of Florida, to go mano a mano. “I’ll bring my hair gel. You bring your hairspray,” he taunted on social media.

The matchup promises to be a heated brawl between rising political stars who lead two of the nation’s most populous and diverse states. And it will mark the first time the politicians meet in person even as they have very publicly traded barbs and insults, in recent weeks attacking each other in fundraising videos and campaign ads.

Front and center will be homelessness and health care, top priorities for voters — and issues that have largely defined the governors’ policies and leadership styles. From abortion to covid-19 vaccines, Newsom and DeSantis could not be further apart.

Earlier this year, DeSantis blasted California for being too generous with public benefit programs, such as Medicaid, which the Golden State has expanded to all eligible residents regardless of immigration status. That sweeping policy takes effect in January and goes well beyond the optional expansion of Medicaid that the Affordable Care Act offered states. In Florida, one of 10 states that have refused to expand Medicaid under Obamacare, DeSantis wears the state’s 11% rate of uninsured residents as a badge of honor.

“We’re not going to be like California and have massive numbers of people on government programs without work requirements,” DeSantis said at a presidential primary debate in Southern California earlier this year.

DeSantis has led his state to restrict abortion and gender-affirming care and to ban covid-related mask and vaccine mandates.

Newsom, a slick and brash surrogate for Democratic President Joe Biden, has slammed DeSantis for putting Floridians in danger and stripping them of their rights.

“Join us in California, where we still believe in freedom,” Newsom said in a political ad earlier this year.

Newsom has earned the moniker of “health care governor” by catapulting the issue to the top of his policy priorities. He made California an abortion sanctuary and is dramatically expanding health care benefits. He had promised to bring single-payer health care to the nation’s most populous state while campaigning for his first term, but that idea hit stiff political opposition early in his tenure. And now Newsom boasts about bringing the state’s uninsured rate to an all-time low of 6.5% by expanding coverage in other ways.

These issues are expected to take center stage during the nationally televised 90-minute debate on Fox News, which could have major reverberations for the presidential contest next year and could even help shape the 2028 field of White House contenders.

In advance of the showdown, KFF Health News analyzed 10 of the governors’ top health care positions and how their policies have improved — or hindered — the health of the residents they represent.

Obamacare

Florida

DeSantis has refused to expand Medicaid eligibility to more people under the Affordable Care Act. Partly as a result, more than 3 million Floridians had coverage through the federal Obamacare exchange as of February, more than any other state. Florida does not have a state-based exchange or offer state-sponsored subsidies.

California

The state has enthusiastically embraced the Affordable Care Act, expanding Medicaid while setting up its own insurance exchange, Covered California. Under Newsom, it has also gone well beyond the provisions of Obamacare and created a state requirement for Californians to have health insurance after the federal mandate was eliminated.

Abortion

Florida

DeSantis approved legislation in April banning abortions after six weeks of pregnancy. However, the Florida Supreme Court has taken up a challenge to the 15-week ban introduced in 2022, which will determine if the six-week ban can take effect.

California

Newsom spearheaded the effort in 2022 to amend the state constitution to enshrine the right to abortion and birth control. He also approved $60 million to help uninsured patients and people from out of state pay for abortions in California, and signed reproductive health care laws, including one protecting doctors who mail abortion pills to other states.

Transgender Care

Florida

Under DeSantis, Florida passed a law this year banning gender-affirming health care for trans minors and mandating that adult patients sign informed consent forms before starting or continuing hormone treatment. The law also restricts who can order hormone therapy to physicians and prohibits the use of telehealth for new prescriptions. A federal lawsuit challenging the law is set to go to trial in mid-December.

California

Newsom and other state leaders have amended state law to ensure all California adults and children are entitled to gender-affirming health care services. And insurance companies doing business in California must include information on in-network providers for gender-affirming services by 2025. State health care agencies are designing “enforceable quality standards” to ensure trans patients have access to comprehensive care.

Homelessness

Florida

DeSantis has not declared homelessness a priority. In a video filmed on the streets of San Francisco and posted to social media in June, DeSantis used the topic as a campaign cudgel to criticize what he called “leftist policies” in California. Florida is experimenting with using Medicaid funds to address homelessness, but the program is limited. Nearly 26,000 people are homeless in Florida, or 12 of every 10,000 residents.

California

Newsom has plowed more than $20 billion into the homelessness crisis, with billions more for health and social services. For example, some homeless Californians can get social services through the state’s Medicaid program, such as money for rental security deposits, utility payments, and first and last month’s rent. Newsom also led a new state initiative that could force some homeless people into mental health or addiction treatment. More than 171,000 people are homeless in California, or 44 of every 10,000 residents.

