Jacob Sweidan has seen his patients through the federal immigration raids of the 1990s, a sitting governor’s call to abolish birthright citizenship, and the highly publicized workplace crackdowns and family separation policies of President Donald Trump’s first term.

But in his 40 years as a pediatrician in Southern California serving those too poor to afford care, including many immigrant families, Sweidan said he’s never seen a drop-off in patient visits like this.

“They are scared to come to the offices. They’re getting sicker and sicker,” said Sweidan, who specializes in neonatology and runs five clinics in Los Angeles and Orange counties. “And when they are near collapsing, they go to the ER because they have no choice.”

In the last two months, he has sent young children to the emergency room because their parents worked up the courage to call his office only after several days of high fever. He said he attended to a 14-year-old boy in the ER who was on the verge of a diabetic coma because he’d run out of insulin, his parents too frightened to venture out for a refill.

Sweidan had stopped offering telehealth visits after the covid-19 pandemic, but he and other health care providers have brought them back as ramped-up immigration enforcement drives patients without legal status — and even their U.S. citizen children — deeper into the shadows.

Patients in need of care are increasingly scared to seek it after Trump rescinded a Biden-era policy that barred immigration officials from conducting operations in “sensitive” areas such as schools, hospitals, and churches. Clinics and health plans have taken a page out of their covid playbooks, revamping tested strategies to care for patients scared to leave the house.

Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said she’s heard from clinic administrators and industry colleagues who have experienced a substantial drop in in-person visits among immigrant patients.

“I don’t think there’s a community health center in the country that is not feeling this,” Rosenbaum said.

At St. John’s Community Health clinics in the Los Angeles area, which serve an estimated 30,000 patients without legal status annually, virtual visits have skyrocketed from roughly 8% of appointments to about 25%, said Jim Mangia, president and chief executive officer. The organization is also registering some patients for in-home health visits, a service funded by private donors, and has trained employees how to read a warrant.

“People are not picking up their medicine,” Mangia said. “They’re not seeing the doctor.”

Mangia said that, in the past eight weeks, federal agents have attempted to gain access to patients at a St. John’s mobile clinic in Downey and pointed a gun at an employee during a raid at MacArthur Park. Last month, Immigration and Customs Enforcement contractors sat in a Southern California hospital waiting for a patient and federal prosecutors charged two health center workers they say interfered with immigration officers’ attempts to arrest someone at an Ontario facility.

C.S., an immigrant from Huntington Park without legal status, said she signed up for St. John’s home visit services in July because she fears going outside. The 71-year-old woman, who asked to be identified only by her initials for fear of deportation, said she has missed blood work and other lab tests this year. Too afraid to take the bus, she skipped a recent appointment with a specialist for her arthritic hands. She is also prediabetic and struggles with leg pain after a car hit her a few years ago.

“I feel so worried because if I don’t get the care I need, it can get much worse,” she said in Spanish, speaking about her health issues through an interpreter. A doctor at the clinic gave her a number to call in case she wants to schedule an appointment by phone.

Officials at the federal Department of Health and Human Services did not respond to questions from KFF Health News seeking comment about the impact of the raids on patients.

There’s no indication the Trump administration intends to shift its strategy. Federal officials have sought to pause a judge’s order temporarily restricting how they conduct raids in Southern California after immigrant advocates filed a lawsuit accusing ICE of deploying unconstitutional tactics. The 9th U.S. Circuit Court of Appeals on Aug. 1 denied the request, leaving the restraining order in place.

In July, Los Angeles County supervisors directed county agencies to explore expanding virtual appointment options after the county’s director of health services noted a “huge increase” in phone and video visits. Meanwhile, state lawmakers in California are considering legislation that would restrict immigration agents’ access to places such as schools and health care facilities — Colorado’s governor, Democrat Jared Polis, signed a similar bill into law in May.

Immigrants and their families will likely end up using more costly care in emergency rooms as a last resort. And recently passed cuts to Medicaid are expected to further stress ERs and hospitals, said Nicole Lamoureux, president of the National Association of Free & Charitable Clinics.

“Not only are clinics trying to reach people who are retreating from care before they end up with more severe conditions, but the health care safety net is going to be strained due to an influx in patient demand,” Lamoureux said.

Mitesh Popat, CEO of Venice Family Clinic, nearly 90% of whose patients are at or below the federal poverty line, said staff call patients before appointments to ask if they plan to come in person and to offer telehealth as an option if they are nervous. They also call if a patient doesn’t show five minutes into their appointment and offer immediate telehealth service as an alternative. The clinic has seen a roughly 5% rise in telehealth visits over the past month, Popat said.

In the Salinas Valley, an area with a large concentration of Spanish-speaking farmworkers, Clinica de Salud del Valle de Salinas began promoting telehealth services with Spanish radio ads in January. The clinics also trained people how to use Zoom and other digital platforms at health fairs and community meetings.

CalOptima Health, which covers nearly 1 in 3 residents of Orange County and is the biggest Medi-Cal benefits administrator in the area, sent more than a quarter-million text messages to patients in July encouraging them to use telehealth rather than forgo care, said Chief Executive Officer Michael Hunn. The insurer has also set up a webpage of resources for patients seeking care by phone or home delivery of medication.

“The Latino community is facing a fear pandemic. They’re quarantining just the way we all had to during the covid-19 pandemic,” said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, an advocacy group that promotes health access for immigrants and Latinos.

But substituting telehealth isn’t a long-term solution, said Isabel Becerra, chief executive officer of the Coalition of Orange County Community Health Centers, whose members reported increases in telehealth visits as high as 40% in the past month.

“As a stopgap, it’s very effective,” said Becerra, whose group represents 20 clinics in Southern California. “Telehealth can only take you so far. What about when you need lab work? You can’t look at a cavity through a screen.”

Telehealth also brings a host of other challenges, including technical hiccups with translation services and limited computer proficiency or internet access among patients, she said.

And it’s not just immigrants living in the country unlawfully who are scared to seek out care. In southeast Los Angeles County, V.M., a 59-year-old naturalized citizen, relies on her roommate to pick up her groceries and prescriptions. She asked that only her initials be used to share her story and those of her family and friends out of fear they could be targeted.

When she does venture out — to church or for her monthly appointment at a rheumatology clinic — she carries her passport and looks askance at any cars with tinted windows.

“I feel paranoid,” said V.M., who came to the U.S. more than 40 years ago and is a patient of Venice Family Clinic. “Sometimes I feel scared. Sometimes I feel angry. Sometimes I feel sad.”

She now sees her therapist virtually for her depression, which began 10 years ago when rheumatoid arthritis forced her to stop working. She worries about her older brother, who has high blood pressure and has stopped going to the doctor, and about a friend from the rheumatology clinic, who ices swollen hands and feet because she’s missed four months of appointments in a row.

“Somebody has to wake up or people are going to start falling apart outside on the streets and they’re going to die,” she said.

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

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EKALAKA, Mont. — There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.

There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

He pointed to Vermont, where a report recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.

The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told KFF Health News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

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Centers for Disease Control and Prevention workers whose jobs have been reinstated after dizzying Trump administration disruptions say they remain stuck in a budgetary, political, and professional limbo.

Their work includes major agency priorities such as HIV testing and monitoring, as well as work at the nation’s leading sexually transmitted infections lab. And while employees are back, many projects have been canceled or stalled, as funding disappears or is delayed.

“For a while, work was staring at a blank screen,” an HIV scientist said. “I had a couple of projects before this. I’m trying to get them restarted.”

“We don’t know what’s happening or what to do,” said an HIV prevention researcher who was fired then rehired.

These employees voiced deep concern over the future of the agency and its work on HIV and other threats. The unprecedented downsizing could lead to loss of life and higher spending on medical care, they say. Their uncertain employment status has sunk morale. Many worry about the future of public health.

On Aug. 8, a gunman identified by Georgia authorities as Patrick Joseph White fired shots at CDC buildings in Atlanta. A first responder on the scene, DeKalb County police officer David Rose, was killed. White, who was found dead, was possibly motivated by his views on vaccines, according to news reports.

The attack added another level of anxiety for agency workers.

“We feel threatened from inside, and, obviously, now from outside,” a lab scientist said Aug. 10. “The trauma runs so differently in all of us. And is this the last straw for some of us? The overall morale — would you go back in the building and you could be shot at?”

Healthbeat interviewed 11 CDC workers, who offered a rare glimpse into conditions at the agency. All but one had been fired then offered their jobs back. Most have worked on HIV-related projects for at least several years. All spoke on the condition of anonymity, citing a fear of retaliation.

They fear their employment, in the HIV scientist’s terms, “is on shaky ground.”

“I’m concerned there is chaos and that we lost ground on HIV prevention” from reductions in data collection and layoffs of local public health workers, an HIV epidemiologist said. “I feel like a pawn on a chessboard.”

HHS spokesperson Emily Hilliard responded to a query with this statement:

“Under Secretary Kennedy’s leadership, the nation’s critical public health functions remain intact and effective. The Trump administration is committed to protecting essential services — whether it’s supporting coal miners and firefighters through NIOSH, safeguarding public health through lead prevention, or researching and tracking the most prevalent communicable diseases. HHS is streamlining operations without compromising mission-critical work. Enhancing the health and well-being of all Americans remains our top priority.”

The workers received some positive news July 31, when a Senate committee voted to keep CDC funding at more than $9 billion, near its current level. “It is very encouraging, but that’s only one step in the appropriations process,” the HIV researcher said.

Still, under the Trump administration’s budget request, the CDC’s programs on HIV face uncertainty. John Brooks, who retired as chief medical officer of the CDC’s Division of HIV Prevention last year, expressed concern over the Ending the HIV Epidemic initiative. Launched in President Donald Trump’s first term, it “breathed new life into HIV prevention,” Brooks said.

The successes of the Ending the HIV Epidemic initiative are jeopardized by the administration plan to scale back HIV prevention efforts, Brooks said. That would include the potential elimination of the CDC Division of HIV Prevention, which provides funds to state health departments and other groups for testing and prevention, conducts HIV monitoring and surveillance, researches HIV prevention and care, and assists medical professionals with training and education.

“There is no way to achieve the goals of EHE without maintaining the national prevention infrastructure it depends on,” Brooks said. “There is every reason to worry that in fact new HIV infections will rise again.”

Under Secretary Robert F. Kennedy Jr., the Department of Health and Human Services carried out widespread layoffs at the CDC and other health agencies beginning in early April. Lawsuits over those mass firings are playing out in federal courts.

The administration’s budget blueprint would move CDC HIV work — with many fewer employees, according to people Healthbeat interviewed — to the Administration for a Healthy America, a new HHS division Kennedy has championed.

The Medical Monitoring Project, which tracks outcomes, quality, and gaps in HIV treatment, is set to be a casualty under the Trump restructuring plan, an HIV prevention physician said.

HHS officials have not communicated with the rank and file about the restructuring, several CDC workers said.

“It’s been crickets,” the HIV scientist said.

