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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Increasingly, Wilson helps older people like Hilton find housing.

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

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

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

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

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

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

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

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

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

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

Communities are looking for solutions.

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

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

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

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

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

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

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

“It was a woo-hoo moment,” she said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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It takes a lot of courage to grow old.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’ll take courage to deal with that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

She blamed her closure on “regulatory dysfunction.”

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

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

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

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

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

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

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

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

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

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

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

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

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In November, Montana voters safeguarded the right to abortion in the state’s constitution. They also elected a new chief justice to the Montana Supreme Court who was endorsed by anti-abortion advocates.

That seeming contradiction is slated to come to a head this year. People on polar sides of the abortion debate are preparing to fight over how far the protection for abortion extends, and the final say will likely come from the seven-person state Supreme Court. With the arrival of new Chief Justice Cory Swanson, who ran as a judicial conservative for the nonpartisan seat and was sworn in Jan. 6, the court now leans more conservative than before the election.

A similar dynamic is at play elsewhere. Abortion rights supporters prevailed on ballot measures in seven of the 10 states where abortion was up for a vote in November. But even with new voter-approved constitutional protections, courts will have to untangle a web of existing state laws on abortion and square them with any new ones legislators approve. The new makeup of supreme courts in several states indicates that the results of the legal fights to come aren’t clear-cut.

Activists have been working to reshape high courts, which in recent years have become the final arbiters of a patchwork of laws regulating abortions. That’s because the 2022 U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned federal abortion protections, leaving rulemaking to the states.

Since then, the politics of state supreme court elections have been “supercharged” as fights around abortion shifted to states’ top courts, according to Douglas Keith, a senior counsel at the nonpartisan Brennan Center for Justice.

“Because we’re human, you can’t scrub these races of any political connotations at all,” said former Montana Supreme Court Justice Jim Nelson. “But it’s getting worse.”

The wave of abortion litigation in state courts has spawned some of the most expensive state supreme court races in history, including more than $42 million spent on the nonpartisan 2023 Supreme Court race in Wisconsin, where abortion access was among the issues facing the court. Janet Protasiewicz won the seat, flipping the balance of the court to a liberal majority.

In many states, judicial elections are nonpartisan but political parties and ideological groups still lobby for candidates. In 2024, abortion surfaced as a top issue in these races.

In Michigan, spending by non-candidate groups alone topped $7.6 million for the two open seats on the state Supreme Court. The Michigan races are officially labeled as nonpartisan, although candidates are nominated by political parties.

An ad for the two candidates backed by Democrats cautioned that “the Michigan state Supreme Court can still take abortion rights away” even after voters added abortion protections to the state constitution in 2022. The ad continued, “Kyra Harris Bolden and Kimberly Thomas are the only Supreme Court candidates who will protect access to abortion.” Both won their races.

Abortion opponent Kelsey Pritchard, director of state public affairs for Susan B. Anthony Pro-Life America, decried the influence of abortion politics on state court elections. “Pro-abortion activists know they cannot win through the legislatures, so they have turned to state courts to override state laws,” Pritchard said.

Some abortion opponents now support changes to the way state supreme courts are selected.

In Missouri, where voters passed a constitutional amendment in November to protect abortion access, the new leader of the state Senate, Cindy O’Laughlin, a Republican, has proposed switching to nonpartisan elections from the state’s current model, in which the governor appoints a judge from a list of three finalists selected by a nonpartisan commission. Although Republicans have held the governor’s mansion since 2017, she pointed to the Missouri Supreme Court’s 4-3 ruling in September that allowed the abortion amendment to remain on the ballot and said courts “have undermined legislative efforts to protect life.”

In a case widely expected to reach the Missouri Supreme Court, the state’s Planned Parenthood clinics are trying to use the passage of the new amendment to strike down Missouri’s abortion restrictions, including a near-total ban. O’Laughlin said her proposal, which would need approval from the legislature and voters, was unlikely to influence that current litigation but would affect future cases.

“A judiciary accountable to the people would provide a fairer venue for addressing legal challenges to pro-life laws,” she said.

Nonpartisan judicial elections can buck broader electoral trends. In Michigan, for example, voters elected both Supreme Court candidates nominated by Democrats last year even as Donald Trump won the state and Republicans regained control of the state House.

In Kentucky’s nonpartisan race, Judge Pamela Goodwine, who was endorsed by Democratic Gov. Andy Beshear, outperformed her opponent even in counties that went for Trump, who won the state. She’ll be serving on the bench as a woman’s challenge to the state’s two abortion bans makes its way through state courts.

Partisan judicial elections, however, tend to track with other partisan election results, according to Keith of the Brennan Center. So some state legislatures have sought to turn nonpartisan state supreme court elections into fully partisan affairs.

In Ohio, Republicans have won every state Supreme Court seat since lawmakers passed a bill in 2021 requiring party affiliation to appear on the ballot for those races. That includes three seats up for grabs in November that solidified the Republican majority on the court from 4-3 to 6-1.

“These justices who got elected in 2024 have been pretty open about being anti-abortion,” said Jessie Hill, an attorney with the American Civil Liberties Union of Ohio, who has been litigating a challenge to Ohio’s abortion restrictions since voters added protections to the state constitution in 2023.

Until the recent ballot measure vote in Montana, the only obstacle blocking Republican-passed abortion restrictions from taking effect had been a 25-year-old decision that determined Montana’s right to privacy extends to abortion.

Nelson, the former justice who was the lead author of the decision, said the court has since gradually leaned more conservative. He noted the state’s other incoming justice, Katherine Bidegaray, was backed by abortion rights advocates.

“The dynamic of the court is going to change,” Nelson said after the election. “But the chief justice has one vote, just like everybody else.”

Swanson, Montana’s new chief justice, had said throughout his campaign that he’ll make decisions case by case. He also rebuked his opponent, Jerry Lynch, for saying he’d respect the court’s ruling that protected abortion. Swanson called such statements a signal to liberal groups.

At least eight cases are pending in Montana courts challenging state laws to restrict abortion access. Martha Fuller, president and CEO of Planned Parenthood Advocates of Montana, said that the new constitutional language, which takes effect in July, could further strengthen those cases but that the court’s election outcome leaves room for uncertainty.

The state’s two outgoing justices had past ties to the Democratic Party. Fuller said they also consistently supported abortion as a right to privacy. “One of those folks is replaced by somebody who we don’t know will uphold that,” she said. “There will be this period where we’re trying to see where the different justices fall on these issues.”

Those cases likely won’t end the abortion debate in Montana.

As of the legislative session’s start in early January, Republican lawmakers, who have for years called the state Supreme Court liberal, had already proposed eight bills regarding abortion and dozens of others aimed at reshaping judicial power. Among them is a bill to make judicial elections partisan.

Montana Sen. Daniel Emrich, a Republican who requested a bill titled “Prohibit dismembering of person and provide definition of human,” said it’s too early to know which restrictions anti-abortion lawmakers will push hardest.

Ultimately, he said, any new proposed restrictions and the implications of the constitutional amendment will likely land in front of the state Supreme Court.

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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Durante la presidencia de Joe Biden, la inscripción en Medicaid alcanzó un nivel récord y la tasa de personas sin seguro médico llegó a su nivel histórico más bajo.

Pero se espera que el regreso de Donald Trump a la Casa Blanca, junto con un Senado y una Cámara de Representantes controlados por republicanos, cambie esta situación.

Los republicanos en Washington afirman que planean utilizar recortes de financiamiento y cambios regulatorios para reducir drásticamente Medicaid, el programa de salud federal gerenciado por los estados que cuesta casi $900.000 millones al año y que, junto con el Programa de Seguro Médico Infantil (CHIP), ofrece atención a unos 79 millones de estadounidenses, en su mayoría de bajos ingresos o con discapacidades.

Las propuestas incluyen revertir la expansión de Medicaid impulsada por la Ley de Cuidado de Salud a Bajo Precio (ACA), que en los últimos 11 años sumó cerca de 20 millones de adultos de bajos ingresos al programa.

Trump ha dicho que quiere recortar drásticamente el gasto del gobierno, lo que podría ser necesario para que los republicanos extiendan los recortes de impuestos de 2017 que vencen a finales de este año.

Trump no habló demasiado sobre Medicaid durante su campaña de 2024. Su primera administración aprobó requisitos de trabajo en varios estados, aunque solo Arkansas los implementó antes de que un juez federal determinara que violaban los principios de ACA. También intentó otorgar financiamiento en bloque a los estados.

El presidente del Comité de Presupuesto de la Cámara, Jodey Arrington (republicano de Texas), dijo a KFF Health News que Medicaid y otros programas federales de beneficencia necesitan cambios importantes para ayudar a reducir la deuda federal. “Sin esos cambios, veremos con pesar cómo este país sufre un colapso fiscal”.

El representante Chip Roy (republicano de Texas), miembro del Comité de Presupuesto, indicó que el Congreso necesita explorar recortes al gasto federal en Medicaid.

“Es necesaria una reforma integral en el sector de salud, que podría incluir deshacer gran parte del daño causado por ACA y Obamacare”, dijo Roy. “Francamente, podríamos terminar proporcionando un mejor servicio si lo hacemos de la manera correcta”.

Defensores de las personas de bajos ingresos temen que los recortes que buscan los republicanos dejen a más estadounidenses sin seguro, dificultándoles el acceso a la atención médica.

“Medicaid es un objetivo obvio para recortes enormes”, dijo Joan Alker, directora ejecutiva del Centro para Niños y Familias de la Universidad Georgetown. “Probablemente se avecina una lucha existencial sobre el futuro de Medicaid”.

El programa, que cumplirá 60 años en julio, está llegando al final de una gran crisis, después que las protecciones de cobertura implementadas durante la pandemia de covid-19 expiraran en 2023, y todos los inscriptos tuvieran que demostrar que seguían siendo elegibles.

Más de 25 millones de personas perdieron su cobertura durante los 18 meses posteriores al inicio del proceso de “desafiliación”, aunque no ha aumentado notablemente el número de personas sin seguro, según los datos más recientes del censo.

Pero este número podría ser insignificante comparado con lo que ocurra en los próximos cuatro años, dijo Matt Salo, ex director ejecutivo y fundador de la Asociación Nacional de Directores de Medicaid. “Lo que vamos a ver es un cambio dramático aún mayor en quiénes estarán cubiertos por Medicaid y cómo operará el programa”, aseguró.

Sin embargo, Salo señaló que cualquier esfuerzo por reducir el programa enfrentará resistencia.

“Muchas entidades poderosas —gobiernos estatales, organizaciones de atención administrada, proveedores de atención de largo plazo y todos aquellos interesados en que Medicaid funcione de manera eficiente— estarán altamente motivadas para resistirse a recortes que consideren draconianos, ya que podrían afectar sus modelos de negocio”, afirmó.

Algunas de las estrategias del partido republicano para reducir el tamaño de Medicaid son:

1. Cambio a financiamiento en bloque. Actualmente, el gobierno federal iguala un porcentaje del gasto estatal anual en Medicaid, sin un límite específico. Los republicanos quieren cambiar a pagos fijos anuales, lo que impactaría en la cantidad de dinero federal que algunos estados reciben. Desde Ronald Reagan, los presidentes republicanos han intentado sin éxito imponer una suma fija de financiación para Medicaid.
2. Recortes a la financiación de ACA para Medicaid. ACA financió la cobertura para estadounidenses con ingresos de hasta el 138% del nivel federal de pobreza ($20.783 de ingresos anuales para un individuo en 2024). Los republicanos podrían intentar reducir ese financiamiento al mismo porcentaje que el gobierno federal paga por el resto de los inscritos en el programa, que promedia un 60%. “Debemos tener en cuenta que estamos subsidiando a la población sana y apta para trabajar que se beneficia de la expansión de Medicaid a un ritmo mayor que el que subsidiamos a los más pobres y enfermos, que era la intención original del programa”, dijo Arrington. “Eso no está bien”.
3. Reducción de fondos federales. Desde su inicio, la tasa de contribución federal varía según la riqueza relativa de la población del estado. Los estados más pobres reciben una tasa más alta y ningún estado recibe menos del 50% en contrapartida. Los republicanos podrían buscar reducir la tasa base del 50% a menos del 40%.
4. Agregar requisitos de trabajo. Aunque los tribunales federales han dictaminado que no se puede condicionar la cobertura a trabajar o a estar buscando trabajo, el Partido Republicano podría intentarlo nuevamente. “Si podemos lograr que los adultos sanos tengan requisitos de trabajo estrictos, eso puede suponer un enorme ahorro de costos”, dijo el representante Tom McClintock (republicano de California) a KFF Health News. Como la mayoría de los inscriptos en Medicaid ya trabajan, van a la escuela o son cuidadores, los críticos dicen que un requisito de ese tipo simplemente agregaría burocracia a la obtención de cobertura, con poco impacto en el empleo.
5. Imponer barreras a la inscripción. Unos 10 estados ofrecen a algunas poblaciones lo que se denomina elegibilidad continua, mediante la cual las personas permanecen inscriptas durante años sin tener que renovar su cobertura. Se ha demostrado que esa política evita que los beneficiarios abandonen el programa durante períodos cortos por dificultades o problemas con el papeleo, lo que puede generar facturas médicas inesperadas y deuda. La administración Trump podría intentar derogar las exenciones que permiten a los estados otorgar elegibilidad continua, lo que obligaría a las personas en esos estados a tener que volver a solicitar cobertura cada año.