Mental Health

Florida

DeSantis has kept his pledge to advocate for mental health treatment programs as governor, although Florida still ranks 43rd nationally in access to mental health care and has the fourth-highest rate of adults with mental illness who are uninsured, according to the Miami Center for Mental Health and Recovery. Under DeSantis, Florida has increased state funding for mental health programs in schools and peer-to-peer mental health services for first responders, and directed funding to suicide prevention.

California

Newsom in 2020 signed one of the nation’s strongest mental health parity laws, which requires insurance companies to cover mental health and substance use disorders just as they would physical health conditions. He is funding a $4.7 billion initiative to provide mental health treatment in schools. Newsom is also leading the campaign for a statewide, $6.4 billion bond measure in 2024 to revamp and expand community-based behavioral health programs, including thousands of new treatment beds.

Addiction

Florida

Florida’s drug overdose death rate was 37.5 per 100,000 people in 2021. In August, DeSantis announced a new statewide addiction recovery program billed as a “first of its kind” in the United States, using peer counselors, medication-assisted treatment, and a coordinated network of support services. DeSantis also authorized Florida counties to adopt needle exchange programs in 2019 to reduce the spread of blood-borne diseases and encourage addiction treatment.

California

California’s drug overdose rate was 26.6 per 100,000 people in 2021. Newsom is sending the state Highway Patrol and National Guard into San Francisco to combat the open-air fentanyl trade and is boosting addiction recovery programs statewide. But he vetoed legislation last year that would have allowed Los Angeles, San Francisco, and Oakland to establish safe injection sites.

Prescription Drugs

Florida

A DeSantis proposal submitted to the FDA in 2020 includes allowing imported medications from Canada. A new state law also sets price limits for pharmacy benefit managers — intermediaries between insurers, pharmacies, and manufacturers — and creates new rules for them around pricing transparency. The law also requires pharmaceutical companies to disclose significant price hikes.

California

Newsom is spearheading a $100 million, first-in-the-nation initiative that puts California in the generic drugmaking business, beginning with insulin and the opioid reversal drug naloxone. California already had a pricing transparency law when Newsom took office. This year, he signed a law that tightens state regulations for pharmacy benefit managers.

Health Care Affordability

Florida

In 2019, DeSantis signed the Patient Savings Act, which allows health insurers to share cost savings with enrollees who shop for health care services, such as imaging and diagnostic tests. Under his leadership, Florida lawmakers have also allowed short-term health plans lasting less than a year and direct health care agreements between a patient and a health care provider that are not considered insurance and are not subject to Florida’s insurance code.

California

One of Newsom’s first health care initiatives was to fund state-financed health insurance subsidies for low- and middle-income residents who purchase insurance through Covered California. Newsom this year also agreed to lower copays and get rid of some deductibles for plans sold through the exchange. California’s newly created Office of Health Care Affordability is capping industry cost increases and could potentially regulate health industry consolidation. California bans short-term health plans.

Public Health

Florida

DeSantis signed legislation in 2021 banning government, schools, and private employers from requiring covid vaccinations. In 2023, he pushed legislators to adopt laws prohibiting certain vaccine and mask requirements. He also formed a Public Health Integrity Committee led by his hand-picked surgeon general, Joseph Ladapo, whose official guidance on covid vaccines contradicts the CDC’s recommendations. The Sunshine State’s covid-19 vaccine booster rate for residents age 5 and older is 12.4%.

California

Newsom became the first U.S. governor to issue a statewide stay-at-home order at the start of the covid-19 pandemic. He pushed strong vaccination and mask mandates and accused DeSantis of being weak on public health. Newsom has also signed laws strengthening childhood vaccination mandates, including a measure that cracks down on bogus medical exemptions granted by doctors. The Golden State’s covid-19 vaccine booster rate for residents ages 5 and older is 21.9%.

Immigrant Health Care

Florida

With DeSantis making immigration a priority, legislators passed a state law requiring all Florida hospitals to ask on their admission forms whether a patient is a U.S. citizen or lawfully present in the country. Doctors, nurses, and health policy experts say the law targets marginalized people who already have difficulty navigating the health care system and will further deter them from seeking care.

California

Beginning in January, all immigrants who meet income qualifications will be eligible for the state’s Medicaid program. Before Newsom took office, California had already expanded eligibility to immigrant children through age 18 living in the state without authorization. Newsom then signed laws expanding the program to young adults up to age 26, adults 50 and older, and, later, immigrants of any age who otherwise meet eligibility requirements.

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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Florida

Gobernador Ron DeSantisEdad: 45Población de Florida: 22.2 million

California

Gobernador Gavin NewsomEdad: 56Población de California: 39 million

El candidato presidencial republicano Ron DeSantis y el gobernador demócrata Gavin Newsom —rivales políticos y representantes de la América roja y azul— se enfrentarán en un debate sin precedentes el 30 de noviembre en Georgia.

