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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Loss requires adaptation,” Benavides said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Los asesores de MiSalud también pueden intentar romper con estereotipos.

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

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

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

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

“La pérdida requiere adaptación”, señaló Benavides.

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

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

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

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

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He has a few more months to figure it out.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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KFF Health News Southern correspondent Sam Whitehead discussed vaccine exemptions on WAMU’s “Health Hub” on Jan. 22. Whitehead also discussed major Georgia health stories of 2025 on WUGA’s “The Georgia Health Report” on Jan. 17.

• Click here to hear Whitehead on “Health Hub”
• Click here to hear Whitehead on “The Georgia Health Report”
• Read Whitehead’s “Childhood Vaccination Rates, a Rare Health Bright Spot in Struggling States, Are Slipping,” co-reported with Daniel Chang

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In his first days in office, President Donald Trump signed an executive order on gender that affects transgender health care. The order aims to directly limit care for trans people incarcerated in federal prisons, but the broader implications on health aren’t clear-cut.

This slide presentation first appeared on KFF Health News’ Instagram account. If you enjoyed this story from the KFF Health News social team, follow us on Instagram @kffhealthnews. 

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The life expectancy among Native Americans in the western United States has dropped below 64 years, close to life expectancies in the Democratic Republic of the Congo and Haiti. For many Asian Americans, it’s around 84 — on par with life expectancies in Japan and Switzerland.

Americans’ health has long been unequal, but a new study shows that the disparity between the life expectancies of different populations has nearly doubled since 2000. “This is like comparing very different countries,” said Tom Bollyky, director of the global health program at the Council on Foreign Relations and an author of the study.

Called “Ten Americas,” the analysis published late last year in The Lancet found that “one’s life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one’s racial and ethnic identity.” The worsening health of specific populations is a key reason the country’s overall life expectancy — at 75 years for men and 80 for women — is the shortest among wealthy nations.

To deliver on pledges from the new Trump administration to make America healthy again, policymakers will need to fix problems undermining life expectancy across all populations.

“As long as we have these really severe disparities, we’re going to have this very low life expectancy,” said Kathleen Harris, a sociologist at the University of North Carolina. “It should not be that way for a country as rich as the U.S.”

Since 2000, the average life expectancy of many American Indians and Alaska Natives has been steadily shrinking. The same has been true since 2014 for Black people in low-income counties in the southeastern U.S.

“Some groups in the United States are facing a health crisis,” Bollyky said, “and we need to respond to that because it’s worsening.”

Heart disease, car fatalities, diabetes, covid-19, and other common causes of death are directly to blame. But research shows that the conditions of people’s lives, their behaviors, and their environments heavily influence why some populations are at higher risk than others.

Native Americans in the West — defined in the “Ten Americas” study as more than a dozen states excluding California, Washington, and Oregon — were among the poorest in the analysis, living in counties where a person’s annual income averages below about $20,000. Economists have shown that people with low incomes generally live shorter lives.

Studies have also linked the stress of poverty, trauma, and discrimination to detrimental coping behaviors like smoking and substance use disorders. And reservations often lack grocery stores and clean, piped water, which makes it hard to buy and cook healthy food.

About 1 in 5 Native Americans in the Southwest don’t have health insurance, according to a KFF report. Although the Indian Health Service provides coverage, the report says the program is weak due to chronic underfunding. This means people may delay or skip treatments for chronic illnesses. Postponed medical care contributed to the outsize toll of covid among Native Americans: About 1 of every 188 Navajo people died of the disease at the peak of the pandemic.

“The combination of limited access to health care and higher health risks has been devastating,” Bollyky said.

At the other end of the spectrum, the study’s category of Asian Americans maintained the longest life expectancies since 2000. As of 2021, it was 84 years.