Si los planes de los republicanos para reducir Medicaid se concretan, expertos dicen que las personas de bajos ingresos que se vean obligadas a comprar seguros privados enfrentarán dificultades para pagar las primas y copagos comunes en estos planes comerciales, que no suelen existir en Medicaid.

El Paragon Health Institute, un centro de estudios conservador dirigido por Brian Blasé, ex asesor de Trump, ha publicado informes que dicen que los miles de millones de dólares adicionales que los estados recibieron para ampliar Medicaid bajo ACA han sido una bendición para las aseguradoras privadas que administran el programa y para las personas relativamente más ricas que, según la organización, no deberían estar inscriptas.

Josh Archambault, miembro senior del conservador Cicero Institute, dijo que espera que la administración Trump haga responsables a los estados por pagar miles de millones de más a los proveedores, y por inscribir en Medicaid a personas que no son elegibles.

Archambault agregó que el Partido Republicano buscará reducir Medicaid a sus poblaciones “tradicionales”: niños, embarazadas y personas con discapacidades.

“Necesitamos reequilibrar el programa que la mayoría de la gente piensa que tiene un bajo rendimiento”, apuntó. La mayoría de los estadounidenses, incluidas grandes mayorías tanto de republicanos como de demócratas, ven el programa de manera favorable, según encuestas.

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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We’ve all read the stories and seen the images: The life-threatening heat waves. The wildfires of unprecedented ferocity. The record-breaking storms washing away entire neighborhoods. The melting glaciers, the rising sea levels, the coastal flooding.

As California wildfires stretch into the colder months and hurricane survivors sort through the ruins left by floodwaters, let’s talk about an underreported victim of climate change: the emotional well-being of young people.

A nascent but growing body of research shows that a large proportion of adolescents and young adults, in the United States and abroad, feel anxious and worried about the impact of an unstable climate in their lives today and in the future.

Abby Rafeek, 14, is disquieted by the ravages of climate change, both near her home and far away. “It’s definitely affecting my life, because it’s causing stress thinking about the future and how, if we’re not addressing the problem now as a society, our planet is going to get worse,” says Abby, a high school student who lives in Gardena, California, a city of 58,000 about 15 miles south of downtown Los Angeles.

She says wildfires are a particular worry for her. “That’s closer to where I live, so it’s a bigger problem for me personally, and it also causes a lot of damage to the surrounding areas,” she says. “And also, the air gets messed up.”

In April, Abby took a survey on climate change for kids ages 12-17 during a visit to the emergency room at Children’s Hospital of Orange County.

Rammy Assaf, a pediatric emergency physician at the hospital, adapted the survey from one developed five years ago for adults. He administered his version last year to over 800 kids ages 12-17 and their caregivers. He says initial results show climate change is a serious cause of concern for the emotional security and well-being of young people.

Assaf has followed up with the kids to ask more open-ended questions, including whether they believe climate change will be solved in their lifetimes; how they feel when they read about extreme climate events; what they think about the future of the planet; and with whom they are able to discuss their concerns.

“When asked about their outlook for the future, the first words they will use are helpless, powerless, hopeless,” Assaf says. “These are very strong emotions.”

Assaf says he would like to see questions about climate change included in mental health screenings at pediatricians’ offices and in other settings where children get medical care. The American Academy of Pediatrics recommends that counseling on climate change be incorporated into the clinical practice of pediatricians and into medical school curriculums, but not with specific regard to mental health screening.

Assaf says anxiety about climate change intersects with the broader mental health crisis among youth, which has been marked by a rise in depression, loneliness, and suicide over the past decade, though there are recent signs it may be improving slightly.

A 2022 Harris Poll of 1,500 U.S. teenagers found that 89% of them regularly think about the environment, “with the majority feeling more worried than hopeful.” In addition, 69% said they feared they and their families would be affected by climate change in the near future. And 82% said they expected to have to make key life decisions — including where to live and whether to have children — based on the state of the environment.

And the impact is clearly not limited to the U.S. A 2021 survey of 10,000 16- to 25-year-olds across 10 countries found “59% were very or extremely worried and 84% were at least moderately worried” about climate change.

Susan Clayton, chair of the psychology department at the College of Wooster in Ohio, says climate change anxiety may be more pronounced among younger people than adults. “Older adults didn’t grow up being as aware of climate change or thinking about it very much, so there’s still a barrier to get over to accept it’s a real thing,” says Clayton, who co-created the adult climate change survey that Assaf adapted for younger people.

By contrast, “adolescents grew up with it as a real thing,” Clayton says. “Knowing you have the bulk of your life ahead of you gives you a very different view of what your life will be like.” She adds that younger people in particular feel betrayed by their government, which they don’t think is taking the problem seriously enough, and “this feeling of betrayal is associated with greater anxiety about the climate.”

Abby believes climate change is not being addressed with sufficient resolve. “I think if we figure out how to live on Mars and explore the deep sea, we could definitely figure out how to live here in a healthy environment,” she says.

If you are a parent whose children show signs of climate anxiety, you can help.

Louise Chawla, professor emerita in the environmental design program at the University of Colorado-Boulder, says the most important thing is to listen in an open-ended way. “Let there be space for kids to express their emotions. Just listen to them and let them know it’s safe to express these emotions,” says Chawla, who co-founded the nonprofit Growing Up Boulder, which works with the city’s schools to encourage kids to engage civically, including to help shape their local environment.

Chawla and others recommend family activities that reinforce a commitment to the environment. They can be as simple as walking or biking and participating in cleanup or recycling efforts. Also, encourage your children to join activities and advocacy efforts sponsored by environmental, civic, or religious organizations.

Working with others can help alleviate stress and feelings of powerlessness by reassuring kids they are not alone and that they can be proactive.

Worries about climate change should be seen as a learning opportunity that might even lead some kids to their life’s path, says Vickie Mays, professor of psychology and health policy at UCLA, who teaches a class on climate change and mental health — one of eight similar courses offered recently at UC campuses.

“We should get out of this habit of ‘everything’s a mental health problem,’” Mays says, “and understand that often a challenge, a stress, a worry can be turned into advocacy, activism, or a reach for new knowledge to change the situation.”

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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On the heels of a scuttled hospital merger between rivals in Terre Haute, Indiana, a state senator introduced a bill that would forbid similar mergers in the future.

Last year, nonprofit Union Health tried to acquire the only other acute care hospital in Vigo County by leveraging a state law it helped create that allows hospital monopolies. Now, Sen. Ed Charbonneau, a key architect of the 2021 law, which allows what is known as a “Certificate of Public Advantage,” or COPA, wants to repeal it.

“I didn’t think I was doing 100% the right thing last time,” the Republican, who chairs the Senate health committee, said of co-authoring Indiana’s 2021 COPA law. “I do think I am this time.”

Indiana is one of 19 states that have COPA laws, which allow hospital mergers that the Federal Trade Commission otherwise considers illegal because they reduce competition and often create monopolies.

In exchange for allowing these deals, the merging hospitals typically agree to meet a number of conditions imposed by the state to mitigate the harms of a monopoly. But health care economists and the FTC have said that state oversight cannot replace competition and that these mergers ultimately harm patients.

The public and the FTC pressured Indiana health regulators to block Union’s merger with its rival, Terre Haute Regional Hospital. Just days before a December deadline for the state to issue a decision on whether to approve the deal, Union Health and Terre Haute Regional Hospital pulled their application.

Union Health and Tennessee-based HCA Healthcare, which owns Terre Haute Regional, declined to answer questions about what prompted the decision to scuttle the deal. In a November statement, Union said it planned to submit a new application.

In 2021, Union Health leaders were instrumental in the passage of Indiana’s COPA law. They supplied draft language for the bill, according to legislative testimony, and Union Health CEO Steve Holman testified before lawmakers that the merger would improve Vigo County’s poor public health rankings.

But Charbonneau’s bill would prevent such deals and make Indiana the sixth state to repeal its COPA law.

In 2023, Maine ended its COPA after heeding warnings from the FTC about the harmful effects of such mergers. Minnesota, Montana, North Carolina, and North Dakota have also repealed such laws.

In comments to Indiana regulators, the FTC referenced KFF Health News’ reporting on Ballad Health, a 20-hospital monopoly in Tennessee and Virginia, as a cautionary tale against such mergers.

COPAs, such as the one under which Ballad operates, “have proven unwieldy,” are “difficult to manage,” and “have failed to protect local communities from the harmful effects of anticompetitive hospital mergers,” the FTC said in its comments on the proposed Union-Regional merger.

Ballad declined to respond to KFF Health News inquiries regarding the FTC’s comments.

Since Ballad launched in 2018 and became the nation’s largest state-approved hospital monopoly, it has not lived up to some of its promises, KFF Health News has reported. It has fallen short of quality and charity care goals, according to annual reports from Ballad and the Tennessee Department of Health. After years of problems and complaints from patients, the state is now trying to hold Ballad more accountable for its quality of care.

In a November interview with KFF Health News, Ballad Health CEO Alan Levine attributed the quality-of-care slump to covid-19 and workforce challenges. He said these issues are unrelated to the COPA merger and the monopoly it created.

In Indiana, Republican Gov.-elect Mike Braun has said tackling health care issues will be a top policy priority. Braun’s policy agenda to “protect Hoosiers from consolidation” calls for rooting out regulations that “promote consolidation” and pose a “barrier” to competition.

Republicans control the state legislature. Charbonneau, a high-ranking senator, has co-authored several bills to combat consolidation, including through restricting noncompete agreements for primary care physicians and requiring hospitals and other health care businesses to notify Indiana’s attorney general of pending mergers and acquisitions.

If Charbonneau’s bill to repeal Indiana’s COPA law passes during the legislative session beginning Jan. 8, it may prevent Union from acquiring Regional. Union would need to submit a new application and get it approved before Charbonneau’s bill would take effect July 1. Both Union and HCA declined to comment on the proposed bill and their future application plans.

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The federal Consumer Financial Protection Bureau on Tuesday issued new regulations barring medical debts from American credit reports, enacting a major new consumer protection just days before President Joe Biden is set to leave office.

The rules ban credit agencies from including medical debts on consumers’ credit reports and prohibit lenders from considering medical information in assessing borrowers.

These rules, which the federal watchdog agency proposed in June, could be reversed after President-elect Donald Trump takes office Jan. 20. But by finalizing the regulations now, the CFPB effectively dared the incoming Trump administration and its Republican allies in Congress to undue rules that are broadly popular and could help millions of people who are burdened by medical debt.

“People who get sick shouldn’t have their financial future upended,” CFPB Director Rohit Chopra said in announcing the new rules. “The CFPB’s final rule will close a special carveout that has allowed debt collectors to abuse the credit reporting system to coerce people into paying medical bills they may not even owe.”

The regulations fulfill a pledge by the Biden administration to address the scourge of health care debt, a problem that touches an estimated 100 million Americans, forcing many to make sacrifices such as limiting food, clothing, and other essentials.

