Union Health is making a new bid to Indiana regulators to buy its rival hospital in Terre Haute as the door looks poised to close on such deals.

The nonprofit health system is trying to leverage an existing state law to acquire Terre Haute Regional Hospital, the only other acute care hospital in Vigo County. After withdrawing its initial application in November amid pushback, Union has shifted its pitch to emphasize what it describes as Regional’s “declining position” while offering more concrete promises, such as limits on price increases.

Union submitted its new application on Feb. 5 as Indiana lawmakers were attempting to nix such mergers in their state. Lawmakers then watered down a bill that threatened to forbid Union’s deal altogether, with the amended legislation now barring mergers sought after Feb. 15, leaving an opening for Union. That means the proposed merger will next face a showdown with the administration of Indiana’s new governor, which has signaled opposition to such deals.

Indiana is among the latest states reconsidering Certificate of Public Advantage laws that greenlight hospital monopolies. This year, Tennessee lawmakers introduced a bill to restructure state oversight of these mergers after an attempt last year to repeal its COPA law. In 2023, Maine repealed its COPA law, joining Minnesota, Montana, North Carolina, and North Dakota.

“I would hope that they are reconsidering the laws because of the research on the long-run harms of COPAs,” said Christopher Garmon, a University of Missouri-Kansas City economist who has studied COPA mergers.

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

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

Union Health’s first application faced pushback. The state’s Department of Health received hundreds of comments, with most opposing the deal, according to a review of documents KFF Health News obtained through a state public records request. Doctors, health economists, and the FTC were among those who called on state regulators to deny Union’s proposal.

Union pulled its application in November, just days before the state was due to rule on the deal.

When Union filed its new application in early February, this time it promised a slew of concrete commitments and pledges to improve residents’ health in the largely rural communities that surround Terre Haute. Among them were promises to keep both hospitals’ emergency rooms open and inpatient services in operation, and to tie increases in hospital charges to the consumer price index for medical care, essentially establishing a cap so charges don’t exceed medical inflation.

It also recast its pitch to describe Regional as a hospital in decline, which Union said puts the region at risk of losing access to services if the merger is not approved. Tennessee-based HCA Healthcare owns Terre Haute Regional.

In that scenario, Union warned, if Regional were to close, the health system would essentially have a monopoly anyway, “without any oversight, terms, or conditions” of a COPA. Instead, it argued, a green light from state regulators could avert a hospital closure and guarantee state oversight of the combined hospital system.

Union’s first application did not argue that the merger was necessary for Regional to remain viable. In public comments submitted in September and March, the FTC argued to state regulators that both hospitals are “financially stable,” adding that Regional is “part of the largest hospital system in the country with tremendous financial resources.” It also cited hospital financial reporting that showed Terre Haute Regional Hospital’s profits were better than those of most other hospitals in the country.

“This repackaged COPA application presents the same problems as before,” Clarke Edwards, acting director of the FTC’s Office of Policy Planning, said in a statement on March 17 after the commission unanimously opposed the merger.

HCA did not respond to questions about Union’s characterization that Regional is a hospital in decline.

Despite Union’s assurances that the merger would benefit the region, an analysis of the first proposal found the opposite. Zack Cooper, a health economist and an associate professor at Yale University, estimated that the price of care would rise by at least 10%, 500 jobs would be lost, and nurses’ pay would decline by at least 7%.

Despite the new application and new promises, “the nature of the deal hasn’t changed,” Cooper said. He said that his findings remain unchanged and that Union stands to benefit — not the community.

“Life is easier for a firm if you face less competition,” he said. “There’s less pressure to compete on quality. There’s less pressure to compete on price.”

In January, state Sen. Ed Charbonneau, a Republican and a key architect of Indiana’s 2021 COPA law, introduced the legislation to repeal the law, which would have foreclosed Union’s chance at a possible second attempt at the merger.

In February, seated side by side at a state Senate health committee hearing, Union Health CEO Steve Holman, Terre Haute Chamber of Commerce President Kristin Craig, and state Sen. Greg Goode, a Republican representing the region, testified against the bill.

Holman told lawmakers the merger would improve the health of the region. He also noted that the hospital system had already spent $3 million on legal fees pursuing the deal. He said it seemed like lawmakers were attempting to cripple Union’s chances. “Why has this come up now?” Holman asked.