Education may partly underlie the reasons certain groups live longer. “People with more education are more likely to seek out and adhere to health advice,” said Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation at the University of Washington, and an author of the paper. Education also offers more opportunities for full-time jobs with health benefits. “Money allows you to take steps to take care of yourself,” Mokdad said.

The group with the highest incomes in most years of the analysis was predominantly composed of white people, followed by the mainly Asian group. The latter, however, maintained the highest rates of college graduation, by far. About half finished college, compared with fewer than a third of other populations.

The study suggests that education partly accounts for differences among white people living in low-income counties, where the individual income averaged less than $32,363. Since 2000, white people in low-income counties in southeastern states — defined as those in Appalachia and the Lower Mississippi Valley — had far lower life expectancies than those in upper midwestern states including Montana, Nebraska, and Iowa. (The authors provide details on how the groups were defined and delineated in their report.)

Opioid use and HIV rates didn’t account for the disparity between these white, low-income groups, Bollyky said. But since 2010, more than 90% of white people in the northern group were high school graduates, compared with around 80% in the southeastern U.S.

The education effect didn’t hold true for Latino groups compared with others. Latinos saw lower rates of high school graduation than white people but lived longer on average. This long-standing trend recently changed among Latinos in the Southwest because of covid. Hispanic or Latino and Black people were nearly twice as likely to die from the disease.

On average, Black people in the U.S. have long experienced worse health than other races and ethnicities in the United States, except for Native Americans. But this analysis reveals a steady improvement in Black people’s life expectancy from 2000 to about 2012. During this period, the gap between Black and white life expectancies shrank.

This is true for all three groups of Black people in the analysis: Those in low-income counties in southeastern states like Mississippi, Louisiana, and Alabama; those in highly segregated and metropolitan counties, such as Queens, New York, and Wayne, Michigan, where many neighborhoods are almost entirely Black or entirely white; and Black people everywhere else.

Better drugs to treat high blood pressure and HIV help account for the improvements for many Americans between 2000 to 2010. And Black people, in particular, saw steep rises in high school graduation and gains in college education in that period.

However, progress stagnated for Black populations by 2016. Disparities in wealth grew. By 2021, Asian and many white Americans had the highest incomes in the study, living in counties with per capita incomes around $50,000. All three groups of Black people in the analysis remained below $30,000.

A wealth gap between Black and white people has historical roots, stretching back to the days of slavery, Jim Crow laws, and policies that prevented Black people from owning property in neighborhoods that are better served by public schools and other services. For Native Americans, a historical wealth gap can be traced to a near annihilation of the population and mass displacement in the 19th and 20th centuries.

Inequality has continued to rise for several reasons, such as a widening pay gap between predominantly white corporate leaders and low-wage workers, who are disproportionately people of color. And reporting from KFF Health News shows that decisions not to expand Medicaid have jeopardized the health of hundreds of thousands of people living in poverty.

Researchers have studied the potential health benefits of reparation payments to address historical injustices that led to racial wealth gaps. One new study estimates that such payments could reduce premature death among Black Americans by 29%.

Less controversial are interventions tailored to communities. Obesity often begins in childhood, for example, so policymakers could invest in after-school programs that give children a place to socialize, be active, and eat healthy food, Harris said. Such programs would need to be free for children whose parents can’t afford them and provide transportation.

But without policy changes that boost low wages, decrease medical costs, put safe housing and strong public education within reach, and ensure access to reproductive health care including abortion, Harris said, the country’s overall life expectancy may grow worse.

“If the federal government is really interested in America’s health,” she said, “they could grade states on their health metrics and give them incentives to improve.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Increasingly, Wilson helps older people like Hilton find housing.

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

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

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

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

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

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

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

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

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

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

Communities are looking for solutions.

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

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

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

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

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

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

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

“It was a woo-hoo moment,” she said.

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

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

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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.”

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

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It takes a lot of courage to grow old.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’ll take courage to deal with that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

She blamed her closure on “regulatory dysfunction.”

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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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.

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