Credit reporting, a threat that has been wielded by medical providers and debt collectors to get patients to pay their bills, is the most common collection tactic used by hospitals, a KFF Health News analysis found.

The impact can be devastating, especially for those with large health care debts.

There is growing evidence, for example, that credit scores depressed by medical debt can threaten people’s access to housing and drive homelessness. People with low credit scores can also have trouble getting a loan or can be forced to borrow at higher interest rates.

That has prompted states including Colorado, New York, and California to enact legislation prohibiting medical debt from being included on residents’ credit reports or factored into their credit scores. Still, many patients and consumer advocates have pushed for a national ban.

The CFPB has estimated that the new credit reporting rule will boost the credit scores of people with medical debt on their credit reports by an average of 20 points.

But the agency’s efforts to restrict medical debt collections have drawn fierce pushback from the collections industry. And the new rules will almost certainly be challenged in court.

Congressional Republicans have frequently criticized the watchdog agency. Last year, then-chair of the House Financial Services Committee Patrick McHenry (R-N.C.) labeled the CFPB’s medical debt proposal “regulatory overreach.”

More recently, billionaire Elon Musk, whom Trump has tapped to co-lead his initiative to shrink government, called for the elimination of the watchdog agency. “Delete CFPB,” Musk posted on the social platform X.

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Joey Ballard is an internal medicine resident at the University of Illinois-Chicago. He wrote to “An Arm and a Leg” about a resolution the American Medical Association recently adopted calling on hospitals to do more to make sure patients who qualify for charity care get it. And that legislators and regulators make sure that’s happening.

Ballard helped write that resolution. He told “An Arm and a Leg” host Dan Weissmann that he first heard about charity care after listening to an episode of the podcast.

Ballard spoke with Weissmann about organizing as a medical student, bringing the resolution to the AMA, and the optimism he feels about the fight for charity care at the hospital where he works.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the transcript Transcript: A Listener Fighting the Good Fight

Dan: Hey there– 

A few weeks ago, we put out an update about charity care. That’s the commitment by hospitals to lower or just forgive bills for folks who can’t pay them. And our story was partly about how much less charity care hospitals give out than their own policies say they should. 

And a few days later, I got an email from a listener. 

Joey: I’m Joey Ballard, and I’m an internal medicine resident. 

Dan: Joey sent me a link: The American Medical Association — or AMA, the country’s largest group representing doctors, and for a long time one of the most powerful lobbying groups in the country– had just passed a resolution supporting legislation that would require hospitals to do more. 

Joey said he was the original author of that resolution. He had proposed it as a medical student. 

And he had gotten the idea from listening to… this podcast. We talked. Joey says he’s listened to every episode, since early in med school — and he sees it as a supplement to what that curriculum provides. 

Joey: I feel like you really have to seek out other sources to understand the system and sort of what I’m actually joining and what I’m facilitating as a physician… I mean, the podcast, like, really did that, and sort of helps peel back this other layer and sort of show more what it’s like for patients that I don’t always get to see from my perspective. 

Dan: This is, I am sure you can imagine, music to my ears. 

And now, he’s pushing for more changes, closer to home — at the institution where he’s doing his residency, the University of Illinois at Chicago. I wanted to bring you a little bit of his story to close out this year. 

This is An Arm and a Leg– a show about why health care costs so freaking much and what we can maybe do about. I’m Dan Weissmann. I’m a reporter and I like a challenge so the job we’ve chosen on this show is to take one of the

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.2 

most enraging, terrifying, and depressing parts of American life and bring you something entertaining, empowering, and useful. 

This is not the only time Joey has proposed a resolution to the AMA. And it’s not his only success. 

Joey: I’ve had four that have been adopted by the AMA, which is pretty, yeah, pretty exciting. And then I’ve had over 10 for Indiana, the Indiana State Medical Association. Um, so yeah, that kept me busy for sure. 

Dan: In Joey’s first year of med school at Indiana University, IU, he joined the med-student division of Physicians for a National Health Program — a membership organization that’s been advocating for single-payer health care for almost 40 years. The med-student version is Students for a National Health Program, SNaHP for short. 

Joey: I was pretty lucky. IU is actually the largest med school in the country. In terms of enrollment. And so we had a pretty strong Snap chapter, that had a lot of great events that really piqued my interest early on. 

Dan: Joey says SNaHP encouraged students to get involved with state medical societies, to help noodge the AMA towards supporting single-payer health care. Joey jumped in. 

Joey: And then like through that, I was like, oh, like, it’s not just single payer. I can sort of use this for any kind of thing in medicine I want to highlight or bring up 

Dan: In his first years of med school, Joey had proposed four resolutions that got adopted by the Indiana State Medical Association, including one supporting policies that would prevent some people from getting kicked off Medicaid. . By early 2023, he was ready to set his sights on the AMA itself. 

Joey: and that’s when I started like reaching out to other student contacts and figure out how does this work? How do I actually do this for the AMA in the first place? 

Dan: The answer turned out to be: Posting a suggestion on a dedicated online forum for student AMA members.

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.3 

Joey: I had posted several and the charity care one was the one that by far and away got the most feedback and people reaching out to me saying that they wanted to work on it and thought it was important. 

Dan: That was almost two years ago. Next came months of online collaboration with other students — Google docs and group chats — to draft and refine the resolution itself. 

Here are a few highlights from what they came up with: 

* Requiring nonprofit hospitals to check to see if any given patient qualifies for charity care BEFORE sending them a bill. 

* Close some loopholes in the federal law: Currently, the law only requires hospitals to HAVE a charity care policy, but it doesn’t set even a minimum standard for how generous that policy has to be. And there’s no mechanism to monitor or enforce even that requirement. 

The resolution says enforcement penalties should even include the loss of tax-exempt status — which is often worth many, many millions of dollars to nonprofit hospitals. 

They worked for months, and there were lots of steps still ahead. 

A big one was a vote by AMA’s student section — November 2023. Then — seven months later — the AMA itself asked a panel called the Council on Medical Service to consider the proposal and make a report. 

And the Council made a tweak: Instead of saying the AMA should “advocate for” policies like this, the Council’s version said the AMA should “support” them. 

Joey: …Which is an important distinction in that it’s not taking active measures to actively seek out these changes or reach out to lawmakers to draft these kinds of things. 

Dan: “Support” is more like, if someone else is pushing this, they can add us to the list of supporters. 

Then in November 2024, the AMA’s house of delegates considered the committee’s report.

Guess what? Not only did they back the resolution, they changed “support” back to “advocate for.” I asked the AMA what that meant they’d actually DO next. A spokesman told me he couldn’t disclose their legislative strategy, so fair enough. 

The meeting was in Florida this year, so Joey — in the middle of residency in Chicago — wasn’t able to be there. 

Joey: these meetings that are days long, you know, different places of the country. It’s especially as like residents that like, I don’t have the time to be able to do that. 

Dan: Joey says residency doesn’t leave him as much time as med school did, to work on AMA resolutions at all. But seeing the resolution pass? That was big. 

Joey: that inspired me to be like, okay, what can I do now? It was like, I feel like I need to take a look at what my institution is doing and what we can improve from that perspective. 

Dan: He’s started working on a proposal to get his hospital, the University of Illinois at Chicago, UIC to screen all patients for charity care before sending a bill, and to swear off practices like suing patients over bills they can’t pay, and seeking to garnish their wages. He says he’s been picking up support as he goes, starting with individual colleagues and other doctors… 

Joey: …and then the big one is our union. 

Dan: Residents at UIC are unionized. Joey says he brought up his pitch at a recent union meeting. His idea is a letter to the chief medical officer, with as many signatures as possible. The union said he could add them to the list. 

Joey says he hopes to have that letter ready in a few weeks. Then what? He’s not sure. 

Joey: There’s things we talked about during the union meeting that, you know, because UIC is a public institution, that there’s a lot more ways that it’s accountable and ways that we can find out things. Which I’m sure we’ll explore. But… optimistic for now. 

Dan: And he’ll keep at it.

Joey: I do find like extreme meaning in my day to day, um, as a physician, but I feel like this advocacy work is just something that’s even in some ways like deeper, and like means more to me. 

Dan: It means so much to me to know that doctors like Joey are making this their work. And it means a lot to me personally that people like Joey are finding the work we do here useful. 

In his initial note, Joey asked me where he might look for certain pieces of data. 

I sent him what I had, and forwarded his note to a couple people. One was Eli Rushbanks, who leads research and policy at Dollar For, the folks who have taught me the most about charity care. 

And the other was Luke Messac, the doctor and historian who wrote the book on some of these issues “Your Money or Your Life: Debt Collection and American Medicine.” You might’ve heard Luke on this show when his book came out in 2023. 

They both wrote back to Joey right away. Luke also wrote to thank me for introducing him to the folks at Dollar For. 

I hope we can keep on making connections for people fighting the good fights. There’s a lot of good fights to be had. 

If you’re catching this the day we release it or the next day– it’s the END of 2024. And our year-end fundraiser is still going. 

Gifts are still being matched. And in fact, we’ve got a new stretch goal. We’ve got backers who will match up to $30,000 in gifts. 

The place to go is arm and a leg show dot com, slash support That’s arm and a leg show, dot com, slash, support. Thank you. We’ll be back in January with more new episodes. 

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. 

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

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KFF Health News Midwest correspondent Cara Anthony and Emily Kwong, host of NPR’s podcast “Shortwave,” talk about Black families living in the aftermath of lynchings and police killings in their communities. Anthony shares her southeastern Missouri-based reporting from “Silence in Sikeston,” a documentary film, podcast, and print reporting project. She discusses the latest research on the health effects of racism and violence, including the emerging, controversial field of epigenetics.

Hear the full podcast episodes Anthony and Kwong reference from “Silence in Sikeston” here. They discuss material from Episode 1, “Racism Can Make You Sick”; Episode 2, “Hush, Fix Your Face”; and Episode 3, “Trauma Lives in the Body.”

In 1942, Mable Cook was a teenager. She was standing on her front porch when she witnessed the lynching of Cleo Wright.

In the aftermath, Cook received advice from her father that was intended to keep her safe.

“He didn’t want us talking about it,” Cook said. “He told us to forget it.”

More than 80 years later, residents of Sikeston, Missouri, still find it difficult to talk about the lynching.

Conversations with Cook, who was one of the few remaining witnesses of the lynching, launch a discussion of the health consequences of racism and violence in the United States. Racial equity scholar Keisha Bentley-Edwards explains the physical, mental, and emotional burdens on Sikeston residents and Black Americans in general.

“Oftentimes, people who experience racial trauma are forced to not acknowledge it,” Bentley-Edwards said. “They’re forced to question whether or not it happened in the first place.”

When Anthony uncovered details of a police killing in her own family while reporting this project, she unpacked her family’s story with Aiesha Lee, a licensed professional counselor and an assistant professor at Penn State.

“This pain has compounded over generations,” Lee said. “We’re going to have to deconstruct it or heal it over generations.”

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 Pawtucket, Rhode Island, near a storefront advertising “free” cellphones, J.R. sat in an empty back stairwell and showed a reporter how he tries to avoid overdosing when he smokes crack cocaine. KFF Health News is identifying him by his initials because he fears being arrested for using illegal drugs.

It had been several hours since his last hit, and the chatty, middle-aged man’s hands moved quickly. In one hand, he held a glass pipe. In the other, a lentil-size crumb of cocaine.

Or at least J.R. hoped it was cocaine, pure cocaine — uncontaminated by fentanyl, a potent opioid that was linked to about 75% of all overdose deaths in Rhode Island in 2022. He flicked his lighter to “test” his supply. He believed that if it had a “cigar-like sweet smell,” he said, it would mean that the cocaine was laced with fentanyl. He put the pipe to his lips and took a tentative puff. “No sweet,” he said, reassured.

But this method offers only false and dangerous reassurance. A mistake can be fatal.

It is impossible to tell whether a drug contains fentanyl by the taste or smell. “Somebody can believe that they can smell it or taste it, or see it … but that’s not a scientific test,” said Josiah “Jody” Rich, an addiction specialist and researcher who teaches at Brown University. “People are going to die today because they buy some cocaine that they don’t know has fentanyl in it.”