The bill to repeal the COPA law advanced out of committee by a 7-4 vote. State Sen. Mike Bohacek, a Republican who represents a region a three-hour drive north of Terre Haute, said he voted against repealing the law out of deference to local officials.

“I have no dog in this fight,” Bohacek said.

Charbonneau later amended his bill, winning support from Union and Goode. The new version sailed through the Senate. It is now backed by two powerful Republican representatives in the House: Brad Barrett, chair of the Public Health Committee, and Bob Heaton, House majority whip. Heaton represents parts of Vigo County.

Union Health spokesperson Amanda Scott said in an email to KFF Health News that Union and Regional Hospital “recognize the significance of a final approval” and that Union views this as its last chance to acquire its rival.

But Indiana’s new governor, Republican Mike Braun, took office in January vowing to crack down on consolidation, especially in health care.

Earlier this year, Braun tapped Gloria Sachdev to lead a newly created Cabinet position overseeing the state’s health care agencies, including the state Department of Health, which will decide on the merger.

As CEO of the Employers’ Forum of Indiana, a coalition of businesses that has combated high hospital prices, Sachdev was an outspoken critic of the proposed merger in Terre Haute. In an October opinion piece in The Indianapolis Star, she urged regulators to consider how these mergers can crush communities.

Sachdev, now the state’s secretary of health and family services, didn’t answer questions on the new bid. After KFF Health News asked the governor’s office whether Braun has final authority over the fate of Union’s merger request, Department of Health spokesperson Greta Sanderson provided a joint statement from the agency and the office of the governor: “Gov. Braun will expect to be informed, ask questions, and ensure that whatever decision is made is thoughtful and objective with the best interests of Hoosiers in mind.”

The state has until June 21 to review the merger application before rendering a decision, according to the Department of Health. The public can comment on the proposal through March 23.

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In 2019, Cristina Iglesias filed a lawsuit that changed the course of treatment for herself and other transgender inmates in federal custody.

Iglesias, a trans woman who had been incarcerated for more than 25 years, was transferred from a men’s prison to a women’s one in 2021. And in 2022, she reached a landmark settlement with the Federal Bureau of Prisons to receive gender-affirming surgery, which the agency said it had never provided for anyone in its custody.

By the time she got the surgery 10 months later, another federal inmate had also received a procedure to align their body with their gender identity. No other such surgeries for people in federal custody are publicly documented, although some people in state prisons have also received gender-affirming surgery, including at least five in Illinois and 20 in California within a U.S. prison population that tops 1.25 million people.

Still, those procedures loomed large in the 2024 presidential election. Political advertising for President Donald Trump and other Republicans included $215 million on anti-trans ads, according to media tracking firm AdImpact. One such ad declared that Democratic presidential nominee Kamala Harris supported “taxpayer-funded sex changes for prisoners,” and concluded, “Kamala is for they/them. President Trump is for you.” Some Democrats bemoaned the ads as having helped tip the election.

In the run-up to the Nov. 5 election, 55% of voters felt support for trans rights had gone too far, according to VoteCast, a survey by The Associated Press and partners including KFF, the health policy research, polling, and news organization that includes KFF Health News.

On Inauguration Day, Trump issued a flurry of executive orders that included a directive to bar federal spending on gender-affirming care in federal prisons and to “ensure that males are not detained” in federal women’s facilities.

“President Trump received an overwhelming mandate from the American people to restore commonsense principles and safeguard women’s spaces — even prisons — from biological men,” White House spokesperson Anna Kelly wrote in an email. “Forcing taxpayers to pay for gender transition for prisoners is the exact sort of insanity that the American people rejected at the ballot box in November.”

But for Iglesias, 50, Trump’s order was a shocking reversal.

“It puts someone’s life in danger being in a men’s prison as a trans woman,” she said from Chicago, where she’s lived since her release in 2023. “It’d be like putting sheep in a hyenas’ den.”

Iglesias said she faced emotional and physical abuse from her father for her desire to be female. When she was 12, she said, he put a gun in her mouth after finding her wearing her sister’s clothes. Iglesias said she ran away from home, stole checks, cars, and jewelry, and ended up in jail.Lockup was not fun, Iglesias said, but it was the first place she got to be treated as a woman. So, she said, she wanted to stay. In 1994, she landed in federal prison after writing threatening letters to federal judges and prosecutors, according to court filings. In 2005, records show, she pleaded guilty to sending a letter to British officials that she falsely claimed contained anthrax. She told investigators she hoped to get extradited.