Newsom, un agitador liberal en su segundo mandato como gobernador de California, no se presenta a las elecciones presidenciales de 2024. Pero incitó a DeSantis, en su segundo mandato como gobernador de Florida, a un cara a cara. “Yo llevaré mi gomina. Tú trae tu laca”, bromeó en las redes sociales.

El enfrentamiento promete ser una acalorada pelea entre estrellas políticas en ascenso que lideran dos de los estados más poblados y diversos del país. Y será la primera vez que los políticos se vean las caras, a pesar de que en las últimas semanas han intercambiado insultos en videos para recaudar fondos y anuncios de campaña.

Los temas principales serán la falta de vivienda y la salud, prioridades de los votantes y cuestiones que han definido, en gran medida, las políticas y los estilos de liderazgo de los gobernadores. Desde el aborto hasta las vacunas contra covid-19, Newsom y DeSantis no podrían ser más opuestos.

A principios de este año, DeSantis criticó a California por ser demasiado generosa con los programas públicos como Medicaid, que el Estado Dorado ha ampliado a todos los residentes elegibles, independientemente de su estatus migratorio. Esa política de gran alcance entra en vigencia en enero y va mucho más allá de la expansión opcional de Medicaid que la Ley de Cuidado de Salud a Bajo Precio (ACA) ofreció a los estados. En Florida, uno de los 10 estados que se ha negado a ampliar Medicaid bajo ACA o Obamacare, DeSantis alardea de la tasa de residentes del estado sin seguro de salud, que es del 11%, como si fuera una medalla de honor.

“No vamos a ser como California y tener un número masivo de personas en programas gubernamentales sin requisitos de trabajo”, dijo DeSantis en un debate de primarias presidenciales en el sur de California a principios de este año.

DeSantis ha llevado a su estado a restringir el aborto y la atención médica de afirmación de género, y a prohibir las máscaras relacionadas con covid y los mandatos de vacunación.

Newsom, un hábil e impetuoso sustituto del presidente demócrata Joe Biden, ha arremetido contra DeSantis por poner a los floridanos en peligro y despojarlos de sus derechos.

“Únete a nosotros en California, donde todavía creemos en la libertad”, expresó Newsom en un anuncio político a principios de este año.

Newsom se ha ganado el apodo de “gobernador de la atención de salud” al catapultar este asunto a lo más alto de sus prioridades políticas. Ha hecho de California un santuario del aborto y está ampliando drásticamente las prestaciones de salud. Durante su primera campaña, prometió estabecer el sistema de salud de pagador único al estado más poblado del país, pero esa idea encontró una dura oposición política al principio de su mandato. Y ahora Newsom se jacta de haber conseguido que la tasa de personas sin seguro en el estado haya alcanzado un mínimo histórico del 6,5% al ampliar la cobertura de otras maneras.

Se espera que estas cuestiones sean el centro del debate de 90 minutos televisado a todo el país por Fox News. Un debate que podría tener importantes repercusiones en la contienda presidencial del próximo año, e incluso ayudar a conformar el grupo de aspirantes a la Casa Blanca en 2028.

Con miras al debate, KFF Health News analizó 10 de las principales posiciones de los gobernadores en materia de salud y cómo sus políticas han mejorado —o perjudicado— la salud de los residentes a los que representan.

Obamacare

Florida

DeSantis se ha negado a ampliar la elegibilidad de Medicaid a más personas bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Una de las consecuencias es que, hacia febrero, más de 3 millones de floridanos tenían cobertura a través del mercado de seguros federal del Obamacare, más que cualquier otro estado. Florida no cuenta con un mercado estatal, ni ofrece subsidios patrocinados por el estado.

California

El estado ha adoptado con entusiasmo la Ley de Cuidado de Salud a Bajo Precio (ACA), ampliando Medicaid y creando su propio mercado de seguros, Covered California. Con Newsom, se ha ido mucho más allá de las disposiciones del Obamacare y se ha creado un requisito estatal que obliga a los californianos a tener un seguro de salud, después de que se eliminara el mandato federal.

Aborto

Florida

DeSantis aprobó en abril una ley que prohíbe los abortos después de las seis semanas de embarazo. Sin embargo, la Corte Suprema de Florida ha tomado un recurso de apelación sobre la prohibición de las 15 semanas introducida en 2022, lo que determinará si la prohibición de las seis semanas puede entrar en vigencia.

California

Newsom encabezó en 2022 la iniciativa de enmendar la constitución estatal para consagrar el derecho al aborto y al control de la natalidad. También aprobó $60 millones para ayudar a pacientes sin seguro y a personas de fuera del estado a pagar abortos en California, y firmó leyes de atención a la salud reproductiva, incluida una que protege a los médicos que envían píldoras abortivas por correo a otros estados.

