At a swim meet just outside St. Louis, heads turned when a team of young swimmers walked through the rec center with their parents in tow.

A supportive mom kept her eye on the clock while the Makos Swim Team athletes tucked their natural curls, braids, and locs into yellow swimming caps. In the bleachers, spectators whispered about the team’s presence at the pool in Centralia, Illinois — as they do at almost every competition.

“They don’t know that we’re listening,” Randella Randell, a swimmer’s mom, later said. “But we’re here to stay. We’re here to represent. We’re going to show you that Black kids know how to swim. We swim, too.”

Randell’s son, Elijah Gilliam, 14, is a member of the Makos’ competitive YMCA and USA Swimming program based in North St. Louis. Almost 40 athletes, ages 4 to 19, swim on the squad, which encourages Black and multiracial kids to participate in the sport. Coached by Terea Goodwin and Torrie Preciado, the team also spreads the word about water safety in their community.

“If we can get everybody to learn how to swim, just that little bit, it would save so many lives,” said Goodwin, a kitchen and bathroom designer by day who is known as Coach T at the pool. “Swimming is life.”

But just like mako sharks, such teams of Black swimmers are rare. Detroit has the Razor Aquatics, Howard University in Washington, D.C., has a team that’s made headlines for winning championships, and some alums from North Carolina A&T’s former swim team created a group to offer water safety classes.

In the past, Black Americans were barred from many public swimming pools. When racial segregation was officially banned, white Americans established private swim clubs that required members to pay a fee that wasn’t always affordable. As a result, swimming remained effectively segregated, and many Black Americans stayed away from pools.

The impact is still felt. More than a third of Black adults report they do not know how to swim, according to Centers for Disease Control and Prevention statistics, more than twice the rate for adults overall.

Seeing a need in their community, the parents of the Makos swimmers formed the Black Swimmers Alliance at the end of 2023 with a goal of “bridging the gap in aquatic skills,” according to its website. But the group, which offers swim lessons to families of color, is concerned about the flow of grant money dwindling because of the recent federal backlash against diversity, equity, and inclusion programs. Even so, they are fundraising directly on their own, because lives are being lost.

In late January, a 6-year-old died at a hotel pool in St. Louis. A boy the same age drowned while taking swim lessons at a St. Louis County pool in 2022. And across the river in Hamel, Illinois, a 3-year-old boy drowned in a backyard pool last summer.

Drowning is the leading cause of death for children ages 1 through 4, according to the CDC. Black children and Black adults drown far more often than their white peers.

Members of the Black Swimmers Alliance discussed those statistics before their advocacy work began. They also had to address another issue — many of the adult volunteers and parents with children on the Makos team didn’t know how to swim. Even though their children were swimming competitively, the fear of drowning and the repercussions of history had kept the parents out of the pool.

The Makos athletes also noticed that their parents were timid around water. That’s when their roles reversed. The children started to look out for the grown-ups.

Joseph Johnson, now 14, called out his mom, Connie Johnson, when she tried to give him a few tips about how to improve his performance.

“He was like, ‘Mom, you have no idea,’” the now-55-year-old recalled. “At first, I was offended, but he was absolutely right. I didn’t know how to swim.”

She signed up for lessons with Coach T.

Najma Nasiruddin-Crump and her husband, Joshua Crump, signed up, too. His daughter Kaia Collins-Crump, now 14, had told them she wanted to join the Makos team the first time she saw it. But among the three of them, no one knew how to swim.

Joshua Crump, 38, said he initially felt silly at the lessons, then started to get the hang of it.

“I don’t swim well enough to beat any of the children in a race,” he said with a chuckle.

Nasiruddin-Crump, 33, said she was terrified the first time she jumped in the deep end. “It is the only moment in my life outside of birthing my children that I’ve been afraid of something,” she said. “But once you do it, it’s freedom. It’s pure freedom.”

Mahoganny Richardson, whose daughter Ava is on the team, volunteered to teach more Makos parents how to swim.

She said the work starts outside the pool with a conversation about a person’s experiences with water. She has heard stories about adults who were pushed into pools, then told to sink or swim. Black women were often told to stay out of the water to maintain hairstyles that would swell if their hair got wet.

Bradlin Jacob-Simms, 47, decided to learn how to swim almost 20 years after her family survived Hurricane Katrina. She evacuated the day before the storm hit but said one of her friends survived only because that woman’s brother was able to swim to find help.

“If it wasn’t for him, they would have died,” she said, noting that hundreds did drown.

“That’s the reason why swimming is important to me,” she said. “A lot of times, us as African Americans, we shy away from it. It’s not really in our schools. It’s not really pushed.”

Makos swimmer Rocket McDonald, 13, encouraged his mom, Jamie McDonald, to get back into the water and stick with it. When she was a child, her parents had signed her up for swim lessons, but she never got the hang of it. Her dad was always leery of the water. McDonald didn’t understand why until she read about a race riot at a pool not far from where her dad grew up that happened after St. Louis desegregated public pools in 1949.

“It was a full-circle moment,” McDonald said. “It all makes sense now.”

Now, at 42, McDonald is learning to swim again.

Safety is always a priority for the Makos team. Coach T makes the athletes practice swimming in full clothing as a survival skill.

Years ago, as a lifeguard in Kansas City, Missouri, Coach T pulled dozens of children out of recreational swimming pools who were drowning. Most of them, she said, were Black children who came to cool off but didn’t know how to swim.

“I was literally jumping in daily, probably hourly, getting kids out of every section,” Goodwin said. After repeated rescues, too many to count, she decided to offer lessons.

Swim lessons can be costly. The Black Swimmers Alliance aimed to fund 1,000 free swim lessons by the end of 2025. It had already funded 150 lessons in St. Louis. But when the group looked for grants, the alliance scaled back its goal to 500 lessons, out of caution about what funding would be available.

It’s still committed to helping Black athletes swim competitively throughout their school years and in college.

Most of the time, the Makos swimmers practice in a YMCA pool that doesn’t have starting blocks. Backstroke flags are held in place with fishing wire, and the assistant coach’s husband, José Preciado, used his 3-D printer to make red, regulation 15-meter markers for the team. Once a week, parents drive the team to a different YMCA pool that has starting blocks. That pool is about 5 degrees warmer for its senior patrons’ comfort. Sometimes the young swimmers fuss about the heat, but practicing there helps them prepare for meets.

Parents said white officials have frequently disqualified Makos swimmers. So some of the team parents studied the rules of the sport, and eventually four became officials to diversify the ranks and ensure all swimmers are treated fairly. Still, parents said, that hasn’t stopped occasional racist comments from bystanders and other swimmers at meets.

“Some didn’t think we’d make it this far, not because of who we are but where we’re from,” Goodwin has taught the Makos swimmers to recite. “So we have to show them.”

And this spring, Richardson is offering lessons for Makos parents while their children practice.

“It’s not just about swimming,” Richardson said. “It’s about overcoming something that once felt impossible.”

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In recent years, states across the Mountain West have passed laws that limit doctors from providing transgender children with certain kinds of gender-affirming care, from prohibitions on surgery to bans on puberty blockers and hormones. Colorado families say their state was a haven for those health services for a long time, but following executive orders from the Trump administration, even hospitals in Colorado limited the care they offer for trans patients under age 19. KFF Health News Colorado correspondent Rae Ellen Bichell spoke with youth and their families.

GRAND JUNCTION, Colo. — On a Friday after school, 6-year-old Esa Rodrigues had unraveled a ball of yarn, spooked the pet cat, polled family members about their favorite colors, and tattled on a sibling for calling her a “butt-face mole rat.”

Next, she was laser-focused on prying open cherry-crisp-flavored lip gloss with her teeth.

“Yes!” she cried, twisting open the cap. Esa applied the gloopy, shimmery stuff in her bedroom, where a large transgender pride flag hung on the wall.

Esa said the flag makes her feel “important” and “happy.” She’d like to take it down from the wall and wear it as a cape.

Her parents questioned her identity at first, but not anymore. Before, their anxious child dreaded going to school, bawled at the barbershop when she got a boy’s haircut, and curled into a fetal position on the bathroom floor when she learned she would never get a period.

Now, that child is happily bounding up a hill, humming to herself, wondering aloud if fairies live in the little ceramic house she found perched on a stone.

Her mom, Brittni Packard Rodrigues, wants this joy and acceptance to stay. Depending on a combination of Esa’s desire, her doctors’ recommendations, and when puberty sets in, that might require puberty blockers, followed by estrogen, so that Esa can grow into the body that matches her being.

“In the long run, blockers help prevent all of those surgeries and procedures that could potentially become her reality if we don’t get that care,” Packard Rodrigues said.

The medications known as puberty blockers are widely used for conditions that include prostate cancer, endometriosis, infertility, and puberty that sets in too early. Now, the Trump administration is seeking to limit their use specifically for transgender youth.

Esa’s home state of Colorado has long been known as a haven for gender-affirming care, which the state considers legally protected and an essential health insurance benefit. Medical exiles have moved to Colorado for such treatment in the past few years. As early as the 1970s, the town of Trinidad became known as “the sex-change capital of the world” when a cowboy-hat-wearing former Army surgeon, Stanley Biber, made his mark performing gender-affirming surgeries for adults.

On his first day in office, President Donald Trump signed an executive order refuting the existence of transgender people by saying it is a “false claim that males can identify as and thus become women and vice versa.” The following week, he issued another order calling puberty blockers and hormones for anyone under age 19 a form of chemical “mutilation” and “a stain on our Nation’s history.” It directed agencies to take steps to ensure that recipients of federal research or education grants stop providing it.

Subsequently, health care organizations in Colorado; California; Washington, D.C.; and elsewhere announced they would preemptively comply. In Colorado, that included three major health care organizations: Children’s Hospital Colorado, Denver Health, and UCHealth. At the end of January and in early February, the three systems announced changes to the gender-affirming care they provide to patients under 19, effective immediately: no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no prescription renewals for those who had, and no surgeries, though Children’s Hospital had never offered it, and such surgery is rare among teens: For every 100,000 trans minors, fewer than three undergo surgery.

Children’s Hospital and Denver Health resumed offering puberty blockers and hormones on Feb. 24 and Feb. 19, respectively, after Colorado joined a U.S. District Court lawsuit in Washington state. The court concluded that Trump’s orders relating to gender “discriminate on the basis of transgender status and sex.” It granted a preliminary injunction blocking them from taking effect in the four states involved in the lawsuit.

Surgeries, however, have not resumed. Denver Health said it will “continue its pause on gender-affirming surgeries for patients under 19 due to patient safety and given the uncertainty of the legal and regulatory landscape.”

UCHealth has resumed neither medication nor surgery for those under 19. “Our providers are awaiting a more permanent decision from federal courts that may resolve the uncertainty around providing this care,” spokesperson Kelli Christensen wrote.

Trans youth and their families said the court ruling and the two Colorado health systems’ decisions to resume treatments haven’t resolved matters. It has bought them time to stockpile prescriptions, to try to find private practice physicians with the right training to monitor blood work and adjust prescriptions accordingly, and, for some, to work out the logistics of moving to another state or country.

The Trump administration has continued to press health providers beyond the initial executive orders by threatening to withhold or cancel federal money awarded to them. In early March, the Health Resources and Services Administration said it would review funding for graduate medical education at children’s hospitals.

KFF Health News requested comment from White House deputy press secretary Kush Desai but did not receive a response. HHS deputy press secretary Emily Hilliard responded with links to two prior press releases.

Medical interventions are just one type of gender-affirming care, and the process to get treatment is long and thorough. Researchers have found that, even among those with private insurance, transgender youth aren’t likely to receive puberty blockers and hormones. Interestingly, most gender-affirming breast reduction surgeries performed on men and boys are done on cisgender — not transgender — patients.

Kai, 14, wishes he could have gone on puberty blockers. He lives in Centennial, a Denver suburb. KFF Health News is not using his full name because his family is worried about him being harassed or targeted.

Kai got his period when he was 8 years old. By the time he realized he was transgender, in middle school, it was too late to start puberty blockers.

His doctors prescribed birth control to suppress his periods, so he wouldn’t be reminded each month of his gender dysphoria. Then, once he turned 14, he started taking testosterone.

Kai said if he didn’t have hormone therapy now, he would be a danger to himself.

“Being able to say that I’m happy in my body, and I get to be happy out in public without thinking everyone’s staring at me, looking at me weird, is such a huge difference,” he said.

His mom, Sherry, said she is happy to see Kai relax into the person he is.

Sherry, who asked to use her middle name to prevent her family from being identified, said she started stockpiling testosterone the moment Trump got elected but hadn’t thought about what impact there would be on the availability of birth control. Yet after the executive orders, that prescription, too, became tenuous. Sherry said Kai’s doctor at UCHealth had to set up a special meeting to confirm the doctor could keep prescribing it.

So, for now, Kai has what he needs. But to Sherry, that is cold comfort.

“I don’t think that we are very safe,” she said. “These are just extensions.”

The family is coming up with a plan to leave the country. If Sherry and her husband can get jobs in New Zealand, they’ll move there. Sherry said such mobility is a privilege that many others don’t have.