The White House’s proposed CDC budget for the next fiscal year contains a cut of more than 50%, plummeting from $9.2 billion in fiscal year 2025 to about $4.2 billion, according to administration documents and public health advocacy groups, with some agency functions transferred to the proposed AHA. The Senate committee, by an overwhelming vote, injected billions back into the agency budget and declined to fund the AHA.

U.S. Sen. Jon Ossoff, a Georgia Democrat, thanked the committee for “rejecting the unacceptable effort to defund most of the CDC.”

“The budget request from the White House included a 56% cut to the world’s preeminent epidemiological agency,” Ossoff said. He also criticized a “systematic destruction of morale at the CDC, the disbandment of entire agencies focused on maternal health and neonatal health and disease prevention at the CDC.”

If the White House prevails and the prevention program is eliminated, “we would see most states have no funding for HIV prevention,” said Emily Schreiber, senior director of policy and legislative affairs for the National Alliance of State and Territorial AIDS Directors. “That means most states would not be able to conduct any HIV testing, any referral to care, and/or referral to preventive services like PrEP,” or pre-exposure prophylaxis, a drug that can prevent HIV infections.

“It means that states would not be able to help people get access to medications,” she said, “and that means that we would see new cases and an increased spread of HIV across the United States.”

“We would definitely see layoffs at the CDC, and I think we’d probably see them at state health departments and community-based organizations as well,” she added.

The Los Angeles County Department of Public Health has recently laid off or reassigned dozens of HIV workers due to funding problems, according to a statement emailed to Healthbeat.

“I fear all HIV prevention work will go away permanently,” the HIV prevention researcher said. “I don’t think this administration wants HIV prevention work to be done by the federal government.”

Georgia leads U.S. states in the rate of new HIV infections, according to the latest data from AIDSVu. CDC workers also said they’re concerned that vulnerable communities of color and LGBTQ+ communities would be deeply harmed by funding cuts.

In Georgia and other states, information provided by the Medical Monitoring Project about access to care will disappear, the HIV physician said. Information on prevention and treatment will dwindle for people who are disadvantaged, he said, including those with substance abuse problems or mental illness, transgender people, and those living in poverty.

“There is a lot of anger and sadness among people over the termination of the project,” the physician said. “A lot of the enthusiasm is gone.”

An effective home testing program for HIV plans to shutter this fall, said Patrick Sullivan, the Together TakeMeHome project’s lead scientist and a professor at Emory University’s Rollins School of Public Health. In its notice canceling funding for the project, the CDC said it no longer had the staff to oversee it. Based at Emory, the project delivered more than 900,000 free home testing kits to people across the country through an easy-to-use website and integration with dating apps.

More than 100 HIV workers were among the more than 450 CDC staffers brought back, said employees interviewed by Healthbeat. Some cited media coverage, support in Congress, and advocacy by patient groups and pharmaceutical companies for their reinstatement. “Members of Congress are going to bat for HIV,” the epidemiologist said.

Several are closely watching a lawsuit brought by 20 Democratic attorneys general, seeking to halt an agency restructuring plan Kennedy announced in March. They are also paying attention to a lawsuit filed in California that challenges the firings.

A few people whose jobs were restored have retired or moved on to other work. “Some people aren’t trusting we will remain, so they’re leaving,” the HIV prevention researcher said.

At the CDC’s sexually transmitted infections lab in Atlanta, work has also slowed due to a shrinking staff and new spending constraints on supplies, the lab scientist said.

Restored lab workers are focusing on high-priority areas such as syphilis and gonorrhea while other diseases have been back-burnered, the scientist said, adding “a lot of what we were doing was staying ahead of the next pathogen, and we feel like our time and effort to do that now is limited.”

“We’re all public health because we know what the mission is,” the scientist said. “We just want to get our job done and protect the American public.”

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As the federal government reworks rules for a $42 billion broadband expansion program, millions of Americans live in places where there aren’t enough health care providers and internet speeds aren’t good enough for telehealth. A KFF Health News analysis found people in these “dead zones” live sicker and die younger on average than their peers in well-connected regions.

KFF Health News has partnered with InvestigateTV to tell the stories of residents whose health care falls into the gap. InvestigateTV’s Caresse Jackman and KFF Health News’ Sarah Jane Tribble take viewers to Alabama, Idaho, and West Virginia to explain why those connectivity gaps persist.

Explore the full investigation here.

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WATERLOO, Iowa — John-Paul Sager appreciates the care he has received at Department of Veterans Affairs hospitals and clinics, but he thinks it should be easier for veterans like him to use their benefits elsewhere.

Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. “It seems like it takes entirely too long,” he said.

Many veterans live hours from VA facilities, or they need health services that aren’t readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.

Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.

Two Republican senators have introduced legislation that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump’s first term.

Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn’t be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.

“My main concern is for veterans, not for the VA,” Sen. Kevin Cramer (R-N.D.) told KFF Health News. “I don’t believe we have an obligation to sustain the bureaucracy.”

About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.

Cramer sponsored a bill that would allow veterans who live within 35 miles of a rural, “critical access” hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.

Cramer, who serves on the Senate Veterans’ Affairs Committee, noted his state has just one VA hospital. It’s in Fargo, on the state’s eastern border, which is more than 400 miles by car from parts of western North Dakota.

Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. “I kept thinking to myself, ‘This doesn’t make any sense at all,’” Cramer said.

Cramer said previous laws, including the VA Mission Act, made it easier for veterans to use their benefits to cover care at community hospitals and clinics.

But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.

“We can’t let the VA itself determine whether a veteran is qualified to receive local care,” he said.

U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans’ Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department’s money to support private health care facilities.

The VA provides specialized care that responds to veterans’ needs and experiences, he argues.

“We must prevent funds from being siphoned away from veterans’ hospitals and clinics, or VA will crumble,” Takano said in a statement released by his office. “Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community.”

Some veterans’ advocacy groups have also expressed concerns.

Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn’t want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.

Retzer said it’s true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. “This is a national crisis.”

Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. “We want to ensure that the VA is the primary provider of that care,” he said.

Veterans Affairs Secretary Doug Collins has pledged to improve the community care program while maintaining the strength of the department’s hospitals and clinics. The department declined a KFF Health News request to interview Collins.

Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer’s bill. Lewis is a Navy veteran who uses the VA’s community care option to pay for treatment of a back injury stemming from his military service.

Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. “It’s frustrating.”

Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they’re entitled to receive locally.

“I think a lot of folks just don’t want to fight the system,” he said. “They don’t want to go through the extra hoops, and so they’ll jump in the van, and they’ll ride along.”

Rep. Mike Bost (R-Ill.), chairman of the House Veterans’ Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.

Bost helped gain the House’s approval for Trump’s request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that passed Aug. 1.

Bost also co-sponsored a House bill that would spell out requirements for the VA to pay for community care.

Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.

Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency’s mission, including its employment of many veterans. “You just feel like you’re being taken care of by your own,” he said.

He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can’t promptly provide.

The local VA doesn’t offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.

Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.

Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn’t have to jump through so many hoops to obtain convenient care.

“After what they’ve done for us? Please,” she said.

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Cuando el presidente Donald Trump firmó una ley que agrega requisitos laborales para algunos beneficiarios de Medicaid, es posible que haya perjudicado a legisladores de al menos 14 estados que estaban diseñando sus propios planes, según observadores del sector de salud.

Georgia es el único estado con un requisito laboral para Medicaid, pero varios estados llevan años intentando implementarlo, solo para ser bloqueados por los tribunales o, más recientemente, por la administración Biden.

Algunos buscan modificaciones específicas a las nuevas normas para cada estado. Otros pretenden implementar los requisitos laborales antes de que la ley federal entre en vigencia a finales de 2026.

Las acciones de estos estados y la enorme ley de impuestos y gastos de Trump comparten una exigencia: para mantener la cobertura de Medicaid, los adultos que puedan trabajar deben demostrar que lo están haciendo por un mínimo de horas en un trabajo o estudiando, o bien calificar para una de las pocas exenciones.

Pero ahora, los estados que se adelantaron deben asegurarse de que sus propuestas, que requieren aprobación federal, no se alejen demasiado de la ley de Trump.

“El estatuto establece el mínimo y el máximo” para los requisitos laborales, afirmó Sara Rosenbaum, profesora de derecho y políticas sanitarias de la Universidad George Washington.

Por ejemplo, Dakota del Sur anunció en julio que no presentaría una solicitud para los requisitos laborales como se había planeado previamente, ante la preocupación de que las normas estatales, menos estrictas, no se permitieran bajo la nueva ley federal. El secretario del Departamento de Servicios Sociales del estado advirtió que trabajar en una propuesta estatal mientras se debatían las normas federales podría ser “un ejercicio inútil”.

El plan de Arkansas, por otro lado, es más estricto que la ley federal. No hay exenciones a sus requisitos laborales en la solicitud, que está pendiente en los Centros de Servicios de Medicare y Medicaid (CMS).

La propuesta de Arizona también incluye algo que no está en la ley federal: la prohibición de que los “adultos sin discapacidad” reciban beneficios de Medicaid por más de cinco años en total a lo largo de su vida.

Funcionarios gubernamentales de Arkansas y Arizona afirmaron estar trabajando con funcionarios federales para adecuar sus planes a las nuevas normas.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), afirmó que el departamento está analizando cómo interactúan las nuevas normas federales con las exenciones estatales.

El HHS debe publicar, antes de junio del próximo año, las normas que describan cómo los estados implementarán los requisitos laborales, según Elizabeth Hinton, quien ha monitoreando estas exenciones como parte del Programa de Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro dedicada a la información de salud que incluye a KFF Health News.

“No sabemos exactamente qué cubrirá”, declaró Hinton.

Hinton agregó que no está claro cómo responderán los funcionarios federales a las solicitudes de los estados, pero dijo que “somos conscientes de que algunos piensan que no hay margen de maniobra”.

Los estados pueden ajustar sus programas de Medicaid mediante las llamadas “exenciones de demostración”, sujetas a la aprobación federal. Estas exenciones están diseñadas para probar nuevas ideas en áreas política “grises”.

Los estados que han presentado o planean presentar solicitudes con requisitos laborales incluyen: Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, Carolina del Norte, Ohio, Carolina del Sur, Dakota del Sur y Utah.

Los republicanos del Congreso que aprobaron el proyecto de ley de reconciliación presupuestaria permitieron a los estados utilizar exenciones para acelerar la aplicación de las normas nacionales. Tara Sklar, profesora a cargo del Programa de Derecho y Políticas de Salud de la Universidad de Arizona, afirmó que espera que los estados que soliciten requisitos más estrictos tengan posibilidades de ser aprobados, mientras que los más flexibles podrían ser rechazados.

Sklar dijo que oficiales federales podrían ver con buenos ojos el plan de Arizona, ya que un límite vitalicio de cinco años para Medicaid es diferente a los requisitos laborales. Incluso si el gobierno federal aprueba estos requisitos más estrictos que los que exige la ley federal, es probable que esos programas enfrenten impugnaciones legales, afirmó.

