Uncertainty around federal efforts to expand high-speed internet — and with it telehealth access — to all Americans swirled fast this week after President Donald Trump vowed to end what he called the “racist” and “unconstitutional” Digital Equity Act. 

The act is part of the $1.2 trillion Infrastructure Investment and Jobs Act of 2021, which passed under former President Joe Biden and included $65 billion for broadband infrastructure. But before Trump’s latest sniping on his Truth Social site, his administration had already thrown another of the infrastructure bill’s broadband programs into question. 

Ten days ago, Republican Sen. Shelley Moore Capito of West Virginia sent a letter to Trump’s Commerce secretary, Howard Lutnick, admonishing him to speed up his department’s review of the $42 billion Broadband Equity, Access, and Deployment Program. 

That program had been set to disburse money to states this spring to start connecting homes and businesses, and West Virginia would’ve been among the first recipients. 

“West Virginians have waited long enough,” Moore Capito wrote. Moore Capito noted her state was six weeks away from completing preparations to put the federal money to work. 

More than 200 mostly rural counties across the U.S. are in dire need of health care providers and reliable high-speed internet, according to a KFF Health News analysis. A quarter of West Virginia’s counties lack these services, making doctor visits either in person or through telehealth difficult or impossible. 

The analysis also showed that people who live in these counties tend to be sicker and die earlier than most other Americans. 

In Lincoln County, West Virginia, where the Mud River bends through hollows and past cattle farms, stroke survivor Ada Carol Adkins has what she calls “wacky” phone and internet service. It goes out frequently for days at a time. 

Adkins has one message for her telecommunications carrier and lawmakers: “Please come and hook me right.” 

She’s not the only West Virginian speaking out about bad connectivity. After receiving a briefing on the potential benefits of fiber and satellite connections, the West Virginia Broadband Enhancement Council last week adopted a resolution reaffirming its commitment to deploy high-speed fiber-optic lines. 

In Grant County, commissioners sent a letter to Republican Gov. Patrick Morrisey expressing “strong support” for the deployment of fiber lines because of the region’s geographic and economic needs. Fiber, they wrote, is more sustainable and affordable than satellite, such as Elon Musk’s Starlink kits. 

“If the residents of Grant County wanted Starlink they could purchase it at any time,” the commissioners wrote.

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.

USE OUR CONTENT

This story can be republished for free (details).

On the last day of patient care at the Planned Parenthood clinic in Marquette, Michigan, a port town on the shore of Lake Superior, dozens of people crowded into the parking lot and alley, holding pink homemade signs that read “Thank You!” and “Forever Grateful.”

“Oh my god,” physician assistant Anna Rink gasped, as she and three other Planned Parenthood employees finally walked outside. The crowd whooped and cheered. Then Rink addressed the gathering.

“Thank you for trusting us with your care,” Rink called out, her voice quavering. “And I’m not stopping here. I’m only going to make it better. I promise. I’m going to find a way.”

“We’re not done!” someone called out. “We’re not giving up!”

But Planned Parenthood of Michigan is giving up on four of its health centers in the state, citing financial challenges. That includes Marquette, the only clinic that provided abortion in the vast, sparsely populated Upper Peninsula. For the roughly 1,100 patients who visit the clinic each year for anything from cancer screenings to contraceptive implants, the next-closest Planned Parenthood will now be a nearly five-hour drive south.

It’s part of a growing trend: At least 17 clinics closed last year in states where abortion remains legal, and another 17 have closed in just the first five months of this year, according to data gathered by ineedana.com. That includes states that have become abortion destinations, like Illinois, and those where voters have enshrined broad reproductive rights into the state constitution, like Michigan.

Experts say the closures indicate that financial and operational challenges, rather than future legal bans, may be the biggest threats to abortion access in states whose laws still protect it.

“These states that we have touted as being really the best kind of versions of our vision for reproductive justice, they too struggle with problems,” said Erin Grant, a co-executive director of the Abortion Care Network, a national membership organization for independent clinics.

“It’s gotten more expensive to provide care, it’s gotten more dangerous to provide care, and it’s just gotten, frankly, harder to provide care, when you’re expected to be in the clinic and then on the statehouse steps, and also speaking to your representatives and trying to find somebody who will fix your roof or paint your walls who’s not going to insert their opinion about health care rights.”

But some abortion rights supporters question whether leaders are prioritizing patient care for the most vulnerable populations. Planned Parenthood of Michigan isn’t cutting executive pay, even as it reduces staff by 10% and shuts down brick-and-mortar clinics in areas already facing health care shortages.

“I wish I had been in the room so I could have fought for us, and I could have fought for our community,” said Viktoria Koskenoja, an emergency medicine physician in the Upper Peninsula, who previously worked for Planned Parenthood in Marquette. “I just have to hope that they did the math of trying to hurt as few people as possible, and that’s how they made their decision. And we just weren’t part of the group that was going to be saved.”

Why Now?

If a clinic could survive the fall of Roe v. Wade, “you would think that resilience could carry you forward,” said Brittany Fonteno, president and CEO of the National Abortion Federation.

But clinic operators say they face new financial strain, including rising costs, limited reimbursement rates, and growing demand for telehealth services. They’re also bracing for the Trump administration to again exclude them from Title X, the federal funding for low- and no-cost family planning services, as the previous Trump administration did in 2019.

PPMI says the cuts are painful but necessary for the organization’s long-term sustainability. The clinics being closed are “our smallest health centers,” said Sarah Wallett, PPMI’s chief medical operating officer. And while the thousands of patients those clinics served each year are important, she said, the clinics’ small size made them “the most difficult to operate.” The clinics being closed offered medication abortion, which is available in Michigan up until 11 weeks of pregnancy, but not procedural abortion.

Planned Parenthood of Illinois (a state that’s become a post-Roe v. Wade abortion destination) shuttered four clinics in March, pointing to a “financial shortfall.” Planned Parenthood of Greater New York is now selling its only Manhattan clinic, after closing four clinics last summer due to “compounding financial and political challenges.” And Planned Parenthood Association of Utah, where courts have blocked a near-total abortion ban and abortion is currently legal until 18 weeks of pregnancy, announced it closed two centers as of May 2.

Earlier this spring, the Trump administration began temporarily freezing funds to many clinics, including all Title X providers in California, Hawaii, Maine, Mississippi, Missouri, Montana, and Utah, according to a KFF analysis.

While the current Title X freeze doesn’t yet include Planned Parenthood of Michigan, PPMI’s chief advocacy officer, Ashlea Phenicie, said it would amount to a loss of about $5.4 million annually, or 16% of its budget.

But Planned Parenthood of Michigan didn’t close clinics the last time the Trump administration froze its Title X funding. Its leader said that’s because the funding was stopped for only about two years, from 2019 until 2021, when the Biden administration restored it. “Now we’re faced with a longer period of time that we will be forced out of Title X, as opposed to the first administration,” said PPMI president and CEO Paula Thornton Greear.

And at the same time, the rise of telehealth abortion has put “new pressures in the older-school brick-and-mortar facilities,” said Caitlin Myers, a Middlebury College economics professor who maps brick-and-mortar clinics across the U.S. that provide abortion.

Until a few years ago, doctors could prescribe abortion pills only in person. Those restrictions were lifted during the covid-19 pandemic, but it was the Dobbs decision in 2022 that really “accelerated expansions in telehealth,” Myers said, “because it drew all this attention to models of providing abortion services.”

Suddenly, new online providers entered the field, advertising virtual consultations and pills shipped directly to your home. And plenty of patients who still have access to a brick-and-mortar clinic prefer that option. “Put more simply, it’s gotta change their business model,” she said.

Balancing Cost and Care

Historically, about 28% of PPMI’s patients receive Medicaid benefits, according to Phenicie. And, like many states, Michigan’s Medicaid program doesn’t cover abortion, leaving those patients to either pay out-of-pocket or rely on help from abortion funds, several of which have also been struggling financially.

“When patients can’t afford care, that means that they might not be showing up to clinics,” said Fonteno of the National Abortion Federation, which had to cut its monthly budget nearly in half last year, from covering up to 50% of an eligible patient’s costs to 30%. “So seeing a sort of decline in patient volume, and then associated revenue, is definitely something that we’ve seen.”

Meanwhile, more clinics and abortion funds say patients have delayed care because of those rising costs. According to a small November-December 2024 survey of providers and funds conducted by ineedana.com, “85% of clinics reported seeing an increase of clients delaying care due to lack of funding.” One abortion fund said the number of patients who had to delay care until their second trimester had “grown by over 60%.”

Even when non-abortion services like birth control and cervical cancer screenings are covered by insurance, clinics aren’t always reimbursed for the full cost, Thornton Greear said.

“The reality is that insurance reimbursement rates across the board are low,” she said. “It’s been that way for a while. When you start looking at the costs to run a health care organization, from supply costs, etc., when you layer on these funding impacts, it creates a chasm that’s impossible to fill.”

Yet, unlike some independent clinics that have had to close, Planned Parenthood’s national federation brings in hundreds of millions of dollars a year, the majority of which is spent on policy and legal efforts rather than state-level medical services. The organization and some of its state affiliates have also battled allegations of mismanagement, as well as complaints about staffing and patient care problems. Planned Parenthood of Michigan staffers in five clinics unionized last year, with some citing management problems and workplace and patient care conditions.

Asked whether Planned Parenthood’s national funding structure needs to change, PPMI CEO Thornton Greear said: “I think that it needs to be looked at, and what they’re able to do. And I know that that is actively happening.”

The Gaps That Telehealth Can’t Fill

When the Marquette clinic’s closure was announced, dozens of patients voiced their concerns in Google reviews, with several saying the clinic had “saved my life,” and describing how they’d been helped after an assault, or been able to get low-cost care when they couldn’t afford other options.

Planned Parenthood of Michigan responded to most comments with the same statement and pointed patients to telehealth in the clinic’s absence:

“Please know that closing health centers wasn’t a choice that was made lightly, but one forced upon us by the escalating attacks against sexual and reproductive health providers like Planned Parenthood. We are doing everything we can to protect as much access to care as possible. We know you’re sad and angry — we are, too.

“We know that telehealth cannot bridge every gap; however, the majority of the services PPMI provides will remain available via the Virtual Health Center and PP Direct, including medication abortion, birth control, HIV services, UTI treatment, emergency contraception, gender-affirming care, and yeast infection treatment. Learn more at ppmi.org/telehealth.”

PPMI’s virtual health center is already its most popular clinic, according to the organization, serving more than 10,000 patients a year. And PPMI plans to expand virtual appointments by 40%, including weekend and evening hours.

“For some rural communities, having access to telehealth has made significant changes in their health,” said Wallett, PPMI’s chief medical operating officer. “In telehealth, I can have an appointment in my car during lunch. I don’t have to take extra time off. I don’t have to drive there. I don’t have to find child care.”

Yet even as the number of clinics has dropped nationally, about 80% of clinician-provided abortions are still done by brick-and-mortar clinics, according to the most recent #WeCount report, which looked at 2024 data from April to June.

And Hannah Harriman, a Marquette County Health Department nurse who previously spent 12 years working for Planned Parenthood of Marquette, is skeptical of any suggestion that telehealth can replace a rural brick-and-mortar clinic. “I say that those people have never spent any time in the U.P.,” she said, referring to the Upper Peninsula.

Some areas are “dark zones” for cell coverage, she said. And some residents “have to drive to McDonald’s to use their Wi-Fi. There are places here that don’t even have internet coverage. I mean, you can’t get it.”

Telehealth has its advantages, said Koskenoja, the emergency medicine physician who previously worked for Planned Parenthood in Marquette, “but for a lot of health problems, it’s just not a safe or realistic way to take care of people.”

She recently had a patient in the emergency room who was having a complication from a gynecological surgery. “She needed to see a gynecologist, and I called the local OB office,” Koskenoja said. “They told me they have 30 or 40 new referrals a month,” and simply don’t have enough clinicians to see all those patients. “So adding in the burden of all the patients that were being seen at Planned Parenthood is going to be impossible.”

Koskenoja, Harriman, and other local health care providers have been strategizing privately to figure out what to do next to help people access everything from Pap smears to IUDs. The local health department can provide Title X family planning services 1½ days a week, but that won’t be enough, Harriman said. And there are a few private “providers in town that offer medication abortion to their patients only — very, very quietly,” she said. But that won’t help patients who don’t have good insurance or are stuck on waitlists.

“It’s going to be a patchwork of trying to fill in those gaps,” Koskenoja said. “But we lost a very functional system for delivering this care to patients. And now, we’re just having to make it up as we go.”

This article is from a partnership with Michigan Public and NPR.

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.

USE OUR CONTENT

This story can be republished for free (details).

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

After all-night markups, two key House committees approved GOP budget legislation that would cut hundreds of billions of dollars from federal health programs over the next decade, mostly from the Medicaid program for people with low incomes or disabilities. The legislation is far from a done deal, though, with at least one Republican senator voicing opposition to Medicaid cuts.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. testified before Congress for the first time since taking office. In sometimes surprisingly combative exchanges with lawmakers in the House and Senate, Kennedy denied cutting programs despite evidence to the contrary and said at one point that he doesn’t think Americans “should be taking medical advice from me.”

This week’s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists Julie Appleby KFF Health News @Julie_appleby Read Julie's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• House Republicans this week released — then quickly ushered through committee — major legislation that would make deep cuts to federal spending while funding President Donald Trump’s domestic priorities, including renewing tax cuts and boosting border security. A preliminary estimate by the Congressional Budget Office found the bill would cut at least $715 billion from federal health spending over 10 years — with most of that money coming from the Medicaid program.
• Overall, the House GOP’s proposal would make it harder to enroll, and stay enrolled, in Medicaid and Affordable Care Act coverage. Among other changes, the bill would impose a requirement that nondisabled adults (with some exceptions) work, volunteer, or study at least 80 hours per month to be eligible for coverage. But Democrats and patient advocates point to evidence that, rather than encouraging employment, such a mandate results in more people losing or dropping coverage under burdensome paperwork requirements.
• Republicans also declined to extend the enhanced tax credits introduced during the covid-19 pandemic that help many people afford ACA marketplace coverage. Those tax credits expire at the end of the year, and premiums are expected to balloon, which could prompt many people not to renew their coverage.
• And Kennedy’s appearances on Capitol Hill this week provided Congress the first opportunity to question the health secretary since he assumed his post. He was grilled by Democrats about vaccines, congressionally appropriated funds, agency firings, and much more.

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

Julie Rovner: The New York Times’ “Elizabeth Holmes’s Partner Has a New Blood-Testing Start-Up,” by Rob Copeland.  

Alice Miranda Ollstein: ProPublica’s “He Became the Face of Georgia’s Medicaid Work Requirement. Now He’s Fed Up With It.” by Margaret Coker, The Current.