For example, David, an 18-year-old student at Western Colorado University in the Rocky Mountain town of Gunnison. He asked to be identified only by his middle name because he worries he could be targeted in this conservative, rural town.

David doesn’t have a passport, but even if he did, he doesn’t want to leave Gunnison, he said. He is studying geology, is learning to play the bass, and has a good group of friends. He has plans to become a paleontologist.

His dorm room shelves are scattered with his essentials: fossils, Old Spice deodorant, microwave macaroni and cheese. But there are no mirrors. David said he got in the habit of avoiding them.

“For the longest time, I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror,” David said. “But when I do, most of the time, I see something that I really like.”

He’s been taking testosterone for three years, and the hormone helped him grow a beard. In January, his doctor at Denver Health was told to stop prescribing it. His mom drove hours from her home to Gunnison to deliver the news in person.

That prescription is back on track now, but the mastectomy he’d planned for this summer isn’t. He’d hoped to have adequate recovery time before sophomore year. But he doesn’t know anyone in Colorado who would perform it until he is 19. He could easily get surgery to enhance his breasts, but he must seek surgical options in other states to reduce or remove them.

“Colorado as a state was supposed to be a safe haven,” said his mother, Louise, who asked to be identified by her middle name. “We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away.”

It has taken eight years and about 10 medical providers and therapists to get David this close to the finish line. That’s a big deal after living through so many years of dysphoria and dysmorphia.

“I’m still going, and I’m going to keep going, and there’s almost nothing they can do to stop me — because this is who I am,” David said. “There have always been trans people, and there always will be trans people.”

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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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

In January, a teenager in suburban St. Louis informed his high school counselor that a classmate said he planned to kill himself later that day.

The 14-year-old classmate denied it, but his mother, Marie, tore through his room and found a suicide note in his nightstand. (She asked KFF Health News to publish only her middle name because she does not want people to misjudge or label her son.)

His parents took him to Mercy Hospital St. Louis. According to his mother, providers told them they didn’t have beds available at their behavioral health center, so the teen spent three days in a room in a secured area of the emergency department and saw a doctor twice, one time virtually.

Joe Poelker, a Mercy hospital spokesperson, declined to answer questions from KFF Health News. Leaders of Mercy and other local hospitals have described the shortage of beds for inpatient pediatric psychiatric care in the St. Louis area as a crisis for years.

Nationwide, psychiatric “boarding” — when a patient waits in the emergency room after providers decide to admit the person — has increased because of a rise in suicide attempts, among other mental health issues, and a shortage of inpatient psychiatric beds, according to a study of 40 hospitals in the journal Pediatrics. It found the number of cases in which children spent at least two days in pediatric hospitals before being transferred for psychiatric care also increased 66% from 2017 through 2023 to reach 16,962 instances.

St. Louis Children’s Hospital leaders aim to address that problem by opening a 77-bed pediatric mental health hospital in the suburb of Webster Groves. But as often happens with such proposals, neighbors objected. They worry it would worsen safety and lower property values.

Over the past decade, proposed psychiatric facilities for minors in California, Colorado, Iowa, Nebraska, and New York have also faced local resistance.

Behavioral health care advocates counter that such concerns are largely unfounded and rooted in stigma. Locating such facilities in remote areas — as neighbors sometimes suggest — reinforces the misconception that people with mental illness are dangerous and makes it harder to help them without their support system nearby, doctors say.

“We wouldn’t take children with cancer and say they need to be two hours away, where there is no one around them,” said Cynthia Rogers, a pediatric psychiatrist at St. Louis Children’s. “These are still children with illnesses, and they want to be in their home city, where their family can visit them.”

In the United States, the number of suicides among minors increased 62% from 2002 to 2022, according to a KFF analysis of data from the Centers for Disease Control and Prevention.

At St. Louis Children’s, the crisis has fueled more emergency room visits, Rogers said, with behavioral health visits nearly quadrupling from 2019 to 2023, jumping from 565 to 2,176. She attributes the increase to factors such as social media engagement, isolation caused by shutdowns during the covid-19 pandemic, and the political climate, which she said has been particularly hard on LGBTQ+ children.

“The pandemic seemed to throw gasoline on the fire,” Rogers said.

In the middle- and upper-class suburb of Webster Groves, St. Louis Children’s and KVC, a behavioral health provider, want to use a site that served as an orphanage in the 19th century to create 65 inpatient beds for children needing care for about a week and 12 residential beds for people requiring longer stays. KVC now runs a school there for students who struggle in traditional classrooms and offers services to help children in foster care.

“Introducing a hospital into this historically significant residential area disrupts its stability by undermining” its character, one resident testified at a January City Council meeting.

Tim Conway, who has lived across from the site for three decades, told KFF Health News that his opposition is primarily because the facility and its parking would take up more space than the existing structures.

The detailed security plans have not eased his concerns. “It makes me wonder why it needs to be that robust,” Conway said.

Samer El Hayek, a psychiatrist at the American Center for Psychiatry and Neurology in the United Arab Emirates, has studied how stigma impacts the locations of psychiatric facilities around the world and said people often don’t want the hospitals nearby because they associate them with violence or unpredictable behavior.

“The misconception of increased danger often stems from outdated stereotypes rather than factual evidence,” El Hayek said.

Little evidence suggests that people with mental illness are more likely to commit a crime or be violent than the general population, with the exception of people with a severe illness such as schizophrenia, who, while it’s still rare, are likelier to commit a violent act.

But residents near mental health hospitals have been rattled by encounters with patients who escaped or reports from law enforcement and local news about missing patients.

In Oklahoma City, Richard Scroggins in 2014 opposed the expansion of Cedar Ridge Behavioral Hospital, which then treated youths and adults, because of its security issues.

Scroggins, who raises horses and cattle on his property, told The Oklahoman newspaper at the time that he once found a stranger raking leaves in his yard. After determining the person was suffering from mental illness and harmless, Scroggins said, he called the police, who retrieved the person.

The Cedar Ridge provider ultimately dropped plans to expand the facility after community opposition.

Scroggins has since encountered other patients from the facility on his property but none in recent years, he told KFF Health News in February. His perspective on the hospital has changed because its staff addressed his security concerns.

“Nobody wants it in their neighborhood, but it’s a necessity,” Scroggins said. “I’m a Christian, so we are supposed to reach out and help.”

Carrie Blumert, CEO of the Mental Health Association Oklahoma, said psychiatric facilities make surrounding areas safer by providing medical care and “treating the root of people’s issues rather than just throwing them in a jail cell.”

In Marie’s case, her son was ultimately admitted to Mercy-affiliate Hyland Behavioral Health Center and spent a few days there until a physician told the family he probably just needed to speak with a counselor, she said. He was discharged.

A day later, she said, the teen said he still wanted to kill himself, so his parents took him to St. Louis Children’s, where he was admitted the same day. After a 15-minute visit, Marie said, a doctor pulled her aside and asked, “Have you ever thought that he might be on the autism spectrum?”

“‘Oh my gosh, you’re the first person to validate my feeling,’” Marie told the doctor.

Her son stayed two weeks at the hospital, during which providers diagnosed him with autism and prescribed antidepressants. He returned to the classroom and baseball field, Marie said, but learning he has autism upset him.

“He’s still trying to process that, and he’s very sensitive. And they are teenagers, so when kids are mean to him at school or make fun of him, he takes that to heart way more than a typical teenager would,” Marie said. “I have hope for him that he will be OK.”

And soon, she knows, kids like her son could have another option in St. Louis if they need acute psychiatric help.

Despite community pushback, the Webster Groves City Council unanimously approved the rezoning needed for the hospital in January. The officials described opponents’ concerns as legitimate but said the hospital would benefit children’s mental health and the surrounding community.

“This is by far and away one of the easiest votes I’ve ever had to take,” said Councilmember David Franklin, adding that the approval demonstrates that “Webster Groves cares not only about its own citizens but the citizens of this region.”

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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Las agresivas tácticas de deportación han aterrorizado a los trabajadores agrícolas, que son el centro de la estrategia nacional contra la gripe aviar, según afirman trabajadores de salud pública.

Los trabajadores de las industrias láctea y avícola han representado la mayoría de los casos de gripe aviar en el país, y prevenir y detectar los casos entre ellos es clave para evitar una pandemia. Sin embargo, los especialistas en salud pública afirman que tienen dificultades para llegar a los trabajadores agrícolas porque muchos tienen miedo de hablar con desconocidos o de salir de casa.

“La gente tiene mucho miedo de salir, incluso para comprar alimentos”, dijo Rosa Yáñez, trabajadora social de Strangers No Longer, una organización católica con sede en Detroit que apoya a inmigrantes y refugiados en Michigan con problemas legales y de salud, incluida la gripe aviar. “La gente está preocupada por perder a sus hijos, o por que sus hijos pierdan a sus padres”.

“Solía ​​hablarle a la gente sobre la gripe aviar, y los trabajadores estaban contentos de recibir esa información”, dijo Yáñez. “Pero ahora solo quieren conocer sus derechos”.

Los trabajadores comunitarios que capacitan a los trabajadores agrícolas sobre la gripe aviar, les proporcionan equipo de protección y los conectan con las pruebas afirman haber notado un cambio drástico —primero en California, el estado más afectado por la gripe aviar— luego de las redadas de inmigración que comenzaron el 7 de enero, un día después que el Congreso certificara la victoria electoral del presidente Donald Trump.

Fue entonces cuando agentes de la Patrulla Fronteriza detuvieron indiscriminadamente a unos 200 trabajadores agrícolas y jornaleros latinos en el Valle Central de California, según informes locales citados en una demanda presentada posteriormente por la Unión Americana de Libertades Civiles (ACLU) en nombre del sindicato United Farm Workers y varias personas que fueron detenidas.

“Los agentes de la Patrulla Fronteriza se lanzaron a una expedición de pesca” en una redada de tres días llamada “Operación Devolución al Remitente” (operation Return to Sender), que “separó a familias y aterrorizó a la comunidad”, alega la demanda.

Entre las personas detenidas se encontraba Yolanda Aguilera Martínez, trabajadora agrícola y abuela que reside legalmente en Estados Unidos y no tiene antecedentes penales. Iba a una cita médica conduciendo a la velocidad límite cuando agentes vestidos de civil en vehículos sin identificación la detuvieron, le ordenaron que bajara del coche, la empujaron al suelo y la esposaron, según la demanda.

Los agentes finalmente liberaron a Aguilera Martínez, pero la demanda indica que otras personas que enfrentaban la deportación fueron detenidas durante días en “celdas frías y sin ventanas” antes de ser trasladadas a México, y abandonadas.

No se les explicó el motivo de su arresto, ni se les dio la oportunidad de defenderse, ni se les permitió llamar a un abogado ni a sus familias, alega la demanda. Indica que los cuatro hijos de un padre deportado, sin antecedentes penales, “se han vuelto silenciosos y temerosos”, y que las convulsiones de uno de los hijos con epilepsia “han empeorado”.

La noticia de la redada se difundió rápidamente en California, donde viven aproximadamente 880.000 trabajadores agrícolas, principalmente latinos. Las lecherías que emplean mano de obra inmigrante producen casi el 80% del suministro de leche de Estados Unidos, según una encuesta de 2014.

“Luego de la Operación Devolución al Remitente, los trabajadores lácteos se mostraron aún más reacios a hablar, incluso anónimamente, sobre la falta de protección en las granjas lecheras y la falta de días por enfermedad cuando se contagian”, declaró Antonio De Loera-Brust, vocero de la Unión de Trabajadores Agrícolas.

Trabajadores comunitarios en otros estados reportan un efecto intimidatorio similar debido a las redadas y las políticas migratorias aprobadas tras la toma de posesión de Trump, quien degradó repetidamente a los inmigrantes y prometió deportaciones masivas durante la campaña electoral. “No son humanos, son animales”, dijo refiriéndose a los inmigrantes que se encontraban sin autorización en Estados Unidos el pasado abril.

La primera medida legislativa de Trump fue promulgar la Ley Laken Riley, que ordena la detención federal de inmigrantes acusados ​​de cualquier delito, independientemente de si hayan sido o no condenados.

El 20 de enero, el Departamento de Seguridad Nacional anuló la política de “áreas protegidas”, permitiendo a los agentes arrestar a personas sin papeles en escuelas, hospitales o iglesias. En marzo, la administración Trump deportó a más de 100 venezolanos y otras personas sin una audiencia previa, ignorando una orden judicial que que obligaba frenar los aviones que los trasladaban a El Salvador.

Las consecuencias para la salud pública de la desaparición de los trabajadores agrícolas son potencialmente enormes: científicos especializados en enfermedades infecciosas afirman que prevenir el contagio de gripe aviar y detectar los casos son fundamentales para prevenir una pandemia. Por eso, el gobierno ha financiado iniciativas para proteger a estos trabajadores, y monitorearlos para detectar signos de gripe aviar, como ojos rojos o síntomas similares a los de la gripe.

“Cada vez que un trabajador se enferma, juega el azar, así que protegerlo es en el interés de todos”, dijo De Loera-Brust. “Al virus no le importa lo que digan tus documentos de inmigración”.