The first wave of the long-running and devastating opioid epidemic began in the United States with the abuse of prescription painkillers in the early 2000s. The second wave involved an increase in heroin use, starting around 2010. The third wave began when powerful synthetic opioids such as fentanyl started appearing in the supply around 2015. Now experts are observing a fourth phase of the deadly epidemic.

The mix of stimulants such as cocaine and methamphetamines with fentanyl — a synthetic opioid 50 times as powerful as heroin — is driving what experts call the opioid epidemic’s “fourth wave.” The mixture of stimulants and fentanyl presents powerful challenges to efforts to reduce overdoses because many users of stimulants don’t know they are at risk of ingesting opioids, so they don’t take overdose precautions.

The only way to know whether cocaine or other stimulants contain fentanyl is to use drug-checking tools such as fentanyl test strips — a best practice for what’s known as “harm reduction,” now embraced by federal health officials in combating drug overdose deaths. Fentanyl test strips cost as little as $2 for a two-pack online, but many front-line organizations also give them out free.

Nationwide, illicit stimulants mixed with fentanyl were the most common drugs found in fentanyl-related overdoses, according to a study published in 2023 in the scientific journal Addiction. The stimulant in the fatal mixture tends to be cocaine in the Northeast, and methamphetamine in the West and much of the Midwest and South.

“The No. 1 thing that people in the U.S. are dying from in terms of drug overdoses is the combination of fentanyl and a stimulant,’’ said Joseph Friedman, a researcher at UCLA and the study’s lead author. “Black and African Americans are disproportionately affected by this crisis to a large magnitude, especially in the Northeast.”

Friedman was also the lead author of another new study, published in the American Journal of Psychiatry, that shows the fourth wave of the opioid epidemic is driving up the mortality rate among older Black Americans (ages 55-64) and, more recently, Hispanic people. Friedman said part of the reason street fentanyl is so deadly is that there’s no way to tell how potent it is. Hospitals have safely used medical-grade fentanyl for surgical pain because the potency is strictly regulated, but “the potency fluctuates wildly in the illicit market” Friedman said.

Studies of street drugs, he said, show that in illicit drugs the potency can vary from 1% to 70% fentanyl.

“Imagine ordering a mixed drink in a bar and it contains one to 70 shots,” Friedman said, “and the only way you know is to start drinking it. … There would be a huge number of alcohol overdose deaths.”

Drug-checking technology can provide a rough estimate of fentanyl concentration, he said, but to get a precise measure requires sending drugs to a laboratory.

It’s not clear how much of the latest trend in polydrug use — in which users mix substances, such as cocaine and fentanyl, for example — is accidental versus intentional. It can vary for individual users: a recent study from Millennium Health found that most people who use fentanyl do so at times intentionally and other times unintentionally.

People often use stimulants to power through the rapid withdrawal from fentanyl, Friedman said. And the high-risk practice of using cocaine or meth with heroin, known as “speedballing,” has been around for decades. Other factors include manufacturers’ adding the cheap synthetic opioid to a stimulant to stretch their supply, or dealers mixing up bags.

Researchers say many people still think they are using unadulterated cocaine or crack — a misconception that can be deadly. “Folks who are using stimulants, and not intentionally using opioids, are unprepared to respond to an opioid overdose,” said Brown University epidemiologist Jaclyn White Hughto, “because they don’t perceive themselves to be at risk.” Hughto is a principal investigator in a new, unpublished study called “Preventing Overdoses Involving Stimulants.”

Hughto and the team surveyed more than 260 people in Rhode Island and Massachusetts who use drugs, including some who manufacture and distribute stimulants such as cocaine. More than 60% of the people they interviewed in Rhode Island had bought or used stimulants that they later found out had fentanyl in them. And many of the people interviewed in the study also use drugs alone. That means that if they do overdose, they may not be found until it’s too late.

In 2022, Rhode Island had the fourth-highest rate of overdose deaths involving cocaine in 2022, after Washington, D.C., Delaware, and Vermont, according to the Centers for Disease Control and Prevention.

The fourth wave is also hitting stimulant users who choose pills over what they perceive as more dangerous drugs such as cocaine in an effort to avoid fentanyl. That’s what happened to Jennifer Dubois’ son Cliffton.

Dubois was a single mother raising two Black sons. The older son, Cliffton, had been struggling with addiction since he was 14, she said. Cliffton also had been diagnosed with attention-deficit/hyperactivity disorder and a mood disorder.

In March 2020, Cliffton had checked into a rehab program as the pandemic ramped up, Dubois said. Because of the lockdown at rehab, Cliffton was upset about not being able to visit with his mother. “He said, ‘If I can’t see my mom, I can’t do treatment,’” Dubois recalled. “And I begged him” to stay in treatment.

But soon after, Cliffton left the rehab program. He showed up at her door. “And I just cried,” she said.

Dubois’ younger son was living at home. She didn’t want Cliffton doing drugs around his younger brother. So she gave Cliffton an ultimatum: “If you want to stay home, you have to stay drug-free.”

Cliffton went to stay with family friends, first in Atlanta and later in Woonsocket, an old mill city that has Rhode Island’s highest rate of drug overdose deaths.

In August 2020, Cliffton overdosed but was revived. Cliffton later confided that he’d been snorting cocaine in a car with a friend, Dubois said. Hospital records show he tested positive for fentanyl.

“He was really scared,” Dubois said. After the overdose, he tried to “leave the cocaine and the hard drugs alone,” she said. “But he was taking pills.” Eight months later, on April 17, 2021, Cliffton was found unresponsive in the bedroom of a family member’s home.

The night before, Cliffton had bought counterfeit Adderall, according to the police report. What he didn’t know was that the Adderall pill was laced with fentanyl. “He thought by staying away from the street drugs and just taking pills, he was doing better,” Dubois said.

A fentanyl test strip could have saved his life.

This article is from a partnership that includes The Public’s Radio, NPR, and KFF Health News.

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CHARLESTON, W.Va. — More than three years have passed since federal health officials arrived in central Appalachia to assess an alarming outbreak of HIV spread mostly between people who inject opioids or methamphetamine.

Infectious disease experts from the Centers for Disease Control and Prevention made a list of recommendations following their visit, including one to launch syringe service programs to stop the spread at its source. But those who’ve spent years striving to protect people who use drugs from overdose and illness say the situation likely hasn’t improved, in part because of politicians who contend that such programs encourage illegal drug use.

Joe Solomon is a Charleston City Council member and co-director of SOAR WV, a group that works to address the health needs of people who use drugs. He’s proud of how his close-knit community has risen to this challenge but frustrated with the restraints on its efforts.

“You see a city and a county willing to get to work at a scale that’s bigger than ever before,” Solomon said, “but we still have one hand tied behind our back.”

The hand he references is easier access to clean syringes.

In April 2021, the CDC came to Charleston — the seat of Kanawha County and the state capital, tucked into the confluence of the Kanawha and Elk rivers — to investigate dozens of newly detected HIV infections. The CDC’s HIV intervention chief called it “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

Now, despite attention and resources directed toward the outbreak, researchers and health workers say HIV continues to spread. In large part, they say, the outbreak lingers because of restrictions state and local policymakers have placed on syringe exchange efforts.

Research indicates that syringe service programs are associated with an estimated 50% reduction in HIV and hepatitis C, and the CDC issued recommendations to steer a response to the outbreak that emphasized the need for improved access to those services.

That advice has thus far gone unheeded by local officials.

In late 2015, the Kanawha-Charleston Health Department launched a syringe service program but shuttered it in 2018 under pressure, with then-Mayor Danny Jones calling it a “mini-mall for junkies and drug dealers.”

SOAR stepped in, hosting health fairs at which it distributed naloxone, an opioid overdose reversal drug; offered treatment and referrals; provided HIV testing; and exchanged clean syringes for used ones.

But in April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID. The Charleston City Council subsequently added guidelines of its own, including requiring individual labeling of syringes.

As a result of these restrictions, SOAR ceased exchanging syringes. West Virginia Health Right now operates an exchange program in the city under the restrictions.

Robin Pollini is a West Virginia University epidemiologist who conducts community-based research on injection drug use. “Anyone I’ve talked to who’s used that program only used it once,” she said. “And the numbers they report to the state bear that out.”

A syringe exchange run by the health department in nearby Cabell County — home to Huntington, the state’s largest city after Charleston — isn’t so constrained. As Solomon notes, that program exchanges more than 200 syringes for every one exchanged in Kanawha.

A common complaint about syringe programs is that they result in discarded syringes in public spaces. Jan Rader, director of Huntington’s Mayor’s Office of Public Health and Drug Control Policy, is regularly out on the streets and said she seldom encounters discarded syringes, pointing out that it’s necessary to exchange a used syringe for a new one.

In August 2023, the Charleston City Council voted down a proposal from the Women’s Health Center of West Virginia to operate a syringe exchange in the city’s West Side community, with opponents expressing fears of an increase in drug use and crime.

Pollini said it’s difficult to estimate the number of people in West Virginia with HIV because there’s no coordinated strategy for testing; all efforts are localized.

“You would think that in a state that had the worst HIV outbreak in the country,” she said, “by this time we would have a statewide testing strategy.”

In addition to the testing SOAR conducted in 2021 at its health fairs, there was extensive testing during the CDC’s investigation. Since then, the reported number of HIV cases in Kanawha County has dropped, Pollini said, but it’s difficult to know if that’s the result of getting the problem under control or the result of limited testing in high-risk groups.

“My inclination is the latter,” she said, “because never in history has there been an outbreak of injection-related HIV among people who use drugs that was solved without expanding syringe services programs.”

“If you go out and look for infections,” Pollini said, “you will find them.”

Solomon and Pollini praised the ongoing outreach efforts — through riverside encampments, in abandoned houses, down county roads — of the Ryan White HIV/AIDS Program to test those at highest risk: people known to be injecting drugs.

“It’s miracle-level work,” Solomon said.

But Christine Teague, Ryan White Program director at the Charleston Area Medical Center, acknowledged it hasn’t been enough. In addition to HIV, her concerns include the high incidence of hepatitis C and endocarditis, a life-threatening inflammation of the lining of the heart’s chambers and valves, and the cost of hospital resources needed to address them.

“We’ve presented that data to the legislature,” she said, “that it’s not just HIV, it’s all these other lengthy hospital admissions that, essentially, Medicaid is paying for. And nothing seems to penetrate.”

Frank Annie is a researcher at CAMC specializing in cardiovascular diseases, a member of the Charleston City Council, and a proponent of syringe service programs. Research he co-authored found 462 cases of endocarditis in southern West Virginia associated with injection drug use, at a cost to federal, state, and private insurers of more than $17 million, of which less than $4 million was recovered.

Teague is further concerned for West Virginia’s rural counties, most of which don’t have a syringe service program.

Tasha Withrow, a harm reduction advocate in bordering rural Putnam County, said her sense is that HIV numbers aren’t alarmingly high there but said that, with little testing and heightened stigma in a rural community, it’s difficult to know.

In a January 2022 follow-up report, the CDC recommended increasing access to harm reduction services such as syringe service programs through expansion of mobile services, street outreach, and telehealth, using “patient-trusted” individuals, to improve the delivery of essential services to people who use drugs.

Teague would like every rural county to have a mobile unit, like the one operated by her organization, offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more. That’s an expensive undertaking. She suggested opioid settlement money through the West Virginia First Foundation could pay for it.

Pollini said she hopes state and local officials allow the experts to do their jobs.

“I would like to see them allow us to follow the science and operate these programs the way they’re supposed to be run, and in a broader geography,” she said. “Which means that it shouldn’t be a political decision; it should be a public health decision.”

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BAKER CITY, Ore. — In what has become a routine event in rural America, a hospital maternity ward closed in 2023 in this small Oregon town about an hour from the Idaho border.

For Shyanne McCoy, 23, that meant the closest hospital with an obstetrician on staff when she was pregnant was a 45-mile drive away over a mountain pass.

When McCoy developed symptoms of preeclampsia last January, she felt she had the best chance of getting the care she needed at a larger hospital in Boise, Idaho, two hours away. She spent the final week of her pregnancy there, too far from home to risk leaving, before giving birth to her daughter.