Julie Appleby: Scientific American’s “How Trump’s National Weather Service Cuts Could Cost Lives,” by Andrea Thompson.  

Joanne Kenen: The Atlantic’s “Now Is Not the Time To Eat Bagged Lettuce,” by Nicholas Florko.

Also mentioned in this week’s podcast:

• Politico’s “‘Rolling Thunder’: Inside Conservatives’ Strategy To Curb Abortion Pill Access,” by Alice Miranda Ollstein.
• The New York Times’ “Josh Hawley: Don’t Cut Medicaid,” by Sen. Josh Hawley (R-Mo.).
• NPR’s “FDA Moves To Ban Fluoride Supplements for Kids, Removing a Key Tool for Dentists,” by Pien Huang.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

NASHVILLE, Tenn. — Federal prosecutors sought a maximum prison sentence of nearly 20 years for the CEO of Pain MD, a company found to have given hundreds of thousands of questionable injections to patients, many reliant on opioids. It would have been among the longest sentences for a health care executive convicted of fraud in recent years.

Instead, he got 18 months.

Michael Kestner, 73, who was convicted of 13 fraud felonies last year, faced at least a decade behind bars based on federal sentencing guidelines. He was granted the substantially lightened sentence due to his age and health Wednesday during a federal court hearing in Nashville.

U.S. District Judge Aleta Trauger described Kestner as a “ruthless businessman” who funded a “lavish lifestyle” by turning medical professionals into “puppets” who pressured patients into injections that did not help their pain and sometimes made it worse.

“In the court’s eyes, he knew it was wrong, and he didn’t really care if it was doing anyone any good,” Trauger said.

But Trauger also said she was swayed by defense arguments that Kestner would struggle in federal prison due to his age and medical conditions, including the blood disorder hemochromatosis. Trauger said she had concerns about prison health care after considering about 200 requests for compassionate release in other court cases.

“The medical care at these facilities,” defense attorney Peter Strianse said, “has always been dodgy and suspect.”

Kestner did not speak at the court hearing, other than to detail his medical conditions. He did not respond to questions as he left the courthouse.

Pain MD ran as many as 20 clinics in Tennessee, Virginia, and North Carolina throughout much of the 2010s. While many doctors were scaling back their use of prescription painkillers due to the opioid crisis, Pain MD paired opioids with monthly injections into patients’ backs, claiming the shots could ease pain and potentially lessen reliance on pills, according to federal court documents.

During Kestner’s October trial, the Department of Justice proved that the injections were part of a decade-long scheme that defrauded Medicare and other insurance programs of millions of dollars by capitalizing on patients’ dependence on opioids.

The DOJ successfully argued at trial that Pain MD’s “unnecessary and expensive injections” were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead. During closing arguments, the DOJ argued Pain MD had turned some patients into “human pin cushions.”

“They were leaned over a table and repeatedly injected in their spine,” federal prosecutor Katherine Payerle said during the May 14 sentencing hearing. “Over and over, month after month, at the direction of Mr. Kestner.”

At last year’s trial, witnesses testified that Kestner was the driving force behind the injections, which amounted to roughly 700,000 shots over about eight years, with some patients receiving up to 24 at once.

Four former patients testified that they tolerated the shots out of fear that Pain MD otherwise would have cut off their painkiller prescriptions, without which they might have spiraled into withdrawal.

One of those patients, Michelle Shaw, told KFF Health News that the injections sometimes left her in so much pain she had to use a wheelchair. She was outraged by Kestner’s sentence.

“I’m disgusted that all they got was a slap on the wrist as far as I’m concerned,” Shaw said May 14. “I hope karma comes back to him. That he suffers to his last breath.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Brian Rigsby was lying with his right wrist shackled to a hospital bed in Montgomery, Alabama, when he learned he didn’t have long to live.

It was September 2023, and Rigsby, 46, had been brought to Jackson Hospital from an Alabama state prison 10 days earlier after complaining of pain and swelling in his abdomen. Doctors found that untreated hepatitis C had caused irreversible damage to Rigsby’s liver, according to his medical records.

Rigsby decided to stop efforts to treat his illness and to decline lifesaving care, a decision he made with his parents. And Rigsby’s mother, Pamela Moser, tried to get her son released to hospice care through Alabama’s medical furlough policy, so that their family could manage his end-of-life care as they saw fit.

But there wasn’t enough time for the furlough request to be considered.

After learning that Rigsby was on palliative care, the staff at YesCare, a private prison health company that has a $1 billion contract with the Alabama Department of Corrections, told the hospital it would stop paying for his stay and then transferred him back to Staton Correctional Facility in Elmore, according to the hospital record his mom provided to KFF Health News.

Moser never saw or spoke to her son again.

“The last day I went to see him in the hospital, I was hoping he would take his last breath,” said Moser, a former hospice nurse. “That is how bad I didn’t want him to go to the infirmary” at the prison.

A week later, Rigsby died of liver failure in the infirmary, according to his autopsy report.

Officials at the corrections department and YesCare did not respond to requests for comment.

As the country’s incarcerated population ages rapidly, thousands die behind bars each year. For some researchers, medical providers, and families of terminally ill people in custody, Rigsby’s situation — and Moser’s frustration — are familiar: Incarcerated people typically have little say over the care they receive at the end of their lives.

That’s despite a broad consensus among standards boards, policymakers, and health care providers that terminally ill people in custody should receive treatment that minimizes suffering and allows them to be actively involved in care planning.

But such guidelines aren’t binding. State policies on end-of-life care vary widely, and they generally give much leeway to correctional officers, according to a 2021 study led by Georgia State University. The result is that correctional officers and medical contractors make the decisions, and they focus more on security concerns than easing the emotional, spiritual, and physical pain of the dying, say researchers and families.

People in jails and prisons often die while shackled to beds, separated from loved ones, and with minimal pain medication, said Nicole Mushero, a geriatrician at Boston University’s Chobanian & Avedisian School of Medicine who studies and works with incarcerated patients.

“When you’re coming at this from a health care perspective, it’s kind of shocking,” Mushero said.

Security vs. Autonomy

Patients are often suspended or dropped from their health coverage, including commercial insurance or Medicaid, when incarcerated. Jails and prisons have their own systems for providing health care, often funded by state and local budgets, and therefore aren’t subject to the same oversight as other public or private systems.

The National Commission on Correctional Health Care, which accredits programs at correctional facilities across the country, says terminally ill people in custody should be allowed to make decisions about treatment options, such as whether to accept life-sustaining care, and appoint a person who can make medical decisions for them.

Jails and prisons should also provide patients with pain medication that wouldn’t otherwise be available to them, allow extra visits with loved ones, and consider them for medical release programs that let them receive hospice care in their communities, said Amy Panagopoulos, vice president of accreditation at the commission. That approach is often at odds with security and safety rules of jails and prisons, so facility leaders may be heavily involved in care decisions, she said.

As a result, the commission plans to release updated standards this summer to provide more details on how facilities should handle end-of-life care to ensure incarcerated patients are more involved in the process.

State laws on medical decision-making, informed consent, and patient privacy apply even to incarcerated patients, said Gregory Dober, who teaches biomedical ethics and is a prison monitor with the Pennsylvania Prison Society, a nonprofit that supports incarcerated patients and their families.

But correctional officers and their medical contractors often prioritize security instead, Dober said.

The Federal Bureau of Prisons allows guards to override do-not-resuscitate orders if they interfere with the security and orderly operation of the institution, according to the agency’s patient care guide.

“This is a wildly understudied area,” said Ben Parks, who teaches medical ethics at Mercy College of Ohio. “In the end, it’s all about the state control of a prisoner’s life.”

About a third of all people who died in federal custody between 2004 and 2022 had a do-not-resuscitate order, according to Bureau of Prisons data obtained by KFF Health News through a Freedom of Information Act request.

The prison bureau’s policy of forcing CPR on patients is cruel, Parks said. CPR can break ribs and bruise organs, with a low likelihood of success. That is why people sign do-not-resuscitate orders refusing the treatment, he said.

“This is the inversion of the death penalty,” Parks said. “Resuscitation against your will.”

Cut Off From Family

In addition, corrections officials decide whether and when to reach out to a patient’s friends or relatives, said Erin Kitt-Lewis, a Penn State College of Nursing associate research professor who has studied the care of older adults in prisons. As a result, terminally ill people in custody often can’t involve their families in end-of-life care decisions.

That was the case for Adam Spurgeon, who was incarcerated in a state prison in Tennessee, his mother said. One morning in November 2018, Kathy Spurgeon got a call from hospital officials in Nashville saying her son had only hours to live, she said.

About a month earlier, she had learned from her son that he had had heart surgery and developed an infection, she said. But she didn’t know much about his treatment.

Around noon, she arrived at the hospital, about a three-hour drive west of where she lives. Adam, 32, died that evening.

Dorinda Carter, communications director at the Tennessee Department of Correction, declined to comment on Spurgeon’s case. “It is our policy to not comment on an individual inmate’s medical care,” she said in an email.

Kathy Spurgeon said providers who treated Adam outside of prison were too deferential to guards.

And physicians who work with incarcerated patients say that can be the case: Even when terminally ill people in custody are treated at hospitals, correctional officers still end up dictating the terms of care.

Hospital staff members often don’t understand the rights of incarcerated patients and are unsure about state laws and hospital policies, said Pria Anand, a neurologist who has treated incarcerated patients in hospitals. “The biggest problem is uncertainty,” she said.

Correctional officers sometimes tell hospital staffers they can’t contact next of kin for security reasons, or they won’t tell a patient about discharge plans because of worries they might escape, Anand said.

And care frequently takes place within prisons, which often are not equipped to handle the complexities of hospice decision-making, including types of treatment, when to stop treatment, and who can make those decisions, said Laura Musselman, director of communications at the Humane Prison Hospice Project, which provides training and education to improve end-of-life care for incarcerated patients.

“Our prison system was not designed to provide care for anyone, especially not people who are chronically ill, terminally ill, older, actively dying,” said Musselman, who noted that her group’s training has 15 modules to cover all aspects of end-of-life care, including grief support, hands-on caregiving, and paperwork.

Rigsby struggled with mental health and addiction for most of his adult life, including a stint in prison for a drug-related robbery. A parole violation in 2018 landed him back in prison.

At Jackson Hospital, Rigsby was given hydromorphone, a powerful pain medication, as well as the anxiety drug lorazepam. Before he was transferred back to prison, a nurse with YesCare — one of the country’s biggest prison health care providers, which has been sued over substandard care —assured hospital staffers he would be provided with the same level of pain medication and oxygen he had received at the hospital, his medical records show.

But Moser said she doesn’t know whether he spent his last days in pain or peace. The state wouldn’t provide Moser with Rigsby’s medical records from the prison, she said. She said she wasn’t allowed to visit her son in the infirmary — and wasn’t told why.

Moser called the infirmary to comfort her son before his death, but staffers told her he couldn’t make it to the phone and they couldn’t take one to him, she said.

Instead, Moser said, she left messages for prison officials to tell her son she loved him.

“It breaks my heart that he could not talk with his mother during his last days,” said Moser, whose son died on Oct. 4, 2023.

Two weeks later, she drove to Woodstock, Alabama, to collect his remains from a crematorium.

KFF Health News data editor Holly K. Hacker contributed to this report.

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

USE OUR CONTENT

This story can be republished for free (details).

BRANCHLAND, W.Va. — Ada Carol Adkins lives with her two dogs in a trailer tucked into the timbers off Upper Mud River Road.

“I’m comfortable here, but I’m having health issues,” said the 68-year-old, who retired from her job as a school cook several years ago after having a stroke. “Things are failing me.”

Her trailer sits halfway up a ridge miles from town and the local health clinic. Her phone and internet are “wacky sometimes,” she said. Adkins — who is fiercely independent and calls herself a “Mountain Momma” — worries she won’t be able to call for help if service goes out, which happens often.

To Frontier Communications, the telecommunications company that owns the line to her home, Adkins says: “Please come and hook me right.”

But she might be waiting years for better service, frustrated by her internet provider and left behind by troubled federal grant programs.

A quarter of West Virginia counties — including Lincoln, where the Mud River bends its way through hollows and past cattle farms — face two barriers to health care: They lack high-speed internet and have a shortage of primary care providers and behavioral health specialists, according to a KFF Health News analysis.

Years of Republican and Democratic administrations have tried to fix the nation’s broadband woes, through flawed attempts. Bad mapping, weak standards, and flimsy oversight have left Adkins and nearly 3 million other rural Americans in dead zones — with eroded health care services and where telehealth doesn’t reach.

Blair Levin, a former executive director of the Federal Communications Commission’s National Broadband Plan, called one rural program rollout during the first Trump administration “a disaster.”

It was launched before it was ready, he said, using unreliable federal maps and a reverse-auction process to select internet carriers. Locations went to the lowest bidder, but the agency failed to ensure winners had the knowledge and resources to build networks, said Levin, who is now an equity analyst with New Street Research.

The fund initially announced awards of $9.2 billion to build infrastructure in 49 states. By 2025, $3.3 billion of those awards were in default and, as a result, the program won’t connect 1.9 million homes and businesses, according to a recent study.

A $42 billion Biden-era initiative still may not help Adkins and many others shortchanged by earlier federal broadband grants. The new wave of funding, the Broadband Equity, Access, and Deployment Program, or BEAD, has an anti-waste provision and won’t provide service in places where previous grants were awarded — even if companies haven’t delivered on their commitments.

The use of federal money to get people connected is “really essential” for rural areas, said Ross DeVol, CEO and chairman of the board of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

“Internet service providers look at the economics of trying to go into some of these communities and there just isn’t enough purchasing power in their minds,” DeVol said, adding that broadband expansion is analogous to rural electrification. Without high-speed internet, “you’re simply at a distinct disadvantage,” he added. “I’ll call it economic discrimination.”

‘I Got Books Full’

Adkins keeps spiral-bound notebooks and calendars filled with handwritten records of phone and internet outages.

In January, while bean soup warmed on the stove, she opened a notebook: “I got books full. Hang on.”

Her finger traced the page as she recounted outages that occurred about once a month last year. Adkins said she lost connectivity twice in November, again in October, and in July, May, and March. Each time she went for days without service.

Adkins pays Frontier Communications $102.13 a month for a “bundle” that includes a connection for her house phone and wireless internet access on her cellphone. Frontier did not respond to requests for comment on Adkins’ and other customers’ service.

Adkins, a widow, spends most of her time at home and said she would do video calls with her doctors if she could. She said she still has numbness on one side of her body after the stroke. She also has high blood pressure and arthritis and uses over-the-counter pain patches when needed, such as after she carries 30-pound dog food bags into the house.