Atención transgénero

Florida

Bajo DeSantis, Florida aprobó este año una ley que prohíbe la atención médica de afirmación de género para menores trans y obliga a los pacientes adultos a firmar formularios de consentimiento informado antes de iniciar o continuar un tratamiento hormonal. La ley también limita la capacidad de los médicos para ordenar la terapia hormonal y prohíbe el uso de la telesalud para nuevas recetas. Está previsto que a mediados de diciembre se celebre un juicio por una demanda federal contra esta ley.

California

Newsom y otros líderes estatales han modificado la ley estatal para garantizar que todos los adultos y niños de California tengan derecho a servicios de atención médica de afirmación de género. Y las compañías de seguros que operan en California deben incluir información sobre los proveedores de la red de servicios de afirmación de género para 2025. Las agencias de salud estatales diseñan “normas de calidad aplicables” para garantizar que los pacientes trans tengan acceso a una atención integral.

Vivienda

Florida

DeSantis no ha declarado que la falta de vivienda sea una prioridad. En un video grabado en las calles de San Francisco, y publicado en redes sociales en junio, utilizó el tema como un arma de campaña para criticar lo que llamó “políticas de izquierda” en California. Florida experimenta con el uso de fondos de Medicaid para hacer frente a la falta de vivienda, pero el programa es limitado. Casi 26,000 personas carecen de hogar en Florida, es decir, 12 de cada 10,000 residentes.

California

Newsom ha destinado más de $20,000 millones a la crisis de los sin techo, y miles de millones más a servicios sociales y de salud. Por ejemplo, algunos californianos sin hogar pueden obtener servicios sociales a través del programa estatal de Medicaid, como dinero para depósitos de alquileres, pagos para servicios públicos, y para el primer y último mes de alquiler. Newsom también lideró una nueva iniciativa estatal que podría obligar a algunas personas sin hogar a someterse a tratamientos de salud mental o de adicciones. En California hay más de 171,000 personas sin hogar, es decir, 44 de cada 10,000 residentes.

Salud mental

Florida

DeSantis ha reiterado su promesa de abogar por programas de tratamiento de salud mental como gobernador, aunque Florida todavía ocupa el puesto 43 a nivel nacional en el acceso a la atención de salud mental y tiene la cuarta tasa más alta de adultos con enfermedades mentales sin seguro, según el Miami Center for Mental Health and Recovery. Con DeSantis, Florida ha aumentado la financiación estatal para programas de salud mental en las escuelas y servicios de salud mental entre pares para personal de primeros auxilios, y ha canalizado fondos para la prevención del suicidio.

California

Newsom firmó en 2020 una de las leyes de paridad en salud mental más estrictas del país, que obliga a las compañías de seguros a cubrir los trastornos mentales y las adicciones de la misma forma que lo harían con las afecciones físicas. Financia una iniciativa de $4,700 millones para proporcionar tratamiento de salud mental en las escuelas. Newsom también lidera en 2024 la campaña a favor de una medida de bonos estatales de $6,400 millones para renovar y ampliar los programas comunitarios de salud mental, incluidas miles de nuevas camas para tratamientos.

Addicciones

Florida

La tasa de muertes por sobredosis de drogas en Florida fue de 37,5 por cada 100,000 personas en 2021. En agosto, DeSantis anunció un nuevo programa estatal para recuperarse de las adicciones, calificado como “el primero de su tipo” en Estados Unidos, que utiliza consejeros pares, tratamiento asistido con medicamentos y una red coordinada de servicios de apoyo. DeSantis también autorizó a los condados de Florida a adoptar programas de intercambio de agujas en 2019 para reducir la propagación de enfermedades por transmisión sanguínea y fomentar el tratamiento de adicciones.

California

La tasa de muertes por sobredosis de drogas en California fue de 26,6 por cada 100, 000 habitantes en 2021. Newsom ha enviado a la Patrulla de Carreteras del estado y a la Guardia Nacional a San Francisco para combatir el comercio de fentanilo al aire libre e impulsa programas de recuperación de adicciones en todo el estado. Pero el año pasado vetó una ley que habría permitido a Los Angeles, San Francisco y Oakland establecer sitios seguros para inyectarse.

Medicamentos recetados

Florida

Una propuesta de DeSantis, presentada a la FDA en 2020, incluye permitir la importación de medicamentos de Canadá. Una nueva ley estatal también establece límites de precios para los administradores de beneficios farmacéuticos —intermediarios entre aseguradoras, farmacias y fabricantes— y crea nuevas normas para ellos en torno a la transparencia de precios. La ley también obliga a las farmacéuticas a revelar aumentos de precios significativos.