Potencial de pandemia

Aproximadamente 65 trabajadores lácteos y de granjas de aves de corral han dado positivo para la prueba de gripe aviar desde marzo de 2024, pero el número real de infecciones es mayor. Una investigación de KFF Health News descubrió que la vigilancia deficiente provocó que casos pasaran desapercibidos en las granjas el año pasado, y estudios han revelado indicios de infecciones previas en trabajadores agrícolas que no se habían realizado la prueba.

Los departamentos de salud estatales y locales estaban empezando a superar las barreras del año pasado para las pruebas de gripe aviar, dijo Salvador Sandoval, médico que se jubiló recientemente del departamento de salud del condado de Merced, en California. Ahora, dijo, “la gente ve una unidad móvil de pruebas y piensa que es la Patrulla Fronteriza”.

El año pasado, las organizaciones de divulgación se conectaron con los trabajadores agrícolas en lugares donde se reunían, como en eventos de distribución de alimentos, pero estos ya no tienen mucha concurrencia, dijeron Sandoval y otros.

“Independientemente de su estatus migratorio, las personas con apariencia de inmigrantes sienten mucho miedo en este momento”, dijo Hunter Knapp, director de desarrollo de Project Protect Food Systems Workers, una organización de defensa de los trabajadores agrícolas en Colorado que realiza actividades de divulgación sobre la gripe aviar. Knapp explicó que algunos trabajadores de salud comunitarios latinos han reducido sus esfuerzos de divulgación por temor a ser acosados ​​por las autoridades o el público.

Una trabajadora comunitaria latina en Michigan, que habló bajo condición de anonimato por temor a represalias contra su familia, dijo: “Mucha gente no va al médico en este momento debido a la situación migratoria”.

“Prefieren quedarse en casa y dejar que el dolor, el enrojecimiento del ojo o lo que sea desaparezca”, agregó. “La situación se ha intensificado mucho este año y la gente está muy, muy asustada”.

Los Centros para el Control y Prevención de Enfermedades (CDC) han reportado muchos menos casos humanos desde que Trump asumió el cargo. Durante los tres meses previos al 20 de enero, la agencia confirmó dos docenas de casos. Desde entonces, solo se han detectado tres, incluidas dos personas con casos lo suficientemente graves como para ser hospitalizadas.

Los CDC han afirmado que continúan monitoreando la gripe aviar, pero Jennifer Nuzzo, directora del Centro de Pandemias de la Universidad de Brown, señaló que la baja de los casos podría deberse a que se hacen menos pruebas. “Me preocupa que estemos observando una disminución en la vigilancia y no necesariamente una disminución en la propagación del virus”.

Las infecciones no detectadas representan una amenaza para los trabajadores agrícolas y para el público en general.

Dado que los virus evolucionan mutando dentro del cuerpo, cada infección es como presionar la palanca de una máquina tragamonedas. Una persona que falleció a causa de la gripe aviar en Louisiana en diciembre ilustra este punto: la evidencia científica sugiere que los virus de la gripe aviar evolucionaron dentro del paciente, generando mutaciones que podrían aumentar su capacidad de propagación entre humanos. Sin embargo, debido a que el paciente estuvo aislado en un hospital, los virus más peligrosos no se transmitieron a otros.

Esto podría no ocurrir si los trabajadores agrícolas enfermos no reciben tratamiento y viven en hogares hacinados o en centros de detención sin ventanas donde podrían infectar a otros, señaló Angela Rasmussen, viróloga de la Universidad de Saskatchewan, en Canadá.

Aunque la gripe aviar aún no se propaga fácilmente entre personas por aire, como la gripe estacional, podría diseminarse ocasionalmente cuando las personas están en espacios reducidos, y evolucionar para hacerlo con más eficiencia.

“Me preocupa que no nos demos cuenta de que esto está sucediendo hasta que algunas personas enfermen gravemente”, dijo Rasmussen. “En ese momento, las cifras serían tan altas que podrían descontrolarse”.

El virus pouede no evolucionar nunca para propagarse fácilmente, pero podría pasar. Rasmussen afirmó que el resultado sería “catastrófico”. Basándose en lo que se sabe sobre las infecciones humanas, ella y sus colegas predicen en un nuevo informe que una pandemia de gripe aviar H5N1 “colapsaría los sistemas de salud” y “causaría millones de muertes más” que la pandemia de covid-19.

Entrega de vacunas

A fines del año pasado, los CDC lanzaron una campaña de vacunación contra la gripe estacional dirigida a más de 200.000 trabajadores ganaderos. La esperanza era que la vacunación contra la gripe redujera la probabilidad de que un trabajador agrícola se infectara simultáneamente con los virus de la gripe estacional y la gripe aviar.

La coinfección permite que ambos virus intercambien genes, creando potencialmente un virus de la gripe aviar que se propagaría con la misma facilidad que la variante estacional.

Sin embargo, Sandoval afirmó que la vacunación contra la gripe disminuyó inmediatamente después del operativo de enero en California.

Funcionarios de Aduanas y Protección Fronteriza informaron en un comunicado que arrestaron a 78 inmigrantes que se encontraban “ilegalmente en Estados Unidos” durante el operativo de tres días.

Entre ellos se encontraba un delincuente sexual convicto y otras personas con antecedentes penales, como vandalismo y hurtos menores, según el comunicado. La agencia no especificó las acusaciones contra cada persona ni si todos habían sido acusados. Ex funcionarios de la administración Biden, que se encontraba en sus últimos días cuando ocurrieron los arrestos, tomarán distancia del operativo en entrevistas con Los Angeles Times.

Mayra Joachin, abogada de la ACLU del Sur de California, afirmó que el operativo era diferente a otros del gobierno de Biden, ya que se trataba de arrestos indiscriminados por parte de la Patrulla Fronteriza en el interior del país.

“Encaja con la campaña más amplia de la administración Trump de infundir miedo en las comunidades inmigrantes”, declaró, “como se vio en la campaña electoral y en acciones posteriores que atacaban a cualquiera que se percibiera como extranjero en el país”.

En marzo, David Kim, subjefe de la unidad de la Patrulla Fronteriza que dirigió el operativo, lo calificó como una “prueba de concepto”.

“Sabemos que ahora podemos superar ese límite en cuanto a distancia”, declaró al medio de comunicación del sur de California Inewsource.

El Departamento de Seguridad Nacional no respondió a las solicitudes de comentarios. En un correo electrónico, Kush Desai, vocero de la Casa Blanca, escribió: “A pesar de lo que creen los ‘expertos’, combatir la epidemia de gripe aviar y hacer cumplir nuestras leyes de inmigración no son mutuamente excluyentes”.

Anna Hill Galendez, abogada gerente del Michigan Immigrant Rights Center, entidad que participa en la difusión de información sobre la gripe aviar, afirmó que las tácticas inusualmente agresivas de los agentes del Servicio de Inmigración y Control de Aduanas (ICE) disuadieron a los trabajadores lácteos enfermos de la Península Superior de Michigan de salir de sus hogares para recibir atención médica a finales de enero. Se pusieron en contacto con el centro para solicitar ayuda.

“Querían atención médica. Querían vacunas contra la gripe. Querían [equipo de protección personal]. Querían hacerse la prueba”, declaró Hill Galendez. “Pero tenían miedo de ir a cualquier parte debido a las medidas de control migratorio”.

Lynn Sutfin, funcionaria de información pública del Departamento de Salud y Servicios Humanos de Michigan (MDHHS), respondió a las preguntas sobre la situación en la península en un correo electrónico a KFF Health News: “Los trabajadores agrícolas no aceptaron la oferta de pruebas del departamento de salud local ni del MDHHS”.

Los CDC se negaron a comentar sobre el impacto de las medidas migratorias en la labor de divulgación con trabajadores agrícolas.

Para adaptarse a la nueva realidad, Yanez ahora destaca sus consejos sobre la gripe aviar en Michigan, combinándolos con información sobre los derechos de los inmigrantes.

En Colorado, Knapp dijo que su organización está cambiando su enfoque y dejando de lado la divulgación sobre la gripe aviar en eventos donde se congregan trabajadores agrícolas, ya que esto podría percibirse como una trampa: el tipo de evento que atraería a los agentes de ICE.

Los trabajadores de divulgación que viven en las mismas comunidades que los trabajadores agrícolas también se están retirando un poco. “Como latinos, siempre nos identifican”, dijo el trabajador comunitario, quien habló bajo condición de anonimato. “Tengo una visa que me protege, pero las cosas están cambiando muy rápidamente bajo la administración Trump, y la verdad es que nada es seguro”.

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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Fentanyl, the deadly synthetic opioid driving the nation’s high drug overdose rates, is also caught up in another increasingly serious problem: misinformation.

False and misleading narratives on social media, in news reports, and even in popular television dramas suggesting people can overdose from touching fentanyl — rather than ingesting it — are now informing policy and spending decisions.

In an episode of the CBS cop drama “Blue Bloods,” for instance, Detective Maria Baez becomes comatose after accidentally touching powdered fentanyl. In another drama, “S.W.A.T.,” Sgt. Daniel “Hondo” Harrelson warns his co-workers: “You touch the pure stuff without wearing gloves, say good night.”

While fentanyl-related deaths have drastically risen over the past decade, no evidence suggests any resulted from incidentally touching or inhaling it, and little to no evidence that any resulted from consuming it in marijuana products. (Recent data indicates that fentanyl-related deaths have begun to drop.)

There is also almost no evidence that law enforcement personnel are at heightened risk of accidental overdoses due to such exposures. Still, there is a steady stream of reports — which generally turn out to be false — of officers allegedly becoming ill after handling fentanyl.

“It’s only in the TV dramas” where that happens, said Brandon del Pozo, a retired Burlington, Vermont, police chief who researches policing and public health policies and practices at Brown University.

In fact, fentanyl overdoses are commonly caused by ingesting the drug illicitly as a pill or powder. And most accidental exposures occur when people who use drugs, even those who do not use opioids, unknowingly consume fentanyl because it is so often used to “cut” street drugs such as heroin and cocaine.

Despite what scientific evidence suggests about fentanyl and its risks, misinformation can persist in public discourse and among first responders on the front lines of the crisis. Daniel Meloy, a senior community engagement specialist at the drug recovery organizations Operation 2 Save Lives and QRT National, said he thinks of misinformation as “more of an unknown than it is an anxiety or a fear.”

“We’re experiencing it often before the information” can be understood and shared by public health and addiction medicine practitioners, Meloy said.

Some state and local governments are investing money from their share of the billions in opioid settlement funds in efforts to protect first responders from purported risks perpetuated through fentanyl misinformation.

In 2022 and 2023, 19 cities, towns, and counties across eight states used settlement funds to purchase drug detection devices for law enforcement agencies, spending just over $1 million altogether. Two mass spectrometers were purchased for at least $136,000 for the Greeley, Colorado, police department, “to protect those who are tasked with handling those substances.”

Del Pozo, the retired police chief, said fentanyl is present in most illicit opioids found at the scene of an arrest. But that “doesn’t mean you need to spend a lot of money on fentanyl detection for officer safety,” he said. If that spending decision is motivated by officer safety concerns, then it’s “misspent money,” del Pozo said.

Fentanyl misinformation is affecting policy in other ways, too.

Florida, for instance, has on the books a law that makes it a second-degree felony to cause an overdose or bodily injury to a first responder through this kind of secondhand fentanyl exposure. Similar legislation has been considered by states such as Tennessee and West Virginia, the latter stipulating a penalty of 15 years to life imprisonment if the exposure results in death.

Public health advocates worry these laws will make people shy away from seeking help for people who are overdosing.

“A lot of people leave overdose scenes because they don’t want to interact with police,” said Erin Russell, a principal with Health Management Associates, a health care industry research and consulting firm. Florida does include a caveat in its statute that any person “acting in good faith” to seek medical assistance for someone they believe to be overdosing “may not” be arrested, charged, or prosecuted.

And even when public policy is crafted to protect first responders as well as regular people, misinformation can undermine a program’s messaging.

Take Mississippi’s One Pill Can Kill initiative. Led by the state attorney general, Lynn Fitch, the initiative aims to provide resources and education to Mississippi residents about fentanyl and its risks. While it promotes the availability and use of harm reduction tools, such as naloxone and fentanyl test strips, Fitch has also propped up misinformation.

At the 2024 Mississippi Coalition of Bail Sureties conference, Fitch said, “If you figure out that pill’s got fentanyl, you better be ready to dispose of it, because you can get it through your fingers,” based on the repeatedly debunked belief that a person can overdose by simply touching fentanyl.

Officers on the ground, meanwhile, sometimes are warned to proceed with caution in providing lifesaving interventions at overdose scenes because of these alleged accidental exposure risks. This caution is often evidenced in a push to provide first responders with masks and other personal protective equipment. Fitch told the crowd at the conference: “You can’t just go out and give CPR like you did before.” However, as with other secondhand exposures, the risk for a fentanyl overdose from applying mouth-to-mouth is negligible, with no clinical evidence to suggest it has occurred.