She does not own a four-wheel-drive truck and, for three weeks in January, the snow and ice were so severe she couldn’t leave. “I’m stranded up here,” she said, adding that neighbors check in: “‘Do you have electric? Have you got water? Are you OK?’”

The neighbors have all seen Adkins’ line. The pale-yellow cord was tied off with green plastic ties around a pole outside her trailer. As it ran down the hill, it was knotted around tree trunks and branches, frayed in places, and, finally, collapsed on the ground under gravel, snow, and ice at the bottom of the hill.

Adkins said a deer stepping on the line has interrupted her phone service.

David and Billi Belcher’s double-wide modular home sits near the top of the ridge past Adkins’ home. Inside, an old hunting dog sleeps on the floor. Belcher pointed out a window toward where he said Frontier’s cable has remained unrepaired for years: “It’s laying on the ground in the woods,” he said.

Frontier is West Virginia’s legacy carrier, controlling most of the state’s old landlines since buying them from Verizon Communications in 2010. Twelve years later, the company won nearly $248 million to install high-speed internet to West Virginia through the Rural Digital Opportunity Fund, an initiative launched during President Donald Trump’s first term.

“Big Daddy,” as local transit driver Bruce Perry called Trump, is popular with the people of Lincoln County. About 80% of the county’s voters picked the Republican in the last election.

The Trump administration awarded Frontier money to build high-speed internet to Upper Mud River Road residents, like Adkins, according to state mapping. Frontier has until Dec. 31, 2028, to build.

But the Belchers needed better internet access for work and could afford to pay $700 for a Starlink satellite internet kit and insurance, they said. Their monthly Starlink bill is $120 — a price many cannot manage, especially since Congress sunset an earlier program that helped offset the cost of high-speed plans for consumers.

Meanwhile, the latest broadband program to connect rural Americans is ensnared in Trump administration policy shifts.

The National Telecommunications and Information Administration, which administers the program, in April announced a 90-day extension for states to finalize their plans during a “comprehensive review” of the program.

West Viriginia Gov. Patrick Morrisey, a Republican, announced his state would take an extension. The move, though, doesn’t make a lot of sense, said Evan Feinman, who left the agency in March after directing the broadband program for the past three years.

Calling the work already done in West Virginia an “incredible triumph,” Feinman said the state had completed the planning, mapping, and the initial selection of companies. The plan that was in place would have brought high-speed fiber lines to homes ahead of schedule and under budget, he said.

“They could be building today, and it’s just deeply disappointing that they’re not,” Feinman said.

When Feinman resigned in March, he sent a lengthy email stating that the new administration wants to take fiber away from homes and businesses and substitute it with satellite connections. The move, he said, would be more expensive for consumers and hurt rural and small-town America.

Morrisey, whose office declined to respond to requests for comment, said in his announcement that he wants to ensure West Virginia spends the money in a manner “consistent with program changes being proposed by the Trump Administration” and “evaluate a broader range of technology options.”

Commissioners from Grant County responded with a letter supporting fiber-optic cables rather than satellite-based connections like those provided by Elon Musk’s Starlink. Nationwide, 115 lawmakers from 28 states sent a letter to federal leaders stating that changes could “delay broadband deployment by a year or more.”

For Adkins and others, the wait has been long enough.

While legislators in Washington and across the country bickered over the broadband program, Adkins went without phone and internet. By late March, she said, her 42-year-old son was increasingly worried, noting “you’re getting up in age.” He told her: “Mom, move out, get off of that hill.”

Worst-Case Scenario

A few miles from Upper Mud River Road, past the McDonald’s and across the road from the local library, Brian Vance sat in his downtown Hamlin, West Virginia, office. He said his company has been trying to “build up there for a while.”

Vance is a general manager for Armstrong Telephone and Cable, a regional telecommunications provider that competes with Frontier. He grew up in the community, and parents of a high school friend live off Upper Mud River. But he said “it’s very difficult” to build fiber along the rocky terrain to homes where “you are hoping that people will hook up, and if they don’t, well, you’ve lost a lot of money.”

A 2022 countywide broadband assessment found that stringing fiber-optic lines along telephone poles would cost more than $5,000 per connection in some areas — work that would need big federal subsidies to be feasible.

Yet Vance said Armstrong cannot apply for the latest BEAD funding to help finance connections. And while he likes that the federal government is “being responsible” by not handing out two federal grants for the same area, Vance said, “we want to see people deliver on the grants they have.”

If Frontier hadn’t already gotten federal funds from the earlier Trump program, “we definitely would have applied to that area,” Vance said.

The 2022 assessment noted the community’s economy would not be sustainable without “ubiquitous broadband.”

High-speed internet brings more jobs and less poverty, said Claudia Persico, an associate professor at American University. Persico, who is also a research associate with the National Bureau of Economic Research, co-authored a recent paper that found increased broadband internet leads to a reduction in the number of suicides as well as improvements in self-reported mental and physical health.

More than 30% of Lincoln County’s population reports cases of depression, according to data from the Centers for Disease Control and Prevention. The rate of opioid prescriptions dispensed in Lincoln County is down about 60% from 2014 to 2024 — but still higher than the state average, according to the West Virginia Board of Pharmacy.

Twenty percent of the county’s population lives below the poverty line, and residents are also more likely than the national average to experience heart disease, diabetes, and obesity.

Lincoln Primary Care Center offers telehealth services such as electronic medical records on a patient portal and a pharmacy app, said Jill Adkins, chief quality and risk officer at Southern West Virginia Health System, which operates the clinic.

But because of limited access, only about 7% of patients use telehealth, she said.

Della Vance was a patient at the clinic but said she has never used a patient portal. If she could, Vance said, she would check records on the baby she is expecting.

“You can’t really get on if you don’t have good service and no internet,” she said. “It makes me angry, honestly.”

Vance and her husband, Isaiah, live off a gravel road that veers from Upper Mud River. There is a tall pole with black wires dangling across the road from their small home. Pointing to the cables, Isaiah Vance said he couldn’t get phone service anymore.

Verizon announced plans last year to buy Frontier for an estimated $20 billion. The deal, which must be approved by federal and state regulators, is expected to be completed in early 2026, according to an investor’s press release.

In its federal merger application, Frontier stated that it had taken on too much debt after emerging from bankruptcy and that debt would make it difficult to finish the work of installing fiber to customers in 25 states.

In West Virginia, Frontier’s Allison Ellis wrote in March 3 testimony, seeking approval for the merger from state regulators, that Verizon will honor the rural program commitments. The previous month, in February, Frontier filed a motion with the state public service commission to keep the number of customers using copper lines and the faster fiber-optic lines confidential.

Kelly Workman, West Virginia’s broadband director, said during a November interview that her office has asked federal regulators for “greater visibility” into Frontier’s rural program construction, particularly because those locations cannot win the Biden-era infrastructure money when it's available.

“The worst-case scenario would be for any of these locations to be left behind,” Workman said.

‘Money Cow’

Frontier’s progress installing fiber-optic lines and its unreliable service have frustrated West Virginians for years. In a 2020 letter to the FCC, U.S. Sen. Shelley Capito (R-W.Va.) cited “the failure of Frontier to deliver on promises to federal partners” and its “mismanagement” of federal dollars, which forced the state to pay back $4.7 million because of improper use and missed deadlines.

Michael Holstine, a longtime member of the West Virginia Broadband Enhancement Council, said the company has “just used West Virginia as a money cow.” Holstine has been fighting for the construction of fiber-optic lines in Pocahontas County for years. “I really just hope I get it before I die.”

Across the state, people like Holstine and Adkins are eager for updated networks, according to interviews as well as letters released under a public records request.

Chrissy Murray, vice president of Frontier’s external communications, acknowledged that the company was “building back our community efforts” in West Virginia after a bankruptcy filing and reorganization. She said there has been a “notable decline” in consumer complaints, though she did not provide specific numbers.

Murray said Frontier built fiber-optic cables to 20% of its designated rural funds locations as of the end of 2024. It has also invested in other infrastructure projects across the state, she said in a January email, adding that the company donated high-speed fiber internet to West Virginia University’s rural Jackson’s Mill campus.

According to data tracked by a federal agency, Frontier has connected 6,100 — or fewer than 10% — of the more than 79,000 locations it was awarded in the Rural Digital Opportunity Fund program.

The FCC oversees the rural fund. The agency did not respond to a request for comment. Frontier expects to receive $37 million annually from the agency through 2032, according to a federal filing.

In April, a new batch of letters from West Virginia residents filed as “support” for Frontier’s merger with Verizon appeared in the state regulatory docket:

“My support for this case depends on whether Verizon plans to upgrade or replace the existing Frontier infrastructure,” wrote one customer in Summers County, in the far southern corner of the state, adding, “West Virginians in my neck of the woods have been held hostage by Frontier for a generation now because no other providers exist.”

A customer from Hardy County, in the state’s northeastern corner, wrote: “This is [a] move by frontier to to [sic] escape its responsibility to continue services.”

‘Deep-Rooted’

Adkins moved to Upper Mud River with her husband, Bobby, decades ago.

For years, Bobby and Ada Carol Adkins ran a “carry-out” on Upper Mud River Road. The old building is still at the rock quarry just down the hill and around the curve from where her trailer sits.

It was the type of store where locals kept a tab — which Bobby treated too much like a “charity,” Adkins said. They sold cigarettes, beer, bread, bags of chips, and some food items like potatoes and rice. “Whatever the community would want,” she said.

Then, Bobby Adkins’ “health started deteriorating and money got tighter,” Adkins said. He died at 62 years old.

Now, Adkins said, “I’m having kidney problems. I got arthritis, they’re treating me for high blood pressure.”

Her doctor has begun sending notes over the internet to refill her blood pressure medicine and, Adkins said, “I love that!”

But Adkins’ internet was out again in early April, and she can’t afford Starlink like her neighbors. Even as Adkins said she is “deep-rooted,” her son’s request is on her mind.

“I’m having health problems,” Adkins said. “He makes a lot of sense.”

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.

USE OUR CONTENT

This story can be republished for free (details).

In his first term, President Donald Trump promised to end America’s HIV epidemic — and he put the resources of the federal government behind the effort. This time, he has deployed the powers of his office to gut funding, abandoning those communities at highest risk of HIV. 

Health care groups across the South are scaling back HIV testing and outreach because of the Trump administration’s budget cuts and layoffs. 

A small clinic in Hattiesburg, Mississippi, is no longer offering people HIV testing. The AIDS Services Coalition’s grant for HIV prevention from the Centers for Disease Control and Prevention had been delayed for months — a situation linked partly to CDC layoffs that included grant administrators. The coalition couldn’t afford to run the clinic with no promise of reimbursement. 

At a recent event in Jackson, nonprofit groups offered free hoagies, showers, blood pressure checks, and HIV tests to people in need. The organizers commiserated over notices they’d received days earlier, cutting hundreds of thousands of dollars in federal funding that had been swept up in the Trump administration’s termination of research dollars and clawback of more than $11 billion from health departments nationwide. That would mean feeding fewer people and offering less care. 

The loss could prove tragic, said June Gipson, CEO of the health care group My Brother’s Keeper. People who lack stable housing, transportation, or access to health care often need extra support to get tested for HIV or to stay on treatment. Otherwise, Gipson said, more people will become sicker with HIV and stand a greater chance of spreading the virus to others. 

Directors of other community-based groups in Mississippi, Alabama, Louisiana, and Tennessee told KFF Health News they too reduced spending on HIV testing and outreach because of delayed or slashed federal funds — or fears of more cuts to come. 

This is a particular problem in the South, as the region accounted for half of the nation’s new HIV cases in 2022. Southern states also heavily rely on federal funds: Mississippi, Alabama, and Louisiana put zero state funds into HIV prevention last year, compared with half of Colorado’s budget coming from the state and 88% of New York’s. 

“When you are in the South, you need the federal government,” Gipson said. 

Since February, My Brother’s Keeper has lost a succession of grants. The National Institutes of Health pulled one worth $12 million, not even two years into a 10-year project, meant to tackle inequities. The NIH’s termination letter echoed executive orders attacking diversity, equity, and inclusion. Next, the group lost a CDC award to reduce health disparities. More cuts are on the horizon if Congress passes the Trump administration’s proposed budget, which slashes the CDC’s budget by $3.59 billion. And its plan, leaked in April, for the Department of Health and Human Services eliminates all funding for Trump’s first-term initiative “Ending the HIV Epidemic.” From 2017 to 2022, new HIV infections decreased by 21% in the cities and Southern states it targeted. 

“We’re seeing an about-face of what it means to truly work towards ending HIV in this country,” said Dafina Ward, executive director of the Southern AIDS Coalition.

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.

USE OUR CONTENT

This story can be republished for free (details).

A prime example of elderspeak: Cindy Smith was visiting her father in his assisted living apartment in Roseville, California. An aide who was trying to induce him to do something —  Smith no longer remembers exactly what — said, “Let me help you, sweetheart.”

“He just gave her The Look — under his bushy eyebrows — and said, ‘What, are we getting married?’” recalled Smith, who had a good laugh, she said. Her father was then 92, a retired county planner and a World War II veteran; macular degeneration had reduced the quality of his vision, and he used a walker to get around, but he remained cognitively sharp.

“He wouldn’t normally get too frosty with people,” Smith said. “But he did have the sense that he was a grown-up and he wasn’t always treated like one.”

People understand almost intuitively what “elderspeak” means. “It’s communication to older adults that sounds like baby talk,” said Clarissa Shaw, a dementia care researcher at the University of Iowa College of Nursing and a co-author of a recent article that helps researchers document its use.

“It arises from an ageist assumption of frailty, incompetence, and dependence.”

Its elements include inappropriate endearments. “Elderspeak can be controlling, kind of bossy, so to soften that message there’s ‘honey,’ ‘dearie,’ ‘sweetie,’” said Kristine Williams, a nurse gerontologist at the University of Kansas School of Nursing and another co-author of the article.

“We have negative stereotypes of older adults, so we change the way we talk.”

Or caregivers may resort to plural pronouns: Are we ready to take our bath? There, the implication “is that the person’s not able to act as an individual,” Williams said. “Hopefully, I’m not taking the bath with you.”

Sometimes, elderspeakers employ a louder volume, shorter sentences, or simple words intoned slowly. Or they may adopt an exaggerated, singsong vocal quality more suited to preschoolers, along with words like “potty” or “jammies.”

With what are known as tag questions — It’s time for you to eat lunch now, right? — “You’re asking them a question but you’re not letting them respond,” Williams explained. “You’re telling them how to respond.”

Studies in nursing homes show how commonplace such speech is. When Williams, Shaw, and their team analyzed video recordings of 80 interactions between staff and residents with dementia, they found that 84% involved some form of elderspeak.

“Most of elderspeak is well intended. People are trying to show they care,” Williams said. “They don’t realize the negative messages that come through.”