California

Newsom encabeza una iniciativa de $100 millones, la primera en el país, que sitúa a California en el negocio de la fabricación de medicamentos genéricos, empezando por la insulina y la naloxona, un fármaco para revertir el efecto de los opioides. California ya contaba con una ley de transparencia de precios cuando Newsom asumió el cargo. Este año, firmó una ley que endurece la normativa estatal para los administradores de beneficios farmacéuticos.

Cuidado de salud asequible

Florida

En 2019, DeSantis firmó la Ley de Ahorro del Paciente, que permite a las aseguradoras de salud compartir los ahorros de costos con los afiliados que compran servicios de atención médica, como imágenes y pruebas de diagnóstico. Bajo su liderazgo, los legisladores de Florida también han permitido planes de salud a corto plazo, que duran menos de un año, y acuerdos de atención médica directa entre un paciente y un proveedor de salud que no se consideran seguros, y no están sujetos al código de seguros de Florida.

California

Una de las primeras iniciativas de Newsom en materia de salud consistió en financiar subvenciones estatales al seguro médico para residentes ingresos bajos y medios que contraten un seguro a través de Covered California. También acordó este año reducir los copagos y eliminar algunos deducibles de los planes vendidos a través del mercado. La recién creada Office of Health Care Affordability de California limita los aumentos de costos del sector y podría regular la consolidación de la industria de la salud. California prohíbe los planes de salud a corto plazo.

Salud Pública

Florida

DeSantis firmó una ley en 2021 que prohíbe al gobierno, las escuelas y los empleadores privados exigir la vacunación contra covid. En 2023, presionó a los legisladores para que aprobaran leyes que prohibieran ciertos requisitos de vacunas y uso de máscaras. También estableció un Comité de Integridad de Salud Pública dirigido por su cirujano general elegido a dedo, Joseph Ladapo, cuya orientación oficial sobre las vacunas de covid contradice las recomendaciones de los CDC. La tasa de vacunación de refuerzo contra covid-19 en el Estado del Sol para los residentes de 5 años en adelante es del 12,4%.

California

Newsom fue el primer gobernador de Estados Unidos en emitir una orden para permanecer en casa en todo el estado al comienzo de la pandemia de covid-19. Impulsó fuertes mandatos de vacunación y máscaras, y acusó a DeSantis de ser débil en materia de salud pública. Newsom también ha firmado leyes que refuerzan los mandatos de vacunación infantil, incluida una severa medida contra las falsas exenciones médicas concedidas por los doctores. La tasa de vacunación de refuerzo contra covid-19 en el Estado Dorado para los residentes de 5 años en adelante es del 21,9%.

Atención de salud del inmigrante

Florida

Al tener DeSantis la inmigración como una prioridad, los legisladores aprobaron una ley estatal que obliga a todos los hospitales de Florida a preguntar en sus formularios de admisión si un paciente es ciudadano estadounidense o se encuentra legalmente en el país. Médicos, enfermeras y expertos en políticas de salud afirman que la ley afecta a personas marginadas, que ya tienen dificultades para desenvolverse en el sistema de salud, y que los disuadirá aún más de buscar atención médica.

California

A partir de enero, todos los inmigrantes que cumplan los requisitos de ingresos podrán acogerse al programa estatal de Medicaid. Antes que Newsom asumiera el cargo, California ya había ampliado la elegibilidad a los niños inmigrantes indocumentados hasta los 18 años. Newsom firmó luego leyes que ampliaron el programa a adultos jóvenes hasta los 26 años, a adultos mayores de 50 años y, más tarde, a los inmigrantes de cualquier edad que cumplieran con los requisitos de elegibilidad.

Esta historia fue producida 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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For Briana Jones, a young Black mother in San Francisco, a city program called the Abundant Birth Project has been a godsend.

Designed to counter the “obstetric racism” that researchers say leads a disproportionate number of African American mothers to die from childbirth, the project has provided 150 pregnant Black and Pacific Islander San Franciscans a $1,000 monthly stipend.

The money enabled Jones, 20, to pay for gas to drive to prenatal clinics, buy fresh fruits and vegetables for her toddler son and herself, and remain healthy as she prepared for the birth of her second child last year.

But the future of the Abundant Birth Project is clouded by a lawsuit alleging that the program, the first of its kind in the nation, illegally discriminates by giving the stipend only to people of a specific race. The lawsuit also targets San Francisco guaranteed-income programs serving artists, transgender people, and Black young adults.

The litigation is part of a growing national effort by conservative groups to eliminate racial preferences in a wide range of institutions following a U.S. Supreme Court ruling that found race-conscious admissions to colleges and universities to be unconstitutional.

In health care, legal actions threaten efforts to provide scholarships to minority medical school students and other initiatives to create a physician workforce that looks more like the nation.