La ley federal incluye un mínimo de 80 horas mensuales para trabajar o estudiar, con exenciones para ciertos adultos, como personas con problemas médicos delicados y padres con hijos pequeños dependientes.

Montana es el primer estado en redactar una solicitud de exención desde que el Congreso finalizó los requisitos laborales nacionales. Legisladores estatales aprobaron inicialmente los requisitos laborales —denominados estándares de “participación comunitaria” según el plan estatal— en 2019, pero la solicitud del estado se estancó hasta el final del primer mandato de Trump y durante la administración Biden.

Luego de la reelección de Trump, los legisladores de Montana levantaron la fecha de vencimiento de 2025 de su programa de expansión de Medicaid, declarando permanente el programa que cubría a más de 76.000 adultos en abril, con la expectativa de que la administración Trump aprobara los requisitos laborales.

A mediados de julio, las autoridades estatales publicaron su plan preliminar para hacerlo realidad “tan pronto como sea posible”.

El plan de Montana se alinea en gran medida con la ley federal, pero crearía exenciones adicionales, incluso para personas sin hogar o que huyen de la violencia doméstica.

La senadora estatal republicana Gayle Lammers afirmó que los requisitos laborales que también protegen a las personas que necesitan Medicaid fueron un factor clave para persuadir a los legisladores a mantener el programa de expansión. En ese momento, las autoridades desconocían la postura del gobierno federal sobre los requisitos laborales. Y ahora, según Lammers, tiene sentido que Montana se apegue a su plan.

“El estado debería tener voz y voto”, afirmó Lammers. “Somos muy independientes y cada persona es diferente”.

En Carolina del Sur, las autoridades estatales buscan implementar requisitos laborales para un número limitado de nuevos beneficiarios de Medicaid elegibles. Carolina del Sur es uno de los 10 estados que no ha ampliado la elegibilidad para Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Sin embargo, en junio presentó una solicitud al gobierno federal para una expansión parcial de Medicaid que incluye un componente de requisito de trabajo que refleja en gran medida las nuevas normas federales.

En una carta al Secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., el gobernador de Carolina del Sur, el republicano Henry McMaster, calificó la propuesta estatal como “una solución específica para el estado”.

El único estado con un programa de requisito de trabajo activo ahora quiere reducirlo y espera la aprobación federal para hacerlo. “Georgia Pathways to Coverage” vence a finales de septiembre a menos que los CMS autoricen una extensión del programa con un cambio clave: exigir a los afiliados que documenten su trabajo una vez al año, no mensualmente. Esto representa un cambio con respecto al diseño inicial del programa, pero también difiere de las nuevas normas federales, que exigen verificaciones cada seis meses.

Fiona Roberts, vocera de la agencia de Medicaid de Georgia, afirmó que el estado aún espera saber si necesita modificar su plan.

Por lo tanto, Georgia se encuentra entre los estados en estado de incertidumbre, a la espera de la orientación del gobierno federal.

Los corresponsales de KFF Health News, Sam Whitehead y Lauren Sausser, contribuyeron con este informe.

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

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When President Donald Trump signed a law adding work requirements for some Medicaid recipients, he may have undercut lawmakers in at least 14 states who were designing their own plans, according to health industry observers.

Georgia is the only state with a work requirement in place for Medicaid, but several states have been pursuing such a policy for years, only to be blocked by courts or, most recently, the Biden administration. Some seek state-specific touches to the new rules. Others aim to implement work requirements before the federal law takes effect at the end of 2026.

These states’ moves and Trump’s massive tax-and-spending law share one demand: To keep their Medicaid health coverage, adults who can work must prove they’re logging a minimum number of hours at a job or school, or else qualify for one of the few exemptions.

But now, states that jumped ahead need to ensure their proposals, which require federal approval, don’t stray too far from Trump’s law.

“The statute sets both the floor and ceiling” for work requirements, said Sara Rosenbaum, a health law and policy professor with George Washington University.

South Dakota, for example, announced in July that it would not submit an application for work requirements as previously planned amid concerns that the state’s laxer rules would not be allowed under the new federal law. The state’s Department of Social Services secretary had warned that working on a state proposal while the federal rules are being hashed out could be “an exercise in futility.”

Arkansas’ plan, on the other hand, is more stringent than the federal law. There are no exemptions to its work requirements in the application, which is pending with the Centers for Medicare & Medicaid Services.

Arizona’s proposal also includes something that’s not in the federal law: a ban on “able-bodied adults” receiving Medicaid benefits for longer than five years total in their lives.

Arkansas and Arizona government officials said they were working with federal officials to square their plans with the new standards.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, said the department is analyzing how the new federal standards interact with state waivers.

The federal health department must release rules by next June that outline how states are to implement work requirements, according to Elizabeth Hinton, who has been tracking such waivers as part of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News.

“We don’t exactly know what that will cover,” Hinton said.

It’s unclear how federal officials will respond to the states’ requests, she added, but “we are aware that some folks think there is no wiggle room here.”

States can tweak their Medicaid programs through what are known as demonstration waivers, which are subject to federal approval. The waivers are designed to test new ideas in policy gray areas.

The states that have filed or plan to file such applications with work requirements include Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, North Carolina, Ohio, South Carolina, South Dakota, and Utah.

Congressional Republicans who passed the budget reconciliation bill left room for states to use waivers to fast-track the national standards. Tara Sklar, a professor leading the University of Arizona’s Health Law & Policy Program, said she expects states seeking certain stricter requirements to have a chance of approval, while more lenient ones may face denials.

Federal officials may look favorably on Arizona’s plan, Sklar said, as a five-year lifetime Medicaid limit is different from work requirements. Even if the federal government greenlights stricter work requirements than the federal law calls for, those programs are likely to face legal challenges, she added.

The federal law includes an 80-hour-per-month minimum for work or education, with exemptions for certain adults, including people who are medically frail and parents with young, dependent children.

Montana is the first state to draft a waiver application since Congress finalized national work requirements. State lawmakers first approved work requirements — called “community engagement” standards under the state plan — in 2019, but the state’s application stalled through the end of the first Trump term and the Biden administration.

After Trump was elected again, Montana lawmakers lifted the 2025 expiration date of its Medicaid expansion program, making permanent the program that covered more than 76,000 adults in April, with the expectation that the Trump administration would approve work requirements. In mid-July, state officials released their draft plan to make that a reality “as soon as is practicable.”

The Montana plan largely aligns with the federal law, but it would create additional exemptions, including for people who are homeless or fleeing domestic violence.

Republican state Sen. Gayle Lammers said work requirements that also protect such people who need Medicaid were a big part of persuading legislators to keep the expansion program. At the time, officials didn’t know where the federal government would land on work requirements. And now, Lammers said, it makes sense for Montana to stick to its plan.

“The state should have a say,” Lammers said. “We’re very independent, and everyone is different.”

In South Carolina, state officials are seeking to roll out work requirements for a limited number of newly eligible Medicaid beneficiaries. South Carolina is one of 10 states that has not expanded Medicaid eligibility under the Affordable Care Act, and yet the state submitted a request with the federal government in June for a partial Medicaid expansion that includes a work requirement component that largely reflects the new federal standards.

In a letter to Health and Human Services Secretary Robert F. Kennedy Jr., South Carolina Gov. Henry McMaster, a Republican, called South Carolina’s proposal “a state-specific solution.”

The only state with an active work requirement program now wants to scale it back and awaits federal approval to do so. “Georgia Pathways to Coverage” expires at the end of September unless CMS greenlights an extension of the program with a key change: requiring enrollees to document once a year that they’re working, not monthly. That’s a pivot away from the program’s initial design but also differs from the new federal rules, which call for checks every six months.

Fiona Roberts, a spokesperson for Georgia’s Medicaid agency, said the state is still waiting to hear whether it needs to alter its plan.

So Georgia is among the states in limbo, awaiting guidance from the federal government.

KFF Health News correspondents Sam Whitehead and Lauren Sausser contributed to this report.

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

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SACRAMENTO, Calif. — As smoke from Canadian wildfires drifted across North America, and western U.S. states girded for their annual fire siege, Neeta Thakur was well into her search for ways to offset the damage of such fumes on people’s health, especially among minority and low-income communities.

For more than a decade, the University of California-San Francisco researcher relied on federal grants without incident. But Thakur, a doctor and a scientist, suddenly found herself leading the charge for public health science against President Donald Trump’s political ideology.

Thakur, 45, a pulmonologist who also is medical director of the Zuckerberg San Francisco General Hospital Chest Clinic, is the lead plaintiff among six UC researchers who in June won a class-action preliminary injunction against the efforts of several federal agencies to carry out Trump’s executive orders seeking to eliminate research grants deemed to focus on areas of diversity, equity, and inclusion. The administration has filed a notice of appeal, and the outcome, whether or not she and her colleagues prevail, could influence both the future of academic research and the health of those she’s spent her life trying to help.

“When this moment hit us, where science was really under attack and lives are at stake, it doesn’t surprise me that she stepped up,” said Margot Kushel, who directs the UCSF Action Research Center for Health Equity and has known Thakur for more than a decade through their work at the center and San Francisco General, the public county hospital.

“We don’t think our work should be political, to be honest,” Kushel said. “Saving people’s lives and making sure people don’t die doesn’t seem to me that it should be a partisan issue.”

Thakur said that after the abrupt funding cuts, she and the other researchers “felt pretty powerless and found that the class-action lawsuit was a way for us to join together and sort of take a stance.”

The suit was filed independently by the researchers and allowed them to show the harm inflicted not just on their own work “but more broadly on public health and public health research,” she said.

Thakur’s study, which received more than $1.3 million in funding from the Environmental Protection Agency and was set to run through November, explores the impact of increased wildfire smoke on low-income communities and communities of color, populations that already experience heightened pollution and other environmental health disparities. The goal is to find ways to help residents limit their smoke exposure, Thakur said, adding that the results could help people no matter their circumstances.

Preliminary findings show that smoke can trigger breathing emergencies among children days after exposure, knowledge that could lead to better treatment, and that smoke intensity may peak during just a few hours when protection is most needed, indicating the need for more precise and timely safety messaging.

Thakur said her studies on health equity and health disparities saw growing federal support during the covid pandemic and a national focus on racism spurred by the murder of George Floyd. The EPA had solicited the grant in 2021 for her and her team to research how climate change affects underserved communities.

Trump, in one of several executive orders blocking federal funding for DEI programs, said they “use dangerous, demeaning, and immoral race- and sex-based preferences” that he said have “prioritized how people were born instead of what they were capable of doing.”

EPA Administrator Lee Zeldin said in March that, in cooperation with the Department of Government Efficiency, the administration had canceled more than 400 grants topping $2 billion “to rein in wasteful federal spending.”

The order by U.S. District Judge Rita Lin in San Francisco temporarily blocking the grant terminations covered the EPA, as well as grants by the National Endowment for the Humanities and the National Science Foundation. Lin’s ruling was not a nationwide injunction of the sort restricted by the U.S. Supreme Court in a June decision.