“I was reading these things where they were allowing trans females to start living with females,” Iglesias said.

She said her outlook changed after the death of her mother in 2010, which prompted her to get serious about having a life outside of prison, and about improving her life inside it.

She began requesting hormone therapy in 2011 and was approved for it in 2015, according to court records. The 2019 lawsuit that led to her transfer to a women’s prison and her surgery was initially handwritten and prepared with the help of only another inmate.

“The lawsuit was the foundation for everything that I am today,” Iglesias said. “For the first time in my life, instead of digging myself in these holes, I was digging myself out.”

Along with her settlement, Iglesias received a commitment from the Federal Bureau of Prisons to create a timeline for considering other inmates’ requests for gender-affirming care, and to recognize permanent hair removal and gender-affirming surgery as medically necessary treatments for gender dysphoria — a medical condition in which the discrepancy between a person’s gender identity and their sex assigned at birth causes significant distress.

In February, in response to Trump’s executive order, the bureau issued new guidelines requiring prison staffers to refer to inmates’ “legal name or pronouns corresponding to their biological sex,” and ending clothing requests “that do not align with an inmate’s biological sex.” The guidelines end referrals for gender-affirming surgery but allow inmates already receiving treatment, such as hormone therapy, to continue.

However, in a lawsuit filed March 7, a trans prisoner alleged the hormone therapy she had been receiving since 2016 was stopped on Jan. 26.

Spokespeople for the bureau did not respond to requests for comment.

The bureau spent $153,000 on hormone therapy in fiscal year 2022, its former director told Congress, 0.01% of its total spending on health care.

The new guidelines on trans inmates say that Trump’s executive order “does not supersede or change” the obligation to comply with federal regulations. But the executive order calls for amending them to prevent trans women from being housed in women’s prisons.

“It hurt my heart when I seen that because I do know other girls that are still in prison,” said Iglesias, who spent more than 25 years in male facilities. “Female prison is safe for a trans woman, and you can be who you are. You’re not penalized because you’re feminine.”

But requesting a transfer to a facility matching inmates’ gender identity had not been easy, and few prisoners had been moved before the order. A 2025 government court filing said that federal prisons house 2,198 trans prisoners out of over 155,000 inmates. Of those, the filing said, 22 are trans women housed in female facilities, and one is a trans man in a men’s facility. Although courts have blocked attempts to move that small subset of trans prisoners after the order, a trans prisoner not included in those suits had been relocated, The Guardian news outlet reported.

A Department of Justice report from 2014 estimated that trans inmates in state and federal prisons were 10 times as likely as other prisoners to report incidents of sexual victimization.

Iglesias said she experienced such violence firsthand. Included in her suit was a copy of a 2017 psychological report that said Iglesias reported being the victim of sexual misconduct or abuse in 1993, 2001, 2013, 2015, 2016, and 2017. Later filings included allegations of having been raped in 2019 and 2020, and a series of rapes, threats, and other abuse in 2021 before she was transferred to a female facility. Iglesias said she faced more abuse than she officially reported.

“Just because you commit a crime doesn’t mean you deserve to have violence against you,” said Michelle García, deputy legal director of the ACLU of Illinois and one of the attorneys who ultimately represented Iglesias.

Federal law requires all inmates to be protected from abuse. A 1994 Supreme Court decision acknowledged trans inmates as particularly vulnerable to attack. Regulations from the Prison Rape Elimination Act, passed unanimously by Congress in 2003, contain specific provisions for trans inmates, including allowing them to shower separately from other inmates and requiring prison officials to consider their health and safety when deciding whether to house them in male or female facilities.

Courts also have ruled that “deliberate indifference” to an inmate’s “serious medical needs” violates the Eighth Amendment’s ban on “cruel and unusual” punishments. The quality of overall medical care for federal prisoners has come under scrutiny amid reports of inmates going without needed medical care and preventable deaths.

Iglesias successfully argued in court that gender-affirming surgery was necessary for her gender dysphoria. She was diagnosed with what was then called “gender identity disorder” soon after entering federal custody in 1994, according to court filings. Her diagnosis was updated to gender dysphoria in 2015.

Iglesias’ court filings documented her having been assessed for the risk of suicide 33 times and placed on suicide watch 12 times, as well as an attempt at self-castration in 2009.

“Defendants are aware of Iglesias’s suffering, but have delayed her treatment without evaluating her medically,” the judge in her case wrote.