The lawsuits also endanger other measures designed to reduce well-documented racial disparities. Black women are three to four times more likely than white women to die in labor or from related complications in the U.S., and Black infants are twice as likely as white infants to be born prematurely and to die before their first birthdays. Racial and ethnic minorities also are more likely to die from diabetes, high blood pressure, asthma, and heart disease than their white counterparts, according to the Centers for Disease Control and Prevention.

A handful of activist nonprofit groups and law firms are leading the charge. Do No Harm, a nonprofit formed in 2022, has sued health commissions, pharmaceutical companies, and public health journals to try to stop them from choosing applicants based on race. Do No Harm claims more than 6,000 members worldwide and partners with nonprofit legal organizations, most notably the Pacific Legal Foundation, which garnered national attention when it defended California’s same-sex marriage ban.

Another nonprofit, the Californians for Equal Rights Foundation, together with a Dallas-based law firm called the American Civil Rights Project, filed the lawsuit against the city of San Francisco and the state of California over the Abundant Birth Project, alleging the program violates the equal protection clause of the Constitution’s 14th Amendment by granting money exclusively to Black and Pacific Islander women. The 14th Amendment was passed after the Civil War to give rights to formerly enslaved Black people.

The lawsuit calls public money used for the project and the three other guaranteed-income programs “discriminatory giveaways” that are “illegal, wasteful, and injurious.”

“The city and county of San Francisco crafted the Abundant Birth Project with the express intention of picking beneficiaries based on race,” Dan Morenoff, executive director of the American Civil Rights Project, said in a phone interview. “It’s unconstitutional. They can’t legally do it, and we are optimistic that the courts will not allow them to continue to do it.”

San Francisco and state officials declined to discuss the case because of the pending litigation, but the city defended the program in its initial response to the lawsuit. The Abundant Birth Project started in June 2021 and plans to make a second round of grants to pregnant mothers this fall, the response says.

The project strives to improve maternal and infant health outcomes by easing the economic stress on pregnant Black and Pacific Islander San Franciscans. People in those groups face some of the worst outcomes in the U.S., where more women die as a result of pregnancy and childbirth than in other high-income nations. The state of California last year awarded $5 million to expand the program to include Black mothers in four other counties.

But Khiara Bridges, a Berkeley law professor and anthropologist who has talked to beneficiaries of the Abundant Birth Project but is not directly involved with it, said the Supreme Court ruling on college affirmative action could actually support the argument that the program is legal.

The court struck down affirmative action in part because the majority said Harvard and the University of North Carolina failed to show measurable outcomes justifying race consciousness in college admissions. While statistics on potential benefits from the Abundant Birth Project are not publicly available, Bridges and others familiar with the program expect researchers to demonstrate it saves and improves lives by comparing the health outcomes of families who received the stipend with those of families who did not. The outcomes could justify employing race to choose program participants, Bridges said.

Bridges also drew another distinction between the role of race in college admissions and the role of race in health disparities.

“If you don’t get into Harvard, there’s always Princeton or Columbia or Cornell,” she said. “Maternal death — the stakes are a little bit higher.”

In California, a voter initiative, Proposition 209, has prohibited race-based selection in public education and employment since 1996. California Assembly member Mia Bonta (D-Oakland) has co-authored a pending bill that would amend the proposition to allow municipalities to grant benefits to specific groups of vulnerable people if they use research-based measures that can reduce health and other disparities.

Bonta, a law school graduate, told KFF Health News that the litigation against the Abundant Birth Project is the result of “conservative groups who want to exist in a world that doesn’t exist, where communities of color have not had to suffer the generational harm that comes from structural racism.”

Bonta has more than once been a victim of medical racism herself.

When she went to the hospital with a serious back injury, she was interrogated by a doctor who appeared to believe she was faking pain so she could obtain drugs.

“But for the intervention of my husband, who happened to be there and moved into health advocacy mode, I, as a Black Latina woman, would not have received the care that I needed,” she said. Bonta’s husband, Rob Bonta, is also a lawyer and is now California’s attorney general.

Briana Jones experiences racism every day, she said.

She was 15 when she gave birth to her first child in a San Francisco hospital. Terrified and in agonizing pain, she did what laboring mothers have always done and screamed.

A nurse ordered her to “shut up.”

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, research shows. They also face other forms of obstetric racism, including barriers to quality care and cumulative stress from lifelong discrimination.

Growing up Black in predominantly white and Asian San Francisco has been a struggle for Jones. But, while carrying her second baby last year, she learned from her mother of the Abundant Birth Project, and within a month, her race and address in Bayview Hunters Point, where some of the city’s poorest residents live, qualified her as one of nearly 150 women to receive the $1,000 a month during her pregnancy and for six months postpartum.

“I really did feel like it was God helping me,” she said.