Six months later, she said it seems clear to her that the health care needs of rural young women like her are largely ignored.

For McCoy and others, figuring out how to obtain adequate care to safely have a baby in Baker City has quickly eclipsed concerns about another medical service lacking in the area: abortion. But in Oregon and elsewhere in the country, progressive lawmakers’ attempts to expand abortion access sometimes clash with rural constituencies.

Oregon is considered one of the most protective states in the country when it comes to abortion. There are no legal limits on when someone can receive an abortion in the state, and the service is covered by its Medicaid system. Still, efforts to expand access in the rural, largely conservative areas that cover most of the state have encountered resistance and incredulity.

It’s a divide that has played out in elections in such states as Nevada, where voters passed a ballot measure in November that seeks to codify abortion protections in the state constitution. Residents in several rural counties opposed the measure.

In Oregon, during the months just before the Baker City closure was announced, Democratic state lawmakers were focused on a proposed pilot program that would launch two mobile reproductive health care clinics in rural areas. The bill specified that the van-based clinics would include abortion services.

State Rep. Christine Goodwin, a Republican from a southwestern Oregon district, called the proposal the “latest example” of urban legislators telling rural leaders what their communities need.

The mobile health clinic pilot was eventually removed from the bill that was under discussion. That means no new abortion options in Oregon’s Baker County — and no new state-funded maternity care either.

“I think if you expanded rural access in this community to abortions before you extended access to maternal health care, you would have an uprising on your hands,” said Paige Witham, 27, a member of the Baker County health care steering committee and the mother of two children, including an infant born in October.

A study published in JAMA in early December that examined nearly 5,000 acute care hospitals found that by 2022, 52% of rural hospitals lacked obstetrics care after more than a decade of unit closures. The health implications of those closures for young women, the population most likely to need pregnancy care, and their babies can be significant. Research has shown that added distance between a patient and obstetric care increases the likelihood the baby will be admitted to a neonatal intensive care unit, or NICU.

Witham said that while she does not support abortion, she believes the government should not “legislate it away completely.” She said that unless the government provides far more support for young families, like free child care and better mental health care, abortion should remain legal.

Conversations with a liberal school board member, a moderate owner of a timber company, members of Baker City’s Republican Party chapter, a local doula, several pregnant women, and the director of the Baker County Health Department — many of whom were not rigidly opposed to abortion — all turned up the same answer: No mobile clinics offering abortions here, please.

Kelle Osborn, a nurse supervisor for the Baker County Health Department, loved the idea of a mobile clinic that would provide education and birth control services to people in outlying areas. She was less thrilled about including abortion services in a clinic on wheels.

“It’s not something that should just be handed out from a mobile van,” she said of abortion services. She said people in her conservative rural county would probably avoid using the clinics for anything if they were understood to provide abortion services.

Both Osborn and Meghan Chancey, the health department’s director, said they would rank many health care priorities higher, including the need for a general surgeon, an ICU, and a dialysis clinic.

Nationally, reproductive health care services of all types tend to be limited for people in rural areas, even within states that protect abortion access. More than two-thirds of people in “maternity care deserts” — all of which are in rural counties — must drive more than a half-hour to get obstetric care, according to a 2024 March of Dimes report. For people in the Southern states where lawmakers installed abortion bans, abortion care can be up to 700 miles away, according to a data analysis by Axios.

Nathan Defrees grew up in Baker City and has practiced medicine here since 2017. He works for a family medicine clinic. If a patient asks about abortion, he provides information about where and how one can be obtained, but he doesn’t offer abortions himself.

“There’s not a lot of anonymity in small towns for physicians who provide that care,” he said. “Many of us aren’t willing to sacrifice the rest of our career for that.”

He also pointed to the small number of patients requesting the service locally. Just six people living in Baker County had an abortion in 2023, according to data from the Oregon Department of Public Health. Meanwhile, 125 residents had a baby that year.

A doctor with obstetric training living in another rural part of the state has chosen to quietly provide early-stage abortions when asked. The doctor, concerned for their family’s safety in the small, conservative town where they live, asked not to be identified.

The idea that better access to abortion is not needed in rural areas seems naive, the doctor said. People most in need of abortion often don’t have access to any medical service not already available in town, the doctor pointed out. The first patient the doctor provided an abortion for at the clinic was a meth user with no resources to travel or to manage an at-home medication abortion.

“It seemed entirely inappropriate for me to turn her away for care I had the training and the tools to do,” the doctor said.

Defrees said it has been easier for Baker County residents to get an abortion since the U.S. Supreme Court overturned Roe v. Wade.

A new Planned Parenthood clinic in Ontario, Oregon, 70 miles away in neighboring Malheur County, was built primarily to provide services to people from the Boise metro area, but it also created an option for many living in rural eastern Oregon.

Idaho is one of the 16 states with near-total bans on abortion. Like many states with bans, Idaho has struggled to maintain its already small fleet of fetal medicine doctors. The loss of regional expertise touches Baker City, too, Defrees said.

For example, he said, the treatment plan for women who have a desired pregnancy but need a termination for medical reasons is now far less clear. “It used to be those folks could go to Boise,” he said. “Now they can’t. That does put us in a bind.”

Portland is the next closest option for that type of care, and that means a 300-mile drive along a set of highways that can be treacherous in winter.

“It’s a lot scarier to be pregnant now in Baker City than it ever has been,” Defrees said.

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).

In 2024, our nationwide team of gumshoes set out to answer your most pressing questions about medical bills, such as: Can free preventive care really come with add-on bills for items like surgical trays? Or, why does it cost so much to treat a rattlesnake bite? Or, if it’s called an urgent care emergency center, which is it?

Affording medical care continues to be among the top health concerns facing Americans today. In the seventh year of KFF Health News’ “Bill of the Month” series, readers shared their most perplexing, vexing, and downright expensive medical bills and asked us to help figure out what happened. Our reporters analyzed $800,000 in charges, including more than $370,000 owed by 12 patients and their families.

This year, we met several patients who fought back.

Caitlyn Mai of Oklahoma City was preapproved for a hearing implant, yet for months she was still hounded by notices saying she owed $139,000.

To resolve the problem, Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department. “I said, ‘I’ve done your job for you — now can you please take it from here?’”

Jamie Holmes of Lynden, Washington, refused to buckle when a surgery center tried to make her pay for two operations after she underwent only one — even after a collection agency sued her.

She showed up at two court hearings and explained her side. “I just got stonewalled so badly. They treated me like an idiot,” she told “Bill of the Month.” “If they’re going to be petty to me, I’m willing to be petty right back.”

As always, we reached out to medical billing experts for their takeaways and learned that these patients had the right idea.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

From our curious, tireless “Bill of the Month” team, happy holidays — and, when in doubt, don’t pay the bill.

The Colonoscopies Were Free. But the ‘Surgical Trays’ Came With $600 Price Tags.

By Samantha Liss, 

January 25, 2024

Health providers may bill however they choose — including in ways that could leave patients with unexpected bills for “free” care. Routine preventive care saddled an Illinois couple with his-and-her bills for “surgical trays.”

Without Medicare Part B’s Shield, Patient’s Family Owes $81,000 for a Single Air-Ambulance Flight

By Tony Leys, 

February 27, 2024

Sky-high bills from air-ambulance providers have sparked complaints and federal action in recent years. But a rural Tennessee resident fell through the cracks of billing protections — and a single helicopter ride could cost much of her estate's value.

A Mom’s $97,000 Question: How Was Her Baby’s Air-Ambulance Ride Not Medically Necessary?

By Molly Castle Work, 

March 25, 2024

There are legal safeguards to protect patients from big bills like out-of-network air-ambulance rides. But insurers may not pay if they decide the ride wasn’t medically necessary.

Sign Here? Financial Agreements May Leave Doctors in the Driver’s Seat

By Katheryn Houghton, 

April 30, 2024

Agreeing to an out-of-network doctor’s own financial policy — which generally protects their ability to get paid and may be littered with confusing insurance and legal jargon — can create a binding contract that leaves a patient owing.

He Fell Ill on a Cruise. Before He Boarded the Rescue Boat, They Handed Him the Bill.

By Bram Sable-Smith, 

May 22, 2024

A man from Michigan was evacuated from a cruise ship after having seizures. First, he drained his bank account to pay his medical bills.

It’s Called an Urgent Care Emergency Center — But Which Is It?

By Renuka Rayasam, 

June 24, 2024

Suffering stomach pain, a Dallas man visited his local urgent care clinic — or so he thought, until he got a bill 10 times what he’d expected.

Her Hearing Implant Was Preapproved. Nonetheless, She Got $139,000 Bills for Months.

By Elisabeth Rosenthal, 

July 17, 2024

Even when patients double-check that their care is covered by insurance, health providers often send them bills as they haggle with insurers over reimbursement, which can last for months. It’s stressful and annoying — but legal.

Patient Underwent One Surgery but Was Billed for Two. Even After Being Sued, She Refused To Pay.

By Tony Leys, 

August 21, 2024

A collection agency sought court authority to garnish a patient’s wages to pay a disputed surgery bill. But after the patient showed up in court to argue the bill was bogus, the judge declined to let the bill collector seize her money.

In Chronic Pain, This Teenager ‘Could Barely Do Anything.’ Insurer Wouldn’t Cover Surgery.

By Lauren Sausser, 

September 25, 2024

An Alabama teen was told he needed surgery for debilitating hip pain. But his family’s insurer denied coverage for the procedure, which lacked a medical billing code. Expected to pay more than $7,000, his father charged it to credit cards.

Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars

By Jackie Fortiér, 

October 30, 2024

For snakebite victims, antivenom is critical — and costly. It took more than $200,000 worth of antivenom to save one toddler’s life after he was bitten by a rattlesnake.

A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445.

By Bram Sable-Smith, 

November 27, 2024

A mom in Peoria, Illinois, took her 3-year-old to the ER one evening last December. While they were waiting to be seen, the toddler seemed better, so they left without seeing a doctor. Then the bill came.

He Went in for a Colonoscopy. The Hospital Charged $19,000 for Two.

By Harris Meyer, 

December 19, 2024

A man in Chicago with a troubling symptom underwent a common procedure. Then he wanted to know why the hospital charged nearly three times its own cost estimate.

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!

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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Bill Hall, 71, has been fighting for his life for 38 years. These days, he’s feeling worn out.

Hall contracted HIV, the virus that can cause AIDS, in 1986. Since then, he’s battled depression, heart disease, diabetes, non-Hodgkin lymphoma, kidney cancer, and prostate cancer. This past year, Hall has been hospitalized five times with dangerous infections and life-threatening internal bleeding.

But that’s only part of what Hall, a gay man, has dealt with. Hall was born into the Tlingit tribe in a small fishing village in Alaska. He was separated from his family at age 9 and sent to a government boarding school. There, he told me, he endured years of bullying and sexual abuse that “killed my spirit.”

Because of the trauma, Hall said, he’s never been able to form an intimate relationship. He contracted HIV from anonymous sex at bath houses he used to visit. He lives alone in Seattle and has been on his own throughout his adult life.

“It’s really difficult to maintain a positive attitude when you’re going through so much,” said Hall, who works with Native American community organizations. “You become mentally exhausted.”

It’s a sentiment shared by many older LGBTQ+ adults — most of whom, like Hall, are trying to manage on their own.

Of the 3 million Americans over age 50 who identify as gay, bisexual, or transgender, about twice as many are single and living alone when compared with their heterosexual counterparts, according to the National Resource Center on LGBTQ+ Aging.

This slice of the older population is expanding rapidly. By 2030, the number of LGBTQ+ seniors is expected to double. Many won’t have partners and most won’t have children or grandchildren to help care for them, AARP research indicates.

They face a daunting array of problems, including higher-than-usual rates of anxiety and depression, chronic stress, disability, and chronic illnesses such as heart disease, according to numerous research studies. High rates of smoking, alcohol use, and drug use — all ways people try to cope with stress — contribute to poor health.

Keep in mind, this generation grew up at a time when every state outlawed same-sex relations and when the American Psychiatric Association identified homosexuality as a psychiatric disorder. Many were rejected by their families and their churches when they came out. Then, they endured the horrifying impact of the AIDS crisis.