The Trump administration agencies affected by the order have reinstated the UC grants as the lawsuit proceeds. The government filed a motion for a temporary stay on the order pending the outcome of its appeal, but a decision had not been issued as of publication.

The EPA declined to comment on the judge’s order blocking the attempted cancellation of the research funding, citing the ongoing litigation, and attorneys representing the government did not respond to requests for comment.

Thakur defends the need for research that spotlights disadvantaged communities. Her interest in health equity stems from childhood experiences. The daughter of immigrants from India, with a physician and an engineer as parents, she grew up relatively well-off in a mixed-income neighborhood in Phoenix. While she prospered, however, she had friends who couldn’t afford college or became pregnant as teenagers.

“I see my research being directed towards trying to understand how where you live and what you experience impacts your health,” Thakur said.

When the grants were suspended in April, the researchers were unable to finish identifying ways to help protect communities from wildfire smoke. Thakur had to dismiss a student intern and dip into discretionary funds to pay her postdoctoral fellow. At least three research papers that could have directly affected public health were in danger of going unpublished without the funding, she said.

The government reinstated her team’s grants about three weeks after the judge’s order, and Thakur is in the process of picking up the pieces. She’s hopeful that researchers can publish two of the three studies they were working on.

Thakur said she is now cautiously optimistic after experiencing “a roller coaster of emotions.” Putting together a project and conducting the research takes years, she said, so “to have all of that end suddenly, it brought me a range of emotions one thinks about when folks are experiencing grief. There’s denial, anger.”

But the Trump administration’s actions have already sapped morale in the field. Rebecca Sugrue, Thakur’s postdoctoral fellow and an expert in health equity and climate change, is rethinking her entire career path.

“I kind of came to the realization that all the expertise I had built up were the kind of things that were being deprioritized,” Sugrue said. She said she and other postdoctoral students and more junior members of the research team even had discussions about leaving academia: “‘Unstable’ and ‘uncertain’ were words that were used a lot.”

The lasting damage is not lost on Thakur. If the grants ultimately disappear, universities won’t have the typical programs to train students or to support academic research, she said, adding that, “I think there are concerns that the sort of divestment from science and research in these particular areas will cause generations of impact.”

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

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

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Now that the Republicans’ big tax-and-spending bill has become law, new bureaucratic hurdles have emerged for millions of Americans who rely on Medicaid for health coverage. A provision in the new law dictates that, in most states, for the first time, low-income adults must start meeting work requirements to keep their coverage.

Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.

When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn’t opposed to work requirements — in principle.

But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state’s work requirements.

“I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I’m like, I know the process,” Corporal said. “I’ve been in human services.”

Corporal has been a social worker for more than two decades in Georgia and was familiar with the state’s social service programs. For years, it had been her job to help others access benefit programs.

But her challenges with paperwork and the process had only begun.

Health advocates point to Georgia’s system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.

Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.

Most states will have to set up verification systems similar to Georgia’s, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.

For Corporal, 48, forgoing coverage wasn’t an option. She had been diagnosed with pre-diabetes and had other medical concerns.

“I have breast cancer in my family history,” she said. “So it was like, I gotta get my mammograms.”

On paper, it looked as if she qualified for Georgia’s program, called Georgia Pathways to Coverage.

It offers Medicaid to adults — who otherwise wouldn’t qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they’re working, attending school, training for a job, or volunteering.

Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.

She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia’s online portal.

“And we were denied. I was like, this makes no sense,” said Corporal, who has a master’s degree in social work. “I did everything right.”

In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.

Corporal recently pulled up one of the denial notices on her cellphone to read aloud: “Your case was denied because you didn’t submit the correct documents. And you didn’t meet the qualifying activity requirement,” she read from the email.

When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.

“Or, they’ll say they called you, and we look at our call log. Nobody called me,” she said. “And the letter will say, you missed your appointment, and it’ll come on the same day” as it was scheduled.

Corporal’s Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.

When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia’s Department of Human Services, emailed this statement: “Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case.”

Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants’ documents. They include “rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents.”

Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It’s stressful, she said.

“It’s still a nightmare, even once I got through the red tape and got approved,” Corporal said. “Now maintaining it is bringing another level of anxiety.”

But she wonders how anyone without her professional background manages to get into the program at all.

“I think the system has to be simplified,” she said.

Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.

It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.

But for now, Corporal’s experience remains typical. And many health advocates fear it will be replicated under Trump’s budget law with its new national Medicaid work mandate. 

“In Georgia, we have seen that people just can’t get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn’t file their paperwork or there’s been some other glitch,” said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.

Another state, Arkansas, tried work requirements in 2018.

But it didn’t go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.

“A lot of the problems were similar to Georgia,” she said, “in terms of the website closed at night, people couldn’t get a hold of people.”

Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse. 

“What we’re doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it,” U.S. House Speaker Mike Johnson said during a June appearance on “The Megyn Kelly Show.” “You’re talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it’s not being used for those purposes because it’s been expanded under the last two Democrat presidents and to cover everybody. So, you’ve got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we’re doing is restoring work requirements to Medicaid. OK, this is common sense.”

National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.

“Work requirements don’t work, except to cut people off of health insurance,” she said.

The logistical steps required to report one’s activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.

The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.

Mikell is a licensed truck driver but does not have coverage through that job. He’s also an electrician who currently does property maintenance in exchange for free housing.

Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal. 

“And I know it wasn’t my device because I would go to the library and use the computer, I would try different devices, and I’ve had the same issues,” he said. “Regardless of the device, it’s something with the website.”

Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.

“They said I was ineligible for everything because of a typo in the system or something, I don’t know what it was. I eventually was able to speak to someone and she fixed it,” he said.

This article is from a partnership with WABE 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.

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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.

In his ongoing effort to reshape health policy, Secretary of Health and Human Services Robert F. Kennedy Jr. reportedly plans to overhaul two more government entities: the U.S. Preventive Services Task Force and the National Vaccine Injury Compensation Program. Ousting the existing members of the task force would give Kennedy a measure of control in determining the kinds of preventive care that are covered at no cost to patients in the United States. And while it’s unclear what the secretary would do to the vaccine injury program, Kennedy has made no secret of his belief that vaccines can do more harm than good.

Meanwhile, last week marked the 35th anniversary of the Americans with Disabilities Act, and President Donald Trump signed an executive order that would enable local and state governments to forcibly hospitalize some people who are homeless and struggling with mental health problems.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories.

Among the takeaways from this week’s episode:

• Less than two months after Kennedy removed all members of the Advisory Committee on Immunization Practices, he is reportedly considering a similar purge of members of the task force that recommends the preventive services insurers must cover — a list whose services, some of them controversial among Trump officials, include drugs that prevent HIV and certain cancer screenings. He is also considering changes to the federal program that compensates people who experience adverse effects from immunizations.
• This week Vinay Prasad, the Food and Drug Administration’s top vaccine official, resigned just months into his tenure. Prasad had come under attack, notably by right-wing personality Laura Loomer, and had been blasted for some agency decisions about new drugs for rare diseases — despite his work limiting the use of covid shots.
• Trump’s newly announced trade deal with the European Union includes a 15% tariff on brand-name pharmaceuticals, which would include, for example, the diabetes drug Ozempic, often used for weight loss. But it would be difficult to lower prices on brand-name drugs through tariffs; it is unlikely that drugmakers, facing higher import costs, would relocate production to the United States.
• Also, Trump’s big tax and spending law, hastened through Congress weeks ago, renders some lawfully present immigrants ineligible for Affordable Care Act subsidies. But a new KFF Health News column points out that the change would actually raise premiums for everyone else, taking more healthy people out of the insurance pool.

Also this week, Rovner interviews George Washington University health policy professor Sara Rosenbaum, one of the nation’s leading Medicaid experts, to mark Medicaid’s 60th anniversary this week.

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

Julie Rovner: KFF Health News’ “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege,” by Fred Schulte.

Anna Edney: The Washington Post’s “Morton Mintz, Post Reporter With a Muckraker Spirit, Dies at 103,” by Stefanie Dazio.

Joanne Kenen: ScienceAlert’s “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield.

Shefali Luthra: The New Yorker’s “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” by Burkhard Bilger.

Also mentioned in this week’s podcast:

• The New York Times’ “Top F.D.A. Official Resigns Under Pressure,” by Christina Jewett.
• KFF Health News’ “Lawfully Present Immigrants Help Stabilize ACA Plans. Why Does the GOP Want Them Out?” by Bernard J. Wolfson.
• The Texas Tribune’s “Texas Man Sues California Doctor in Federal Court, Testing a New Angle to Crackdown on Abortion Pills,” by Eleanor Klibanoff.

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.

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On a recent weekday evening, Ashly Richards helped her 13-year-old son, Case, with homework. He did math problems and some reading, underscoring how much he’s accomplished at his school for children with autism.

Richards has heard Trump administration officials suggest that food dyes and pediatric vaccines cause autism and ADHD. That stance, she said, unfairly blames parents.

“There’s no evidence to support it,” said Richards, 44, a marketing director in Richmond, Virginia. “As a parent, it’s infuriating.”

In their zeal to “Make America Healthy Again,” Trump administration officials are making statements that some advocacy and medical groups say depict patients and the doctors who treat them as partly responsible for whatever ails them.

Health and Human Services Secretary Robert F. Kennedy Jr. and agency leaders have attributed a panoply of chronic diseases and other medical issues — such as autism, attention-deficit/hyperactivity disorder, depression, diabetes, and obesity — to consumers and their lifestyle choices, according to a review of 15 hours of recorded interviews, social media statements, and federal reports.

He said at a news conference on April 16 that autism is preventable and that rates are rising because of toxic substances in the environment, despite a lack of evidence there is any link.

“These are kids who will never pay taxes. They’ll never hold a job. They’ll never play baseball. They’ll never write a poem. They’ll never go out on a date,” he said. “Many of them will never use a toilet unassisted.”

The vast majority of people on the spectrum do not have those severe challenges.

The statements are more than rhetoric. These attitudes, ranging from judgments about individual behaviors to criticism of the chronically poor, are shaping policies that affect millions of people. The sentiments have been a factor behind decisions to cut Medicaid, keep federal insurance programs from covering anti-obesity drugs, and impose new barriers to covid vaccines for healthy people, say public health leaders and doctors. GOP lawmakers and federal health officials, they say, hold a reproachful stance toward chronic illnesses and the estimated 129 million people in the U.S. affected by them.

“This is at the heart of so much of our national problem with health,” said Robert Califf, who led the Food and Drug Administration during the Obama and Biden administrations. “It’s these two extreme views. It’s every health decision is up to the ‘rugged individual,’ versus the other extreme view that it’s all controlled by environment and social determinants of health. The truth is, it’s on a continuum.”

The Blame Game

Self-reliance is a common theme among adherents of MAHA, an informal movement for which Kennedy has fashioned himself the figurehead that promotes medical freedom, skepticism of vaccines, and a focus on nontraditional medicine to treat disease.