For example, among nursing home residents with dementia, studies have found a relationship between exposure to elderspeak and behaviors collectively known as resistance to care.

“People can turn away or cry or say no,” Williams explained. “They may clench their mouths shut when you’re trying to feed them.” Sometimes, they push caregivers away or strike them.

She and her team developed a training program called CHAT, for Changing Talk: three hourlong sessions that include videos of communication between staff members and patients, intended to reduce elderspeak.

It worked. Before the training, in 13 nursing homes in Kansas and Missouri, almost 35% of the time spent in interactions consisted of elderspeak; that share dropped to about 20% afterward.

Furthermore, resistant behaviors accounted for almost 36% of the time spent in encounters; after training, that proportion fell to about 20%.

A study conducted in a Midwestern hospital, again among patients with dementia, found the same sort of decline in resistance behavior.

What’s more, CHAT training in nursing homes was associated with lower use of antipsychotic drugs. Though the results did not reach statistical significance, due in part to the small sample size, the research team deemed them “clinically significant.”

“Many of these medications have a black box warning from the FDA,” Williams said of the drugs. “It’s risky to use them in frail, older adults” because of their side effects.

Now, Williams, Shaw, and their colleagues have streamlined the CHAT training and adapted it for online use. They are examining its effects in about 200 nursing homes nationwide.

Even without formal training programs, individuals and institutions can combat elderspeak. Kathleen Carmody, owner of Senior Matters Home Health Care and Consulting in Columbus, Ohio, cautions her aides to address clients as Mr. or Mrs. or Ms., “unless or until they say, ‘Please call me Betty.’”

In long-term care, however, families and residents may worry that correcting the way staff members speak could create antagonism.

A few years ago, Carol Fahy was fuming about the way aides at an assisted living facility in suburban Cleveland treated her mother, who was blind and had become increasingly dependent in her 80s.

Calling her “sweetie” and “honey babe,” the staff “would hover and coo, and they put her hair up in two pigtails on top of her head, like you would with a toddler,” said Fahy, a psychologist in Kaneohe, Hawaii.

Although she recognized the aides’ agreeable intentions, “there’s a falseness about it,” she said. “It doesn’t make someone feel good. It’s actually alienating.”

Fahy considered discussing her objections with the aides, but “I didn’t want them to retaliate.” Eventually, for several reasons, she moved her mother to another facility.

Yet objecting to elderspeak need not become adversarial, Shaw said. Residents and patients — and people who encounter elderspeak elsewhere, because it’s hardly limited to health care settings — can politely explain how they prefer to be spoken to and what they want to be called.

Cultural differences also come into play. Felipe Agudelo, who teaches health communications at Boston University, pointed out that in certain contexts a diminutive or term of endearment “doesn’t come from underestimating your intellectual ability. It’s a term of affection.”

He emigrated from Colombia, where his 80-year-old mother takes no offense when a doctor or health care worker asks her to “tómese la pastillita” (take this little pill) or “mueva la manito” (move the little hand).

That’s customary, and “she feels she’s talking to someone who cares,” Agudelo said.

“Come to a place of negotiation,” he advised. “It doesn’t have to be challenging. The patient has the right to say, ‘I don’t like your talking to me that way.’”

In return, the worker “should acknowledge that the recipient may not come from the same cultural background,” he said. That person can respond, “This is the way I usually talk, but I can change it.”

Lisa Greim, 65, a retired writer in Arvada, Colorado, pushed back against elderspeak recently when she enrolled in Medicare drug coverage.

Suddenly, she recounted in an email, a mail-order pharmacy began calling almost daily because she hadn’t filled a prescription as expected.

These “gently condescending” callers, apparently reading from a script, all said, “It’s hard to remember to take our meds, isn’t it?” — as if they were swallowing pills together with Greim.

Annoyed by their presumption, and their follow-up question about how frequently she forgot her medications, Greim informed them that having stocked up earlier, she had a sufficient supply, thanks. She would reorder when she needed more.

Then, “I asked them to stop calling,” she said. “And they did.”

The New Old Age is produced through a partnership with The New York Times.

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.

USE OUR CONTENT

This story can be republished for free (details).

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

After narrowly passing a budget resolution this spring foreshadowing major Medicaid cuts, Republicans in Congress are having trouble agreeing on specific ways to save billions of dollars from a pool of funding that pays for the program without cutting benefits on which millions of Americans rely. Moderates resist changes they say would harm their constituents, while fiscal conservatives say they won’t vote for smaller cuts than those called for in the budget resolution. The fate of President Donald Trump’s “one big, beautiful bill” containing renewed tax cuts and boosted immigration enforcement could hang on a Medicaid deal.

Meanwhile, the Trump administration surprised those on both sides of the abortion debate by agreeing with the Biden administration that a Texas case challenging the FDA’s approval of the abortion pill mifepristone should be dropped. It’s clear the administration’s request is purely technical, though, and has no bearing on whether officials plan to protect the abortion pill’s availability.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sandhya Raman of CQ Roll Call.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Maya Goldman Axios @mayagoldman_ @maya-goldman.bsky.social Read Maya's stories Sandhya Raman CQ Roll Call @SandhyaWrites @SandhyaWrites.bsky.social Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Congressional Republicans are making halting progress on negotiations over government spending cuts. As hard-line House conservatives push for deeper cuts to the Medicaid program, their GOP colleagues representing districts that heavily depend on Medicaid coverage are pushing back. House Republican leaders are eying a Memorial Day deadline, and key committees are scheduled to review the legislation next week — but first, Republicans need to agree on what that legislation says.
• Trump withdrew his nomination of Janette Nesheiwat for U.S. surgeon general amid accusations she misrepresented her academic credentials and criticism from the far right. In her place, he nominated Casey Means, a physician who is an ally of HHS Secretary Robert F. Kennedy Jr.’s and a prominent advocate of the “Make America Healthy Again” movement.
• The pharmaceutical industry is on alert as Trump prepares to sign an executive order directing agencies to look into “most-favored-nation” pricing, a policy that would set U.S. drug prices to the lowest level paid by similar countries. The president explored that policy during his first administration, and the drug industry sued to stop it. Drugmakers are already on edge over Trump’s plan to impose tariffs on drugs and their ingredients.
• And Kennedy is scheduled to appear before the Senate’s Health, Education, Labor and Pensions Committee next week. The hearing would be the first time the secretary of Health and Human Services has appeared before the HELP Committee since his confirmation hearings — and all eyes are on the committee’s GOP chairman, Sen. Bill Cassidy of Louisiana, a physician who expressed deep concerns at the time, including about Kennedy’s stances on vaccines.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who co-reported and co-wrote the latest KFF Health News’ “Bill of the Month” installment, about an unexpected bill for what seemed like preventive care. If you have an outrageous, baffling, or infuriating medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: NPR’s “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured,” by Andrea Hsu. 

Maya Goldman: Stat’s “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. 

Anna Edney: Bloomberg News’ “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare,” by Zachary R. Mider and Zeke Faux. 

Sandhya Raman: The Louisiana Illuminator’s “In the Deep South, Health Care Fights Echo Civil Rights Battles,” by Anna Claire Vollers. 

Also mentioned in this week’s podcast:

• ProPublica’s series “Life of the Mother: How Abortion Bans Lead to Preventable Deaths,” by Kavitha Surana, Lizzie Presser, Cassandra Jaramillo, and Stacy Kranitz, and the winner of the 2025 Pulitzer Prize for public service journalism.
• The New York Times’ “G.O.P. Targets a Medicaid Loophole Used by 49 States To Grab Federal Money,” by Margot Sanger-Katz and Sarah Kliff.
• KFF Health News’ “Seeking Spending Cuts, GOP Lawmakers Target a Tax Hospitals Love to Pay,” by Phil Galewitz.
• Axios’ “Out-of-Pocket Drug Spending Hit $98B in 2024: Report,” by Maya Goldman.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

PHOENIX — As an Arizona bill to block people from using government aid to buy soda headed to the governor’s desk in April, the nation’s top health official joined Arizona lawmakers in the state Capitol to celebrate its passage.

Health and Human Services Secretary Robert F. Kennedy Jr. said to applause that the legislation was just the start and that he wanted to prevent federal funding from paying for other unhealthy foods.

“We’re not going to do that overnight,” Kennedy said. “We’re going to do that in the next four years.”

Those words of caution proved prescient when Arizona’s Democratic governor, Katie Hobbs, vetoed the bill a week later. Nevertheless, state legislation to restrict what low-income people can buy using Supplemental Nutrition Assistance Program benefits is gaining momentum, boosted by Kennedy’s touting it as part of his “Make America Healthy Again” platform. At least 14 states have considered bills this year with similar SNAP restrictions on specific unhealthy foods such as candy, with Idaho and Utah passing such legislation as of mid-April.

Healthy food itself isn’t largely a partisan issue, and those who study nutrition tend to agree that reducing the amount of sugary food people eat is a good idea to avoid health consequences such as heart disease. But the question over the government’s role in deciding who can buy what has become political.

The organization largely behind SNAP restriction legislation is the Foundation for Government Accountability, a conservative policy think tank out of Florida, and its affiliated lobbying arm, which has used the name Opportunity Solutions Project.

FGA has worked for more than a decade to reshape the nation’s public assistance programs. That includes SNAP, which federal data shows helps an average of 42 million people afford food each month. It also advocates for ways to cut Medicaid, the federal-state program that connects 71 million people to subsidized health care, including efforts in Idaho and Montana this year.

FGA’s proposals often seek to limit who taps into that aid and the help they receive. Those backing the group’s mission say the goal is to save tax dollars and help people lift themselves out of poverty. Critics argue that FGA’s proposals are a backdoor way to cut off aid to people who need it and that making healthy food and health care more affordable is a better fix.

Now, FGA sees more room for change under the Trump administration and the Kennedy-led health department, calling 2025 a “window of opportunity for major reform,” according to its latest annual report.

A Vision for Limiting Government Benefits

Tarren Bragdon, a former Maine legislator, founded FGA in 2011 to promote policies to “free millions from government dependency and open the doors for them to chase their own American Dream,” he said in a statement on FGA’s website. The main foundation started out as a staff of three with about $60,000 in the bank. As of 2023, it had a budget of more than $15 million and a team of roughly 64, according to the latest available tax documents, and that’s not counting the lobbying arm.

The foundation got early funding from a grant from the State Policy Network, which has long backed right-leaning think tanks with ties to conservative activists including brothers Charles and David Koch.

FGA declined several interview requests for this article.

In recent years, the nonprofit helped draft a 2017 Mississippi law, the Jackson Free Press found, which intensified eligibility checks for public aid that made it more difficult for some applicants to qualify. It successfully pushed a 2023 effort in Idaho to impose work requirements for food benefits that health care advocates said led some recipients to lose access.

The same year, the group helped pass SNAP restrictions affecting eligibility in Iowa. Since those restrictions have taken effect, the Food Bank of Iowa has seen a record number of people show up at its pantries amid rising grocery prices and a scaling back of covid pandemic-era federal support, said Annette Hacker, a vice president at the nonprofit.

Part of the group’s strategy is to pass legislation state by state, with the idea that the crush of new laws will increase pressure on the federal government. For example, states can’t limit what food is purchased through SNAP without federal approval through a waiver process. And in the past, some of FGA’s efforts have stalled because states never got that approval.

Kennedy’s agenda now echoes some of FGA’s key messages, and he has said states can expect approval of their waivers. Meanwhile, congressional leaders are eyeing nationwide Medicaid cuts and work requirements, which FGA considers among its major issues. The foundation also has a connection working inside the administration: Its former policy director, Sam Adolphsen, was tapped to advise President Donald Trump on domestic matters.

“We’re excited to fight from Topeka to Washington, D.C., as opposed to Washington, D.C., to Topeka,” Roy Lenardson, FGA’s state government affairs director, told Kansas lawmakers in February when testifying in support of SNAP legislation there.

Shaping State Policies

In the states, FGA has become known as a conservative “thought leader,” said Brian Colby, vice president of public policy for Missouri Budget Project, a progressive nonprofit that provides analysis of state policy issues.

“Conservatives used to try to chop away at the federal budget,” Colby said. “These guys are doing it at the state level.”

In its 14 years, FGA has created a playbook to shape state policy discussions around public benefits behind the scenes. In Montana, retired Republican legislator Cary Smith, who worked with FGA, said not all of the think tank’s ideas split along party lines.

“They offer a buffet of options,” he said. “Their agenda is making government accountable; it’s in the name.”

He said besides drafting legislation, FGA provides talking points and data to help policymakers support their arguments. “They would go in and would say, ‘This is what Medicaid fraud is costing us,’” Smith said. “That would be the number you’d want to use in your bill.”

In January, FGA released a memo for states to “stop taxpayer-funded junk food.” In February, Stateline reported that Wyoming Republican state Rep. Jacob Wasserburger said the group asked him to sponsor a SNAP restriction bill. The state sponsor of similar legislation in Missouri has repeated at least one of FGA’s talking points, as reported by the Missouri Independent. In Arizona, Republican Rep. Leo Biasiucci, who sponsored the SNAP legislation there, told KFF Health News FGA was behind that bill as well.

Opponents of such bills argue the proposals are not as simple as they sound. Amid debate on a SNAP bill in Montana, Kiera Condon, with the Montana Food Bank Network, testified the legislation would force grocery store workers to sort through what counts as soda or candy, “which could result in retailers not participating in SNAP at all.”

State lawmakers tabled the Montana bill in April.

Montana legislators also easily passed a bill to extend the state’s Medicaid expansion program even after FGA began publishing a series of papers that asserted the program was “breaking” Montana’s budget. FGA had presented data saying most Montanans on the program don’t work, which state data refutes.

Ed Bolen, who leads food aid strategies at the left-leaning Center on Budget and Policy Priorities think tank, said FGA has a pattern of proposing technical changes to existing laws and “unworkable work requirements” that cause people to lose benefits.

After working with policymakers in Kansas for a decade, FGA helped pass legislation that limited how long people can access cash assistance, added work requirements to SNAP, and banned the state from spending federal or state funds to promote public aid. Many of those changes came through 2015 legislation known as the “HOPE Act” drafted by FGA, The Washington Post reported.

Analysis from Kansas Appleseed, an advocacy organization for low-income Kansans, found the SNAP caseload sharply declined after the bill was enacted because of the new hurdles, dropping from 140,000 households in January 2014 to 90,000 as of January 2020.

“It’s death by a thousand cuts,” said Karen Siebert, an adviser for Harvesters, a community food bank network in Kansas and Missouri. “Some of these FGA proposals are such complex policies, it’s hard to argue against and to explain the ripple effects.”

In 2024, the foundation produced more than two dozen videos featuring state politicians from across the nation touting the organization’s goals and dozens of research papers arguing public benefits are wrecking state budgets. FGA also has its own polling team to produce data out of the states it’s working to influence.