Her comments underscore growing concerns, often not supported by science, that officers and first responders increasingly face exposure risks during overdose responses. Her office did not respond to questions about these comments.

Health care experts say they are not against providing first responders with protective equipment, but that fentanyl misinformation is clouding policy and risks delaying critical interventions such as CPR and rescue breathing.

“People are afraid to do rescue breathing because they’re like, ‘Well, what if there’s fentanyl in the person’s mouth,’” Russell said. Hesitating for even a moment because of fentanyl misinformation could delay a technique that “is incredibly important in an overdose response.”

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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Because of past fraud by rogue brokers, some Affordable Care Act policyholders may get an unexpected tax bill this season.

But that isn’t the only potential shock. Other changes coming soon — stemming from proposals by the administration of President Donald Trump — could affect their coverage and its cost. And sorting out related problems and challenges may take longer as federal workers are laid off and funding for assistance programs is cut.

First up: Taxes

Tax season is when some consumers learn they were fraudulently enrolled in an ACA plan or switched to a different one without their knowledge.

Those unauthorized enrollments or changes took off in late 2023 and continued through last year, drawing more than 274,000 complaints in the first eight months of 2024 to the Centers for Medicare & Medicaid Services, mostly about rogue agents or call centers.

Tax problems can arise if those enrollments resulted in premium tax credits exceeding the amount the consumer should have received. In those cases, consumers may have to pay all or part of those credits back. The amount owed could range from a few hundred dollars to thousands, with some caps based on income.

The first clue some people have is when they get a 1095-A form in the mail.

Those documents are sent out by the state and federal marketplaces to the IRS and ACA enrollees, showing any tax credit payments made to health insurers on a taxpayer’s behalf. Taxpayers use the premium tax credit information from the 1095-A when completing their return.

Returns can be held up if the IRS has information indicating the taxpayer has ACA coverage that they failed to report on their return, or if there are other discrepancies.

The Biden administration last year took steps to slow the fraudulent switching, including requiring a three-way call between the broker, client, and marketplace for some enrollment issues.

“While we may be seeing less [fraud], we’re still dealing with 2024 taxes,” said Erin Kinard, director of systems and intake for the Health and Economic Opportunity Program at Pisgah Legal Services, a nonprofit serving western North Carolina that offers both legal help and assistance with ACA problems.

Consumers who suspect they were fraudulently enrolled should immediately call their federal or state ACA marketplace, experts say. Some consumers will be referred to special federal caseworkers through the marketplaces. But some of those caseworkers are now part of the broad reduction in force by the Trump administration.

In recent days, “they laid off two divisions on the Affordable Care Act side,” said Jeffrey Grant, who oversaw ACA issues as CMS’ deputy director for operations in the Center for Consumer Information and Insurance Oversight before leaving in February.

With fewer caseworkers, “it will take longer to get problems taken care of,” said Grant, who is now president of Schedule F Healthcare Strategies, a consulting group that aims to help laid-off federal workers find new jobs. “The marketplace is twice as big as it was the last time the Trump administration was here, and now they are cutting caseworkers to less than were around then.”

And these cases are difficult because the rogue brokers who enrolled consumers sometimes misstated their income so they would qualify for the largest tax credits possible. Other consumers have found they were enrolled even though they had affordable employer coverage, making them ineligible for ACA subsidies.

That’s what happened to Anthony Akra and his wife, Ashley Zukoski, in Charlotte, North Carolina. They were enrolled in a plan without their knowledge in 2023, by a broker in Florida with whom they had never spoken. The couple had health insurance through Zukoski’s employer. The broker listed an income that qualified the household for a large subsidy that fully offset the monthly premium cost, so the couple never received a bill. One day, a 1095-A form showed up in their mailbox.

“I didn’t know what the hell it was,” said Akra, who said the form showed that he had been receiving hundreds of dollars a month in premium tax credits. He would owe a big chunk of that back unless he could get the plan retroactively canceled.

Because their pharmacy, part of a national chain, had switched them to the new plan, also without telling them, they had used the new coverage every time they filled a prescription. That inadvertent use of the policy complicated their efforts to get the fraudulent coverage revoked. Meanwhile, the IRS withheld more than $4,000 from their tax refund based on the information sent through that 1095-A form. Months passed, but with assistance from a “navigator” program — a government-funded nonprofit that helps people deal with insurance problems — they were able to get the incorrect insurance canceled and a refund at the end of October.

It is not unusual for people to spend weeks or even months trying to sort out the mess, said Kinard, whose organization is similar to the one that helped Akra.

While navigator programs nationwide are still operating to help people sign up for health coverage or address issues, the Trump administration has targeted their funding for a 90% cut.

Meanwhile, ACA enrollees may face a range of other surprises due to policy and budget steps proposed by the Trump administration.

More Potential Changes

Congress must decide whether to extend premium tax credits that were enhanced during the covid pandemic, which expanded eligibility for the credits and made them larger for many enrollees. Keeping them in place would be expensive, with the nonpartisan Congressional Budget Office and Joint Committee on Taxation estimating it would add $335 billion to the deficit through 2034.

That debate will come amid another deficit-affecting decision: whether to extend tax cuts enacted during the first Trump administration, which would add trillions to the budget deficit through 2034.

If the enhanced subsidies are not renewed, monthly premium costs would rise by an average of over 75%, according to KFF, a health information nonprofit that includes KFF Health News. Premiums could more than double in some states, including many GOP-led ones, such as Texas, Mississippi, Utah, Wyoming, and West Virginia.

That could spark a political backlash. Additionally, the enhanced subsidies are seen as a main reason for strong enrollment growth, leading to more than 24 million people signing up for ACA plans for this year. A recent KFF study found the 15 states with the most enrollment growth since 2020 were all won by Trump in 2024.

A proposed rule released last month by the Trump administration includes provisions to shorten the annual enrollment period, get rid of a special open enrollment period that allows low-income people to sign up year-round, and require stricter verification of income and other information when people apply for coverage. The administration says most of these steps are needed to reduce fraud in the system.

The administration estimates that 750,000 to 2 million fewer people would enroll in coverage as a result of the changes.

The new rule, if finalized, will make it harder for people to enroll, said Xonjenese Jacobs, director of Florida Covering Kids & Families at the University of South Florida College of Public Health. Losing the year-round enrollment for very low-income people, for example, would affect people short on cash who move often to stay with relatives or friends, and those who have unsteady employment, making it hard to know when or where to enroll and what their income might be in the coming year.

“They don’t have the same ability to plan,” Jacobs said. “It’s definitely going to make a difference for a lot of the individuals that we service.”

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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Aggressive deportation tactics have terrorized farmworkers at the center of the nation’s bird flu strategy, public health workers say.

Dairy and poultry workers have accounted for most cases of the bird flu in the U.S. — and preventing and detecting cases among them is key to averting a pandemic. But public health specialists say they’re struggling to reach farmworkers because many are terrified to talk with strangers or to leave home.

“People are very scared to go out, even to get groceries,” said Rosa Yanez, an outreach worker at Strangers No Longer, a Detroit-based Catholic organization that supports immigrants and refugees in Michigan with legal and health problems, including the bird flu. “People are worried about losing their kids, or about their kids losing their parents.”

“I used to tell people about the bird flu, and workers were happy to have that information,” Yanez said. “But now people just want to know their rights.”

Outreach workers who teach farmworkers about the bird flu, provide protective gear, and connect them with tests say they noticed a dramatic shift — first in California, the state hit hardest by the bird flu — after immigration raids beginning on Jan. 7, the day after Congress certified President Donald Trump’s election victory. That’s when Border Patrol agents indiscriminately stopped about 200 Latino farmworkers and day laborers in California’s Central Valley, according to local reports cited in a lawsuit subsequently filed by the American Civil Liberties Union on behalf of the United Farm Workers union and several people who were stopped and detained.

“Border Patrol agents went on a fishing expedition” in a three-day raid called “Operation Return to Sender” that “tore families apart and terrorized the community,” the lawsuit alleges.

Among those stopped was Yolanda Aguilera Martinez, a farmworker and grandmother who lives legally in the U.S. and has no criminal record. She was driving at the speed limit on her way to a doctor’s appointment when plainclothes agents in unmarked vehicles pulled her over, ordered her out of the car, pushed her to the ground, and handcuffed her, the lawsuit says. Agents eventually released Aguilera Martinez, but the lawsuit says others who faced deportation were detained for days in “cold, windowless cells” before they were transported to Mexico and abandoned.

They weren’t told why they had been arrested, given an opportunity to defend themselves, or allowed to call a lawyer or their families, the lawsuit alleges. It says that the four children of one deported father, who had no criminal record, “have become quiet and scared” and that his epileptic son’s “seizures have worsened.”

News of the raid spread quickly in California, where an estimated 880,000 mainly Latino farmworkers live. Dairies that employ immigrant labor produce nearly 80% of the U.S. milk supply, according to a 2014 survey.

“After Operation Return to Sender, dairy workers became even less willing to speak about the lack of protection on dairy farms and the lack of sick pay when they’re infected — even anonymously,” said Antonio De Loera-Brust, a spokesperson for the United Farm Workers.

Outreach workers in other states report a similar chilling effect from raids and immigration policies passed after Trump took office. He repeatedly degraded immigrants and pledged mass deportations on the campaign trail. “They’re not humans, they’re animals,” he said of immigrants illegally in the U.S. last April.

Trump’s first legislative action was to sign the Laken Riley Act into law, mandating federal detention for immigrants accused of any crime, regardless of whether they’re convicted. On Jan. 20, the Department of Homeland Security rescinded the “protected areas” policy, allowing agents to arrest people who don’t have legal status while they’re in schools, churches, or hospitals. Last month, the Trump administration deported more than 100 Venezuelans and others without a hearing, ignoring a court order to turn around planes flying the men to El Salvador.

The public health ramifications of farmworkers shrinking from view are potentially massive: Infectious disease scientists say that preventing people from getting bird flu and detecting cases are critical to warding off a bird flu pandemic. That’s why the government has funded efforts to protect farmworkers and monitor them for signs of bird flu, like red eyes or flu-like symptoms.

“Every time a worker gets sick, you’re rolling the die, so it’s in everyone’s interest to protect them,” De Loera-Brust said. “The virus doesn’t care what your immigration papers say.”

Pandemic Potential

About 65 dairy and poultry workers have tested positive for the bird flu since March 2024, but the true number of infections is higher. A KFF Health News investigation found that patchy surveillance resulted in cases going undetected on farms last year, and studies have revealed signs of prior infections in farmworkers who hadn’t been tested.

State and local health departments were beginning to overcome last year’s barriers to bird flu testing, said Salvador Sandoval, a doctor who retired recently from the Merced County health department in California. Now, he said, “people see a mobile testing unit and think it’s Border Patrol.”

Last year, outreach organizations connected with farmworkers at places where they gathered, like at food distribution events, but those are no longer well attended, Sandoval and others said.

“Regardless of immigration status, people who look like immigrants are feeling a lot of fear right now,” said Hunter Knapp, the development director at Project Protect Food Systems Workers, a farmworker advocacy organization in Colorado that does bird flu outreach. He said some Latino community health workers have scaled back their outreach efforts because they worry about being harassed by the authorities or members of the public.

A Latina outreach worker in Michigan, speaking on the condition of anonymity because she’s worried about retaliation against her family, said, “Many people don’t go to the doctor right now, because of the immigration situation.”

“They prefer to stay at home and let the pain or redness in the eye or whatever it is go away,” she said. “Things have really intensified this year, and people are very, very scared.”

The Centers for Disease Control and Prevention has reported far fewer human cases since Trump took office. During the three months before Jan. 20, the agency confirmed two dozen cases. Since then, it’s detected only three, including two people with cases severe enough to be hospitalized.

The CDC has said it continues to track the bird flu, but Jennifer Nuzzo, director of the Pandemic Center at Brown University, said the slowdown in cases might be due to a lack of testing. “I am concerned that we are seeing a contraction in surveillance and not necessarily a contraction in the spread of the virus.”

Undetected infections pose a threat to farmworkers and to the public at large. Because viruses evolve by mutating within bodies, each infection is like a pull of a slot machine lever. A person who died of the bird flu in Louisiana in December illustrates that point: Scientific evidence suggests that bird flu viruses evolved inside the patient, gaining mutations that may make the viruses more capable of spreading between humans. However, because the patient was isolated in a hospital, the more dangerous viruses didn’t transmit to others.

That might not happen if sick farmworkers don’t receive treatment and live in crowded households or windowless detention centers where they might infect others, said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. Although the bird flu doesn’t yet have the ability to spread easily between people through the air, like the seasonal flu, it might occasionally spread when people are in close quarters — and evolve to do so more efficiently.

“I worry that we might not figure out that this is happening until some people get severely sick,” Rasmussen said. “At that point, the numbers would be so large it could go off the rails.”

The virus might never evolve to spread easily, but it could. Rasmussen said that outcome would be “catastrophic.” Based on what’s known about human infections, she and her colleagues predict in a new report that an H5N1 bird flu pandemic “would overwhelm healthcare systems” and “cause millions more deaths” than the covid-19 pandemic.