Taking medication to manage diabetes? FDA Commissioner Marty Makary suggested on Fox News in late May that it would be effective to “treat more diabetes with cooking classes” instead of “just throwing insulin at people.”

People with Type 1 diabetes must take insulin because their pancreases don’t produce it, according to the National Institutes of Health, which also notes that many with Type 2 diabetes “need to take diabetes medicines as well.”

Taking birth control pills? Casey Means, President Donald Trump’s nominee to be U.S. surgeon general, has said that’s a “disrespect of life” for short-term gain and efficiency.

“We are prescribing them like candy,” she said last year on “The Tucker Carlson Show,” adding that birth control medications “are literally shutting down the hormones in the female body that create this cyclical, life-giving nature of women.”

Have a child on ADHD meds? Calley Means, who is an adviser to Kennedy and is Casey Means’ brother, said on the same show that Adderall is prescribed as the standard of care when children get a little fidgety because they’re in sedentary environments with limited sunlight and eat too much ultraprocessed food.

As a society, he said, “we’re really committing mass child abuse in many ways, and we’re normalizing that and we’re not speaking out about that. And then we’re giving people stimulants developed by Nazi Germany.”

Calley Means was probably referring to Pervitin, a methamphetamine-based drug administered to Adolf Hitler’s forces in World War II. Adderall is a prescription drug containing amphetamine, a stimulant that’s not the same as methamphetamine.

The Department of Health and Human Services didn’t respond to messages seeking comment from Means.

Some conservatives and MAHA adherents argue that people need to take more responsibility for their health. But comments that shift blame to patients and physicians risk perpetuating stigmas, fostering the spread of misinformation, and eroding trust in modern medicine, say medical groups, doctors, and patient advocacy groups.

The statements assume consumers and patients have control over improving their health and preventing chronic disease when the reality is more complex, according to some public health leaders. Lower-income people, they say, often lack access to grocery stores and healthy food, may juggle too many jobs to have time to cook from scratch, and may live in dangerous areas where it’s harder to get outside and exercise.

Jerome Adams, surgeon general during the previous Trump administration, told KFF Health News that he worries efforts to promote health will be undone by “the return of vaccine-preventable diseases, increasing mistrust in the health care system, and the tearing down of social supports which are critical for making healthy choices.”

Tough Talk

The attitudes held by top Trump health officials have affected policy decisions, some doctors and public health leaders say.

Kennedy and other Trump administration health leaders have been especially outspoken, targeting issues they consider especially egregious in recent federal actions, research, or policy.

For example, the Biden administration proposed a rule in November that would let Medicare cover weight loss medications such as Wegovy and Zepbound. But Kennedy and other political appointees at HHS and its agencies have criticized the drugs and the people who take them.

“I think it’s very dark,” Calley Means told Carlson, referring to the weight loss drugs. “I think it’s a stranglehold on the U.S. population, almost like solidifying this idea that there is a magic pill.”

He added: “Where is the urgency on saying ‘Hey parents, maybe we shouldn’t feed our kids toxic food?’”

Kennedy, too, has criticized the medications and people who use them, saying in October on Fox News that drugmakers “are counting on selling it to Americans because we’re so stupid and so addicted to drugs.”

In April, the Trump administration announced it would not finalize the Biden-era coverage rule.

“It’s impacting the kind of care and treatments patients will have,” said Andrea Love, a biomedical scientist and founder of ImmunoLogic, a science communication organization. “It sends the message that it’s your fault. It’s very much victim-blaming. It creates the idea that scientific progress is the devil, demonizes things that aren’t individually harming health, while avoiding addressing systemic issues that play a much larger role in health.”

Kennedy and HHS didn’t return messages seeking comment.

Data shows that the medications are effective. People who took the highest dose of Zepbound in clinical trials lost an average of 48 pounds, and 1 in 3 on that dose lost more than 58 pounds, or 25% of their body weight.

Kennedy and other agency leaders also oppose many covid-era health restrictions and rules. Some physicians and public health leaders note these officials downplayed covid risks while criticizing vaccines developed during the previous Trump administration.

Kennedy has said that people who died from covid actually fell victim to chronic diseases such as obesity, diabetes, or asthma.

“That’s really what killed them,” Kennedy said on “Dr. Phil Primetime” in April. “These were people who were so sick they were basically hanging from a cliff, and covid came along and stamped on their fingers and dropped them off. But they were already living lives that were burdened by sickness.”

Covid was the underlying cause of death for more than 940,000 people in the U.S. from Aug. 1, 2021, to July 31, 2022, according to a 2023 report in JAMA Network, an open-access journal on biomedical sciences published by the American Medical Association.

Covid ranked first among deaths caused by infectious or respiratory diseases for youths under age 19, based on the report. Infants under a year old may be at higher risk of experiencing severe illness from covid compared with older children, studies show, and risks are also higher for infants under 6 months and those with underlying medical conditions.

“Vaccination during pregnancy can help protect infants after birth,” according to the CDC.

But Kennedy announced in May that the federal government would no longer recommend covid vaccines for pregnant people and children who are healthy. Medical groups such as the American Academy of Pediatrics opposed this decision and filed a lawsuit. 

Kennedy also helped promote beliefs that many childless adults on Medicaid, the federal-state program for low-income people, don’t work and thereby drain resources from the program.

At a May hearing of the House Energy and Commerce Committee, Kennedy said the program was in jeopardy because of “all the able-bodied people who are not working [or] looking for jobs.”

It’s a view embraced by Republican lawmakers who portrayed adults enrolled in Medicaid as lazy or shirking work as they advanced a budget bill estimated to cut federal spending on the program by about $1 trillion over a decade, in part by imposing work requirements on many adult beneficiaries.

“Thirty-five-year-olds sitting at home playing video games, they’re going to now have to go get a job,” said House Majority Leader Steve Scalise of Louisiana.

The legislation, which Trump signed into law this month, will cause about 10 million more people to be without health insurance by 2034, the Congressional Budget Office estimates.

Some health leaders who criticized the legislation say the statements inaccurately maligned Medicaid enrollees, who by law cannot hold high-paying jobs and remain in the program.

Nonetheless, nearly two-thirds of adults ages 19 to 64 covered by Medicaid in 2023 were working. For about 3 in 10, caregiving responsibilities, an illness or disability, or school attendance prevented them from working, according to KFF, a health information nonprofit that includes KFF Health News.

“It’s using anti-welfare tropes for something that is basic health care, not a cash benefit,” said Anthony Wright, executive director at Families USA, which supports the Affordable Care Act and expanded health coverage. He summarized the Republican message: “We’re going to make it harder to get the help you need by imposing a bunch of paperwork, and if you don’t get it, it’s your fault.”

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

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In retrospect, Erica Kahn realizes she made two big mistakes.

The first was choosing to temporarily forgo health insurance when she was laid off from her job.

The second was screaming when a wild bat later landed on her face.

The bizarre encounter happened last August, while the Massachusetts resident was photographing the night sky during a vacation at the Glen Canyon National Recreation Area in Arizona. Kahn, now 33, noticed a few bats flying around but didn’t worry about them — until one flew up to her and got tangled between her camera and her face.

She screamed, and part of the bat went in her mouth. She doesn’t know which part or for how long, though she estimates it was only a few seconds. “It seemed longer,” she said.

The bat flew away, leaving Kahn shaken.

She didn’t think the animal had bitten her. Regardless, her father, who is a physician and was traveling with her, said she should go to a hospital within a day or so and begin vaccinations against rabies.

Figuring she would be covered as long as she obtained insurance before going to the hospital, Kahn said, she found a policy online the day after the bat incident. She said she called the company before she bought its policy and was told services related to an accident or “life-threatening” emergency would be covered.

Kahn went the next day to a hospital in Flagstaff, Arizona, where she started rabies prevention treatment. Over the next two weeks, she received the rest of the rabies shots at clinics in Arizona and Massachusetts and at a hospital in Colorado.

Then the bills came.

The Medical Procedure

Kahn received a total of four doses of the rabies vaccine. The doses are administered over the course of 14 days. Along with her first vaccination, she received three shots of immunoglobulin, which boosts antibodies against the virus.

Rabies is typically transmitted through bites or scratches from an infected animal. Experts recommend precautionary measures when a person has been potentially exposed to rabies, because once the neurological disease causes symptoms, it is fatal. The Centers for Disease Control and Prevention says postexposure rabies treatment has reduced the number of human fatalities to fewer than 10 a year in the U.S.

The Final Bill

According to explanation-of-benefits statements, Kahn owed a total of $20,749 for her care at the four facilities. Most of the charges were from the hospital where she was first treated, Flagstaff Medical Center: $17,079, including $15,242 for the rabies and immunoglobulin shots.

The Billing Problem: Most Insurance Doesn’t Start Immediately

Kahn’s policy did not pay for any of the services. “The required waiting period for this service has not been met,” said an explanation-of-benefits letter she received in December.

Kahn was stunned. “I thought it must have been a mistake,” she said. “I guess I was naive.”

When Kahn was laid off from her job as a biomedical engineer last summer, she had the option to temporarily stay on her former employer’s insurance under a COBRA plan, at a cost of about $650 a month. But as a young, healthy person, she gambled that she could get by without insurance until she found another job. She figured that if she needed medical care, she could quickly buy a private policy.

According to the Centers for Medicare & Medicaid Services, those who qualify for COBRA must be given at least 60 days to sign up — and if they do, the coverage applies retroactively. Kahn, who was still within that period at the time of the incident, said recently that she did not realize she had that option.

The policy she purchased after the bat episode, which cost about $311 a month, was from a Florida company called Innovative Partners LP. Documents Kahn provided to KFF Health News say the policy has a 30-day waiting period, which “does not apply to benefits regarding an accident or loss of life.”

Kahn said that after receiving notice that her claims were denied, she called the company to ask how she could appeal and was told a doctor would have to file paperwork. She said she wrote a letter that was signed by a doctor at Flagstaff Medical Center and submitted it in March but was unable to reach doctors at the other facilities.

Kahn said she was given conflicting answers about where to send the paperwork. She said a representative with the company recently told her it had not received any appeals from her.

Benefits statements Kahn received in early July show Innovative Partners had not paid the claims. The company did not respond to requests for comment for this article.

Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, said most health coverage plans take effect on the first day of the month after a customer enrolls.

“The insurance companies — for good reason — don’t want people to wait to sign up for coverage until they are sick,” she said, noting the premiums healthy people pay help balance the costs of paying for health care.

The Affordable Care Act requires insurers to cover preexisting conditions, such as diabetes or heart issues. But that doesn’t mean they have to pay for treatment of an injury sustained shortly before a person enrolls in coverage, she said.

Corlette, who reviewed a brief benefits overview provided by Kahn, said the policy appears to have been a limited, “fixed indemnity” plan, which would pay only set amounts toward treatments per day or other period regardless of total expenses incurred. Such plans have been around for decades and aren’t required to meet ACA standards, she said.