The organization released a list of 14 states it labeled as “redder and better” places to exert more influence. That included Idaho, where the group has four registered lobbyists in the state Capitol.

In 2023, FGA helped present and successfully lobby for legislation there to require people receiving food aid to work at least 80 hours a month. The organization called the resulting law “landmark welfare reform” years in the making.

And this year, Idaho lawmakers passed more requirements for people enrolled in Medicaid who can work. FGA staffers worked with one of the co-sponsors of the legislation on a similar bill last year that failed, then again this year. A compromise bill passed with FGA’s backing, marking another victory for the foundation.

David Lehman, a lobbyist for the Idaho Association of Community Providers, which represents health organizations that have opposed FGA bills, said Idaho illustrates how FGA works with sympathetic lawmakers in conservative states to gain more ground.

“They’re pushing an already rolling rock downhill,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

When the news broke on Jan. 31 that a New York physician had been indicted for shipping abortion medications to a woman in Louisiana, it stoked fear across the network of doctors and medical clinics who engage in similar work.

“It’s scary. It’s frustrating,” said Angel Foster, co-founder of the Massachusetts Medication Abortion Access Project, a clinic near Boston that mails mifepristone and misoprostol pills to patients in states with abortion bans. But, Foster added, “it’s not entirely surprising.”

Ever since the Supreme Court overturned Roe v. Wade in 2022, abortion providers like her had been expecting prosecution or another kind of legal challenge from states with abortion bans, she said.

“It was unclear when those tests would come, and would it be against an individual provider or a practice or organization?” she said. “Would it be a criminal indictment, or would it be a civil lawsuit,” or even an attack on licensure? she wondered. “All of that was kind of unknown, and we’re starting to see some of this play out.”

The indictment also sparked worry among abortion providers like Kohar Der Simonian, medical director for Maine Family Planning. The clinic doesn’t mail pills into states with bans, but it does treat patients who travel from those states to Maine for abortion care.

“It just hit home that this is real, like this could happen to anybody, at any time now, which is scary,” Der Simonian said.

Der Simonian and Foster both know the indicted doctor, Margaret Carpenter.

“I feel for her. I very much support her,” Foster said. “I feel very sad for her that she has to go through all of this.”

On Jan. 31, Carpenter became the first U.S. doctor criminally charged for providing abortion pills across state lines — a medical practice that grew after the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision on June 24, 2022, which overturned Roe.

Since Dobbs, 12 states have enacted near-total abortion bans, and an additional 10 have outlawed the procedure after a certain point in pregnancy, but before a fetus is viable.

Carpenter was indicted alongside a Louisiana mother who allegedly received the mailed package and gave the pills prescribed by Carpenter to her minor daughter.

The teen wanted to keep the pregnancy and called 911 after taking the pills, according to an NPR and KFF Health News interview with Tony Clayton, the Louisiana local district attorney prosecuting the case. When police responded, they learned about the medication, which carried the prescribing doctor’s name, Clayton said.

On Feb. 11, Louisiana’s Republican governor, Jeff Landry, signed an extradition warrant for Carpenter. He later posted a video arguing she “must face extradition to Louisiana, where she can stand trial and justice will be served.”

New York’s Democratic governor, Kathy Hochul, countered by releasing her own video, confirming she was refusing to extradite Carpenter. The charges carry a possible five-year prison sentence.

“Louisiana has changed their laws, but that has no bearing on the laws here in the state of New York,” Hochul said.

Eight states — New York, Maine, California, Colorado, Massachusetts, Rhode Island, Vermont, and Washington — have passed laws since 2022 to protect doctors who mail abortion pills out of state, and thereby block or “shield” them from extradition in such cases. But this is the first criminal test of these relatively new “shield laws.”

The telemedicine practice of consulting with remote patients and prescribing them medication abortion via the mail has grown in recent years — and is now playing a critical role in keeping abortion somewhat accessible in states with strict abortion laws, according to research from the Society of Family Planning, a group that supports abortion access.

Doctors who prescribe abortion pills across state lines describe facing a new reality in which the criminal risk is no longer hypothetical. The doctors say that if they stop, tens of thousands of patients would no longer be able to end early pregnancies safely at home, under the care of a U.S. physician. But the doctors could end up in the crosshairs of a legal clash over the interstate practice of medicine when two states disagree on whether people have a right to end a pregnancy.

Doctors on Alert but Remain Defiant

Maine Family Planning, a network of clinics across 19 locations, offers abortions, birth control, gender-affirming care, and other services. One patient recently drove over 17 hours from South Carolina, a state with a six-week abortion ban, Der Simonian said.

For Der Simonian, that case illustrates how desperate some of the practice’s patients are for abortion access. It’s why she supported Maine’s 2024 shield law, she said.

Maine Family Planning has discussed whether to start mailing abortion medication to patients in states with bans, but it has decided against it for now, according to Kat Mavengere, a clinic spokesperson.

Reflecting on Carpenter’s indictment, Der Simonian said it underscored the stakes for herself — and her clinic — of providing any abortion care to out-of-state patients. Shield laws were written to protect against the possibility that a state with an abortion ban charges and tries to extradite a doctor who performed a legal, in-person procedure on someone who had traveled there from another state, according to a review of shield laws by the Center on Reproductive Health, Law, and Policy at the UCLA School of Law.

“It is a fearful time to do this line of work in the United States right now,” Der Simonian said. “There will be a next case.” And even though Maine’s shield law protects abortion providers, she said, “you just don’t know what’s going to happen.”

Data shows that in states with total or six-week abortion bans, an average of 7,700 people a month were prescribed and took mifepristone and misoprostol to end their pregnancies by out-of-state doctors practicing in states with shield laws. The data, covering the second quarter of 2024, is part of a #WeCount report estimating the volume and types of abortions in the U.S., conducted by the Society of Family Planning.

Among Louisiana residents, nearly 60% of abortions took place via telemedicine in the second half of 2023 (the most recent period for which estimates are available), giving Louisiana the highest rate of telemedicine abortions among states that passed strict bans after Dobbs, according to the #WeCount survey.

Organizations like the Massachusetts Medication Abortion Access Project, known as the MAP, are responding to the demand for remote care. The MAP was launched after the Dobbs ruling, with the mission of writing prescriptions for patients in other states.

During 2024, the MAP says, it was mailing abortion medications to about 500 patients a month. In the new year, the monthly average has grown to 3,000 prescriptions a month, said Foster, the group’s co-founder.

The majority of the MAP’s patients — 80% — live in Texas or states in the Southeast, a region blanketed with near-total abortion restrictions, Foster said.

But the recent indictment from Louisiana will not change the MAP’s plans, Foster said. The MAP currently has four staff doctors and is hiring one more.

“I think there will be some providers who will step out of the space, and some new providers will step in. But it has not changed our practice,” Foster said. “It has not changed our intention to continue to practice.”

The MAP’s organizational structure was designed to spread potential liability, Foster said.

“The person who orders the pills is different than the person who prescribes the pills, is different from the person who ships the pills, is different from the person who does the payments,” she explained.

In 22 states and Washington, D.C., Democratic leaders helped establish shield laws or similarly protective executive orders, according to the UCLA School of Law review of shield laws.

The review found that in eight states, the shield law applies to in-person and telemedicine abortions. In the other 14 states plus Washington, D.C., the protections do not explicitly extend to abortion via telemedicine.

Most of the shield laws also apply to civil lawsuits against doctors. Over a month before Louisiana indicted Carpenter, Texas Attorney General Ken Paxton filed a civil suit against her. A Texas judge ruled against Carpenter on Feb. 13, imposing penalties of more than $100,000.

By definition, state shield laws cannot protect doctors when they leave the state. If they move or even travel elsewhere, they lose the first state’s protection and risk arrest in the destination state, and maybe extradition to a third state.

Physicians doing this type of work accept there are parts of the U.S. where they should no longer go, said Julie F. Kay, a human rights lawyer who helps doctors set up telemedicine practices.

“There’s really a commitment not to visit those banned and restricted states,” said Kay, who worked with Carpenter to help start the Abortion Coalition for Telemedicine.

“We didn’t have anybody going to the Super Bowl or Mardi Gras or anything like that,” Kay said of the doctors who practice abortion telemedicine across state lines.

She said she has talked to other interested doctors who decided against doing it “because they have an elderly parent in Florida, or a college student somewhere, or family in the South.” Any visits, even for a relative’s illness or death, would be too risky.

“I don’t use the word ‘hero’ lightly or toss it around, but it’s a pretty heroic level of providing care,” Kay said.

Governors Clash Over Doctor’s Fate

Carpenter’s case remains unresolved. New York’s rebuff of Louisiana’s extradition request shows the state’s shield law is working as designed, according to David Cohen and Rachel Rebouché, law professors with expertise in abortion laws.

Louisiana officials, for their part, have pushed back in social media posts and media interviews.

“It is not any different than if she had sent fentanyl here. It’s really not,” Louisiana Attorney General Liz Murrill told Fox 8 News in New Orleans. “She sent drugs that are illegal to send into our state.”

Louisiana’s next step would be challenging New York in federal courts, according to legal experts across the political spectrum.

NPR and KFF Health News asked Clayton, the Louisiana prosecutor who charged Carpenter, whether Louisiana has plans to do that. Clayton declined to answer.

Case Highlights Fraught New Legal Frontier

A major problem with the new shield laws is that they challenge the basic fabric of U.S. law, which relies on reciprocity between states, including in criminal cases, said Thomas Jipping, a senior legal fellow with the Heritage Foundation, which supports a national abortion ban.

“This actually tries to undermine another state’s ability to enforce its own laws, and that’s a very grave challenge to this tradition in our country,” Jipping said. “It’s unclear what legal issues, or potentially constitutional issues, it may raise.”

But other legal scholars disagree with Jipping’s interpretation. The U.S. Constitution requires extradition only for those who commit crimes in one state and then flee to another state, said Cohen, a law professor at Drexel University’s Thomas R. Kline School of Law.

Telemedicine abortion providers aren’t located in states with abortion bans and have not fled from those states — therefore they aren’t required to be extradited back to those states, Cohen said. If Louisiana tries to take its case to federal court, he said, “they’re going to lose because the Constitution is clear on this.”

“The shield laws certainly do undermine the notion of interstate cooperation, and comity, and respect for the policy choices of each state,” Cohen said, “but that has long been a part of American law and history.”

When states make different policy choices, sometimes they’re willing to give up those policy choices to cooperate with another state, and sometimes they’re not, he said.

The conflicting legal theories will be put to the test if this case goes to federal court, other legal scholars said.

“It probably puts New York and Louisiana in real conflict, potentially a conflict that the Supreme Court is going to have to decide,” said Rebouché, dean of the Temple University Beasley School of Law.

Rebouché, Cohen, and law professor Greer Donley worked together to draft a proposal for how state shield laws might work. Connecticut passed the first law — though it did not include protections specifically for telemedicine. It was signed by the state’s governor in May 2022, over a month before the Supreme Court overturned Roe, in anticipation of potential future clashes between states over abortion rights.

In some shield-law states, there’s a call to add more protections in response to Carpenter’s indictment.

New York state officials have. On Feb. 3, Hochul signed a law that allows physicians to name their clinic as the prescriber — instead of using their own names — on abortion medications they mail out of state. The intent is to make it more difficult to indict individual doctors. Der Simonian is pushing for a similar law in Maine.

Samantha Glass, a family medicine physician in New York, has written such prescriptions in a previous job, and plans to find a clinic where she could offer that again. Once a month, she travels to a clinic in Kansas to perform in-person abortions.

Carpenter’s indictment could cause some doctors to stop sending pills to states with bans, Glass said. But she believes abortion should be as accessible as any other health care.

“Someone has to do it. So why wouldn’t it be me?” Glass said. “I just think access to this care is such a lifesaving thing for so many people that I just couldn’t turn my back on it.”

This article is from a partnership that includes WWNO, NPR, and KFF Health News.

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.

USE OUR CONTENT

This story can be republished for free (details).

Reproductive rights groups in Alabama wasted no time resuming their work after a federal judge ruled in early April that the state’s attorney general can’t prosecute — or threaten to prosecute — people or organizations who help Alabama residents seek an abortion by traveling to another state.

One of the plaintiffs, the reproductive justice nonprofit Yellowhammer Fund, wasted no time in returning to one of its core missions: to provide financial support to traveling patients.

“The decision came at about 5:30. I think we funded an abortion at 5:45 — because that’s how severe the need is, that’s how urgent it is that we get back to the work that we’re doing,” said Jenice Fountain, executive director of Yellowhammer Fund, which advocates for abortion access.

On April 2, the U.S. Supreme Court heard oral arguments on whether South Carolina can remove Planned Parenthood clinics from the state’s Medicaid program. This came just days after Planned Parenthood received notice that the Trump administration would withhold funding from the Title X Family Planning Program for nine of the group’s affiliates.

“We’re just seeing kind of a multiplying of conflicts where we have unanswered questions about the meaning of the First Amendment in this context, about the right to travel in this context, about due process in this context — about these sort of clashing state laws and choosing which one applies,” said Mary Ziegler, a law professor at the University of California-Davis who specializes in the politics and history of reproductive rights.

Alabama has one of the strictest bans on abortion in the country — with no exceptions for rape or incest. The law was  approved by the state legislature in 2019 and remained at the ready should Roe v. Wade be overturned. It took effect immediately when the Supreme Court did just that on June 24, 2022, in the Dobbs v. Jackson Women’s Health Organization decision.

At the time, Yellowhammer Fund was getting about 100 calls a week from people seeking financial help with getting an abortion, Fountain said.

For more than two years, the organization has been unable to help such callers.

“The thing with the ban was it was so vague that it was incredibly hard to interpret, especially if you weren’t a person that was legally inclined,” Fountain said. “So the effect that it had, which was its intention, was a chilling effect.”

During that time, Yellowhammer continued to promote reproductive justice and maternal and infant health through community efforts such as distributing diapers, formula, menstrual supplies, and emergency contraception.

Beyond the alarm created by the statutory language in Alabama’s abortion ban, fears were stoked by Alabama’s attorney general, Steve Marshall, Fountain said.

Almost seven weeks after the 2022 Dobbs decision, Marshall said in a radio interview that groups that assist people seeking an abortion in another state could face criminal prosecution.

“There’s no doubt that this is a criminal law and the general principles that apply to a criminal law would apply to this, with its status of the Class A felony, that’s the most significant offense that we have as far as punishment goes under our criminal statue, absent a death penalty case,” Marshall said in the interview with Breitbart TV editor Jeff Poor.

“If someone was promoting themselves out as a funder of abortion out of state, then that is potentially criminally actionable for us,” Marshall said.