“Dozens of people were dying every day,” Hall said. “Your life becomes going to support groups, going to visit friends in the hospital, going to funerals.”

It’s no wonder that LGBTQ+ seniors often withdraw socially and experience isolation more commonly than other older adults. “There was too much grief, too much anger, too much trauma — too many people were dying,” said Vincent Crisostomo, director of aging services for the San Francisco AIDS Foundation. “It was just too much to bear.”

In an AARP survey of 2,200 LGBTQ+ adults 45 or older this year, 48% said they felt isolated from others and 45% reported lacking companionship. Almost 80% reported being concerned about having adequate social support as they grow older.

Embracing aging isn’t easy for anyone, but it can be especially difficult for LGBTQ+ seniors who are long-term HIV survivors like Hall.

Related Links

• Americans With HIV Are Living Longer. Federal Spending Isn’t Keeping Up. Jun 17, 2024
• ‘Stonewall Generation’ Confronts Old Age, Sickness — And Discrimination May 22, 2019
• Staying Out Of The Closet In Old Age Oct 17, 2016

Of 1.2 million people living with HIV in the United States, about half are over age 50. By 2030, that’s estimated to rise to 70%.

Christopher Christensen, 72, of Palm Springs, California, has been HIV-positive since May 1981 and is deeply involved with local organizations serving HIV survivors. “A lot of people living with HIV never thought they’d grow old — or planned for it — because they thought they would die quickly,” Christensen said.

Jeff Berry is executive director of the Reunion Project, an alliance of long-term HIV survivors. “Here people are who survived the AIDS epidemic, and all these years later their health issues are getting worse and they’re losing their peers again,” Berry said. “And it’s triggering this post-traumatic stress that’s been underlying for many, many years. Yes, it’s part of getting older. But it’s very, very hard.”

Being on their own, without people who understand how the past is informing current challenges, can magnify those difficulties.

“Not having access to supports and services that are both LGBTQ-friendly and age-friendly is a real hardship for many,” said Christina DaCosta, chief experience officer at SAGE, the nation’s largest and oldest organization for older LGBTQ+ adults.

Diedra Nottingham, a 74-year-old gay woman, lives alone in a one-bedroom apartment in Stonewall House, an LGBTQ+-friendly elder housing complex in New York City. “I just don’t trust people,“ she said. “And I don’t want to get hurt, either, by the way people attack gay people.”

When I first spoke to Nottingham in 2022, she described a post-traumatic-stress-type reaction to so many people dying of covid-19 and the fear of becoming infected. This was a common reaction among older people who are gay, bisexual, or transgender and who bear psychological scars from the AIDS epidemic.

Nottingham was kicked out of her house by her mother at age 14 and spent the next four years on the streets. The only sibling she talks with regularly lives across the country in Seattle. Four partners whom she’d remained close with died in short order in 1999 and 2000, and her last partner passed away in 2003.

When I talked to her in September, Nottingham said she was benefiting from weekly therapy sessions and time spent with a volunteer “friendly visitor” arranged by SAGE. Yet she acknowledged: “I don’t like being by myself all the time the way I am. I’m lonely.”

Donald Bell, a 74-year-old gay Black man who is co-chair of the Illinois Commission on LGBTQ Aging, lives alone in a studio apartment in subsidized LGBTQ+-friendly senior housing in Chicago. He spent 30 years caring for two elderly parents who had serious health issues, while he was also a single father, raising two sons he adopted from a niece.

Bell has very little money, he said, because he left work as a higher-education administrator to care for his parents. “The cost of health care bankrupted us,” he said. (According to SAGE, one-third of older LGBTQ+ adults live at or below 200% of the federal poverty level.) He has hypertension, diabetes, heart disease, and nerve damage in his feet. These days, he walks with a cane.

To his great regret, Bell told me, he’s never had a long-term relationship. But he has several good friends in his building and in the city.

“Of course I experience loneliness,” Bell said when we spoke in June. “But the fact that I am a Black man who has lived to 74, that I have not been destroyed, that I have the sanctity of my own life and my own person is a victory and something for which I am grateful.”

Now he wants to be a model to younger gay men and accept aging rather than feeling stuck in the past. “My past is over,” Bell said, “and I must move on.”

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).

“An Arm and a Leg” updates a popular episode from 2019 — a story about giving.

In 1980, a young father named Denny Buehler was battling leukemia and needed to travel from Ohio to Seattle for treatment. To raise money for the trip, his friends and family organized a softball tournament.

Denny passed away a few months later, but his friends and family turned the softball tournament into a beloved tradition. For more than 40 years, they have hosted the games and sold hot dogs to raise money for other people in the area who need help with medical expenses.

In 2019, the Denny Buehler Memorial Foundation found a way to make a bigger impact, buying up old medical debt — and erasing it. Today, its partner in the effort, now known as Undue Medical Debt, has wiped away billions in debt.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Adam Raymonda Audio wizard Ellen Weiss Editor Ann Heppermann Editor Click to open the Transcript Transcript: Revisiting ‘Christmas In July’

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

We are bringing back a story we first put out five years ago. We called it “Christmas in July” because it’s a story about giving. 

Some things have changed since 2019 — hi, we’ve had a couple big presidential elections and a pandemic. And there’s been some news on our beat recently. We’ll have some updates and some context to add at the end. 

For now, here’s the story:

In 1980, Denny Buehler was a 24 year old guy with three kids and leukemia.  He needed a bone marrow transplant, and in those days, that was not available in Cincinnati, where he lived. He had to go to Seattle, with his sister, who was the donor. And his wife.

Jenny: Well I remember my dad and I’m the only one of my siblings who does.

This is Denny’s oldest daughter, Jenny Spring. She was four when he went to Seattle.

Jenny: I do remember knowing he was sick. I remember, you know, we lived with his parents, our grandparents, while he and my mom and aunt Cynthia were in Seattle.

It was a long distance relationship:  Letters. Sending tapes back and forth– in those days, long-distance phone calls were expensive. 

Jenny: I remember reading my first book, go dog, go onto a cassette tape and sending it out to Seattle.

Back home, Denny’s other sister, Mary Beth, organized a softball tournament to raise money for all the expenses: Flights to Seattle, places to stay.  

[[ENTER THEME]]

And that softball tournament– that one-off event that was part of one family’s struggle– became the germ of something that is now– 40 years later — starting to help a LOT of people. 

This is An Arm and a Leg, a show about the cost of health care. I’m Dan Weissmann.

[[THEME FADES UNDER NEXT TRACK]]

The bone marrow transplant worked but Denny died of pneumonia a few months later. February 14, 1981

Jenny: We had a Valentine’s day party at school. I was in kindergarten and my mom’s brother, my uncle Tim came to pick me up from school, which was very strange. 

Jenny (cont): And he took me over to my dad’s parents’ house.

Jenny: And I remember I was eating a red heart shaped lollipop sitting in the front seat of the car cause kids were allowed to do that back then. And uh, I remember he stopped hard and I bit down on the lollipop It broke in my mouth and I looked over at him and, and I realized he was trying not to cry. 

[[ENTER MUSIC:  LOW-COAL CAMPER]]

They got there. The whole family was there– both sides– all waiting to give her the news

Jenny: I remember I said, my daddy died?

And that left the family in a tough situation, and not just emotionally.

[MUSIC FADES — OUT AFTER “HE WAS 24]

Jenny: You know, he was 24 and then my mom, you know, same age. Three kids, five and under, high school diploma. Trying to figure out how to make things work.

ED: You know we didn’t have a whole lot. 

This is Jenny’s brother Ed. Four years younger

ED: You know, there were times where we had to go grocery shopping at grandma and grandpa’s house, you know.

Jenny: That is true. I remember– yeah we’d go in and you know, mom would take food from the cabinets in the fridge and we’d take it home. And I’d, you know, they knew she was doing it. But they bought extra and it was just, you know, nobody talked about it. But that was the way it worked for a while.

The grandparents also stepped forward to help out in bigger ways. Like they purchased a house for the family in a close-knit little suburb, Greenhills. Good schools, a sense of community, all thanks to grandma and grandpa.

Jenny: Without them, I don’t know where we would’ve been. You know as a teacher, I work with a lot of kids that come from low income families and they tell me about their lives and I, you know, I reflect on that. That’s so easily how things could have been for my family without support from both sets of grandparents.

[[MUSIC STARTS FADING UP DURING NEXT TRACK:  Heartland Flyer]]

The life Jenny’s grandparents made possible included more than just food and shelter, a sense of safety. Being part of that community meant time for celebration, for PLAY. In Greenhills, it meant… softball.  

Ed: There’s a drive to the left.

Jenny: We kind of grew up at the ball field . You know, my mom played. My aunt Mary Beth, it was just, you know, kind of that softball life and it’s hard to know in my memory where the separation is between just being up there because they were playing in leagues– and when the tournament began.

The tournament. 

After Denny died, his sister Mary Beth and her friends organized a SECOND tournament. This one was to help out a friend who had gotten into a motorcycle accident.

After that, the tournament became an annual tradition. 

Announcer: We’re at Spoils Field in Green Hills for the 15th annual Denny Buehler Memorial Charity Softball Tournament. 

There was pretty much always somebody in the community to help. Somebody with big medical problems, not enough money. Sometimes more than one somebody. 

For Denny Buehler’s kids, the tournament was part of every year’s routine.

ED: My whole life, you know, it’s just been, it’s like Christmas or you know Easter or new years. It’s like a holiday for us in the family. You know, we have, another one that just happens to come in July.

Ed was an athletic kid, couldn’t wait to be able to play in the tournament himself. He had to wait until he was 17.  

[[MUSIC OUT]]

Then, not that many years later, when Ed was 25, the group of friends that had been running the tournament said they were ending it. 

ED: They ran it for 25 years and they were, they were just ready to be done, they were like you know we made it 25 years. It ran its course.

These folks had been young when they started it– in their mid-20s. 

[MUSIC FADES IN:  Perspiration — Lighter Touch (Adam, let’s kill the whistling, via stems please)]]

That was 1980. Now it was 2005. They had enjoyed a lot of good times, they’d worked hard, they’d helped dozens of people, played a LOT of softball, drank a lot of beer. It was a thing they had done for a long, important period in their lives. 

For Denny Buehler’s kids, it was more than that. It was an annual tradition they had always known– not for part of their lives, their whole lives. It was a celebration they could count on, a community event– a chance for their family, a family that had struggled, to be in a position to give back, to be leaders. And it was a legacy from the dad they had grown up without.

Jenny for one was NOT ready for it to end. A couple of her friends, and her husband said they would help. Of course Ed was game too. 

[MUSIC FADES AND OUT]]

Jenny told her Aunt Mary Beth she wanted to take over the tournament.

Jenny: And she was a little skeptical because I’ll tell you what, when I was, Oh gosh, back then, let me think. What was I doing in life? I was singing in a punk band.

[[MUSIC: Shut Up, B—  by the Hypochondriacs]]

Jenny:  [Laughs]  I probably had pink hair.

The band was called the Hypochondriacs!  This is their hit.

These days Jenny is a teacher, and a leader for her daughter’s girl scout troop. She sings with a community choir — with 1200 members — that she helped start. 

But at the time…

Jenny: I didn’t have a big track record for taking on projects and responsibilities. 

Jenny: I had learned to book and promote shows and I guess that would be the first type of project that I took on was promoting punk rock bands, but, you know, to my family, that wasn’t a serious thing. That wasn’t.

[[MUSIC BUMPS IN VOLUME, THEN OUT]]

But of course Jenny’s aunt Mary Beth wasn’t about to tell her no, she couldn’t try. Mary Beth introduced Jenny to the rest of the committee that had run the tournament. They taught her what they could about how the thing worked, and then it was up to her and whoever she could round up. 

Jenny: So I remember the first year we did the tournament, just not being able to sleep, you know?

[MUSIC IN:  Spunk Lit]]

JENNY, cont: Just being so nervous about if we were going to be able to pull it off

Jenny: It was my brother, my sister, my husband, a few of my friends — the guitar player from my band coming up there with purple hair.