Vaccinations Drop Off

Late last year, the CDC rolled out a seasonal flu vaccine campaign targeted at more than 200,000 livestock workers. The hope was that flu vaccinations would lessen the chance of a farmworker being infected by seasonal flu and bird flu viruses simultaneously. Co-infection gives the two flu viruses a chance to swap genes, potentially creating a bird flu virus that spreads as easily as the seasonal variety.

Yet Sandoval said flu vaccine uptake dropped immediately after the January operation in California.

U.S. Customs and Border Protection officials said in a statement that they arrested 78 immigrants “unlawfully present in the U.S.” during the three-day operation. They included a convicted sex offender and others with criminal histories including vandalism and petty theft, the statement said. The agency did not name allegations against each person and did not say whether all had been charged.

Former officials with the Biden administration, which was in its waning days as the arrests occurred, distanced itself from the operation in interviews with the Los Angeles Times.

Mayra Joachin, an attorney at the ACLU of Southern California, said the operation was unlike others under the Biden administration in that these were indiscriminate arrests by Border Patrol in the interior of the country. “It fits with the Trump administration’s broader campaign of instilling fear in immigrant communities,” she said, “as seen in the election campaign and in subsequent actions attacking anyone perceived to be a noncitizen in the country.”

In March, an assistant chief in the Border Patrol unit that conducted the operation, David Kim, called the operation a “proof of concept.”

“We know we can push beyond that limit now as far as distance goes,” he told the Southern California news outlet Inewsource.

The Department of Homeland Security did not respond to requests for comment. In an email, White House spokesperson Kush Desai wrote, “Despite what the ‘experts’ believe, combatting the Avian flu epidemic and enforcing our immigration laws are not mutually exclusive.”

Anna Hill Galendez, a managing attorney at the Michigan Immigrant Rights Center, which is involved in bird flu outreach, said unusually aggressive tactics by Immigration and Customs Enforcement agents deterred sick dairy workers in Michigan’s Upper Peninsula from leaving their homes for care in late January. They contacted the center for help.

“They wanted medical care. They wanted flu vaccines. They wanted [personal protective equipment]. They wanted to get tested,” Hill Galendez said. “But they were afraid to go anywhere because of immigration enforcement.”

Lynn Sutfin, a public information officer at the Michigan Department of Health and Human Services, responded to queries about the situation in the peninsula in an email to KFF Health News, saying, “The farmworkers did not take the local health department and MDHHS up on the testing offer.”

The CDC declined to comment on the impact of immigration actions on farmworker outreach.

To adapt to the new reality, Yanez now draws attention to her advice on the bird flu in Michigan by pairing it with information on immigrant rights. Knapp, in Colorado, said his organization is shifting its approach away from bird flu outreach at events where farmworkers congregate, because that could be perceived as a setup — and could inadvertently become one if ICE agents targeted such an event.

Outreach workers who live among farmworkers are withdrawing a little, too. “Being Latinos, we are always identified,” said the outreach worker who spoke on the condition of anonymity. “I have a visa that protects me, but things are changing very quickly under the Trump administration, and the truth is, nothing is certain.”

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Más de una docena de clínicas de vacunación se cancelaron en el condado de Pima, en Arizona.

También una campaña en medios para que los niños de bajos recursos del condado de Washoe, en Nevada, se pusieran al día con sus vacunas.

Otras clínicas planificadas se cancelaran en Texas, Minnesota y Washington, entre otros lugares.

Los esfuerzos de inmunización en todo el país se vieron afectados después que, a fines de marzo, los Centros para el Control y Prevención de Enfermedades (CDC) cancelaran abruptamente $11.400 millones en fondos relacionados con covid-19 para los departamentos de salud estatales y locales.

Un juez federal bloqueó temporalmente los recortes a principios de abril, pero muchas de las organizaciones que reciben los fondos dijeron que deben proceder como si ya no hubiera más dinero, lo que genera preocupación en medio de un resurgimiento del sarampión, un aumento en la reticencia a las vacunas, y una creciente desconfianza en las agencias de salud pública.

“Me preocupa especialmente la accesibilidad de las vacunas para las poblaciones vulnerables”, declaró a KFF Health News Jerome Adams, ex cirujanos general de Estados Unidos. Adams formó parte del primer gobierno del presidente Donald Trump. “Sin altas tasas de vacunación, estamos exponiendo a esas poblaciones y comunidades a daños prevenibles”.

El Departamento de Salud y Servicios Humanos (HHS), bajo el cual operan los CDC, no hace comentarios sobre litigios en curso, según la vocera Vianca Rodríguez Feliciano. Sin embargo, envió un comunicado sobre la medida original, afirmando que el HHS realizó los recortes porque la pandemia de covid-19 ha terminado: “El HHS ya no malgastará miles de millones de dólares de los contribuyentes respondiendo a una pandemia inexistente que los estadounidenses superaron hace años”.

El punto es que las clínicas han utilizado ese dinero para abordar otras enfermedades prevenibles como la gripe, mpox (virus símica) y el sarampión. Más de 500 casos de sarampión en un brote en Texas hasta la fecha han provocado 57 hospitalizaciones y la muerte de dos niños en edad escolar.

En el condado de Pima, Arizona, las autoridades se enteraron de que uno de sus programas de vacunación tendría que interrumpirse debido a que el gobierno federal retiró el millón de dólares restante de la subvención. El condado tuvo que cancelar unos 20 eventos de vacunación que ya tenía programados, que ofrecían vacunas contra covid-19 y la gripe, según informó Theresa Cullen, directora del departamento de salud del condado. Y no puede planificar más, agregó.

El condado alberga a Tucson, la segunda ciudad más grande de Arizona. También abarca extensas zonas rurales, incluyendo parte de la Nación Tohono O’odham, que están lejos de muchas clínicas de salud y farmacias, explica Cullen.

El condado de Pima utilizó la subvención federal para ofrecer vacunas gratuitas en zonas principalmente rurales, en general los fines de semana o después del horario laboral habitual entre semana, explicó Cullen. Los programas se realizan en organizaciones comunitarias, durante ferias y otros eventos, o en autobuses convertidos en clínicas de salud móviles.

La cancelación de las subvenciones relacionadas con las vacunas tiene un impacto que va más allá de las tasas de inmunización, afirmó Cullen. Los eventos de vacunación también son una oportunidad para ofrecer educación sanitaria, conectar a las personas con otros recursos que puedan necesitar y fomentar la confianza entre las comunidades y los sistemas de salud pública, apuntó.

Los líderes del condado sabían que los fondos se agotarían a finales de junio, pero Cullen explicó que el departamento de salud había estado en conversaciones con las comunidades locales para hallar la manera de continuar con los eventos. Ahora, “les hemos dicho: ‘Lo sentimos, teníamos un compromiso con ustedes y no podemos cumplirlo'”, declaró.

Cullen afirmó que el departamento de salud no reanudará los eventos a pesar de que un juez bloqueó temporalmente los recortes de fondos.

“La subvención para la equidad en las vacunas es una subvención que va de los CDC al estado y a nosotros”, explicó. “El estado es quien nos dio la orden de suspender actividades”.

El impacto total de los recortes de los CDC aún no está claro en muchos lugares. Funcionarios del Departamento de Salud Pública de California estimaron que la cancelación de las subvenciones resultaría en pérdidas de al menos $840 millones en fondos federales para su estado, incluyendo $330 millones destinados al monitoreo del virus, pruebas, vacunas infantiles y la atención a las disparidades en salud.

“Estamos trabajando para evaluar el impacto de estas medidas”, declaró Erica Pan, directora del Departamento de Salud Pública de California.

En el condado de Washoe, en Nevada, los recortes sorpresivos de fondos federales implican la pérdida de dos empleados contratados que organizan y anuncian los eventos de vacunación, incluyendo las vacunas obligatorias para el regreso a clases contra enfermedades como el sarampión.

“Nuestro equipo principal no puede estar en dos lugares a la vez”, declaró Lisa Lottritz, directora de la división de servicios de salud comunitaria y clínica del Departamento de Salud Pública del Norte de Nevada.

Esperaba retener a los contratistas hasta junio, fecha prevista de vencimiento de las subvenciones. El distrito de salud se apresuró a encontrar fondos para mantener a los dos trabajadores unas semanas más. Consiguieron suficiente para pagarles solo hasta mayo.

Lottritz canceló de inmediato una campaña publicitaria enfocada en que los niños con seguro médico público estuvieran al día con sus vacunas. Los eventos de vacunación en la clínica de salud pública continuarán, pero serán muy reducidos y con menos personal, dijo.

Las enfermeras que ofrecen vacunas en iglesias, centros para personas mayores y bancos de alimentos dejarán de hacerlo en mayo, cuando se agote el dinero para pagar a los trabajadores.

“El personal tiene otras responsabilidades. Realizan visitas de cumplimiento, gestionan nuestra clínica, así que no tendré los recursos para organizar eventos como ese”, dijo Lottritz.

El efecto de las cancelaciones se sentirá durante mucho tiempo, dijo Chad Kingsley, oficial de salud del distrito de Salud Pública del Norte de Nevada, y podrían pasar años hasta que se sienta el alcance total de la disminución de la vacunación.

“Nuestra sociedad no tiene un conocimiento colectivo de esas enfermedades y lo que causaron”, dijo.

El sarampión es una preocupación prioritaria en Missouri, donde una conferencia sobre el fortalecimiento de los esfuerzos de inmunización a nivel estatal se canceló abruptamente debido a los recortes.

La Coalición de Inmunización de Missouri, que organizó el evento del 24 y 25 de abril, también tuvo que despedir a la mitad de su personal, según la presidenta de la junta, Lynelle Phillips. Esta coalición, que coordina la promoción y educación sobre vacunación en todo el estado, ahora debe encontrar financiación alternativa para seguirá operando.

“Es simplemente cruel y completamente incorrecto hacer esto en medio de un resurgimiento del sarampión en el país”, declaró Phillips.

Dana Eby, del departamento de salud del condado de New Madrid, en Missouri, tenía previsto compartir en la conferencia consejos sobre cómo generar confianza en las vacunas en las comunidades rurales, incluyendo el uso de enfermeras escolares y el programa Vacunas para Niños, financiado por los CDC.

New Madrid tiene una de las tasas de vacunación infantil más altas del estado, a pesar de pertenecer a la región mayoritariamente rural de “Bootheel”, conocida por sus malas condiciones sanitarias. Más del 98% de los niños de kínder del condado recibieron la vacuna contra el sarampión, las paperas y la rubéola en el ciclo escolar 2023-24, en comparación con el promedio estatal de alrededor del 91% y tasas tan bajas como el 61% en otros condados.

“Diré que creo que el sarampión será un problema antes de jubilarme”, dijo Eby, de 42 años.

También estaba previsto que hablara en el evento de Missouri el ex director general de servicios de salud, Adams, quien comentó que planeaba enfatizar la necesidad de la colaboración comunitaria y la importancia de la vacunación para proteger la salud pública y reducir las enfermedades prevenibles. Agregó que el momento era especialmente oportuno dado el aumento repentino de casos de sarampión en Texas y el aumento de casos y muertes por tos ferina en Louisiana.

“No podemos hacer a Estados Unidos más saludable retrocediendo en nuestras tasas de vacunación históricamente altas”, afirmó Adams. “No puedes morir de enfermedades crónicas a los 50 años si ya has muerto de sarampión, polio o tos ferina a los 5”.

Christine Mai-Duc, corresponsal en California, colaboró con este artículo.

Nos gustaría hablar con personal en funciones y ex empleados del Departamento de Salud y Servicios Humanos o sus agencias que crean que el público debe comprender el impacto de lo que está sucediendo dentro de la burocracia federal de salud. Por favor, envía un mensaje a KFF Health News en Signal al (415) 519-8778 o contáctanos aquí.

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EUTAW, Ala. — Leroy Walker arrived at the county hospital short of breath. Walker, 65 and with chronic high blood pressure, was brought in by one of rural Greene County’s two working ambulances.

Nurses checked his heart activity with a portable electrocardiogram machine, took X-rays, and tucked him into Room 122 with an IV pump pushing magnesium into his arm.

“I feel better,” Walker said. Then: Beep. Beep. Beep.

The Greene County Health System, with only three doctors, has no intensive care unit or surgical services. The 20-bed hospital averages a few patients each night, many of them, like Walker, with chronic illnesses.

Greene County residents are some of the sickest in the nation, ranking near the top for rates of stroke, obesity, and high blood pressure, according to data from the federal Centers for Disease Control and Prevention.

Patients entering the hospital waiting area encounter floor tiles that are chipped and stained from years of use. A circular reception desk is abandoned, littered with flyers and advertisements.

But a less visible, more critical inequity is working against high-quality care for Walker and other patients: The hospital’s internet connection is a fraction of what experts say is sufficient. High-speed broadband is the new backbone of America’s health care system, which depends on electronic health records, high-tech wireless equipment, and telehealth access.