For Morenoff, though, it’s just another form of discrimination, and he says the city must either open the Abundant Birth Project to all pregnant women or close it down. “The whole point of the 14th Amendment is to require America to treat all Americans as Americans with the same equal rights,” he said.

Jones had high blood pressure, leading to swollen ankles and dizziness, during both her pregnancies. In her more recent one, the birth project stipend helped enable her to quit couch surfing and move into an apartment, and she gave birth to a healthy boy named Adonis.

“It’s known that people of color struggle way harder than other races,” Jones said. “Where I live, it’s nothing but struggle here, people trying to make ends meet.”

“For them to try to take this program away from us,” she said, “it’s wrong.”

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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The Department of Defense relies on hundreds, if not thousands, of weapons and products such as uniforms, batteries, and microelectronics that contain PFAS, a family of chemicals linked to serious health conditions.

Now, as regulators propose restrictions on their use or manufacturing, Pentagon officials have told Congress that eliminating the chemicals would undermine military readiness.

PFAS, known as “forever chemicals” because they don’t break down in the environment and can build up in the human body, have been associated with such health problems as cancer. In July, a new federal study showed a direct link between testicular cancer and PFOS, a PFAS chemical that has been found in the blood of thousands of military personnel.

Congress has pressured the Defense Department to clean up U.S. military sites and take health concerns more seriously. Under the fiscal 2023 James M. Inhofe National Defense Authorization Act, the Pentagon was required to assess the ubiquity of per- and polyfluoroalkyl substances, or PFAS, in products and equipment used by the military.

In a report delivered to Congress in August, Defense Department officials pushed back against health concerns raised by environmental groups and regulators. “DoD is reliant on the critically important chemical and physical properties of PFAS to provide required performance for the technologies and consumable items and articles which enable military readiness and sustainment,” the authors said.

Further, they wrote: “Losing access to PFAS due to overly broad regulations or severe market contractions would greatly impact national security and DoD’s ability to fulfill its mission.”

According to the report, most major weapons systems, their components, microelectronic chips, lithium-ion batteries, and other products contain PFAS chemicals. These include helicopters, airplanes, submarines, missiles, torpedoes, tanks, and assault vehicles; munitions; semiconductors and microelectronics; and metalworking, cooling, and fire suppression systems — the latter especially aboard Navy ships.

PFAS are also present in textiles such as uniforms, footwear, tents, and duffel bags, for which the chemicals help repel water and oil and increase durability, as well as nuclear, chemical, and biological warfare protective gear, the report says.

The Pentagon’s report to Congress was released last month by the American Chemistry Council.

Defending a Tradition of Defense

Military officials’ defense of PFAS use comes as concerns mount over the health risks associated with the chemicals. Beyond cancer, some types of PFAS have been linked to low birth weight, developmental delays in children, thyroid dysfunction, and reduced response to immunizations. Health concerns grew with the release of the study definitively linking testicular cancer in military firefighters to a foam retardant containing PFAS.

But that wasn’t the first time U.S. military officials were warned about the potential health threat. In the 1970s, Air Force researchers found that firefighting foam containing PFAS was poisonous to fish and, by the 1980s, to mice.

In 1991, the U.S. Army Corps of Engineers told Fort Carson, Colorado, to stop using firefighting retardants containing PFAS because they were “considered hazardous material in a number of states.”

The Environmental Protection Agency has struggled to determine whether there are acceptable levels of PFAS in drinking water supplies, given the existence of hundreds of varieties of these chemicals. But in March, the EPA did propose federal limits on the levels of PFAS in drinking water supplies.

The regulation would dramatically reduce limits on six types of the chemicals, with caps on the most common compounds, known as PFOA and PFOS, at 4 parts per trillion. Currently, the Defense Department’s threshold for drinking water is 70 parts per trillion based on a 2016 EPA advisory. As part of a widespread testing program, if levels are found on installations or in communities above that amount, the military furnishes alternative drinking water supplies.

The Defense Department has used PFAS-laced firefighting foam along with other products containing the chemicals for more than a half-century, leading to the contamination of at least 359 military sites or nearby communities, with an additional 248 under investigation, according to the department.

In its report, however, the Department of Defense did not address the health concerns and noted that there is “no consensus definition of PFAS as a chemical class.” Further, it said that the broad term, which addresses thousands of man-made chemical chains, “does not inform whether a compound is harmful or not.”

Researchers with the Environmental Working Group, an advocacy group that focuses on PFAS contamination nationwide, said the report lacked acknowledgment of the health risks or concerns posed by PFAS and ignored the availability of PFAS-free replacements for material, tents, and duffel bags.

The military report also did not address possible solutions or research on non-PFAS alternatives or address replacement costs, noted EWG’s Jared Hayes, a senior policy analyst, and David Andrews, a senior scientist.