García called the Trump administration’s targeting of care for trans inmates cruel, unnecessary, and illogical.

“They’re not assessing the constitutional rights of people,” García said. “They’re making choices because this is a vulnerable community that they can rally people behind to hate.”

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

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KFF Health News senior correspondent David Hilzenrath discussed how the FDA allows risky chemicals in America’s food supply on CBS’ “CBS Mornings Plus” on March 11.

• Click here to watch Hilzenrath on “CBS Mornings Plus”
• Read Hilzenrath’s “How the FDA Opens the Door to Risky Chemicals in America’s Food Supply”

KFF Health News editor-at-large for public health Céline Gounder discussed the measles outbreak on CBS’ “CBS Mornings” on March 7. She also discussed how measles affects the immune system on CBS 24/7’s “The Daily Report” on March 5.

• Click here to watch Gounder on “CBS Mornings”
• Click here to watch Gounder on “The Daily Report”

KFF Health News Midwest correspondent Cara Anthony discussed her documentary, “Silence in Sikeston,” on KBIA on March 7.

• Click here to hear Anthony on KBIA
• Explore Anthony’s series, “Silence in Sikeston”

KFF Health News Southern correspondent Sam Whitehead discussed the basics of Medicaid on WUGA’s “The Georgia Health Report” on Feb. 28.

• Click here to hear Whitehead on “The Georgia Health Report”
• Read Whitehead and Renuka Rayasam’s “Republicans Are Eyeing Cuts to Medicaid. What’s Medicaid, Again?”

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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BOSTON — On days when the sun was shining and the air was warm with a gentle, cooling breeze, Ateiya Sowers-Hassell liked to keep the salon door open. Labor Day was one of those days. Sowers-Hassell was tending to two clients at Salvaged Roots, the natural hair salon and spa in the Four Corners section of Boston’s Dorchester neighborhood where she works as a stylist. She was in a groove, soothing music playing in the background, when gunshots boomed through the air.

She saw people running from Exclusive Barbershop next door. She heard a voice telling a 911 operator that someone had been shot in the head. Her hands shook as she ventured outside. Then she saw 20-year-old Elijah Clunie slumped in a barber’s chair, haircut unfinished.

In the chaos, a 7-year-old boy stood in shock, eyes bulging at Clunie’s body. Sowers-Hassell asked the boy to come with her and sheltered him at the salon until his father arrived. “He kept going, ‘I can’t breathe. I can’t breathe,’” she said, and he later told her he never wanted to get his hair cut again.

Barbershops and salons are regarded in the Black community as safe, sacred spaces, where men and women gather to laugh, debate, and see their unofficial therapists: the barbers and stylists. When those refuges are violated by gun violence, an unspoken bond is broken.

Clunie’s killing cost Dorchester more than his own young life. Shootings send ripples of trauma through communities that can carry across generations. A 2020 study found that exposure to gun killings was linked to higher levels of depression, suicidal ideation, and other mental health difficulties. Children and young adults were the most susceptible, and Black youth were disproportionately affected.

When economists calculate the societal costs of gun violence, “what they find is that much bigger than hospital treatment or criminal justice response or anything, is the fear and trauma and how it affects individuals and businesses,” said Daniel Webster, a professor and distinguished scholar with the Johns Hopkins Center for Gun Violence Solutions.

Four Corners — home largely to African American, Caribbean, and Puerto Rican families — is not a destination neighborhood. A historic Methodist church is one of the few attractions. There aren’t any major supermarkets, fine dining restaurants, or hospitals. Of the businesses that do exist, many cover their doors and windows in plexiglass and metal bars.

“We talk about these food deserts of good, healthy food; the truth of the matter is, it’s a desert for everything,” Webster said. “Businesses generally don’t want to be there.”

The owner of Salvaged Roots, Shanita Clarke, said she intended her salon to stand out as an oasis in the community.

Clarke was planning to take her then-13-year-old son to the salon to get his hair done when she got a phone call about the shooting. She rushed to work to check on her stylists. Clarke, her staff, and clients spent the next three hours waiting while officers collected evidence. In the weeks that followed, calls came in to push back appointments. Clarke said she could sense her clients’ anxiety and understood it. Even though she wasn’t in the shop when Clunie was shot, she experienced the incident vicariously through the sound of gunshots captured on the salon’s security footage and accounts from her employees.