Greene is one of more than 200 counties with some of the nation’s worst access to not only reliable internet, but also primary care providers and behavioral health specialists, according to a KFF Health News analysis. Despite repeated federal promises to support telehealth, these places remain disconnected.

During his first term, President Donald Trump signed an executive order promising to improve “the financial economics of rural healthcare” and touted “access to high-quality care” through telehealth. In 2021, President Joe Biden committed billions to broadband expansion.

KFF Health News found that counties without fast, reliable internet and with shortages of health care providers are mostly rural. Nearly 60% of them have no hospital, and hospitals closed in nine of the counties in the past two decades, according to data collected by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill.

Residents in these “dead zone” counties tend to live sicker and die younger than people in the rest of the United States, according to KFF Health News’ analysis. They are places where systemic poverty and historical underinvestment are commonplace, including the remote West, Appalachia, and the rural South.

“It will always be rural areas with low population density and high poverty that are going to get attended to last,” said Stephen Katsinas, director of the Education Policy Center at the University of Alabama. “It’s vital that the money we do spend be well deployed with a thoughtful plan.”

Now, after years of federal and state planning, Biden’s $42 billion Broadband Equity Access and Deployment, or BEAD, program, which was approved with bipartisan support in 2021, is being held up, just as states — such as Delaware — were prepared to begin construction. Trump’s new Department of Commerce secretary, Howard Lutnick, has demanded “a rigorous review” of the program and called for the elimination of regulations.

Trump’s nominee to lead the federal agency overseeing the broadband program, Arielle Roth, repeatedly said during her nomination hearing in late March that she would work to get all Americans broadband “expeditiously.” But when pressed by senators, Roth declined to provide a timeline for the broadband program or confirm that states would receive promised money.

Instead, Roth said, “I look forward to reviewing those allocations and ensuring the program is compliant with the law.”

Sen. Maria Cantwell (D-Wash.), the Senate commerce committee’s ranking minority member, said she wished Roth had been more committed to delivering money the program promised.

The political wrangling in Washington is unfolding hundreds of miles from Greene County, where only about half of homes have high-speed internet and 36% of the population lives below the poverty line, according to the U.S. Census Bureau.

Walker has lived his life in Alabama’s Black Belt and once worked as a truck driver. He said his high blood pressure emerged when he was younger, but he didn’t take the medicine doctors prescribed. About 11 years ago, his kidneys failed. He now needs dialysis three times a week, he said.

While lying in the hospital bed, Walker talked about his dialysis session the day before, on his birthday. As he talked, the white sheet covering his arm slipped and revealed where the skin around his dialysis port had swollen to the size of a small grapefruit.

Room 122, where Walker rested, is sparse with a single hospital bed, a chair, and a TV mounted on the wall. He was connected to the IV pump, but no other tubes or wires were attached to him. The IV machine’s beeping echoed through the hallway outside. Staffers say they must listen for the high-pitched chirps because the internet connection at the hospital is too slow to support a modern monitoring system that would display alerts on computers at the nurses’ station.

Aaron Brooks, the hospital’s technology consultant, said financial challenges keep Greene County from buying monitoring equipment. The hospital reported a $2 million loss on patient care in its most recent federal filing. Even if Greene could afford a system, it does not have the thousands of dollars to install a high-speed fiber-optic internet connection necessary to operate it, he said.

Lacking central monitoring, registered nurse Teresa Kendrick carries a portable pulse oximeter device, she said — like ones sold at drugstores that surged in popularity during the covid-19 pandemic.

Doing her job means a “continuous spot-check,” Kendrick said. Another longtime nurse described her job as “a lot of watching and checking.”

Beep. Beep.

The beeping in Room 122 persisted for more than two minutes as Walker talked. He wasn’t in pain — he was just worried about the beeping.

About 50 paces down the hall — past the pharmacy, an office, and another patient room — registered nurse Jittaun Williams sat at her station behind plexiglass. She was nearly 20 minutes past the end of her 12-hour shift and handing off to the three night-shift nurses.

They discussed plans for patients’ care, reviewing electronic records and flipping through paper charts. The nurses said the hospital’s internal and external computer systems are slow. They handwrite notes on paper charts in a patient’s room and duplicate records electronically. “Our system isn’t strong enough. There are many days you kind of sit here and wait,” Williams said.

Broadband dead zones like Greene County persist despite decades of efforts by federal lawmakers that have created a patchwork of more than 133 funding programs across 15 agencies, according to a 2023 federal report.

Alabama’s leaders, like others around the U.S., are actively spending federal funds from the Biden-era American Rescue Plan Act, according to public records. And Greene County Hospital is on the list of places waiting for ARPA construction, according to agreements provided by the Alabama Department of Economic and Community Affairs.

“It is taking too long, but I am patient,” said Alabama state Sen. Bobby Singleton, a Democrat who represents the district that includes Greene County Hospital and two others he said lack fast-enough connectivity. Speed bumps such as a need to meet federal requirements and a “big fight” to get internet service providers to come into his rural district slowed the release of funds, Singleton said.

Alabama received its first portion of ARPA funds in June 2021, which Singleton said included money for building fiber-optic cables to anchor institutions like the hospital. Alabama’s awards require the projects to be completed by February 2026 — nearly five years after money initially flowed to the state.

Singleton said he now sees fiber lines being built in his district every day and knows the hospital is “on the map” to be connected. “This doesn’t just happen overnight,” he said.

Alabama Fiber Network, a consortium of electric cooperatives, won a total of $45.7 million in ARPA funding specifically for construction to anchor institutions in Greene and surrounding counties. James Hoffman, vice president of external affairs for AFN, said the company is ahead of schedule. It plans to offer the hospital a monthly service plan that uses fiber-optic lines by year’s end, he said.

Greene County Health System chief executive Marcia Pugh confirmed that she had talked with multiple companies but said she wasn’t sure the work would be complete in the time frame the companies predicted.

“You know, you want to believe,” Pugh said.

Beep. Beep.

Nurse Williams had finished the night-shift handoff when she heard beeps from Walker’s room.

She rushed toward the sound, accidentally ducking into Room 121 before realizing her mistake.

Once in Walker’s room, Williams pressed buttons on the IV pump. The magnesium flowing in the tube had stopped.

“You had a little bit more left in the bag, so I just turned it back on,” Williams told Walker. She smiled gently and asked if he was warm enough. Then she hand-checked his heart rate and adjusted his sheets. At the bottom of the bed, Walker’s feet hung off the mattress and Williams gently moved them and made sure they were covered.

Walker beamed. At this hospital, he said, “they care.”

As rural hospitals like Greene’s wait for fast-enough internet, nurses like Williams are “heroes every single day,” said Aaron Miri, an executive vice president and the chief digital and information officer for Baptist Health in Jacksonville, Florida.

Miri, who served under both Democratic and Republican administrations on Department of Health and Human Services technology advisory committees, said hospitals need at least a gigabit of speed — which is 1,000 megabits per second — to support electronic health records, video consultations, the transfer of scans and images, and continuous remote monitoring of patients’ heartbeats and other vital signs.

But Greene’s is less than 10% of that level, recorded on the nurses’ station computer as nearly 90 megabits per second for upload and download speeds.

It’s a “heartbreaking” situation, Miri said, “but that’s the reality of rural America.”

The Beeping Stopped

Michael Gordon, one of the hospital’s three doctors, arrived the next morning for his 24-hour shift. He paused in Room 122. Walker had been released overnight.

Not being able to monitor a cardiovascular patient’s heart rhythm, well, “that’s a problem,” Gordon said. “You want to know, ‘Did something really change or is that just a crazy IV machine just beeping loud and proud and nobody can hear it?’”

Despite the lack of modern technology tools, staffers do what they can to take care of patients, Pugh said. “We show the community that we care,” she said.

Pugh, who started her career as a registered nurse, arrived at the hospital in 2017. It was “a mess,” she said. The hospital was dinged four years in a row, starting in 2016, with reduced Medicare payments for readmitting patients. Pugh said that at times the hospital had not made payroll. Staff morale was low.

In 2021, federal inspectors notified Pugh of an “immediate jeopardy” violation — grounds for regulators to shut off federal payments — because of an Emergency Medical Treatment and Labor Act complaint. Among seven deficiencies inspectors cited, the hospital failed to provide a medical screening exam or stabilizing treatment and did not arrange appropriate transfer for a 23-year-old woman who arrived at the hospital in labor, according to federal reports.

Inspectors also said the hospital failed to ensure a doctor was on duty and failed to create and maintain medical records. An ambulance took the woman to another hospital, where the baby was “pronounced dead upon arrival,” according to the report.

Federal inspectors required the hospital to take corrective actions and a follow-up inspection in July 2021 found the hospital to be in compliance.

In 2023, federal inspectors again cited the hospital’s failure to maintain records and noted it had the “potential to negatively affect patients.”

Inspectors that year found that medical records for four discharged patients had been lost. The “physical record” included consent forms, physician orders, and treatment plans and was found in another department, where it had been left for two months.

Pugh declined to comment on the immediate jeopardy case. She confirmed that a lack of internet connectivity and use of paper charts played a role in federal findings, though she emphasized the charts were discharge papers rather than for patients being treated.

She said she understands why federal regulators require electronic health records but “our hospitals just aren’t the same.” Larger facilities that can “get the latest and greatest” compared with “our facilities that just don’t have the manpower or the financials to purchase it,” she said, “it’s two different things.”

Walker, like many rural Americans, relies on Medicaid, a joint state and federal insurance program for people with low incomes and disabilities. Rural hospitals in states such as Alabama that have not expanded Medicaid coverage to a wider pool of residents fare worse financially, research shows.

During Walker’s stay, because the hospital can’t afford to modernize its systems, nurses dealt with what Pugh later called an “astronomical” number of paper forms.

Later, at Home

Walker sat on the couch in the modest brick home he shares with his sister and nephew. In a pinch, Greene County Hospital, he said, is good “for us around here. You see what I’m saying?”

Still, Walker said, he often bypasses the county hospital and drives up the road to Tuscaloosa or Birmingham, where they have kidney specialists.

“We need better,” Walker said, speaking for the 7,600 county residents. He wondered aloud what might happen if he didn’t make it to the city for specialty care.

Sometimes, Walker said, he feels “thrown away.”

“People done forgotten about me, it feels like,” he said. “They don’t want to fool with no mess like me.”

Maybe Greene County’s health care and internet will get better, Walker said, adding, “I hope so, for our sake out in a rural area.”

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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More than a dozen vaccination clinics were canceled in Pima County, Arizona.

So was a media blitz to bring low-income children in Washoe County, Nevada, up to date on their shots.

Planned clinics were also scuttled in Texas, Minnesota, and Washington, among other places.

Immunization efforts across the country were upended after the federal Centers for Disease Control and Prevention abruptly canceled $11.4 billion in covid-related funds for state and local health departments in late March.

A federal judge temporarily blocked the cuts last week, but many of the organizations that receive the funds said they must proceed as though they’re gone, raising concerns amid a resurgence of measles, a rise in vaccine hesitancy, and growing distrust of public health agencies.

“I’m particularly concerned about the accessibility of vaccines for vulnerable populations,” former U.S. surgeon general Jerome Adams told KFF Health News. Adams served in President Donald Trump’s first administration. “Without high vaccination rates, we are setting those populations and communities up for preventable harm.”

The Department of Health and Human Services, which houses the CDC, does not comment on ongoing litigation, spokesperson Vianca Rodriguez Feliciano said. But she sent a statement on the original action, saying that HHS made the cuts because the covid-19 pandemic is over: “HHS will no longer waste billions of taxpayer dollars responding to a non-existent pandemic that Americans moved on from years ago.”

Still, clinics have also used the money to address other preventable diseases such as flu, mpox, and measles. More than 500 cases of measles so far in a Texas outbreak have led to 57 hospitalizations and the deaths of two school-age children.

In Pima County, Arizona, officials learned that one of its vaccination programs would have to end early because the federal government took away its remaining $1 million in grant money. The county had to cancel about 20 vaccine events offering covid and flu shots that it had already scheduled, said Theresa Cullen, director of the county health department. And it isn’t able to plan any more, she said.

The county is home to Tucson, the second-largest city in Arizona. But it also has sprawling rural areas, including part of the Tohono O’odham Nation, that are far from many health clinics and pharmacies, she said.

The county used the federal grant to offer free vaccines in mostly rural areas, usually on the weekends or after usual work hours on weekdays, Cullen said. The programs are held at community organizations, during fairs and other events, or inside buses turned into mobile health clinics.

Canceling vaccine-related grants has an impact beyond immunization rates, Cullen said. Vaccination events are also a chance to offer health education, connect people with other resources they may need, and build trust between communities and public health systems, she said.

County leaders knew the funding would run out at the end of June, but Cullen said the health department had been in talks with local communities to find a way to continue the events. Now “we’ve said, ‘Sorry, we had a commitment to you and we’re not able to honor it,’” she said.

Cullen said the health department won’t restart the events even though a judge temporarily blocked the funding cuts.

“The vaccine equity grant is a grant that goes from the CDC to the state to us,” she said. “The state is who gave us a stop work order.”