“It’s kind of like that report you turn in at school,” Andrews said, “when you get a comment back that you did the minimum amount possible.”

Andrews added that the report fell short in effort and scope.

The Defense Department announced this year it would stop buying firefighting foam containing PFAS by year’s end and phase it out altogether in 2024. It stopped using the foam for training in 2020, by order of Congress.

The report noted, however, that while new Navy ships are being designed with alternative fire suppression systems such as water mists, “limited use of [PFAS-containing systems] remains for those spaces where the alternatives are not appropriate,” such as existing ships where there is no alternative foam that could be swapped into current systems.

According to the report, “the safety and survivability of naval ships and crew” from fires on ships depends on current PFAS-based firefighting foams and their use will continue until a capable alternative is found.

Pervasive Yet Elusive

Commercially, PFAS chemicals are used in food packaging, nonstick cookware, stain repellents, cosmetics, and other consumer products.

The fiscal 2023 National Defense Authorization Act also required the Defense Department to identify consumer products containing PFAS and stop purchasing them, including nonstick cookware and utensils in dining facilities and ship galleys as well as stain-repellent upholstered furniture, carpeting, and rugs.

But in a briefing to Congress in August accompanying the report on essential uses, Pentagon officials said they couldn’t comply with the law’s deadline of April 1, 2023, because manufacturers don’t usually disclose the levels of PFAS in their products and no federal laws require them to do so.

Come Jan. 1, however, makers of these chemicals and products containing them will be required to identify these chemicals and notify “downstream” manufacturers of other products of the levels of PFAS contained in such products and ingredients, even in low concentrations, according to a federal rule published Oct. 31 by the EPA.

This would include household items like shampoo, dental floss, and food containers.

Officials reiterated that the Defense Department is committed to phasing out nonessential and noncritical products containing PFAS, including those named above as well as food packaging and personal protective firefighting equipment.

And it is “developing an approach” to remove items containing PFAS from military stores, known as exchanges, also required by the fiscal 2023 NDAA.

Risk-Benefit Assessments

In terms of “mission critical PFAS uses,” however, the Pentagon said the chemicals provide “significant benefits to the framework of U.S. critical infrastructure and national and economic security.”

Andrews of EWG noted that the industry is stepping up production of the chemicals due to market demand and added that the federal government has not proposed banning PFAS chemicals, as the Defense Department alluded to when it emphasized the critical role these substances play in national security and warned against “overly broad regulations.”

“The statements are completely unsubstantiated, and it’s almost a fear-mongering statement,” Andrews said. “I think the statement is really going beyond anything that’s even being considered in the regulatory space.”

“There haven’t been realistic proposals policy-wise of a complete ban on PFAS,” his colleague Hayes added. “What people have been pushing for and talking about are certain categories of products where there are viable alternatives, where there is a PFAS-free option. But to ban it outright? I haven’t really seen that as a realistic policy proposal.”

Kevin Fay, executive director of the Sustainable PFAS Action Network, a coalition of corporations, industry advocates, and researchers who support the use and management of PFAS compounds, said the Defense Department has a point and it is up to federal regulators to “responsibly manage” these chemicals and their use to strike a balance among environmental, health, and industrial needs.

“The U.S. Department of Defense’s report on critical PFAS uses is crystal clear: regulating PFAS through a one-size fits all approach will gravely harm national security and economic competitiveness,” Fay wrote in an email to KFF Health News.

Adding that not all PFAS compounds are the same and arguing that not all are harmful to human health, Fay said risk-based categorization and control is vital to the continued use of the chemicals.

But, he added, in locations where the chemicals pose a risk to human health, the government should act.

“The federal government should implement plans to identify and remediate contaminated sites, properly identify risk profiles of the many types of PFAS compounds, and encourage innovation by clearing the regulatory path for viable alternatives to specific dangerous compounds,” Fay wrote.

Assessments are completed or underway at 714 active and former military installations, National Guard facilities, and other former defense sites to determine the extent of contamination in groundwater, soil, and the water supply to these locations and nearby communities.

Last year, the Pentagon issued a temporary moratorium on burning materials containing PFAS. Studies have shown that the practice can release toxic gases. But on July 11, the Defense Department lifted the moratorium on incineration, along with interim guidance on PFAS disposal.

Military personnel who were exposed to PFAS — including through firefighting foam — say they live in fear that they or their family members will develop cancer as a result of their service.

“I’ve got more of some of those materials in my system than 90-plus percent of those on the planet. This is bad. It doesn’t go away,” said Christian Jacobs, who served in the Army for four years and worked as a civilian Defense Department firefighter for nearly three decades. “It keeps me up at night.”

KFF Health News visual reporter Hannah Norman contributed to this report.

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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This story can be republished for free (details).