But she said even if Kahn had bought comprehensive health insurance, it probably wouldn’t have covered treatment received so soon after she purchased it.

David Shlim, a travel medicine specialist in Wyoming who studies rabies, said Kahn made the right choice by promptly seeking treatment, even though she didn’t feel the bat bite her. The disease is deadly, and the fact that the bat went into her mouth meant she could have been infected from its saliva, he said: “You could hardly have a more direct exposure than that.”

Shlim, who recently co-wrote a federal advisory about rabies prevention, added that  healthy bats don’t normally fly into people, as the one in this case did. The animal’s entanglement with Kahn suggests it could have been sick, possibly with rabies, he said.

Rabies prevention treatment is much more expensive in the United States than in most other countries, Shlim said. The priciest part is immunoglobulin, which is made from the blood plasma of people who have been vaccinated against rabies.

The treatment is often administered in hospital emergency rooms, which add their own steep charges, Shlim noted.

The Resolution

Kahn said she is employed again and has good health insurance but is still facing most of the bills from her misadventure at Glen Canyon. She said she paid a doctor bill from Flagstaff Medical Center after negotiating it down from $706 to $420. She said she’s also arranged a $10-a-month plan to pay off the $530 she owes for one of her rabies shots at another facility.

She said she plans to continue appealing the denials of payment for the rest of the bills, which total more than $19,000.

In a statement on behalf of the Flagstaff hospital — where Kahn incurred the highest charges — Lauren Silverstein, a spokesperson at Northern Arizona Healthcare, said the health system does what it can to limit costs. “We have less ability to control the prices of critical supplies that we use to treat patients, including pharmaceuticals, biologics, diagnostics and medical devices made by other companies,” she said.

Silverstein said the hospital needs to keep immunoglobulin on hand to prevent rabies, even though such cases are relatively rare and the drug is expensive.

The Takeaway

COBRA insurance policies, named for the Consolidated Omnibus Budget Reconciliation Act of 1985, enable many people who lose job-based coverage to pay to stay on those plans temporarily. There is a 60-day window to choose COBRA coverage, and once a beneficiary pays for it, the coverage applies retroactively — meaning that medical care is covered even if it occurred when the person was uninsured.

Corlette said Kahn’s predicament illustrates why people need to make sure they have health insurance.

She said people who lose employer-based coverage should consider enrolling in individual insurance plans sold on federal or state marketplaces. Many people who buy such policies qualify for substantial ACA subsidies to help pay premiums and other costs.

“If you are losing your job, COBRA is not your only option,” Corlette said.

Kahn wishes she had signed up for insurance coverage when she was laid off, even though she felt confident she would find another job within a few months. “That’s a very big lesson I learned the hard way,” she said.

Her wildlife encounter did not destroy her love of the outdoors. She even sees humor in it.

“I know what bats taste like now. It’s an earthy, sweet kind of flavor,” she joked. “It’s actually a pretty funny story — if it weren’t for the horrible medical bill that came with it.”

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

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ELKO, Nev. — At the Two Spirit Conference in northern Nevada in June, Native Americans gathered in support of the LGBTQ+ community amid federal and state rollbacks of transgender protections and gender-affirming health care.

“I want people to not kill themselves for who they are,” said organizer Myk Mendez, a trans and two-spirit citizen of the Fort Hall Shoshone-Bannock Tribes in Idaho. “I want people to love their lives and grow old to tell their stories.”

“Two-spirit” is used by Native Americans to describe a distinct gender outside of male or female.

The conference in Elko reflects how some tribal citizens are supporting their LGTBQ+ community members as President Donald Trump rolls back protections and policies. In March, the National Indian Health Board, which represents and advocates for federally recognized Native American and Alaska Native tribes, passed a resolution declaring tribal sovereignty over issues affecting the Native American community’s health, including access to gender-affirming care.

The resolution calls on the federal government to preserve and expand programs that support the health and well-being of two-spirit and LGBTQ+ Native Americans. Tribes and tribal organizations are navigating how to uphold their sovereignty without jeopardizing the relationships and resources that support their communities, said Jessica Leston, the owner of the Raven Collective, a Native public health consulting group, and a member of the Ketchikan Indian Community.

In January, Trump signed an executive order recognizing only two sexes — male and female — and another to terminate diversity, equity, and inclusion programs within the federal government.

An Indian Health Service website describing two-spirit people was removed this year but restored following a court order. The page now has a disclaimer at the top that declares any information on it “promoting gender ideology” is “disconnected from the immutable biological reality that there are two sexes, male and female.”

Two-spirit is not a sexual orientation but refers to people of a “culturally and spiritually distinct gender exclusively recognized by Native American Nations,” according to a definition created by two-spirit elders in 2021. According to two-spirit leaders, people who did not fit into the Western binary of male and female have lived in their communities since before colonization.

Already, tribal citizens and leaders say some people have had trouble accessing gender-affirming care in recent months, with some community members being denied hormone treatments or having their medications delayed, even in places where gender-affirming care remains legal. Panic has spread, and tribal citizens have considered leaving the country.

“There is a chilling effect,” said Itai Jeffries, who is trans, nonbinary, and two-spirit, of the Occaneechi people from North Carolina, and a consultant for the Raven Collective.

Mendez said he requested hormone treatment at his local Indian Health Service clinic at the end of June and was told by his provider that the facility has had trouble receiving the treatment for patients.

Lenny Hayes, a two-spirit citizen of the Sisseton-Wahpeton Oyate in South Dakota, said the Indian Health Service clinic on the reservation also isn’t dispensing hormone treatment, though it is legal for people 18 and older. Hayes is the owner and operator of Tate Topa Consulting and provides educational training on two-spirit and LGTBQ+ Native Americans and Alaska Natives.

The National Congress of American Indians passed a resolution in 2015 to encourage the creation of policies to protect two-spirit and LGBTQ+ communities. And the organization adopted a resolution in 2021 to support providing gender-affirming care in Indian Health Service, tribal, and urban facilities.

The National Indian Health Board’s resolution cites homophobia and transphobia as contributing to higher rates of truancy, incarceration, self-harm, attempted suicide, and suicide among two-spirit young people. The board also lists health disparities among the broader Native LGBTQ+ population, including increased risks of anxiety, depression, and suicide.

Two-spirit and LGBTQ+ Native American and Alaska Native young people are particularly vulnerable to depression, suicidality, and sexual exploitation. In Minnesota, a 2019 state survey found that two-spirit and LGBTQ+ Native American and Alaska Native students had the highest rates of those ages 15-19 who responded “yes” to having traded sex or sexual activity for money, food, drugs, alcohol, or shelter.

Tribal leaders are also concerned that Medicaid cuts recently approved in Trump’s budget law will undercut efforts to expand testing and treatment for HIV infection in Native American communities.

The rates of HIV diagnosis among Native American and Alaska Native gay and bisexual men increased 11% from 2018 to 2022, according to the Centers for Disease Control and Prevention.

Despite this increase, Native American and Alaska Native gay and bisexual men are among the groups with the least access to HIV tests outside of health care settings, such as community-based organizations, mobile testing units, and shelters.

As tribes respond to state and federal regulations of two-spirit and LGBTQ+ people, organizations and communities are focused on providing information and resources to protect those in Indian Country, even from the president.

“He will never, ever wipe out our identity, no matter what he does,” Hayes said.

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

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A child developed a rash after he was prevented from changing his underwear for four days. A little boy, bored and overcome with despair, began hitting himself in the head. A child with autism and attention-deficit/hyperactivity disorder was forced to go without his medication, despite his mother’s pleas.

“I heard one officer say about us ‘they smell like sh–,’” one detained person recounted in a federal court filing. “And another officer responded, ‘They are sh–.’”

Attorneys for immigrant children collected these stories, and more, from youth and families detained in what they called “prison-like” settings across the U.S. from March through June, even as the Trump administration has requested a federal district court judge terminate existing protections that mandate basic rights and services — including safe and sanitary conditions — for children held by the government.

The administration argues that the protections mandated under what is known as the Flores Settlement Agreement encourage immigration and interfere with its ability to establish immigration policy. U.S. District Court Judge Dolly Gee, who is in California, is expected to issue a ruling on the request after an Aug. 8 hearing.

With the agreement in place, children are being held in “unsafe and unsanitary” U.S. Customs and Border Protection facilities such as tents, airports, and offices for up to several weeks despite the agency’s written policy saying people generally should not be held in its custody longer than 72 hours, according to the June court filing from immigrants’ attorneys. In addition to opposing the U.S. Department of Justice’s May request to terminate the Flores consent decree, the attorneys demanded more monitoring for children in immigration detention.

“The biggest fear is that without Flores, we will lose a crucial line of transparency and accountability,” said Sergio Perez, executive director of the California-based Center for Human Rights and Constitutional Law. “Then you have a perfect storm for the abuse of individuals, the violation of their rights, and the kind of treatment that this country doesn’t stand for.”

The Flores agreement has set minimum standards and oversight for detained immigrant children since 1997, when it brought an end to a decade-long lawsuit filed on behalf of unaccompanied immigrant minors who had been subjected to poor treatment in unsafe and unsanitary conditions without access to medical care. It is named for Jenny Lisette Flores, a 15-year-old from El Salvador who was taken into U.S. custody in the mid-1980s, subjected to strip searches, and housed alongside unrelated men.

The agreement established national standards for the protection of immigrant children detained by federal authorities, with requirements for safe and sanitary detention facilities, access to clean water, appropriate food, clothing, bedding, recreational and educational opportunities, sanitation, plus appropriate medical and mental health care. Children in immigrant detention range from infants to teens.

In 2015, Gee ruled that the agreement includes children accompanied by adults.

The Justice Department and the Department of Homeland Security, which includes both the Customs and Border Protection agency and Immigration and Customs Enforcement, declined to respond on the record to questions about the administration’s intent to end the Flores agreement or about the conditions in which kids are detained. In a May court filing, government attorneys argued, among other points, that the agreement improperly directs immigration decisions to the courts, not the White House. U.S. Attorney General Pam Bondi also has said that the Flores agreement has “incentivized illegal immigration,” and that Congress and federal agencies have resolved the problems Flores was designed to fix.

ICE detention facilities have the “highest standards,” Abigail Jackson, a White House spokesperson, said in an email to KFF Health News. “They are safe, clean, and hold illegal aliens who are awaiting final removal proceedings.”

Immigration lawyers and researchers have pushed back on the idea that the Flores agreement encourages migration, arguing that the conditions in people’s homelands are driving them to move.

Trump is not the first president to seek to modify, or end, the agreement.

In 2016, President Barack Obama’s administration unsuccessfully sought to exempt accompanied minors from the Flores agreement, arguing that an influx of immigrants from Central America had overwhelmed the system.

In 2019, following a policy that caused family separation, the first Trump administration announced it would replace Flores with new regulations to expand family detention and eliminate detention time limits. The courts rejected that plan, too.

In 2024, President Joe Biden’s administration successfully requested to remove the Department of Health and Human Services from the agreement after the Office of Refugee Resettlement incorporated some Flores standards into agency regulations.