The full effect of the CDC cuts is not yet clear in many places. California Department of Public Health officials estimated that grant terminations would result in at least $840 million in federal funding losses for its state, including $330 million used for virus monitoring, testing, childhood vaccines, and addressing health disparities.

“We are working to evaluate the impact of these actions,” said California Department of Public Health Director Erica Pan.

In Washoe County, Nevada, the surprise cuts in federal funding mean the loss of two contract staffers who set up and advertise vaccination events, including state-mandated back-to-school immunizations for illnesses such as measles.

“Our core team can’t be in two places at once,” said Lisa Lottritz, division director for community and clinical health services at Northern Nevada Public Health.

She expected to retain the contractors through June, when the grants were scheduled to sunset. The health district scrambled to find money to keep the two workers for a few more weeks. They found enough to pay them only through May.

Lottritz immediately canceled a publicity blitz focused on getting children on government insurance up to date on their shots. Vaccine events at the public health clinic will go on, but are “very scaled back” with fewer staff members, she said. Nurses offering shots out and about at churches, senior centers, and food banks will stop in May, when the money to pay the workers runs out.

“The staff have other responsibilities. They do compliance visits, they’re running our clinic, so I won’t have the resources to put on events like that,” Lottritz said.

The effect of the cancellations will reverberate for a long time, said Chad Kingsley, district health officer for Northern Nevada Public Health, and it might take years for the full scope of decreasing vaccinations to be felt.

“Our society doesn’t have a collective knowledge of those diseases and what they did,” he said.

Measles is top of mind in Missouri, where a conference on strengthening immunization efforts statewide was abruptly canceled due to the cuts.

The Missouri Immunization Coalition, which organized the event for April 24-25, also had to lay off half its staff, according to board president Lynelle Phillips. The coalition, which coordinates immunization advocacy and education across the state, must now find alternative funding to stay open.

“It’s just cruel and unthinkably wrong to do this in the midst of a measles resurgence in the country,” Phillips said.

Dana Eby, of the health department in New Madrid County, Missouri, had planned to share tips about building trust for vaccines in rural communities at the conference, including using school nurses and the Vaccines for Children program, funded by the CDC.

New Madrid has one of the highest childhood vaccination rates in the state, despite being part of the largely rural “Bootheel” region that is often noted for its poor health outcomes. Over 98% of kindergartners in the county received the vaccine for measles, mumps, and rubella in 2023-24 compared with the state average of about 91%, and rates in some other counties as low as 61%.

“I will say I think measles will be a problem before I retire,” Eby, 42, said.

Also slated to speak at the Missouri event was former surgeon general Adams, who said he had planned to emphasize the need for community collaboration and the importance of vaccinations in protecting public health and reducing preventable diseases. He said the timing was especially pertinent given the explosion in measles cases in Texas and the rise in whooping cough cases and deaths in Louisiana.

“We can’t make America healthy again by going backwards on our historically high U.S. vaccination rates,” Adams said. “You can’t die from chronic diseases when you’re 50 if you’ve already died from measles or polio or whooping cough when you’re 5.”

California correspondent Christine Mai-Duc contributed to this article.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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Christopher Julian’s opioid journey is familiar to many Americans.

He was prescribed painkillers as a teenager for a series of sports injuries. He said the doctor never warned him they could be addictive. Julian didn’t learn that fact until years later, when he was cut off and began suffering withdrawal symptoms. At that point, he started siphoning pills from family members and buying them from others in his southern Maine community.

After his brother died of brain cancer in 2011, Julian used opioids to cope with more than physical pain.

He stole to support his addiction, cycled in and out of jail and treatment, and overdosed 10 times, he said. His mother once gave him CPR on their bathroom floor.

Life was “hell on Earth,” said Julian, now 43 and in long-term recovery.

Like tens of thousands of others who have suffered similarly, Julian filed claims for compensation from pharmaceutical companies accused of fueling the opioid crisis.

Earlier this year, he received his first payout: $324.58.

That’s enough to fill his car with gas about eight times or pay about a tenth of the rent for an apartment he shares with his fiancee and two children.

Meanwhile, Maine’s Cumberland County, where Julian lives, has received more than $700,000 in opioid settlement money and expects nearly $1.6 million more in the coming years, according to a newly updated database from KFF Health News. Jurisdictions throughout his state have received more than $68 million to date, and governments nationwide have raked in upward of $10 billion, the database shows.

That discrepancy between individuals’ and governments’ compensations highlights a sense of injustice felt by people directly affected by the crisis who say their suffering is the reason that governments secured these settlements.

Opioid settlements with companies like Purdue Pharma, Walmart, and Johnson & Johnson have led to headline-grabbing multibillion-dollar payouts, but most of the windfall is flowing to state and local governments, not directly to victims of the crisis.

Only a handful of companies — those that filed for bankruptcy, including Purdue Pharma, Mallinckrodt, Endo, and Rite Aid — have set aside payouts for individuals. To qualify, people must have filed claims within a certain window and provided documents proving they were prescribed painkillers from that company. Even then, many victims will receive just a few thousand dollars, lawyers and advocates estimate. Most of these companies have not started paying yet, so victims might have to wait months or years more before seeing the cash.

In contrast, state and local governments have already received settlement money. To understand the size of those payouts, KFF Health News in January downloaded data from BrownGreer, the court-appointed firm administering many national opioid settlements, and used it to update a searchable database that allows users to determine how much their city, county, or state has received or expects to receive each year.

Governments are receiving that money because attorneys general argued that their states’ public safety, health, and social service systems were harmed by the opioid crisis. Jurisdictions are supposed to spend settlement money on addiction treatment, recovery, and prevention programs. But many affected individuals and families say governments have failed to adhere to that mission.

“At the very minimum, they could spend these dollars right to prevent the future loss of life,” said Ryan Hampton, a national recovery advocate and previous co-chair of a committee in the Purdue Pharma bankruptcy case, where he represented victims. “That is the opposite of what we’ve seen to date.”

In Pennsylvania, a group of bereaved family members raised similar concerns to Democratic Gov. Josh Shapiro, who finalized opioid settlements when he was attorney general.

“Instead of directing funds toward evidence-based solutions, you and your administration have allowed counties to divert these resources into law enforcement, ineffective programs, and initiatives that already have other funding streams available — disrespecting both our families and the lives lost,” they wrote in a letter dated Feb. 14. “Meanwhile, bereaved families — many of whom have lost everything — have no financial relief.”

‘Governments Were Way More Powerful’

To be sure, many governments have spent millions of settlement dollars on treatment programs, recovery supports, distribution of overdose reversal medications, and other efforts. Some officials in charge of the money say those services, which reach many residents, can have a greater impact than individual payouts.

Will Simons, a spokesperson for the Pennsylvania governor, said in a statement that the Shapiro administration has invested nearly $90 million of settlement funds into treatment, recovery, harm reduction, and prevention initiatives, including prevention programs for youths, a drug and alcohol call center, and loan repayment programs aimed at retaining workers in the addiction treatment and recovery field.

Many of the awarded organizations “support families who have lost loved ones to this crisis, providing counseling and other family supports,” Simons said.

A few jurisdictions have created fairly modest funds directed at individuals, such as one in Boston to aid families who have lost loved ones to addiction, and a fund in Alabama for grandparents having to raise children because of parental substance use.

But nationwide, there’s little that resembles the widespread cash payments that many advocates, like Hampton, originally envisioned.

In the mid-2010s, Hampton said, he and other advocates considered filing class action lawsuits against pharmaceutical companies but realized they didn’t have the resources.

A few years later, when state attorneys general began pursuing cases against those companies, victims were thrilled, thinking they would finally get compensation alongside their governments. Hampton and other advocates held rallies, shared their stories publicly, and galvanized support for the states’ lawsuits.

In 2019, when Hampton became co-chair of the Official Committee of Unsecured Creditors in Purdue Pharma’s bankruptcy and arrived at the negotiating table with state attorneys general and other entities, he thought “everybody was there to take on the big bad pharmaceutical company and to put victims’ interests first,” he said. But as the negotiation proceeded among various creditors vying for the company’s assets, he said, “governments were way more powerful than victims and believed that they were more harmed than victims in terms of cost.”

Details of the Purdue settlement are still being finalized, and payments are unlikely to start until next year, but estimates suggest state and local governments will receive the lion’s share, while more than 100,000 victims will split a fraction of the bankruptcy payout.

Mallinckrodt, a manufacturer of generic opioids, is the only company that had begun paying victims as of early 2025, said Frank Younes, a partner at the Nebraska-based law firm High & Younes, which is representing personal injury claimants in several opioid bankruptcies.

After paying roughly 25% in administrative fees to the national trust overseeing the bankruptcy and an additional 40% in attorney fees, some of his clients have received between $400 and $700, Younes said.

He expects payouts from two other companies — Endo and Rite Aid — “will be even lower.”

But many victims won’t receive anything. Some didn’t know they could file claims until it was too late. Others struggled to obtain medical records from shuttered doctors’ offices or pharmacies that didn’t retain older documents.

Out of nearly 20,000 people who contacted Younes’ firm to participate in the various opioid bankruptcies, he said, only about 3,500 were able to file.

‘Do Something for These Families’

John McNerney was told his Purdue Pharma claim didn’t qualify, because he hadn’t been prescribed enough OxyContin to meet the threshold. He submitted claims for Mallinckrodt and Endo instead.

McNerney, 60, who lives in Boca Raton, Florida, said he suffered a spinal injury decades ago from a fall during a plumbing repair. For years afterward, he was prescribed various painkillers. Once his doctors cut him off, he began using pills a friend bought off the street. McNerney spent about $30,000 on rehabs before he entered long-term recovery.

Now when he sees governments spending settlement money on police cars or library books about addiction “instead of putting 100% of it into rehab,” he said, “it really bothers the heck out of me.”

“I haven’t received a nickel,” he said.

In Ohio, a group of affected families were similarly frustrated that money wasn’t reaching them or the places where they thought it was needed most.

The families teamed up with local nonprofits to submit grant applications to the OneOhio Recovery Foundation, which controls most of the state’s opioid settlement funds. They asked for several million dollars to put toward family support groups, training for family members who take in children whose parents have substance use disorders, and emergency cash aid for families to buy cribs or school supplies and cover funeral costs.

Jackie Lewis, a member of the group, said that when her 34-year-old son, Shaun, died of an overdose, she had to pay his funeral costs by credit card. She has filed a claim in the opioid bankruptcies but hasn’t received any money yet.

“Too many families didn’t have a credit card to do that with,” Lewis said. “There are families I’ve talked to that couldn’t do flowers. Some had to do a cremation instead of a traditional funeral.”

Her group did not receive funding in the first round of grants from the OneOhio Recovery Foundation.

Connie Luck, a spokesperson for the foundation, said the legal documents that established the foundation do not allow direct payments to individuals affected by the crisis. The foundation has awarded over $45 million to 245 projects throughout the state, including dozens that provide family support services like child care and rental assistance.

“We deeply empathize with those who have lost loved ones to the opioid epidemic — their pain is real, and it fuels the Foundation’s mission to end this crisis and prevent it from happening again,” Luck said in a statement.

In Maine, Julian has made peace with his $325 payout, deciding to consider it a surprise bonus rather than compensation for his years of suffering.

But he hopes governments will use their more substantial sums to provide real help — food and rental assistance for people in recovery and more treatment beds so no one has to wait six months to enter rehab as he once did.

“They’re getting millions of dollars,” said Julian, who has lost numerous close friends to overdose. “They could do something for these families that have suffered great losses.”

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

Methodology

For more than two years, KFF Health News has been tracking how state and local governments use — and misuse — billions of dollars in opioid settlement funds. This database marks our third update of data showing how much money state and local governments have received through national settlements with companies that made or distributed prescription painkillers.

BrownGreer, the court-appointed firm administering many national opioid settlements, tracks how much money it has delivered to various state and local governments, as well as how much is allocated to those jurisdictions for future years. It initially kept this information private.

In 2023, KFF Health News negotiated to obtain that information and made it public for the first time. Five months later, BrownGreer began posting updated versions of the information on a public website.

Last year, KFF Health News downloaded BrownGreer’s data on payouts from pharmaceutical distributors AmerisourceBergen (now called Cencora), Cardinal Health, and McKesson, as well as opioid manufacturer Janssen (now known as Johnson & Johnson Innovative Medicine), and used the state-by-state spreadsheets with separate entries for each settling company to create a searchable database.

This year, KFF Health News has updated that database with new data from BrownGreer, including payouts from opioid manufacturers Allergan and Teva, as well as CVS, Walgreens, and Walmart pharmacies.

KFF Health News downloaded data from BrownGreer’s website between Jan. 20 and 24, 2025, concerning payouts from all companies. Users can use the database to determine the total dollar amount their city, county, or state has received or expects to receive each year.

Although this is the most comprehensive data available at a national scale, it provides just a snapshot of all opioid settlement payouts. Other settlements, including with OxyContin manufacturer Purdue Pharma, are still pending. This data does not reflect additional settlements that some state and local governments have entered into beyond the national deals, such as the agreement between Illinois, Indiana, Kentucky, Michigan, and Ohio and regional supermarket chain Meijer. As such, this database undercounts the amount of opioid settlement money most places have received and will receive.