A case statement from the commonwealth of Massachusetts alleges the suspect in Clunie’s killing, Diamond Jose Brito, entered Exclusive Barbershop wearing all black clothing and a ski mask. Brito walked to the back of the shop, where Clunie was seated, and asked his barber how long the wait was for a haircut. About 45 minutes later, the statement alleges, Brito returned, walked to Clunie’s chair, shot him in the back of the head with a small silver revolver, then shot another victim multiple times.

Brito, of Canton, Massachusetts, was arrested in Mattapan in October and is being held without bail. He pleaded not guilty to all the charges against him, including murder.

“Mr. Brito maintains his innocence and we are looking forward to presenting his defense at trial,” Brito’s attorney, David Leon, said in a statement to KFF Health News.

Boston City Councilor Brian Worrell’s office is around the corner from Salvaged Roots and Exclusive Barbershop. The neighborhood requires investment and initiatives by elected officials and policymakers, he said. Residents have to feel that homeownership and stable careers are possible.

“That can’t be some far-off thinking,” said Worrell, who represents District 4, which includes that part of Dorchester. “They have to be able to see it, and it has to show up in their lives, in a real, tangible way.”

Clunie had been a student at TechBoston Academy and a basketball player who was named player of the game after a big win his senior year, in 2022. But in a draft senior presentation uploaded to the presentation site Prezi in June of that year, a user presumed to be Clunie wrote: “When I first moved to the Dorchester area I thought I was going to die,” noting “the killings on the news” every day.

Moments after the shooting, an unknown person walked into the barbershop and recorded a graphic video of Clunie’s body, which was then uploaded to social media platforms. It spread on Facebook and X, leading users to find Clunie’s personal accounts, on which some commenters made light of his death. He would have turned 21 the Saturday following his killing.

Worrell called the video especially inappropriate and callous. But apathy in the face of violence, he said, isn’t hard to imagine in a community suffering food and housing insecurity, struggling schools, and a persistent lack of opportunity.

Clarke said she’s torn on how to move forward. Loud noises and being alone trigger anxiety, and she now sometimes locks the salon doors once clients are in for their appointments. She’s felt anger and isolation, she said.

Recovering from the trauma of witnessing gun violence is often more difficult for onlookers when they still live and work where the shootings happened.

“We want to address the mental health trauma from gun violence, but let’s not kid ourselves,” Webster said. “If we don’t actually address gun violence, we’re swimming against a really strong tide.”

Since she opened her salon almost six years ago, Clarke has been active in community efforts to make the neighborhood safer, attending civic association and neighborhood meetings and speaking with police and local politicians.

Clarke believes efforts to clean up nearby Melnea Cass Boulevard moved more drug users into Dorchester. Salvaged Roots is next to a commuter rail station, which Clarke said attracts transients who set up camps and leave behind trash and sometimes drug paraphernalia. Only a week before Clunie’s killing, there was a fatal shooting across the street from the salon.

In 2024, there were about 20 shootings in the police district that includes Four Corners, five of them fatal. Most of the victims were Black men, according to a KFF Health News analysis of Boston Police Department data.

Though gun violence overall is at a record low in Boston since 2023 and the city has invested more in investigative resources — including police detectives, management, and oversight — a disproportionate amount occurs in Boston’s historically Black communities.

Since Clarke opened Salvaged Roots, she feels Four Corners has gotten both better and worse. “If other businesses leave, then where do people that live in the community — where are the nice places that they get to go to?” she asked.

Residents of neighborhoods with frequent gun violence and crime can mistakenly be perceived as being desensitized, but “we can never accept the violence as normal,” Boston City Council President Ruthzee Louijeune said. She’s volunteered and worked in Four Corners and said tackling the violence takes a multipronged approach, including getting guns off the street and providing access to affordable housing, secure jobs, and good health care.

In communities of color, she said, intergenerational trauma from racism and poverty must also be addressed.

In Dorchester, Louijeune said, a high number of residents resort to visiting emergency rooms for mental health issues. The neighborhood needs more access to health care, she said, especially for young people. Across Boston, Black residents were nearly twice as likely to go to the ER for mental health care than white residents, according to the Boston Public Health Commission’s 2024 Mental Health Report.

Months later, attention and curiosity over the shooting had died down, but the trauma remained. Sowers-Hassell continues to work at Salvaged Roots, and though the city sent a trauma team to meet with the stylists after the shooting, she still has flashbacks. She said the influx of resources was helpful and that Four Corners has been a little quieter. But she’s skeptical the reprieve will last.