Allegations of unsafe conditions under the agreement also predate this latest immigration crackdown under Trump. One court filing from 2019 said that attorneys visiting two Texas detention centers found at least 250 infants, children, and teens, some of whom had been held at the facility for nearly a month. “Children were filthy and wearing clothes covered in bodily fluids, including urine,” the filing said.

Seven children are known to have died while in federal custody from 2018 to 2019, according to media reports.

And in 2023, 8-year-old Anadith Danay Reyes Alvarez became sick and died while in Customs and Border Protection custody in Texas for nine days. Her parents had turned over medical records detailing the girl’s medical history, including diagnoses of sickle cell disease and congenital heart disease, upon their detention. Yet her mother’s repeated pleas for emergency medical care were ignored.

Her family filed a wrongful death claim in May.

Advocates attributed the deaths partly to prolonged detention in increasingly crowded facilities and delayed medical care. Officials have said they increased medical services and acknowledged failures in the wake of the deaths.

But with the Trump administration’s unprecedented push to detain and deport migrants — including families — the threat to the health of children caught up in those sweeps is alarming child advocates.

“Very rarely do you have spikes in populations of detained folk that you don’t see a drastic decrease in the quality of their medical care,” said Daniel Hatoum, a senior supervising attorney at the Texas Civil Rights Project, one of the groups that filed the wrongful death claim for Anadith’s family.

Recent reports from court-appointed monitors cite continued lack of access to appropriate medical care; temperature extremes; few outside recreational opportunities; lack of appropriate food and clothing; and an inability to dim lights to sleep.

Terminating the Flores agreement would remove all outside oversight of immigration detention facilities by court-ordered monitors and attorneys. The public would have to depend on the government for transparency about the conditions in which children are held.

“Our system requires that there be some oversight for government, not just the Department of Homeland Security, but in general,” Hatoum said. “We know that. So, I do not believe that DHS could police itself.”

In the months after Trump took office and the Elon Musk-led Department of Government Efficiency began cuts, the administration shuttered DHS’ Office for Civil Rights and Civil Liberties, the Office of the Citizenship and Immigration Services Ombudsman, and the Office of the Immigration Detention Ombudsman, which were intended to add a layer of oversight. After a lawsuit, the Trump administration reversed action and noted the offices would remain open, but it is unclear how those offices have been affected by shifts in policy and cuts in staffing.

Leecia Welch, an attorney with the legal advocacy group Children’s Rights, said the Flores agreement itself, or efforts to hold the government responsible for abiding by its requirements, are not rooted in partisan politics. She said she raised concerns about conditions during Biden’s administration, too.

“These are not political issues for me,” Welch said. “How does our country want to treat children? That’s it. It’s very simple. I’m not going to take it easy on any administration where children are being harmed in their care.”

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

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A un niño le apareció un sarpullido después de cuatro días sin que le dejaran cambiarse la ropa interior. Otro pequeño, aburrido y abrumado por la desesperación, comenzó a golpearse la cabeza. A un menor con autismo y trastorno por déficit de atención no le dejaron tomar su medicamento, a pesar de las súplicas de su madre.

“Escuché a un oficial decir sobre nosotros: ‘huelen a mier–’, y otro agregó: ‘son mier–’”, contó una persona detenida en una declaración presentada ante un tribunal federal.

Entre marzo y junio, abogados de menores inmigrantes recopilaron estos testimonios, y otros de jóvenes y familias detenidas, en lo que describen entornos “con apariencia carcelaria” en distintos puntos de Estados Unidos.

Esto mientras el gobierno de Trump solicitaba a un juez federal poner fin a las protecciones vigentes que garantizan derechos y servicios básicos —como seguridad y condiciones higiénicas— para los niños bajo custodia del gobierno.

La administración argumenta que las protecciones establecidas en lo que se conoce como el Flores Settlement Agreement (el Acuerdo Flores) fomentan la inmigración e interfieren con su capacidad de implementar políticas migratorias. Se espera que la jueza Dolly Gee, del Tribunal de Distrito de Estados Unidos en California, emita una decisión luego de la audiencia del 8 de agosto.

Con el acuerdo aún vigente, los menores están siendo retenidos en instalaciones de la Oficina de Aduanas y Protección Fronteriza de Estados Unidos que “no son seguras ni higiénicas”, como carpas, aeropuertos y oficinas, durante semanas, a pesar que las reglas de la agencia indican que las personas no deben permanecer bajo su custodia más de 72 horas, según una declaración judicial presentada en junio por abogados de inmigrantes.

Además de oponerse a la solicitud del Departamento de Justicia de Estados Unidos para poner fin al Acuerdo Flores, los abogados exigieron mayor supervisión para los menores en detención migratoria.

“El mayor temor es que, sin Flores, perderemos una línea crucial de transparencia y rendición de cuentas”, dijo Sergio Pérez, director ejecutivo del Center for Human Rights and Constitutional Law, con sede en California. “Y entonces se da una tormenta perfecta para el abuso, la violación de derechos y el tipo de trato que este país no debería permitir”.

Desde 1997, el Acuerdo Flores ha establecido estándares básicos y supervisión para la detención de menores inmigrantes, tras poner fin a una demanda que se extendió por una década en nombre de menores inmigrantes no acompañados a los que se maltrató, manteniéndolos en condiciones inseguras e insalubres, sin acceso a atención médica.

El acuerdo lleva el nombre de Jenny Lisette Flores, una adolescente de 15 años de El Salvador, quien fue detenida por las autoridades estadounidenses a mediados de los años 80, sometida a requisas, desnuda, y alojada junto a hombres adultos desconocidos para ella.

El acuerdo estableció normas nacionales para la protección de menores inmigrantes bajo custodia federal, incluyendo el requerimiento de condiciones seguras y sanitarias en los centros de detención, acceso a agua potable, alimentación adecuada, ropa, cama, actividades recreativas y educativas, saneamiento, así como atención médica y de salud mental apropiadas.

Los menores en detención migratoria incluyen desde bebés hasta adolescentes.

En 2015, la jueza Gee dictaminó que el acuerdo también aplicaba a menores acompañados por adultos.

El Departamento de Justicia y el Departamento de Seguridad Nacional (DHS) —que incluye tanto a la Oficina de Aduanas y Protección Fronteriza como al Servicio de Inmigración y Control de Aduanas (ICE)— rechazaron responder públicamente a preguntas sobre la intención del gobierno de poner fin al Acuerdo Flores o sobre las condiciones en las que se encuentran los menores detenidos.

En una presentación judicial de mayo, los abogados del gobierno argumentaron, entre otras cosas, que el acuerdo asigna indebidamente decisiones migratorias a los tribunales en lugar de a la Casa Blanca. La fiscal general Pam Bondi también afirmó que el Acuerdo Flores ha “incentivado la inmigración ilegal”, y que el Congreso y las agencias federales ya resolvieron los problemas que Flores buscaba corregir.

Las instalaciones del ICE “tienen los estándares más altos”, dijo en un correo electrónico Abigail Jackson, vocera de la Casa Blanca. “Son seguras, limpias y albergan a extranjeros ilegales que están a la espera de los últimos procedimientos para ser removidos”.

Abogados de inmigración e investigadores han cuestionado la idea de que el Acuerdo Flores fomente la migración, argumentando que las condiciones en los países de origen es lo que impulsa a las personas a migrar.

Trump no fue el primer presidente en intentar modificar o eliminar el acuerdo.

En 2016, el gobierno del presidente Barack Obama intentó, sin éxito, eximir del Acuerdo Flores a los menores acompañados, alegando que un aumento en la migración desde Centroamérica había saturado el sistema.

En 2019, luego de una política que provocó la separación de familias, el primer gobierno de Trump anunció que reemplazaría el Acuerdo Flores con nuevas regulaciones para ampliar la detención familiar y eliminar los límites de tiempo. Los tribunales también rechazaron ese plan.

En 2024, el gobierno del presidente Joe Biden logró excluir al Departamento de Salud y Servicios Humanos (HHS) del acuerdo, después que la Oficina de Reasentamiento de Refugiados adoptara algunos estándares de Flores en sus propias regulaciones.

Las denuncias sobre condiciones inseguras bajo el acuerdo son anteriores a la última ofensiva migratoria de Trump. Una declaración judicial de 2019 afirmó que abogados que visitaron dos centros de detención en Texas encontraron al menos a 250 menores —desde bebés hasta adolescentes— algunos de los cuales habían estado detenidos casi un mes. “Los niños estaban sucios y vestían ropa manchada con fluidos corporales, incluida orina”, decía la declaración.

Según informes de prensa, se sabe que al menos siete menores murieron bajo custodia federal entre 2018 y 2019.

En 2023, Anadith Danay Reyes Álvarez, una niña de 8 años, se enfermó y murió luego de permanecer nueve días bajo custodia de la Oficina de Aduanas y Protección Fronteriza en Texas. Al momento de su detención, sus padres entregaron los expedientes médicos que documentaban su historial de enfermedades, incluyendo enfermedad de células falciformes y una afección cardíaca congénita,. Sin embargo, las repetidas súplicas de su madre para recibir atención médica de emergencia fueron ignoradas.

Su familia presentó una demanda por muerte por negligencia en mayo.

Defensores atribuyen las muertes, en parte, a la prolongada detención en centros cada vez más saturados y a demoras en la atención médica. Las autoridades han dicho que ampliaron los servicios médicos y han reconocido fallas tras las muertes.

Pero, con el esfuerzo sin precedentes del gobierno de Trump por detener y deportar migrantes —incluidas familias—, la amenaza para la salud de los menores atrapados en esas redadas alarma a los defensores de la infancia.

“Muy rara vez hay aumentos en la población detenida sin que se vea una disminución drástica en la calidad de la atención médica”, dijo Daniel Hatoum, abogado supervisor senior del Texas Civil Rights Project, una de las organizaciones que presentó la demanda por la muerte de Anadith.

Informes recientes de supervisores designados por la corte señalan que persisten problemas como la falta de atención médica adecuada, temperaturas extremas, pocas oportunidades de recreación al aire libre, alimentación y vestimenta inadecuadas, y la imposibilidad de apagar las luces para dormir.

Eliminar el Acuerdo Flores implicaría eliminar toda supervisión externa de los centros de detención migratoria por parte de monitores y abogados asignados por el tribunal. El público tendría que depender exclusivamente del gobierno para conocer las condiciones en que se encuentran los menores detenidos.

“Nuestro sistema requiere que haya algún tipo de supervisión del gobierno, no solo del Departamento de Seguridad Nacional, sino en general”, dijo Hatoum. “Sabemos eso. Así que no creo que el DHS pueda supervisarse a sí mismo”.

En los meses posteriores al regreso de Trump a la presidencia, y tras los recortes implementados por el Departamento de Eficiencia Gubernamental liderado por Elon Musk, la administración cerró la Oficina de Derechos Civiles y Libertades Civiles del DHS, la Oficina del Defensor del Ciudadano para Servicios de Ciudadanía e Inmigración, y la Oficina del Defensor de la Detención Migratoria, que estaban destinadas a proporcionar una capa adicional de supervisión.