Payment details for some states are not available, because those states were not part of national settlement agreements, had unique settlement terms, or opted not to have their payments distributed via BrownGreer. A few examples:

• West Virginia declined to join several national settlements and instead reached individual settlements with many of these companies.• Texas and Nevada were paid in full by Janssen outside the national settlement, so their payout data reflects payments only from other companies with which they entered national settlements.• Florida, Louisiana, and Pennsylvania, among others, opted to receive a lump-sum payment via BrownGreer then distribute the money to localities themselves.

BrownGreer shows that several states received some of their anticipated 2027 payment from the distributors (AmerisourceBergen — now called Cencora — Cardinal Health, and McKesson) early in 2024. However, for three states — Colorado, Michigan, and Washington — BrownGreer does not provide data on how much of this prepayment went to each locality. As such, locality payments in these states may be undercounted for 2024 and overcounted for 2027.

For Oregon, BrownGreer shows 2024 payments from Walmart as fully paid in its statewide data but lists some August 2024 payments for localities as “projected.” Since the data was downloaded well past that August 2024 date, we have included those “projected” amounts in the 2024 paid total for Oregon localities. No other states had this discrepancy.

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 the catastrophic Los Angeles fires broke out, John Volckens suspected firefighters and residents were breathing toxic air from the burning homes, buildings, and cars, but it was unclear how much risk the public faced. So, the professor of environmental health at Colorado State University devised a plan to get answers.

Volckens shipped 10 air pollution detectors to Los Angeles to measure the amounts of heavy metals, benzene, and other chemicals released by the flames, which burned more than 16,000 homes, businesses, and other structures, making it one of the country’s costliest natural disasters.

“These disaster events keep happening. They release pollution into the environment and to the surrounding community,” said Volckens, who shared his results with local air regulators. “We have this kind of traumatic experience, and then we’re left with: Well, what did we just breathe in?”

Scientists and public health officials have long tracked the pollutants that cause smog, acid rain, and other environmental health hazards and shared them with the public through the local Air Quality Index. But the monitoring system misses hundreds of harmful chemicals released in urban fires, and the Los Angeles fires have led to a renewed push for state and federal regulators to do more as climate change drives up the frequency of these natural disasters.

It’s questionable whether the Trump administration will act, however. Last month, Environmental Protection Agency Administrator Lee Zeldin announced what he described as the “biggest deregulatory” action in history, which critics warn will lead to a rollback of environmental health regulations.

While Air Quality Index values are a good starting place for knowing what’s in the air, they don’t provide a full picture of pollutants, especially during disasters, said Yifang Zhu, a professor of environmental health sciences at UCLA. In fact, the AQI could be in a healthy range, “but you could still be exposed to higher air toxins from the fires,” she added.

In February, nearly a dozen lawmakers from California called on the EPA to create a task force of local and federal authorities to better monitor what’s in the air and inform the public. Locals are “unsure of the actual risks they face and confused by conflicting reports about how safe it is to breathe the air outside, which may lead to families not taking adequate protective measures,” the lawmakers wrote in a letter to James Payne, who was then the acting EPA administrator. The EPA press office declined to comment in an e-mail to KFF Health News.

Lawmakers have also introduced bills in Congress and in the California legislature to address the gap. A measure by U.S. Rep. Mike Thompson (D-Calif.) and U.S. Sen. Jeff Merkley (D-Ore.) would direct the EPA to allocate grant money to local air pollution agencies to communicate the risks of wildfire smoke, including deploying air monitors. Meanwhile, a bill by Democratic state Assembly member Lisa Calderon would create a “Wildfire Smoke Research and Education Fund” to study the health impacts of wildfire smoke, especially on firefighters and residents affected by fires.

The South Coast Air Quality Management District, a regional air pollution control agency, operates about 35 air monitoring stations across nearly 11,000 square miles of the Los Angeles region to measure pollutants like ozone and carbon monoxide.

During the fires, the agency, which is responsible for the air quality of 16.8 million residents, relied on its network of stations to monitor five common pollutants, including PM2.5, the fine particles that make up smoke and can travel deep inside the body. After the fires, the South Coast AQMD deployed two mobile monitoring vans to assess air quality in cleanup areas and expanded neighborhood-level monitoring during debris removal, said Jason Low, head of the agency’s monitoring and analysis division.

Local officials also received the data collected by Volcken’s devices, which arrived on-site four days after the fires broke out. The monitors — about the size of a television remote control and housed in a plastic cover the size of a bread loaf — were placed at air monitoring stations around the fires’ perimeters, as well as at other sites, including in West Los Angeles and Santa Clarita. The devices, called AirPens, monitored dozens of air contaminants in real time and collected precise chemical measurements of smoke composition.

Researchers replaced the sensors every week, sending the filters to a lab that analyzed them for measurements of volatile organic compounds like benzene, lead, and black carbon, along with other carcinogens. Volcken’s devices provided public health officials with data for a month as cleanup started. The hope is that the information provided can help guide future health policies in fire-prone areas.

“There’s not one device that can measure everything in real time,” Low said. “So, we have to rely on different tools for each different type of purpose of monitoring.”

ASCENT, a national monitoring network funded by the National Science Foundation, registered big changes after the fires. One monitor, about 11 miles south of the Eaton fire in the foothills of the San Gabriel Mountains, detected 40 times the normal amount of chlorine in the air and 110 times the typical amount of lead in the days following the fires. It was clear the chemical spikes came from urban wildfire smoke, which is more dangerous than what would be emitted when trees and bushes burn in rural areas, said Richard Flagan, the co-principal investigator at the network’s site in Los Angeles.

“Ultimately, the purpose is to get the data out there in real time, both for the public to see but also for people who are doing other aspects of research,” said Flagan, adding that chemical measurements are critical for epidemiologists who are developing health statistics or doing long-term studies of the impact of air pollution on peoples’ health.

Small, low-cost sensors could fill in gaps as government networks age or fail to adequately capture the full picture of what’s in the air. Such sensors can identify pollution hot spots and improve wildfire smoke warnings, according to a March 2024 U.S. Government Accountability Office report.

Although the devices have become smaller and more accurate in the past decade, some pollutants require analysis with X-ray scans and other costly high-level equipment, said J. Alfredo Gómez, director of the Natural Resources and Environment team at the GAO. And Gómez cautioned that the quality of the data can vary depending on what the devices monitor.

“Low-cost sensors do a good job of measuring PM2.5 but not such a good job for some of these other air toxins, where they still need to do more work,” Gómez said.

UCLA’s Zhu said the emerging technology of portable pollution monitors means residents — not just government and scientists — might be able to install equipment in their backyards and broaden the picture of what’s happening in the air at the most local level.

“If the fires are predicted to be worse in the future, it might be a worthwhile investment to have some ability to capture specific types of pollutants that are not routinely measured by government stations,” Zhu said.

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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Rural hospital leaders are questioning whether they can continue to afford to do business with Medicare Advantage companies, and some say the only way to maintain services and protect patients is to end their contracts with the private insurers.

Medicare Advantage plans pay hospitals lower rates than traditional Medicare, said Jason Merkley, CEO of Brookings Health System in South Dakota. Merkley worried the losses would spark staff layoffs and cuts to patient services. So last year, Brookings Health dropped all four contracts it had with major Medicare Advantage companies.

“I’ve had lots of discussions with CEOs and executive teams across the country in regard to that,” said Merkley, whose health system operates a hospital and clinics in the small city of Brookings and surrounding rural areas.

Merkley and other rural hospital operators in recent years have enumerated a long list of concerns about the publicly funded, privately run health plans. In addition to the reimbursement issue, their complaints include payment delays and a resistance to authorizing patient care.

But rural hospitals abandoning their Medicare Advantage contracts can leave local patients without nearby in-network providers or force them to scramble to switch coverage.

Medicare is the main federal health insurance program for people 65 or older. Participants can enroll in traditional, government-run Medicare or in a Medicare Advantage plan run by a private insurance company.

In 2024, 56% of urban Medicare recipients were enrolled in a private plan, according to a report by the Medicare Payment Advisory Commission, a federal agency that advises Congress. While just 47% of rural recipients enrolled in a private plan, Medicare Advantage has expanded more quickly in rural areas.

In recent years, average Medicare Advantage reimbursements to rural hospitals were about 90% of what traditional Medicare paid, according to a new report from the American Hospital Association. And traditional Medicare already pays hospitals much less than private plans, according to a recent study by Rand Corp., a research nonprofit.

Carrie Cochran-McClain, chief policy officer at the National Rural Health Association, said Medicare Advantage is particularly challenging for small rural facilities designated critical access hospitals. Traditional Medicare pays such hospitals extra, but the private insurance companies aren’t required to do so.

“The vast majority of our rural hospitals are not in a position where they can take further cuts to payment,” Cochran-McClain said. “There are so many that are just really in a precarious financial spot.”

Nearly 200 rural hospitals have ended inpatient services or shuttered since 2005.

Mehmet Oz — doctor, former talk show host, and newly confirmed head of the Centers for Medicare & Medicaid Services — has promoted and worked for the private Medicare industry and called for “Medicare Advantage for all.” But during his recent confirmation hearing, he called for more oversight as he acknowledged bipartisan concerns about the plans’ cost to taxpayers and their effect on patients.

Cochran-McClain said some Republican lawmakers want to address these issues while supporting Medicare Advantage.

“But I don’t think we’ve seen enough yet to really know what direction that’s all going to take,” she said.

Medicare Advantage plans can offer lower premiums and out-of-pocket costs for some participants. Nearly all offer extra benefits, such as vision, hearing, and dental coverage. Many also offer perks, such as gym memberships, nutrition services, and allowances for over-the-counter health supplies.

But a recent study in the Health Services Research journal found that rural patients on private plans struggled to access and afford care more often than rural enrollees on traditional Medicare and urban participants in both kinds of plans.

Susan Reilly, a spokesperson for the Better Medicare Alliance, said a recent report published by her group, which promotes Medicare Advantage, found that private plans are more affordable than traditional Medicare for rural beneficiaries. That analysis was conducted by an outside firm and based on a government survey of Medicare recipients.

Reilly also pointed to a study in The American Journal of Managed Care that found the growth of private plans in rural areas from 2008-2019 was associated with increased financial stability for hospitals and a reduced risk of closure.

Merkley said that’s not what he’s seeing on the ground in rural South Dakota.

He said traditional Medicare reimbursed Brookings Health System 91 cents for every dollar it spent on care in 2023, while Medicare Advantage plans paid 76 cents per dollar spent. He said his staff tried negotiating better contracts with the big Medicare Advantage companies, to no avail.

Patients who remain on private plans that no longer contract with their local hospitals and clinics may face higher prices unless they travel to in-network facilities, which in rural areas can be hours away. Merkley said most patients at Brookings Health switched to traditional Medicare or to regional Medicare Advantage plans that work better with the hospital system.

But switching from private to traditional Medicare can be unaffordable for patients.

That’s because in most states, Medigap plans — supplemental plans that help people on traditional Medicare cover out-of-pocket costs — can deny coverage or base their prices on patients’ medical history if they switch from a private plan.

Some rural health systems say they no longer work with any Medicare Advantage companies. They include Great Plains Health, which serves parts of rural Nebraska, Kansas, and Colorado, and Kimball Health Services, which is based in two small towns in Nebraska and Wyoming.

Medicare Advantage plans often limit the providers patients can see and require referrals and prior authorization for certain services. Requesting referrals, seeking preauthorization, and appealing denials can delay treatment for patients while adding extra work for doctors and billing staff.

“The unique rural lens on that is that rural providers really tend to be pretty bare-bone shops,” Cochran-McClain said. “That kind of administrative burden pulls people away from really being able to focus on providing quality care to their beneficiaries.”

Jonathon Green, CEO of Taylor Health Care Group in rural Georgia, said his system had to set up a team to deal solely with coverage denials, mostly from Medicare Advantage companies. He said some plans frequently decline to authorize payments before treatments, refuse to cover services they already approved, and deny payment for care that shouldn’t need approval.

In these cases, Green said, the companies argue that the care wasn’t appropriate for the patient.

“We hear that term constantly — ‘It’s not medically necessary,’” he said. “That’s the catchall for everything.”

Green said Taylor Health Care Group has considered dropping its Medicare Advantage contracts but is keeping them for now.

Cochran-McClain said her group supports policy changes, such as a federal bill that aims to streamline prior authorization while requiring Medicare Advantage companies to share data about the process. The 2024 bill was co-sponsored by more than half of U.S. senators, but needs to be reintroduced this year.

Cochran-McClain said rural-health advocates also want the government to require private plans to pay critical access hospitals and similar rural facilities as much as they would receive from traditional Medicare.

Green and Merkley stressed that they aren’t against the concept of private Medicare plans; they just want them to be fairer to rural facilities and patients.

Green said rural and independent hospitals don’t have the leverage that urban hospitals and large chains do in negotiations with giant Medicare Advantage companies.

“We just don’t have the ability to swing the pendulum enough,” he said.

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

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