Marshall was explicitly referring to such groups as Yellowhammer Fund, Fountain said.

“He mentioned the group from Tuscaloosa that helps people get to care, which is Yellowhammer Fund,” Fountain said. “He all but ‘@’d us.”

Yellowhammer Fund and other abortion rights groups filed the lawsuit against Marshall on July 31, 2023.

In his ruling, U.S. District Judge Myron Thompson of the Middle District of Alabama in Montgomery, agreed with them, saying Marshall would be violating both First Amendment free speech rights and the constitutional right to travel if he tried to bring criminal charges.

Thompson also warned against overlooking the “broader, practical implications of the Attorney General’s threats,” in the matter of Alabama trying to enforce laws outside the state.

“For example,” Thompson wrote in his ruling, “the Alabama Attorney General would have within his reach the authority to prosecute Alabamians planning a Las Vegas bachelor party, complete with casinos and gambling, since casino-style gambling is outlawed in Alabama.”

Another group involved in the case, WAWC Healthcare in Tuscaloosa (formerly West Alabama Women’s Center), also resumed work that had been paused.

“We have spent the last few years worried that if we had provided any form of information to patients about where they could access a legal abortion, that that is something that the attorney general might try to prosecute us over,” said Robin Marty, WAWC’s executive director.

Before the Dobbs decision, WAWCprovided abortion as part of its services. It continues to offer free reproductive health care, including prenatal care, contraception, and HIV testing.

Clinical staffers at WAWC weren’t allowed even to suggest to someone that they could leave the state to get an abortion, Marty said.

“There is nothing harder than looking into somebody’s face when they are in crisis and saying, ‘I’m sorry, I just can’t help you anymore,’” Marty said. “That was really wearing on my staff because our job was to provide the best information possible. And to know that we could not give them the full care that they required was heartbreaking.”

With the ruling, WAWC can now offer “all-options counseling,” which includes information on how and where patients can access abortion services in other states, Marty said.

“If they do not feel like they are able to continue the pregnancy, we can tell them, ‘OK, you are this far along, so you are able to go this clinic in North Carolina, because you’re under their limit” for gestational age, “or you can go to this clinic in Illinois because you’re under their limit,’” Marty said. “We’ll be able to tell them exactly where they can go and even be able to help them with the referral process along the way.”

The attorney general could file an appeal, but now it’s unclear whether his office will do so. Marshall’s office did not respond to NPR’s request for an interview, but in a statement said, “The office is reviewing the decision to determine the state’s options.”

But legal expert Ziegler said she’d be surprised if Marshall didn’t file an appeal, given his office’s vigorous defense in the lawsuit.

In addition, the potential political costs of pursuing that kind of prosecution may have eased, because states like Texas and Louisiana have already taken legal action regarding out-of-state abortion providers, said Ziegler.

On the other hand, the attorney general might not appeal because his office was the defendant in the lawsuit, and he may not want to draw attention to the case, Ziegler said.

If Marshall did file an appeal, it would go to the U.S. Court of Appeals for the 11th Circuit, which Ziegler called conservative-leaning. The case could ultimately go to the U.S. Supreme Court, Ziegler said, which may have to weigh in more on abortion-related cases, such as when it temporarily allowed emergency abortions in Idaho in June 2024.

“I think the takeaway is that the U.S. Supreme Court is going to be more involved than ever in fights about reproduction and abortion, not less, notwithstanding the fact that Roe is gone,” Ziegler said.

This article is from a partnership that includes Gulf States Newsroom, NPR and KFF Health News.

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.

USE OUR CONTENT

This story can be republished for free (details).

Republicans have long pushed to force working-age adults enrolled in Medicaid to show they are, in fact, working. 

Party members argue Medicaid, a taxpayer-funded program for people with low incomes and disabilities, shouldn’t cover Americans who aren’t actively trying to improve their financial situations. And Republicans are closer than ever to achieving a national work requirement, after winning the White House and both chambers of Congress, and unlocking a fast-track process to secure big spending cuts. 

A national Medicaid work requirement would slash spending by reducing the number of people covered. About 5 million adults could lose Medicaid coverage in 2026 if Congress imposes one. 

But here’s the thing: Most adults with Medicaid who can work are already working, or have some reason they can’t (such as they’re full-time caregivers). And the experiences of two states that have implemented work requirements reveal the hidden costs of adding those layers of bureaucracy.  

The nonpartisan U.S. Government Accountability Office confirmed last week that, at the request of three Democratic senators, it’ll examine the costs of running a work requirement program that Georgia spent millions of dollars to establish. 

The GAO investigation comes at a critical time, said Leo Cuello, a research professor at Georgetown University’s Center for Children and Families. 

“Congress seems to be pursuing cuts in Medicaid in a frenetic and rushed manner,” he said. The GAO report could outline for Congress the full extent of problems with work requirements “before they rush forward and do this without thinking.” 

The GAO previously found that work requirement programs can be extremely expensive for states to run — hundreds of millions of dollars, in some cases — and that federal officials failed to consider those costs when approving the programs, which are not allowed to increase Medicaid spending. 

States must introduce new technology and have enough staffers to verify whether enrollees meet complex eligibility requirements and to monitor their continued compliance. 

When Arkansas tried its work requirement program, which applied to those covered by Medicaid expansion, 18,000 people lost coverage in less than a year before a federal judge stopped it. 

So, yeah, a work requirement would cut federal spending, but potentially also anger voters. 

New polling released Thursday by KFF, a nonprofit health policy organization that includes KFF Health News, shows a majority of Americans — regardless of party — oppose funding cuts to Medicaid. 

Moderate Republicans are showing trepidation about changes to the program: House Republican Don Bacon, a key centrist from Nebraska, said this week he wouldn’t support more than half a trillion dollars in cuts to Medicaid over a decade. The House-passed version of a congressional budget resolution called for as much as $880 billion. 

While Donald Trump has emphasized his goal of rooting out waste in federal programs, he’s also asking Congress to extend his 2017 tax cuts and spend more on border security. 

That the opinion of one House member from Nebraska could draw so much attention this week underlines the hard math House Speaker Mike Johnson faces in passing those pricey priorities; he can’t lose more than a handful of GOP votes to get it done.

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.

USE OUR CONTENT

This story can be republished for free (details).

HELENA, Mont. — Montana’s frayed behavioral health care system, still recovering from the effects of past budget cuts, will get a shot in the arm after state lawmakers approved sweeping changes to upgrade and expand facilities, increase community services, and revise commitment procedures.

Lawmakers backed the bulk of Republican Gov. Greg Gianforte’s multimillion-dollar vision to bolster and expand the system, which has experienced waitlists for care and has been working in recent years to reverse the loss of community-based mental health services and regain federal certification of the state psychiatric hospital, lost in 2022 after a spate of patient deaths. Legislators then went several steps further to fill what they saw as gaps in the governor’s proposals.

They agreed to build a new mental health facility in eastern Montana, add more beds at existing state facilities, fund more crisis beds in communities, revise some civil and criminal commitment procedures, and reimburse counties when criminal defendants ordered to state facilities are held in county jails.

“For our families that struggle in these systems, it gives us so much hope,” said Matt Kuntz, executive director of the National Alliance on Mental Illness’ Montana chapter, about the legislative action.

The state’s behavioral health system faced an array of problems going into the 2025 legislative session. They included shortages in community services, particularly in rural areas, created by deep cuts made in 2017 in response to a state budget shortfall, along with a backlog of criminal defendants waiting for evaluations and services at the state-run psychiatric hospital.

The prospects of the situation improving seemed dim for a long time, Kuntz said. “Then you have the governor’s office, the legislature, the counties, the county attorneys all working together to bring tangible solutions. And they got the votes,” he said.

That support built over time as the state spent money on improvements needed to regain the Montana State Hospital’s federal certification and counties came under increasing pressure due to a lack of services and treatment beds. The legislature and governor committed to review the system in 2023.

In all, lawmakers approved about $124 million in state spending and up to $40 million in federal funds over the next two years for behavioral health services, a new state-owned facility, and additional beds in existing facilities.

“The people that need our support, the people that can’t take care of themselves, the families that are struggling with their family member that can’t take care of themselves at some points in time are going to benefit from what we did,” Republican state Sen. John Esp said in summing up the legislature’s work.

The spending approved by the legislature goes well beyond the money Gianforte requested for behavioral health changes. He included 10 funding requests in his proposed state budget for the next two years that totaled about $43.5 million in state funds and $42 million in federal funds. The requests were based on recommendations from the Behavioral Health System for Future Generations Commission.

Lawmakers created that commission in 2023 to review state-funded services for people with mental illness, substance use disorders, and developmental disabilities. Legislators that year set aside $300 million to be spent in future years on recommendations made by the commission.

Even before the start of the session, some legislators questioned whether the governor’s budget did enough to address the lack of both community-based crisis services and forensic beds at the Montana State Hospital, which are for people in the criminal justice system.

Two bills introduced in January — House Bill 236 and HB 237 — sought to address lengthy jail holds experienced by some people waiting for mental health evaluations or treatment before their trials can proceed. Defendants generally obtain those services at the Montana State Hospital’s forensic unit.

Both bills failed. But testimony on the measures, as well as on the governor’s budget requests, drew attention to the backlog of people waiting in jails across the state. Legislators heard of prolonged delays — some stretching more than a year — that sometimes led to cases being dismissed because of concerns that the delays had violated the defendants’ constitutional right to a speedy trial.

By April, the legislature was considering possible fixes on several fronts. Some resulted from long hours of discussion among the parties involved.

During an April 15 hearing on Senate Bill 429 to revise criminal commitment procedures, Chad Parker, a state health department attorney, described the measure as “a very robustly negotiated bill.” Nanette Gilbertson, representing the Montana County Attorneys’ Association and the Montana Sheriffs and Peace Officers Association, said it contained elements “that I know were tough pills to swallow for both the associations I work for and the department.”

The bill would allow involuntary medication of defendants in county jails under certain circumstances — an idea state officials initially opposed — and prohibit the filing of a contempt charge if someone isn’t admitted to the Montana State Hospital for treatment because a bed isn’t available, which was important to the state to include.

Gilbertson told the House Judiciary Committee the bill was just one of several that, “taken in a package, are going to create immense change in the mental health and behavioral health system in the state of Montana.”

They include bills to reimburse counties for the costs of holding people waiting for state mental health services, allow short-term mental health holds in the community, improve delivery and payment for community services, and create more beds in state facilities for people committed through both criminal and civil procedures.

Legislators also approved money for a new mental health facility, expected to be built in eastern Montana, that will include more forensic beds.

Gianforte spokesperson Kaitlin Price said Gianforte would carefully consider the bills passed in addition to his proposals.

The governor’s original budget request focused primarily on community services. Legislators approved all but one, which would have created an electronic bed registry. The approved requests will revise reimbursement rates for developmental disability services, residential youth psychiatric treatment, and crisis and outpatient behavioral health services. They also will reopen clinics for early diagnosis of developmental disabilities in children, provide workforce incentives, and seek to improve delivery of services to people with developmental disabilities who have complex needs.

Esp, who served on the behavioral health commission and sponsored several of the bills, cautioned that the success of this year’s efforts will depend on whether future legislatures and governors spend the money needed to continue the new services.

“The problem we’ve always had around here is we look at things in two-year increments and towards the next election instead of looking at what’s the best policy for the state of Montana, long term,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

Food bank shortages caused by high demand and cuts to federal aid programs have some residents of a small community that straddles Idaho and Nevada growing their own food to get by.

For those living in Duck Valley, a reservation of about 1,000 people that is home to the Shoshone-Paiute Tribes, there’s just one grocery store where prices are too high for many to afford, said Brandy Bull Chief, local director of a federal food distribution program for tribes. The next-closest grocery stores are more than 100 miles away in Mountain Home, Idaho, and Elko, Nevada. And the local food bank’s troubles are mirrored by many nationwide, squeezed between growing need and shrinking aid.

Reggie Premo, a community outreach specialist at the University of Nevada-Reno Extension, grew up cattle ranching and farming alfalfa in Duck Valley. He runs workshops to teach residents to grow produce. Premo said he has seen increased interest from tribal leaders in the state worried about high costs while living in food deserts.

“We’re just trying to bring back how it used to be in the old days,” Premo said, “when families used to grow gardens.”

Food bank managers across the country say their supplies have been strained by rising demand since the covid pandemic-era emergency Supplemental Nutrition Assistance Program benefits ended two years ago and steepening food prices. Now, they say, demand is compounded by recent cuts in federal funding to food distribution programs that supply staple food items to pantries nationwide.

In March, the U.S. Department of Agriculture cut $500 million from the Emergency Food Assistance Program, which buys food from domestic producers and sends it to pantries nationwide. The program has supplied more than 20% of the distributions by Feeding America, a nonprofit that serves a network of over 200 food banks and 60,000 meal programs.

The collision between rising demand and falling support is especially problematic for rural communities, where the federal program might cover 50% or more of food supplied to those in need, said Vince Hall, chief government relations officer of Feeding America. Deepening the challenge for local food aid organizations is an additional $500 million the Trump administration slashed from the USDA Local Food Purchase Assistance Cooperative Agreement Program, which helped state, tribal, and territorial governments buy fresh food from nearby producers.

“The urgency of this crisis cannot be overstated,” Hall said, adding that the Emergency Food Assistance Program is “rural America’s hunger lifeline.”

Farmers who benefited from the USDA programs that distributed their products to food banks and schools will also be affected. Bill Green is executive director for the Southeast region of Common Market, a nonprofit that connects farmers with organizations in the Mid-Atlantic, the Southeast, Texas, and the Great Lakes. Green said his organization won’t be able to fill the gap left by the federal cuts, but he hopes some schools and other institutions will continue buying from those farmers even after the federal support dries up.

“I think that that food access challenge has only been aggravated, and I think we just found the tip of the iceberg on that,” he said.

Food Bank for the Heartland in Omaha, Nebraska, for example, is experiencing four times the demand this year than in 2018, according to Stephanie Sullivan, its assistant director of marketing and communications. The organization expects to provide food to 580,000 households across the 93 counties it serves in Nebraska and western Iowa this fiscal year, the highest number in its history, she said.

“These numbers should be a wake-up call for all of us,” Sullivan said.

The South Plains Food Bank in Texas projects it will distribute approximately 121,000 food boxes this year to people in need across the 19 counties it serves, compared with an average 90,000 annually before the pandemic. CEO Dina Jeffries said the organization now is serving about 25% more people, while shouldering the burden of decreased funding and food products.

In Nevada, the food bank that helps serve communities in the northern part of the state, including the Shoshone-Paiute Tribes of the Duck Valley Reservation, provides food to an average of 160,000 people per month. That’s a 76% increase over its clientele before the pandemic, and the need continues to rise, said Jocelyn Lantrip, director of marketing and communications for the Food Bank of Northern Nevada.