They pulled it off. Barely. 

And they had a lot to learn. For instance, for a long time the most important money-maker for the whole event has been running a grill, hot dogs, and burgers, selling food. But the new generation’s first time out, they didn’t make much.  

It turned out their idea for STAFFING the grill had some built in problems. That idea seemed like a way to quickly grab some extra volunteer power:  When a team got eliminated, their players would take a turn staffing the grill. 

ED: And then we realized, wait, we’re not making any money because they’re just giving all the food away you know to their friends. They lost and they’re handing out burgers and hot dogs like they’re candy.

Over time, Jenny and Ed and the rest of their crew tightened things up– and got a LOT more volunteers, and made some new rules. 

These days the tournament raises about ten thousand dollars a year.  

[MUSIC OUT]]

[AMBI:  SOFTBALL!!] 

Here’s how it works. 

There’s 18 teams, double elimination. It starts Friday night– like a half a dozen games– then up bright and early on Saturday, there till late at night. Then all day Sunday, maybe into the evening. 

Ed says a couple thousand people might come every year. Alot of games, a lot of beer, burgers and corn on the cob.

[[AMBI FADES]]

In 2015, ten years after the new generation took over, they took a new step: turning this ad-hoc event, this thing that had just somehow kept going for more than 30 years– into an institution: 

They incorporated as the Denny Buehler Memorial Foundation, an official tax-exempt non-profit organization.  

The idea was, they could start to think bigger. 

ED: You know we’re working really hard. We’re doing really good things that we, we all really like and we’re all really bought into. But the impact is, is relatively small for the amount of work that goes into it. You know, I don’t want to say $10,000 is not a lot of money, but life is hard and when something’s gotten in your way, $10,000 doesn’t go really, really far.

Jenny: We would love to help more people. And so we talked for a long time about what that should be. And when I say talk, I mean we argued. (Laughs) 

And when she says a long time, she means two years. The foundation was incorporated in 2015. In the fall of 2017, they were…  still … talking. 

And then one day, inspiration. Inspiration that has led Ed and Jenny and the foundation to help their neighbors to the tune of a million dollars so far. 

That’s right after this.

This episode of An Arm and a Leg is a co-production with KFF Health News. That’s a national nonprofit newsroom producing in-depth journalism about health issues. Their reporters do amazing work — and win all kinds of awards every year. We’re honored to work with them.

So. Fall 2017. Jenny was driving home from seeing a friend– 

Jenny: And I had been talking to her about, you know, the foundation and how we were struggling to come up with an idea.

She passed through a neighborhood dense with hospitals. 

Jenny: So I’m driving through this hospital district and just all of a sudden I thought about what John Oliver did 

The year before, in 2016, the comedian John Oliver had done one of his most famous stunts on his HBO show “Last Week Tonight.” It was about a whole industry lots of us had never heard of: The buying and selling of 

JOHN OLIVER: DEBT.  

Debt. Especially medical debt. It turns out, if you’re hearing from a debt collector about an old debt, they probably don’t represent whoever you originally got in debt to– like say, a hospital. 

At some point, the hospital-or-whoever SOLD your debt — really, the right to collect on it — 

to someone else. For a lot less than you owed. 

JOHN OLIVER: and that debt buyer can then come after you for the full original amount. And if it can’t collect, potentially, it can then resell that debt for a fraction of what it paid to someone else who can still come after you for the original amount

Or sell it to somebody else for even cheaper. To the point where really old debts sell for pennies on the dollar. Actually, less than pennies.

To demonstrate how cheap it was– and how easily debt was bought and sold– John Oliver bought 15 million dollars in old medical debt, for less than half a cent on the dollar.

JOHN OLIVER: We thought: Well, instead of collecting on the money, why not forgive it? Because on one hand it’s obviously the right thing to do, but much more importantly, we’d be staging the largest one time giveaway in television show history. 

JOHN OLIVER: So what do you say? Are you ready to make television history? Let’s do this!

Jenny: It was just like an inspiration –I was like, this is the idea!

She got home and got to work.

Jenny: You know, I pulled out my laptop and I started researching and… 

She found that John Oliver had worked with a non-profit that specializes in raising money to buy and forgive old medical debts. They’re called RIP Medical Debt. 

Jenny: John Oliver had vetted them. 

Check. Good sign. She kept going. A few hours later, she was talking with Jerry Ashton, one of the group’s co-founders.

Jenny: I said, how are you doing this? How does this work?

And she liked what she heard.   

Jenny:  I love their story of how they were debt collectors. And realized how they could use that power for good.

Yep. Jerry Ashton and Craig Antico had been debt collectors for decades. They reversed course after working with volunteers from Occupy Wall Street, who raised money for a project called “Rolling Jubilee” to buy up and forgive old debts.

Jerry Ashton: We were, basically, a back office for them. 

This is Jerry.  

JERRY: They went out, and they raised a $700,000 eventually. 

Jerry says he and Craig helped them use that money to buy up — and forgive — $30 million in debt.  And when the Rolling Jubilee wound down, Jerry and Craig started RIP Medical Debt. That was in 2014. 

Jerry Ashton: The first year or so we starved to death. But then John Oliver discovered us. 

John Oliver brought folks to them– folks like Jenny Spring. 

This year, RIP Medical Debt has raised enough money to pay off a billion dollars in old debt. Craig Antico says two things allow them to do it for about a penny on the dollar. 

[[MUSIC IN: Lobo Lobo]] 

One is: They’re buying old debts. Hard-to-collect-on debts. The companies that own these debts now– the right to collect on those debts– they don’t expect to get 100 percent of what’s owed, or ANYTHING like it and anything they get, they’re going to spend years chasing. 

Craig Antico: Let’s say they’re only going to collect 2% over the next 10 years.

Cash upfront sounds good. The other thing is, RIP Medical Debt is buying in bulk.

Craig Antico: If I went to a hospital and said, “I see you have $1,000 bill here for Jane.” And I offered them $10, they’re gonna laugh. If I put a thousand of those Janes together 

That’s worth talking about. Instead of a thousand negotiations for ten dollars each, it’s one negotiation for ten thousand dollars.

So, it’s only because we abolish so much debt at one time that they’re willing to do this.

Jenny took it all in. It added up. 

[MUSIC STARTS TO FADE]]

Jenny: I came to the board meeting and I, and I said, Hey look, here’s a little bit of research I’ve done and I think purchasing and forgiving medical debt 

[MUSIC OUT] 

… and everybody was like, yes. I mean the consensus was instant.

That was the fall of 2017. In November, Jenny and Ed went to New York to meet the RIP Medical Debts founders in person.

By January 2018, the board had decided: They were in. With some details to work out.

ED: The interesting thing is the, the roadblock that we ran into was, Oh, man, but we love the tournament so much.

They took it slow, waited until that year’s softball tournament–before even announced what they had in mind. 

Jenny: You know, we printed up some flyers that kind of explained it. We wanted to be really sure that everybody knew that we weren’t changing the softball tournament.

That was July 2018. It took almost another year before they actually raised money for the new initiative. 

Finally, in June 2019, they put on an event at a local bar. They called it Blues, Booze and Brunch.

[MUSIC IN:  CHRIS LEE QUARTET, “BACKDOOR STRANGER”]]

They charged twenty bucks– ten for kids– and put out a taco bar for the spread. If you ordered a bloody mary from the bar, a dollar went to the cause. For entertainment, there was a blues band led by one of Jenny’s old punk-rock pals. 

There was a grill on site– and they figured out how to scramble eggs on it– but everything else had to be made in advance.

MUSIC!! 

Jenny: Let’s see: Our board member Tracy spent about an hour cracking eggs before we went up there. My sister baked breakfast muffins and little pastries and things like that for weeks and put them in her freezer 

That raised the first couple of thousand. A few weeks later, the tournament went ahead as usual– raising money for a teacher’s aide at a local school with five kids and kidney cancer. 

And then, it was back to raising money to forgive medical debts. Doing whatever they could think of. Local brew-pubs hosted events — a dollar for every pint sold on a fund-raiser night went to the cause. 

[MUSIC FADES,OUT BY MIDDLE OF NEXT SENTENCE]

And there was a lot of going on facebook, asking friends to chip in five dollars or ten.

Jenny: People work hard and we’re living in a time where wages are not keeping up with, you know, the cost of things. And so it’s hard to give for a lot of families. But when people realize 10 bucks can become $1,000, that helps somebody out in a really impactful way, then they’re willing to donate. 

[[MUSIC, “HELIOTROPE,” STARTED FADING IN UNDER “willing to donate”]]

Ed’s kids made tags for Christmas gifts– you know like, from Dan to whoever

ED: My wife broadcasted it on Facebook, Hey, we’re making gift tags. You can buy six of ’em for $5. Um, and they raised $255 just making Christmas gift tags. 

Which– because of the multiplier effect– means they wiped out more than $20,000 in medical debt. With Christmas tags.

The group did a bunch of asks on Giving Tuesday at the beginning of December. Jenny says they raised $2,000 on Facebook that way, which took them over the top:  They had raised more than twelve thousand bucks– enough money to buy that first million dollars worth of medical debt: 

Jenny: People are just going to get this magic envelope in the mail 

Magic envelopes. 

ED: that say: You had this debt that had gone to collections. And it was purchased and forgiven. You never have to worry about it again.

[[MUSIC SWELLS, THEN FADES UNDER NEXT CUT, OUT BY “MILLION”]

They called RIP Medical Debts and said: We’re ready to pay off that first million. What next?

Jenny: And immediately they come back and say there’s about $37 million in your area. 

DAN: Like if you wanted to take on the whole of Cincinnati, basically. 

JENNY: Uh, well we do. We intend to, we’re going to keep going. There’s no reason to stop. 

Jenny: Medical debt is unlike any other kind of debt.  You choose to take on the debt or you choose to die. 

DAN:  Yeah.

Jenny: And it’s just, it’s not right. It’s not right. And it’s like I tell my kids: When you have everything that you need, it’s your job– it’s your responsibility to help people who don’t. And I believe that to my core because that’s what people did for us when we needed it.  

Jenny says: We’re living in weird times. It is easy to be cynical. But this — making things a little bit better this is what we’re here for. It’s what we owe to each other. 

JENNY: And, why not? What else do you have to do?  

Dan: That’s the story, as we ran it in 2019. 

Some things have changed since then. For one, RIP Medical Debt changed its name, earlier this year, to Undue Medical Debt — that’s spelled U – N – D – U – E. Like this debt is no longer due to anyone. Or as in Medical debt is an undue — improper — thing. 

But it does sound like unDOing medical debt. Which, nice. 

They’ve also gotten a lot bigger since 2019, when they said they’d abolished a billion dollars in debts. By 2021, their website says that number was 5 billion. By 2023, it was 10 billion.

In the last couple years, state and local governments have started partnering with Undue to get old debts forgiven– often using federal money to buy up those debts: New York City, Cook County, Illinois; the state of New Jersey; And in Ohio alone, Cleveland, Akron and Cincinnati.

Recently, I caught up with Jenny Spring. COVID slowed down her family’s work on medical debt. The summer of 2020, when gatherings like softball tournaments were still basically a “no,” they organized a concert of sorts on zoom.

[AUDIO?] 

And in the years since, just running the tournament took pretty much everything they had in them. The pandemic was a big deal.

Jenny: It changed our lives in ways we couldn’t predict. Everyone’s lives had become more complicated.

Dan: And it’s taken a long time to regroup. 

But now, she says, they’re ready to take on more. And seeing how much Undue Medical Debt has grown– it leaves them thinking maybe they should take on something different.

Jenny: It’s great paying off medical debt. We’re really glad we did that. But, um, is there something more immediate that we can do? Is there something that helps people before they’re in medical debt, before they’re facing bankruptcy, before their family is, you know, on the brink of financial ruin?

Dan: One idea they’re thinking about draws inspiration from two sources they’ve drawn on before. 

One is family experience. In this case, professional experience. Jenny’s mom works in medical billing.

The other is… pop culture.

Jenny: I don’t, if you’ve ever seen the Incredibles, there’s this great scene where Mr. Incredible gets himself fired from his health insurance job and they’re mad at him because he’s telling everyone how to get their claims paid

Boss: They’re experts! Experts, Bob!] Exploiting every loophole! Dodging every obstacle! 