Luego de una demanda, el gobierno de Trump revirtió la decisión y anunció que las oficinas seguirían abiertas, aunque no está claro cómo han sido afectadas por los cambios de política y recortes de personal.

Leecia Welch, abogada del grupo legal Children’s Rights, dijo que el Acuerdo Flores en sí, o los esfuerzos por exigir al gobierno que cumpla sus requisitos, no están motivados por ideologías políticas. También se expresaron preocupaciones sobre las condiciones en estas instalaciones durante la administración Biden.

“Para mí, estos no son asuntos políticos”, dijo Welch. “¿Cómo quiere nuestro país tratar a los niños? De eso se trata. Así de simple. No voy a tolerar que ningún gobierno dañe a niños bajo su cuidado”.

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A Georgia woman declared brain-dead and kept on life support for more than three months because she was pregnant was removed from a ventilator in June and died, days after doctors delivered her 1-pound, 13-ounce baby by emergency cesarean section. The baby is in the neonatal intensive care unit.

The case has drawn national attention to Georgia’s six-week abortion ban and its impacts on pregnancy care.

Adriana Smith was put on life support at Emory University Hospital in Atlanta in February. The then-30-year-old Atlanta nurse was more than eight weeks pregnant and suffering dangerous complications.

Her condition deteriorated as doctors tried to save her life, Smith’s mother told Atlanta TV station WXIA.

“They did a CT scan, and she had blood clots all in her head,” April Newkirk said. “So they had asked me if they could do a procedure to relieve them, and I said yes. And then they called me back and they said that they couldn’t do it.”

She said doctors declared Smith brain-dead and put her on life support without consulting her.

“And I’m not saying that we would have chose to terminate her pregnancy,” Newkirk said, “but what I’m saying is, we should have had a choice.”

Emory Healthcare declined to comment on the specifics of Smith’s case. After doctors removed Smith from life support, Emory issued a statement.

“The top priorities at Emory Healthcare continue to be the safety and wellbeing of the patients and families we serve,” the health system said. “Emory Healthcare uses consensus from clinical experts, medical literature and legal guidance to support our providers as they make medical recommendations. Emory Healthcare is legally required to maintain the confidentiality of the protected health information of our patients, which is why we are unable to comment on individual matters and circumstances.”

In a previous statement, Emory Healthcare said it complies “with Georgia’s abortion laws and all other applicable laws.”

Abortion Laws and Fetal Personhood

Georgia’s HB 481 — the Living Infants Fairness and Equality, or LIFE, Act — passed in 2019. It took effect shortly after the U.S. Supreme Court overturned Roe v. Wade with its ruling in Dobbs v. Jackson Women’s Health Organization on June 24, 2022.

The law bans abortion after the point at which an ultrasound can detect cardiac activity in an embryo. Typically, this occurs about six weeks into pregnancy, often before women know they’re pregnant.

The law also gave fetuses the same rights as people.

It says that “unborn children are a class of living, distinct persons” and that the state of Georgia “recognizes the benefits of providing full legal recognition to an unborn child.”

Nineteen states now ban abortion at or before 19 weeks of gestation; 13 of those have a near-total ban on all abortions with very limited exceptions, according to the Guttmacher Institute, a nonpartisan research group that supports abortion rights.

Like Georgia, some of these states built their abortion restrictions around the legal concept of “personhood,” thus conferring legal rights and protections on an embryo or fetus during pregnancy.

Smith’s case has represented a major test of how this type of law will be applied in certain medical situations.

Despite mainly being unified in their opposition to abortion, conservatives and politicians in Georgia do not publicly agree on the scope of the law in cases like Smith’s.

For example, Georgia Attorney General Chris Carr, a Republican, said that the law should not restrict the options for care in a case like Smith’s and that removing life support wouldn’t be equivalent to aborting a fetus.

“There is nothing in the LIFE Act that requires medical professionals to keep a woman on life support after brain death,” Carr said in a statement. “Removing life support is not an action ‘with the purpose to terminate a pregnancy.’”

But Republican state Sen. Ed Setzler, who authored the LIFE Act, disagreed. Emory’s doctors acted appropriately when they put Smith on life support, he told The Associated Press.

“I think it is completely appropriate that the hospital do what they can to save the life of the child,” Setzler said. “I think this is an unusual circumstance, but I think it highlights the value of innocent human life. I think the hospital is acting appropriately.”

Mary Ziegler, a law professor at the University of California-Davis and author of “Personhood: The New Civil War Over Reproduction,” said the problem is that Georgia’s law “isn’t just an abortion ban. It’s a ‘personhood’ law declaring that a fetus or embryo is a person, that an ‘unborn child,’ as the law puts it, is a person.”

The legal concept of “personhood” has implications beyond abortion care, such as with the regulation of fertility treatment, or the potential criminalization of pregnancy complications such as stillbirth and miscarriage.

Under Georgia’s law, extending rights of personhood to a fetus changes how child support is calculated. It also allows an embryo or fetus to be claimed as a dependent on state taxes.

But the idea of personhood is not new, Ziegler said.

“It has been the goal for virtually everyone in the anti-abortion movement since the 1960s,” she said. “That doesn’t mean Republicans like that. It doesn’t necessarily mean that that’s what’s going to happen. But there is no daylight between the anti-abortion movement and the personhood movement. They’re the same.”

The personhood movement has gained more traction since the Dobbs ruling in 2022.

In Alabama, after the state’s Supreme Court ruled that frozen embryos are people, the state legislature had to step in to allow fertility clinics to continue their work.

“This is sort of the future we’re looking at if we move further in the direction of fetal personhood,” Ziegler said. “Any state Supreme Court, as we just saw in Alabama, can give them new life,” she said referring to personhood laws elsewhere.

Fetal Personhood Laws Can Delay Care  

In Georgia, dozens of OB-GYNs have said that the law interferes with patient care — in a state where the maternal mortality rate is one of the worst in the U.S. and where Black women are more than twice as likely to die from a pregnancy-related cause than white women. 

Members of Georgia’s Maternal Mortality Review Committee — who were later dismissed from the panel — linked the state’s abortion ban to delayed emergency care and the deaths of at least two women in the state, as ProPublica reported.

The personhood provision is having a profound effect on medical care, said Atlanta OB-GYN Zoë Lucier-Julian.

“These laws create an environment of fear and attempt to coerce us as providers to align with the state, as opposed to aligning with our patients that we work so hard to serve,” Lucier-Julian said.

Lucier-Julian said that’s what happened to Emory Healthcare in Smith’s case.

Cole Muzio, president of the Frontline Policy Council, a conservative Christian group, said the state’s abortion law shouldn’t have affected how Emory handled Smith’s care.

“This is a pretty clear-cut case, in terms of how it’s defined in the language of HB 481,” he said. “What this bans is an abortion after a heartbeat is detected. That is the scope of our law.”

“Taking a woman off life support is not an abortion. It just isn’t,” Muzio said.“Now, I am incredibly grateful that this child will be born even in the midst of tragic circumstances. That is a whole human life that will be able to be lived because of this beautiful mother’s sacrifice.”

A suit challenging Georgia’s law and its impact on public health is working its way through the courts. A coalition of physicians, the American Civil Liberties Union of Georgia, Planned Parenthood, the Center for Reproductive Rights, and other groups filed the suit.

Newkirk said her daughter had initially gone to a different Atlanta-area hospital for help with severe headaches, was given some medicine, and was sent home, where her symptoms quickly worsened.

“She was gasping for air in her sleep, gargling,” she told WXIA in May. “More than likely, it was blood.”

Now, Newkirk said, the family is praying for her grandson to make it after the stress from months of life support. 

He is fighting, she said.

“My grandson may be blind, may not be able to walk, wheelchair-bound,” she said. “We don’t know if he’ll live.”

She added that the family will love him no matter what.

This article is from a partnership with WABE 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.

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KFF Health News chief Washington correspondent Julie Rovner discussed the impact of Medicaid cuts on WAMU’s “1A” on July 23.

• Click here to hear Rovner on “1A.”

KFF Health News correspondent Rachana Pradhan discussed cuts at the National Cancer Institute and the ensuing chaos on PBS’ “PBS News Weekend” on July 19.

• Click here to watch Pradhan on “PBS News Weekend.”
• Read Pradhan’s “World’s Premier Cancer Institute Faces Crippling Cuts and Chaos,” with reporting from Arthur Allen.

KFF Health News Southern correspondent Sam Whitehead discussed how Georgia and other states will be affected by President Donald Trump’s budget law on WUGA’s “The Georgia Health Report” on July 18.

• Click here to hear Whitehead on “The Georgia Health Report.”
• Read Whitehead’s “In a First, Trump and GOP-Led Congress Prepare To Swell Ranks of US Uninsured,” with reporting from Renuka Rayasam.

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

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RAPID CITY, S.D. — Native American tribes and health organizations are responding to concerns about low measles vaccination rates and patients’ difficulty getting care as an outbreak of the disease spreads around the country.

They’re hosting mobile vaccine clinics, running social media campaigns, making sure health providers are vaccinated, reaching out to the parents of unvaccinated children, and hosting online training sessions.

The push to ensure Native American communities are protected from the virus comes as the U.S. is experiencing its worst measles outbreak since 1992. The South Dakota health department announced in early June that the first case in the state was an adult from the Rapid City area.

Cassandra Palmier and her son, Makaito Cuny, have benefited from this outreach. Palmier jumped at the opportunity to get her 5-year-old vaccinated after learning that a mobile clinic would make a stop near her home in a predominately Native American neighborhood in Rapid City.

She had been meaning to get Makaito his second and final dose of the measles vaccine. But car problems made it difficult to get to the doctor.

“I was definitely concerned about the epidemic and the measles,” said Palmier, a member of the Oglala Sioux Tribe. “I wanted to do my part.”

Meghan O’Connell is the chief public health officer at the Great Plains Tribal Leaders’ Health Board, which organized the mobile clinic. She said data on Native Americans’ vaccination rates is imperfect but suggests that a smaller percentage have received measles shots than the overall U.S. population.

O’Connell said lower vaccination rates may stem from challenges in accessing shots and other health care. Native Americans on rural reservations may be an hour or more from a clinic. Or, like Palmier, they may not have reliable transportation.

Another reason, O’Connell said, is that some Native Americans distrust the Indian Health Service, which is chronically underfunded and understaffed. If the federal agency runs the only nearby health care facility, patients may delay or skip care, she said.

Mirroring a nationwide trend, vaccine skepticism and mistrust of the entire health care system are growing in Native American communities, O’Connell added.

During the mobile clinic’s stop in his Rapid City neighborhood, Makaito walked onto the bus and hopped into an exam chair.

“I’m not going to be scared,” he announced. Makaito sat still as a nurse gave him the shot and placed a bandage on his arm. “I did it!” he said while smiling at his mother.

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

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