Lantrip said one of the most troubling things for the food bank is that the USDA commodities shipped for local distribution often are foods that donations don’t usually cover — things like eggs, dairy, and meat.

“That’s really valuable food to our neighbors,” she said. “Protein is very difficult to replace.”

Forty percent of people who sought assistance from food banks during the pandemic did so for the first time, Hall said. “Many of those families have come to see their neighborhood food bank not as a temporary resource for emergency help but an essential component of their monthly budget equation.”

About 47 million people lived in food-insecure households in 2023, the most recent USDA data available.

Bull Chief, who also runs a small food pantry on the Duck Valley Reservation, said workers drive to Elko to pick up food distributed by the Food Bank of Northern Nevada. But sometimes there’s not much to choose from. In March, the food pantry cut down its operation to just two weeks a month. She said sometimes they must weigh whether it’s worth spending money on gas to pick up a small amount of food.

When the food pantry opened in 2020, Bull Chief said, it helped 10 to 20 households a month. That number is 60 or more now, made up of a broad range of community members — teens fresh out of high school and living on their own, elders, and people who don’t have permanent housing or jobs. She said providing even small amounts of food can help households make ends meet between paychecks or SNAP benefit deposits.

“Whatever they need to get to survive for the month,” Bull Chief said.

Pinched food banks, elevated need, and federal cuts mean there’s very little resiliency in the system, Hall said. Additional challenges, like an economic slowdown, policy changes to SNAP or other federal nutrition programs, or natural disasters could render food banks unable to meet needs “because they are stretched to the breaking point right now.”

A proposed budget resolution passed by the U.S. House of Representatives in April would require $1.7 trillion in net funding cuts, and anti-hunger advocates fear SNAP could be a target. More people living in rural parts of the country rely on SNAP than people in urban areas because of higher poverty rates, so they would be disproportionately affected.

An extension of the federal 2018 Farm Bill, which lasts until Sept. 30, included about $450 million for the Emergency Food Assistance Program for this year. But the funding that remains doesn’t offset the cuts, Hall said. He hopes lawmakers pass a new farm bill this year with enough money to do so.

“We don’t have a food shortage,” he said. “We have a shortage of political will.”

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.

USE OUR CONTENT

This story can be republished for free (details).

The Trump administration quietly restored federal family planning money to Tennessee and Oklahoma, despite court rulings that the states weren’t entitled to funds because they refused to provide women information about terminating pregnancies or abortion referrals on request.

The decision by the Department of Health and Human Services to restore millions of dollars for the two states came as it simultaneously withheld nearly $66 million from clinics in the Title X program elsewhere. Title X for more than 50 years has provided sexual and reproductive health services especially to low-income, hard-to-reach people, including minors.

The Biden administration in 2023 cut off funding to Tennessee and Oklahoma, saying they violated federal rules by not offering counseling to patients about abortion. The states sued federal health officials. And courts ruled against the states.

On March 31, HHS restored $3.1 million in family planning funds for the Tennessee Department of Health and nearly $2 million for the Oklahoma State Department of Health, according to court filings. In the notices, HHS said family planning funds were sent to the two states “pursuant to a settlement agreement with the recipient.”

Yet “there has been no agreement with Tennessee to settle this litigation,” Department of Justice lawyers wrote in an April 23 court filing.

Zach West, an official with the Office of the Oklahoma Attorney General, separately wrote on April 17 that the state’s grant notice “wrongly indicated that a settlement agreement had been reached. No agreement has yet been entertained or discussed in any substantial manner in this case.”

“To our knowledge no settlement has been reached between the State of Oklahoma and HHS in the pending litigation,” Erica Rankin-Riley, public information officer for the Oklahoma State Department of Health, said in an email in response to questions. She said the state’s Title X clinics are not providing referrals for abortion or counseling pregnant women about terminating pregnancies.

“We are appreciative of all that has been involved in restoring Oklahoma’s long-standing and successful Title X grant,” Rankin-Riley said, “and look forward to continuing these important services throughout the state as we have done for over 50 years.”

Spokespeople for HHS and the Tennessee Department of Health did not respond to requests for comment.

Title X was established to reduce unintended pregnancies and provide related preventive health care. As of 2023, more than 3,800 clinics across the country used federal grants to supply free or low-cost contraception, testing for sexually transmitted infections, screening for breast and cervical cancer, and pregnancy-related counseling.

Nationwide, more than 4 in 5 people who use Title X’s services are women, according to HHS.

Federal law prohibits clinics from using Title X money to pay for abortions. However, HHS regulations issued in 2021 say participating clinics must offer pregnant women information about prenatal care and delivery, infant care, foster care, adoption, and pregnancy termination. That includes counseling patients about abortion and providing abortion referrals on request.

HHS under President Donald Trump has not yet revised the Biden-era regulations, which means participating clinics are still required to provide abortion counseling and abortion referrals for pregnant women who request them.

After the Supreme Court’s June 2022 decision in Dobbs v. Jackson Women’s Health Organization, which ended the constitutional right to an abortion, Tennessee and Oklahoma enacted strict abortion bans with few exceptions. The states told their Title X clinics they could discuss or make referrals only for services that were legal in their states, effectively cutting off any talk about abortion.

“Continued funding is not in the best interest of the government,” two HHS officials wrote to Tennessee officials on March 20, 2023.

Tennessee and Oklahoma subsequently sued in federal court. A three-judge panel for the U.S. Court of Appeals for the 6th Circuit ruled against Tennessee, while Oklahoma asked the Supreme Court to review the case after that state lost in the U.S. Court of Appeals for the 10th Circuit.

State officials suggested even they weren’t sure why they got some of their funding back before the lawsuits were resolved. “If Oklahoma’s award is not being restored pursuant to a settlement agreement, then what is the reason for the partial restoration, and is it permanent?” West wrote.

“Tennessee has not yet ascertained the formal position of HHS with respect to whether HHS intends to fully restore Tennessee’s Title X funding,” Whitney Hermandorfer of the Office of the Tennessee Attorney General wrote in an April 7 letter.

A report from HHS’ Office of Population Affairs said 60% of roughly 2.8 million patients who received Title X services in 2023 had family incomes at or below the poverty line. Twenty-seven percent were uninsured, more than three times the national uninsured rate.

In fiscal 2024, the federal government awarded Title X grants to nearly 90 entities, a mix of state and local governments and private organizations. Those grantees distribute funds to public or private clinics.

The decision to restore some of Tennessee and Oklahoma’s funding diverges sharply from the approach HHS under Trump has taken with other Title X participants.

On March 31, HHS withheld family planning funds from 16 entities, including nine Planned Parenthood affiliates.

At least seven states — California, Hawaii, Maine, Mississippi, Missouri, Montana, and Utah — now do not have any Title X-funded family planning services, according to a lawsuit filed in federal court by the ACLU and the National Family Planning and Reproductive Health Association, which lobbies for Title X clinics.

Overall, 865 family planning clinics are unable to provide services to roughly 842,000 people, the lawsuit states.

“We know what happens when health care providers cannot use Title X funding: People across the country suffer, cancers go undetected, access to birth control is severely reduced, and the nation’s STI crisis worsens,” Alexis McGill Johnson, president and CEO of Planned Parenthood Action Fund, said in a statement.

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.

USE OUR CONTENT

This story can be republished for free (details).

Adelaide Tovar, a University of Michigan scientist who researches genes related to diabetes, used to feel like an impostor in a laboratory. Tovar, 32, grew up poor and was the first in her family to graduate from high school. During her first year in college, she realized she didn’t know how to study.

But after years of studying biology and genetics, Tovar finally got proof that she belonged. Last fall, the National Institutes of Health awarded her a prestigious grant. It would fund her research and put her on track to be a university professor and eventually launch a laboratory of her own.

“I felt like receiving the award was a form of acceptance, like I had finally made it,” Tovar said. “But I think many of us now fear that this is going to poison the rest of our careers.”

Tovar is one of nearly 200 young scientists across the nation whose research and job prospects have been jeopardized by the sudden termination of the NIH’s MOSAIC grant program, one of many ended by sweeping cuts across the federal scientific agencies. The grant was created by the first Trump administration to foster a new generation of diverse scientists in biomedical research, then defunded in the second Trump administration’s ongoing purge of diversity, equity, and inclusion programs.

In interviews with KFF Health News, Tovar and three other grant recipients worried that the loss of funding — coupled with President Donald Trump’s crusade against diversity programs — may transform a grant that was supposed to jump-start their careers into a blemish on their résumés that could cost them the jobs and funding that make their research possible.

“We might end up blacklisted by the NIH because of having this award — for who we are,” said Erica Rodriguez, 35, a grant recipient at Columbia University who conducts brain research that could lead to a better understanding of psychiatric disorders.

“Because not only is it for people with diverse backgrounds,” she said, “but it’s for people who advocate for other people with diverse backgrounds.”

The MOSAIC program — short for “Maximizing Opportunities for Scientific and Academic Independent Careers” — was created in 2019 to provide early-career support to promising scientists from “underrepresented backgrounds” with a long-term goal to “enhance diversity in the biomedical research workforce,” according to NIH grant documents.

The five-year grant was awarded to scientists who have finished their doctorates and work in research laboratories at universities across the country. In the first two years, scientists generally receive $100,000 to $150,000, which is largely used to pay their salaries.

By the third year, the scientists are expected to have been hired as a professor, likely at a different university, where the grant funding helps them launch their own research lab. In the final three years of the grant, funding increases to about $250,000 a year, which is used to buy supplies and hire other young scientists to work in the lab, completing the cycle.

MOSAIC awardees were chosen using a broad definition of diversity beyond race, gender, and disability. It includes those who grew up in poor households or rural areas or were raised by parents who do not have college degrees. Many of those chosen for the grant also have a history of supporting other budding scientists from underrepresented backgrounds.

MOSAIC funds research on cancer, Alzheimer’s disease, spinal cord injuries, cochlear implants, fentanyl overdoses, stroke recovery, neurodevelopmental disorders, and more.

But in recent weeks the NIH has notified most MOSAIC recipients that the program was “terminated” and their funding will end by this summer, regardless of the years left on their grant, according to NIH emails reviewed by KFF Health News. Other awardees have received no official notification and only learned through word of mouth that their funding was canceled.

Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, confirmed in an email statement to KFF Health News that MOSAIC had been defunded. She said the grants “no longer align” with agency priorities or the president’s executive orders “eliminating wasteful, ideologically driven DEI initiatives.”

Trump signed one of those orders on his first day back in the White House, instructing the entire federal government to end programs that promoted diversity, referring to them as “shameful,” “immoral,” and an “immense public waste.”

Diversity programs have been slashed across the government, including at the NIH and other HHS agencies, which have canceled hundreds of grants worth billions of dollars since March. On April 21, the NIH issued a notice that banned recipients from receiving grants if they have DEI programs and said the agency could “recover all funds” from those that do not comply.

“At HHS, we are dedicated to restoring our agencies to their tradition of gold-standard, evidence-based science – not one driven by political ideology,” Rodriguez Feliciano said. “We will leave no stone unturned in identifying the root causes of the chronic disease epidemic as part of our mission to Make America Healthy Again.”

Many MOSAIC scientists are focused on chronic diseases. Tovar, for example, researches specific genes that make people more susceptible to diabetes, which affects about 38 million Americans.

“We have a lot of treatments for diabetes that are great for the people that they work for,” Tovar said. “In my research, I use genetics to help find better drug targets so we can find medicines for people who don’t already have therapies that work.”

In interviews, Tovar and the other MOSAIC recipients described how the sudden loss of funding will throw research and careers into upheaval: Some postdoctoral researchers may lose their current jobs when funding runs dry in months; awardees competing for professor jobs will lose research funding that made them stronger candidates; and those already hired will have less money for salaries and supplies in their research labs.

Ashley Albright, 32, who grew up poor in rural North Carolina, is now a scientist at the University of California-San Francisco, where she studies Stentor coeruleus, a large single-celled organism with regenerative abilities. She plans to start applying for professor jobs this fall.

Albright said MOSAIC funding would have given her a “better shot at my dream,” which was to give other scientists from diverse backgrounds opportunities to work in her research lab.

“I feel crushed,” she said. “I feel like someone is stepping on half of my life. … I’ve spent the last 10 years in grad school and my postdoc working toward this so I can do science, but also help other people do science.”

Hannah Grunwald, 33, a grant recipient at Harvard who studies eyeless cave fish to better understand complex genetic traits, said one of her worst fears was that universities won’t hire MOSAIC awardees at a time when the White House is ordering schools to abandon DEI programs and withholding billions from those that do not bend to the Trump agenda.

“There has been an enormous debate in our community about what we should say on our résumés,” Grunwald said. “I just don’t know if having my grant canceled because it had to do with diversity is going to limit my ability to get funding in the future.”

The termination of MOSAIC drew quick condemnation from several scientific organizations that receive grant funding to work closely with the awarded scientists, with some calling it “short-sighted” and “a significant step backward.”

Mary Munson, president of the American Society for Cell Biology, who has mentored awardees since MOSAIC began, became choked up and covered her face with her hands as she considered the possibility the grant could end up holding them back.

“Taking this grant away now does not take away the fact that they won this competitive award. It doesn’t take away that they are amazing scientists,” Munson said. “I hope that institutions will still see that nonetheless.”

Stefano Bertuzzi, CEO of the American Society for Microbiology, which also mentors grant awardees, said the mass termination of MOSAIC and other NIH grants may have a cumulative effect that will stifle scientific innovation for decades.

Bertuzzi, who immigrated from Italy in the ’90s because of America’s robust funding for science, said scientists will not stay in or flock to a nation where research funding vanishes on a political whim.

“We are going to be losing a full generation of scientists,” Bertuzzi said. “Other countries in the world will thrive.”

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.

USE OUR CONTENT

This story can be republished for free (details).

POLSON, Mont. — When someone accused of a crime in this small northwestern Montana town needs mental health care, chances are they’ll be locked in a basement jail cell the size of a walk-in closet.

Prisoners, some held in this isolation cell for months, have scratched initials and the phrase “love hurts” into the metal door’s brown paint. Their pacing has worn a path into the cement floor. Many are held in a sort of limbo, not convicted of a crime but not stable enough to be released. They sleep on a narrow cot next to a toilet. The only view is a fluorescent-lit hallway visible through a small window in the door.

Lake County Attorney James Lapotka stood at the cell’s center talking about the people he helps confine here. He stretched out his arms, his fingertips just shy of touching opposite walls. “I’m getting anxiety just being in here,” Lapotka said.

Last year, a man sentenced for stealing a rifle stayed in that cell 129 days. He was waiting for a spot to open at Montana’s only state-run psychiatric hospital after a mental health evaluator deemed he needed care, according to court records.