Jenny: Bob, they’re navigating the bureaucracy. Um, so, my mom is really good at navigating that bureaucracy

Dan: And over the years, in her spare time, she’s helped a lot of people navigate it. 

Jenny: Her eyes are sharp and when she goes through bills, she picks up on these things, right? And so, what if we could scale that up? What if we could raise enough money to hire contractors to do this for people for free, right? And maybe a lawyer or two to send an occasional threatening letter.

Dan: Jenny says they’re still workshopping this idea. It’ll take time to figure out details. Make a budget, a fundraising plan, all of it. More than a year. But I do love this idea so much. 

As we’re getting ready to release this, Luigi Mangione, who allegedly shot United Healthcare’s CEO, has just been arrested. 

People have been expressing their anger at insurance companies like United all week. 

It’s an anger that we’re deeply, intimately familiar with, around here. 

We say every time: We’ve taken on one of the most enraging, terrifying, depressing parts of American life. 

And no one of us can solve this. 

But that doesn’t mean there’s *nothing* we can do.  

So, among other things, I want to continue talking to people like Jenny Spring and her family. Over decades, they’ve been patiently, creatively doing what they can do. 

Put on a softball tournament. Raise money to relieve old debts. Find a way to help more neighbors stay OUT of debt. They can’t do everything. But they’re doing what they can, one step at a time.

Jenny says the board of the Denny Beuhler Memorial Foundation recently welcomed two new members — in their twenties. A third generation coming together to keep the fight going. 

I’ll catch you in a couple weeks. 

Till then, take care of yourself.  

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta. Our story was edited by Ann Hepperman in 2019. Ellen Weiss edited this re-release.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. 

Lynne Johnson is our operations manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at arm and a leg show, dot com, slash: support. 

And here the names of just some of the people who have pitched in since our last episode. Plus, at the end, a little audio thank-you gift.

Thanks this time to… [names redacted]

And now for that audio thank-you gift: Here is Jenny Spring — do gooder, choir nerd, mom, and Girl Scout troop leader, listening to one of her old punk rock songs for the first time in a dozen years. Jenny: It’s kind of violent. Oh my god. So, it was, uh, I’m tired of your s I’m tired of your s And I don’t care if you cry. You better quit before I sock you in the eye. Ha ha ha.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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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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MIAMI — When leaders of Florida’s most populous county met in September to pick a site for what could become the nation’s largest trash incinerator, so many people went to the government center to protest that overflow seating spilled into the building’s atrium.

“MIRAMAR SAYS NO TO INCINERATOR! NOT IN OUR BACKYARD,” read green T-shirts donned by some attendees who wanted to stop the new industrial waste facility — capable of burning up to 4,000 tons of garbage a day — from being built near their homes.

Residents feared the site would not only sink their property values and threaten the environment, but also potentially harm people’s health.

Even more, the locations appeared to have been selected in a way that worried civil rights and environmental advocacy groups. All four sites considered that day were in, or near, some of the region’s most diverse communities, and the state is arguing in federal court that race should not be a consideration in permitting industries that pollute the environment.

“Historically, communities of color have suffered the impacts of toxic plants near our cities, affecting our health and well-being,” Elisha Moultrie, a 30-year Miramar resident and committee leader with the Miami-Dade NAACP, told the county commissioners.

It’s “environmental injustice and racial injustice,” she said.

Miami-Dade leaders see a different challenge: the need to effectively manage trash. The county produces nearly double the national average per person of garbage, in part due to one of the region’s major industries: tourism.

Yet, throughout 2024, Miami-Dade’s elected officials delayed a decision on where to build the planned $1.5 billion incinerator, as the county mayor and commissioners wrestled with politics. County leaders are scheduled to vote on a new site in February.

“There is no perfect place,” Miami-Dade Mayor Daniella Levine Cava said in a recent memo to county leaders.

The conundrum unfolding in South Florida is indicative of what some see as a broader trend in the national fight for environmental justice, which calls for a clean and healthy environment for all, including low-wealth and minority communities. Too often land inhabited by Black and Hispanic people is unfairly overburdened with air pollution and other emissions from trash incinerators, chemical plants, and oil refineries that harm their health, said Mike Ewall, director of Energy Justice Network, a nonprofit that advocates for clean energy and maps municipal solid waste incinerators.

“All the places that they would consider putting something no one wants are in communities of color,” he said.

More than 60 municipal solid waste incinerators operate nationwide, according to data from Energy Justice. Even though more than 60% of incinerators are in majority-white communities, those in communities of color have more people living nearby, burn more trash, and emit more pollutants, Ewall said.

And in Florida, six of the nine existing incinerators are in places where the percentages of people of color are higher than the statewide average of 46%, according to data from the Environmental Protection Agency’s EJScreen, an online tool for measuring environmental and socioeconomic information for specific areas.

Before Miami-Dade County’s old trash incinerator burned down in February 2023, the county sent nearly half of its waste to the facility. Now, the county is burying much of its trash in a local landfill or trucking it to a central Florida facility — an unsustainable solution.

Joe Kilsheimer, executive director of the Florida Waste-to-Energy Coalition, a nonprofit that advocates for owners and operators of trash incinerators, acknowledges that choosing a location is hard. Companies decide based on industry-accepted parameters, he said, and local governments must identify strategies to manage waste in ways that are both safe and efficient.

“We have an industrial-scale economy that produces waste on an industrial scale,” Kilsheimer said, “and we have to manage it on an industrial scale.”

‘Those People Don’t Matter’

Florida burns more trash than any other state, and at least three counties besides Miami-Dade are considering plans to build new facilities. Managing the politics of where to place the incinerator has especially been a challenge for Miami-Dade’s elected officials.

In late November, commissioners in South Florida considered rebuilding the incinerator where it had been for nearly 40 years — in Doral, a predominantly Hispanic community that also is home to Trump National Doral, a golf resort owned by the president-elect less than 3 miles from the old site. But facing new opposition from the Trump family, the county mayor requested delaying a vote that had been scheduled for Dec. 3.

President Joe Biden created a national council to address inequities about where toxic facilities are built and issued executive orders mandating that the Environmental Protection Agency and Department of Justice address these issues.

Asked if Trump would carry on Biden’s executive orders, Karoline Leavitt, the incoming White House press secretary, said in an email that Trump “advanced conservation and environmental stewardship” while reducing carbon emissions in his first term.

“In his second term, President Trump will once again deliver clean air and water for American families while Making America Wealthy Again,” Leavitt said.

However, during his presidency, Trump proposed drastic reductions to the EPA’s budget and staff, and rolled back rules on clean air and water, including the reversal of regulations on air pollution and emissions from power plants, cars, and trucks.

That’s a big concern for minority neighborhoods, especially in states such as Florida, said Dominique Burkhardt, an attorney with the nonprofit legal aid group Earthjustice, which filed a complaint against Florida’s Department of Environmental Protection in March 2022.

The complaint, on behalf of Florida Rising, a nonprofit voting rights group, alleges that Florida’s environmental regulator violated the Civil Rights Act of 1964 by failing to translate into Spanish documents and public notices related to the permitting of incinerators in Miami and Tampa, and by refusing to consider the impact of the facilities on nearby minority communities.

“They’re not in any way taking into account who’s actually impacted by air pollution,” Burkhardt said of the state agency. The EPA is now investigating the complaintinvestigating the complaint.

Conservative lawmakers and state regulators have been hostile to laws and regulations that center on the rights of people of color, Burkhardt said. Florida Gov. Ron DeSantis, a Republican, has signed into law bills limiting race education in public schools and banning public colleges and universities from spending money on diversity, equity, and inclusion programs.

“They want to be race-neutral,” Burkhardt said. But that ignores “the very real history in our country of racism and entrenched systemic discrimination.”

Historical racism like segregation and redlining, combined with poor access to health care and exposure to pollution, has a lasting impact on health, said Keisha Ray, a bioethicist with the University of Texas Health Science Center at Houston.

Studies have found that neighborhoods with more low-income and minority residents tend to have higher exposure to cancer-causing pollutants. Communities with large numbers of industrial facilities also have stark racial disparities in health outcomes.

Incinerators emit pollutants such as carbon monoxide, nitrogen oxides, and fine particulate matter, which have been associated with heart disease, respiratory problems, and cancer. People living near them often don’t have the political power to push the industries out, Ray said.

Ignoring the disparate impact sends a clear message to residents who live there, she said.

“What you’re saying is, ‘Those people don’t matter.’”

Covered in Ash

Florida is one of 23 states that have petitioned the courts to nullify key protections under the Civil Rights Act. The protections prohibit racial discrimination by organizations receiving federal funding and prevent polluting industries from overburdening communities of color.

Those rules ask the states “to engage in racial engineering,” argued Florida Attorney General Ashley Moody in an April 2024 letter to the EPA, co-signed by attorneys general for 22 other states. A federal court in Louisiana, which sued the EPA in May 2023, has since stopped the agency from enforcing the rules against companies doing business in that state.

Miami-Dade’s incinerator, built west of the airport in 1982, was receiving nearly half the county’s garbage when it burned down in February 2023. Though the facility had pollution control devices, those measures did not always protect nearby residents from the odor, smoke, and ash that the incinerator emitted, said Cheryl Holder, an internal medicine physician who moved into the neighborhood in 1989.

Holder said every morning her car would be covered in ash. Residents persuaded the county, which owned the facility, to install “scrubbers” that trapped the ash in the smokestack. But the odor persisted, she said, describing it as “a strange chemical — faint bleach/vinegar mixed with garbage dump smell” — that often occurred in the late evening and early morning.

Holder still started a family in the community, but by 2000 they moved, out of concern that pollution from the incinerator was affecting their health.

“My son ended up with asthma … and nobody in my family has asthma,” said Holder, who in 2018 helped found Florida Clinicians for Climate Action, a group focused on the health harms of climate change. Though she cannot prove that incinerator pollution caused her son’s illness — the freeways, airport, and landfill nearby also emit toxic substances — she remains convinced it was at least a contributing factor.

Many South Florida residents are concerned about the health effects of burning trash, despite assurances from Miami-Dade Mayor Cava and the county’s environmental consultants that modern incinerators are safe.

Cava’s office did not respond to KFF Health News’ inquiries about the incinerator. She has said in public meetings and a September memo to county commissioners that the health and ecological danger from the new incinerator would be minimal. She cited an environmental consultant’s assessment that the health risk is “below the risk posed by simply walking down the street and breathing air that includes car exhaust.”

But some environmental health experts say it’s not only a facility’s day-to-day operations that are cause for concern. Unplanned events, such as the fire that destroyed Miami-Dade’s incinerator, can cause environmental catastrophes.

“It might not be part of their regular operations,” said Amy Stuart, a professor of environmental and occupational health at the University of South Florida’s College of Public Health. “But it happens every once in a while. And it hasn’t been that well regulated.”

No Easy Solutions

In addition to Miami-Dade’s planned incinerator, three other facilities have been proposed elsewhere in the state, according to Energy Justice Network and news reports.

State lawmakers adopted a law in 2022 that awards grants for expansions of existing trash incinerators and financial help for waste management companies losing revenue on the sale of the electricity their facilities generate.

A bill filed in the Florida Legislature by Democrats this year would have required an assessment of a facility’s impact on minority communities before the state provided financial incentives. The legislation died in committee.

As local governments in Florida and elsewhere turn to incineration to manage waste, the industry has argued that burning trash is better than burying it in a landfill.

Kilsheimer, whose group represents the incinerator industry, said Miami-Dade has no room to build another landfill, though the toxic ash left behind from burning trash must be disposed of in a landfill somewhere.

“This is the best solution we have for the conditions that we have to operate in,” he said.

But University of South Florida’s Stuart said that burning trash isn’t the only option and that the government should not ignore historical and environmental racism. The antidote cannot be to put more incinerators and other polluting facilities in majority-white neighborhoods, she said.

The focus of public money instead should be on reducing waste altogether to eliminate the need for incinerators and landfills, Stuart said, by reducing communities’ consumption and increasing recycling, repurposing, and composting of refuse.

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).