A man in the next cell around the same time was on the same waitlist roughly five months. He faced near-daily stints in the jail’s emergency restraint chair — a steel contraption wrapped in foam with straps for his shoulders, arms, and legs. He regularly saw the jail’s mental health doctor. Still, Joel Shearer, a Lake County detention commander, said the man routinely experienced psychotic episodes and asked to be locked in the chair when he felt one coming on and stayed there until his screams subsided.

“Somebody who’s having a mental health crisis — they don’t belong here,” Lapotka said. “We don’t have anywhere else.”

Lake County’s two, roughly 30-square-foot isolation cells are an example of how communities nationwide are failing to provide mental health services — crisis care, in particular. Nearly half of the people locked in local jails in the U.S. have a mental illness.

More than half of Wyoming’s 23 sheriffs told lawmakers there that they were housing people in crisis awaiting mental health care for months, WyoFile reported in January. Nevada has struggled despite a $500 daily fine for each jailed patient whose treatment is delayed. Disability Rights Oregon has said delays in that state continue after two people died in jail while on the state’s psychiatric waitlist.

In Montana, counties are jailing mental health patients they’re not equipped to handle when the Montana State Hospital is at capacity. Few local hospitals have their own inpatient psychiatric beds. As a result, people arrested for anything from petty theft to felony assault can be jailed for months or longer as their mental health worsens. Many haven’t been convicted of a crime.

Montana officials have known for years they have a problem. State officials have said they don’t have space for all the people ordered to the hospital. The psychiatric hospital has 270 beds, with 54 for people in the criminal justice system. Staffing shortages can shrink that capacity further.

The Montana Department of Public Health and Human Services backed two bills this legislative session that would shield the state from liability for delays when the Montana State Hospital is full. Ahead of the bills, the agency wrote the hospital has “struggled to maintain appropriate levels of care” due to money and staffing constraints, a lack of community-based services, and having no control over the flow patients Montana courts send its way.

The agency also announced April 23 that $6.5 million was available through one-time grants to help set up jail-based mental health stabilization services.

Officials have said patients deserve care closer to home, in less restrictive settings. But counties say the local services needed don’t exist.

“You have to do the hard things first,” said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness. “You have to build the beds.”

Health advocates have backed a proposal that would require the state to pay for community commitments. That measure is headed to Republican Gov. Greg Gianforte after passing the state House and Senate. Another bill that was still pending would create a new psychiatric hospital for people in the justice system. But implementing those ideas could take years.

The number of inpatient beds for people with a serious mental illness nationwide has plummeted. At one time, that drop was intentional, part of a movement away from locking people up in state-run mental hospitals. But the intended fix, local homelike centers, hasn’t filled the void.

One of Montana’s biggest providers, Western Montana Mental Health Center, had to close some of its crisis sites because of money problems, said Western’s CEO, Bob Lopp. That includes a facility less than a mile from the Lake County jail.

“If that’s not where the funding is, you can’t just do it for the sake of argument and hope that it comes,” Lopp said.

Gianforte has promised to pour money into rebuilding the state’s behavioral health system. Mental health workers in small towns find such promises hard to trust after seeing local services come and go for years.

Health department spokesperson Holly Matkin said the agency is proud of its work to fix “systems that have been broken for too long” and that it will improve services for people who need inpatient care in their communities.

Lake County is known to outsiders as an Instagram-worthy stop on their way to Glacier National Park. It overlaps with the Flathead Indian Reservation, land of the Bitterroot Salish, Upper Pend d’Oreille, and Kootenai tribes. It’s home to a slice of the Rocky Mountains and a gateway to millions of acres of wilderness. Polson, the county seat and site of the jail, is a town of 5,600 on the southern shore of Flathead Lake, one of the largest lakes west of the Mississippi River.

Vincent River has worked as the jail’s sole mental health clinician for 25 years. He said he’s not always available because he’s the only psychologist in four northwestern Montana counties evaluating whether a person in jail needs psychiatric care.

Some are released without care if they linger too long on the state hospital’s waitlist.

“I talk to these family members. I hear them plead with me with their fear in their voices and tell me all that’s been going on for days or weeks or months,” River said. “And then I can’t get people into the hospital. That is a giant crisis.”

It’s not just the state hospital. River said he can’t get people into any psychiatric bed in Montana because there are too few. Instead, he tries to stabilize people while they’re jailed. That has shortfalls.

The jail can’t force someone in psychosis to take medication without a court order and a qualified doctor on hand to administer the prescription. Lake County’s aging facility has faced lawsuits because of poor conditions amid overcrowding, and River has to see patients wherever there’s room.

There isn’t even space for the jail’s restraint chair. Jail workers leave strapped-down prisoners in a hallway or locker room.

River said many gradually get better and leave isolation. Some don’t.

“They languish there, psychotic and lonely,” he said, “at the mercy of what the voices are telling them.”

Locals are working to fill some gaps. A mobile team launched in February is staffed by people who have lived with mental and substance use disorders to provide peer support. But someone truly in crisis has only two options: jail or an emergency room.

The room reserved for people in crisis at Providence St. Joseph Medical Center in Polson leaves patients both isolated and without privacy. The locked door’s thick glass looks onto a busy emergency room hallway.

Those who deteriorate enough to be deemed dangerous to themselves or others are sent down the road to jail.

Rebecca Bontadelli, an ER physician, said patients can be housed in the room for days as hospital staffers scour Montana and nearby states for an open psychiatric bed. Some reject care in the meantime.

“We’re not really helping them,” Bontadelli said. “They feel like they’re in prison.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Mientras la epidemia de sarampión más grave en una década ha causado la muerte de dos niños y se ha extendido a 27 estados sin dar señales de desacelerar, las creencias sobre la seguridad de la vacuna contra esta infección y la amenaza de la enfermedad se polarizan rápido, alimentadas por las opiniones antivacunas del funcionario de salud de mayor rango del país.

Aproximadamente dos tercios de los padres con inclinaciones republicanas desconocen el aumento en los casos de sarampión este año, mientras que cerca de dos tercios de los demócratas sabían sobre el tema, según una encuesta de KFF publicada el miércoles 23 de abril.

Los republicanos son mucho más escépticos con respecto a las vacunas y tienen el doble de probabilidades (1 de cada 5) que los demócratas (1 de cada 10) de creer que la vacuna contra el sarampión es peor que la enfermedad, según la encuesta realizada a 1.380 adultos estadounidenses.

Alrededor del 35% de los republicanos que respondieron a la encuesta, realizada del 8 al 15 de abril por internet y por teléfono, aseguraron que la teoría desacreditada que vincula la vacuna contra el sarampión, las paperas y la rubéola con el autismo era definitiva o probablemente cierta, en comparación con solo el 10% de los demócratas.

Las tendencias son prácticamente las mismas que las reportadas por KFF en una encuesta de junio de 2023.

Sin embargo, en la nueva encuesta, 3 de cada 10 padres creían erróneamente que la vitamina A puede prevenir las infecciones por el virus del sarampión, una teoría que Robert F. Kennedy Jr., el secretario de Salud y Servicios Humanos, ha diseminado desde que asumió el cargo, en medio del brote de sarampión.

Se han reportado alrededor de 900 casos en 27 estados, la mayoría en un brote centrado en el oeste de Texas.

“Lo más alarmante de la encuesta es que estamos observando un aumento en la proporción de personas que han escuchado estas afirmaciones”, afirmó la coautora Ashley Kirzinger, directora asociada del Programa de Investigación de Encuestas y Opinión Pública de KFF. (KFF es una organización sin fines de lucro dedicada a la información sobre salud que incluye a KFF Health News).

“No es que más gente crea en la teoría del autismo, sino que cada vez más gente escucha sobre ella”, afirmó Kirzinger. Debido a que las dudas sobre la seguridad de las vacunas es factor directo de la decision de los padres reducer la vacunación de sus hijos, “esto demuestra la importancia de que la información veraz forme parte del panorama mediático”, añadió.

“Esto es lo que cabría esperar cuando la gente está confundida por mensajes contradictorios provenientes de personas en posiciones de autoridad”, afirmó Kelly Moore, presidenta y directora ejecutiva de Immunize.org, un grupo de defensa de la vacunación.

Numerosos estudios científicos no han establecido ningún vínculo entre cualquier vacuna y el autismo. Sin embargo, Kennedy ha ordenado al Departamento de Salud y Servicios Humanos (HHS) que realice una investigación sobre los posibles factores ambientales que contribuyen al autismo, prometiendo tener “algunas de las respuestas” sobre el aumento en la incidencia de la afección para septiembre.

La profundización del escepticismo republicano hacia las vacunas dificulta la difusión de información precisa en muchas partes del país, afirmó Rekha Lakshmanan, directora de estrategia de The Immunization Partnership, en Houston.

El 23 de abril, Lakshmanan iba a presentar un documento sobre cómo contrarrestar el activismo antivacunas ante el Congreso Mundial de Vacunas en Washington. El documento se basaba en una encuesta que reveló que, en las asambleas estatales de Texas, Louisiana, Arkansas y Oklahoma, los legisladores con profesiones médicas se encontraban entre los menos propensos a apoyar las medidas de salud pública.

“Hay un componente político que influye en estos legisladores”, afirmó. Por ejemplo, cuando los legisladores invitan a quienes se oponen a las vacunas a testificar en las audiencias legislativas, se alimenta una avalancha de desinformación difícil de refutar, agregó.

Eric Ball, pediatra de Ladera Ranch, California, área afectada por un brote de sarampión en 2014-2015 que comenzó en Disneyland, afirmó que el miedo al sarampión y las restricciones más estrictas del estado de California sobre las exenciones de vacunas evitaron nuevas infecciones en su comunidad del condado de Orange.

“La mayor desventaja de las vacunas contra el sarampión es que funcionan muy bien. Todos se vacunan, nadie contrae sarampión, todos se olvidan del sarampión”, concluyó. “Pero cuando regresa la enfermedad, se dan cuenta de que hay niños que se están enfermando de gravedad, y potencialmente muriendo en la propia comunidad, y todos dicen: ‘¡Caramba! ¡Mejor que vacunemos!’”.

En 2015, Ball trató a tres niños muy enfermos de sarampión. Después, su consultorio dejó de atender a pacientes no vacunados. “Tuvimos bebés expuestos en nuestra sala de espera”, dijo. “Tuvimos una propagación de la enfermedad en nuestra oficina, lo cual fue muy desagradable”.

Aunque dos niñas que eran sanas murieron de sarampión durante el brote de Texas, “la gente todavía no le teme a la enfermedad”, dijo Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia, que ha atendido algunos casos.

Pero las muertes “han generado más angustia, según la cantidad de llamadas que recibo de padres que intentan vacunar a sus bebés de 4 y 6 meses”, contó Offit. Los niños generalmente reciben su primera vacuna contra el sarampión al año de edad, porque tiende a no producir inmunidad completa si se administra antes.

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.

USE OUR CONTENT

This story can be republished for free (details).

While the most serious measles epidemic in a decade has led to the deaths of two children and spread to 27 states with no signs of letting up, beliefs about the safety of the measles vaccine and the threat of the disease are sharply polarized, fed by the anti-vaccine views of the country’s seniormost health official.

About two-thirds of Republican-leaning parents are unaware of an uptick in measles cases this year while about two-thirds of Democratic ones knew about it, according to a KFF survey released Wednesday.

Republicans are far more skeptical of vaccines and twice as likely (1 in 5) as Democrats (1 in 10) to believe the measles shot is worse than the disease, according to the survey of 1,380 U.S. adults.

Some 35% of Republicans answering the survey, which was conducted April 8-15 online and by telephone, said the discredited theory linking the measles, mumps, and rubella vaccine to autism was definitely or probably true — compared with just 10% of Democrats.

The trends are roughly the same as KFF reported in a June 2023 survey. But in the new poll, 3 in 10 parents erroneously believed that vitamin A can prevent measles infections, a theory Health and Human Services Secretary Robert F. Kennedy Jr. has brought into play since taking office during the measles outbreak.

About 900 cases have been reported in 27 U.S. states, mostly in a West Texas-centered outbreak.

“The most alarming thing about the survey is that we’re seeing an uptick in the share of people who have heard these claims,” said co-author Ashley Kirzinger, associate director of KFF’s Public Opinion and Survey Research Program. KFF is a health information nonprofit that includes KFF Health News.

“It’s not that more people are believing the autism theory, but more and more people are hearing about it,” Kirzinger said. Since doubts about vaccine safety directly reduce parents’ vaccination of their children, “that shows how important it is for actual information to be part of the media landscape,” she said.

“This is what one would expect when people are confused by conflicting messages coming from people in positions of authority,” said Kelly Moore, president and CEO of Immunize.org, a vaccination advocacy group.

Numerous scientific studies have established no link between any vaccine and autism. But Kennedy has ordered HHS to undertake an investigation of possible environmental contributors to autism, promising to have “some of the answers” behind an increase in the incidence of the condition by September.

The deepening Republican skepticism toward vaccines makes it hard for accurate information to break through in many parts of the nation, said Rekha Lakshmanan, chief strategy officer at The Immunization Partnership, in Houston.

Lakshmanan on April 23 was to present a paper on countering anti-vaccine activism to the World Vaccine Congress in Washington. It was based on a survey that found that in the Texas, Louisiana, Arkansas, and Oklahoma state assemblies, lawmakers with medical professions were among those least likely to support public health measures.

“There is a political layer that influences these lawmakers,” she said. When lawmakers invite vaccine opponents to testify at legislative hearings, for example, it feeds a deluge of misinformation that is difficult to counter, she said.

Eric Ball, a pediatrician in Ladera Ranch, California, which was hit by a 2014-15 measles outbreak that started in Disneyland, said fear of measles and tighter California state restrictions on vaccine exemptions had staved off new infections in his Orange County community.

“The biggest downside of measles vaccines is that they work really well. Everyone gets vaccinated, no one gets measles, everyone forgets about measles,” he said. “But when it comes back, they realize there are kids getting really sick and potentially dying in my community, and everyone says, ‘Holy crap; we better vaccinate!’”

Ball treated three very sick children with measles in 2015. Afterward his practice stopped seeing unvaccinated patients. “We had had babies exposed in our waiting room,” he said. “We had disease spreading in our office, which was not cool.”

Although two otherwise healthy young girls died of measles during the Texas outbreak, “people still aren’t scared of the disease,” said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, which has seen a few cases.

But the deaths “have created more angst, based on the number of calls I’m getting from parents trying to vaccinate their 4-month-old and 6-month-old babies,” Offit said. Children generally get their first measles shot at age 1, because it tends not to produce full immunity if given at a younger age.

KFF Health News’ Jackie Fortiér contributed to this report.

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

USE OUR CONTENT

This story can be republished for free (details).