“Everybody talks a good game,” she said, “but when it’s time to get something done, what’s going to happen?”

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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DENVER. — Hace siete años, Erica Green se enteró a través de Facebook que le habían disparado a su hermano.

Corrió al hospital, uno gerenciado por Denver Health, el sistema de seguridad social de la ciudad, pero no pudo obtener información de los trabajadores de la sala de emergencias: se quejaron de que ella estaba generando un disturbio.

“Estaba afuera, angustiada y llorando, cuando Jerry salió por la puerta principal”, dijo.

Jerry Morgan es un rostro familiar en el barrio de Green, en Denver. Había ido al hospital después de que su pager lo alertara del tiroteo. Como profesional de la prevención de la violencia en el programa At-Risk Intervention and Mentoring (AIM), Morgan brinda su apoyo en el hospital a los pacientes víctimas de violencia con armas de fuego y a sus familias.

Es lo que hizo el día en que le dispararon al hermano de Green.

“Me ayudó a que atravesara mucho mejor esa experiencia traumática. Al punto que después pensé: yo también quiero dedicarme a eso”, contó Green.

Ahora, Green trabaja con Morgan como directora de AIM, un programa de intervención contra situaciones de violencia vinculado a los hospitales. AIM se puso en marcha en 2010 como una asociación entre Denver Health y la organización sin fines de lucro Denver Youth Program. Desde entonces, se ha ido ampliado para incluir el Hospital Infantil de Colorado y el Hospital de la Universidad de Colorado.

En todo el país existen docenas de programas de intervención contra la violencia vinculados a hospitales, como AIM. El objetivo de estos programas es identificar los factores sociales y económicos que contribuyeron a que una persona terminara en una sala de emergencias con una herida de bala, por ejemplo, la falta de una vivienda adecuada, la pérdida de empleo o sentirse inseguro en el propio vecindario.

Este tipo de programas, que abordan la lucha contra la violencia con armas de fuego desde una perspectiva de salud pública, han tenido éxito.

En San Francisco, uno de ellos logró reducir en un 75% la cantidad de personas que volvieron a sufrir heridas por hechos violentos en un período de seis años.

Pero las órdenes ejecutivas del presidente Donald Trump, que piden la revisión tanto de las políticas de armas de la administración Biden como de los billones de dólares en subvenciones y préstamos federales, han creado incertidumbre en torno a la financiación federal a largo plazo de estos programas. Algunos organizadores creen que no se verán afectados, pero otros ya están buscando asegurar fuentes de financiamiento alternativas.

“Nos preocupa que se produzca un efecto dominó, una reacción en cadena. Y nos preguntamos cómo nos afectará. Hay muchas incógnitas”, explica John Torres, director asociado de Youth Alive, una organización sin fines de lucro con sede en Oakland, California.

Los datos federales muestran que la violencia con armas de fuego se convirtió en una de las principales causas de muerte entre niños y adultos jóvenes a principios de esta década y que en 2022 estuvo relacionada con más de 48.000 muertes entre personas de todas las edades.

El pediatra de Nueva York Chethan Sathya, especializado en cirugía y traumatología, investiga cómo prevenir lesiones por armas de fuego, financiado por los Institutos Nacionales de Salud (NIH). Sathya sostiene que las estadísticas muestran que esta forma de violencia debe ser considerada como un problema de salud pública. “Está matando a demasiada gente”, argumentó.

Las investigaciones demuestran que haber sufrido una lesión violenta aumenta el riesgo de tener otras en el futuro. Y también que el riesgo de muerte aumenta significativamente luego de la tercera lesión violenta. Los datos surgen de un estudio de 2006 publicado en The Journal of Trauma: Injury, Infection and Critical Care.

Benjamin Li, médico de la sala de emergencias en Denver Health y director médico del sistema de salud de AIM, dijo que la emergencia es un entorno ideal para intervenir ante la violencia con armas de fuego, ya que permite investigar y comprender los eventos que llevaron a que un paciente haya sido baleado.

 “Si solo atendemos a la persona, la curamos y luego la enviamos de vuelta a vivir en las mismas condiciones, sabemos que es muy probable que vuelva a resultar herida”, explicó Li. “Es fundamental que abordemos los determinantes sociales de salud y tratemos de cambiar esa realidad”.

Eso podría significar que se proporcione a las víctimas de disparos soluciones alternativas para evitar que busquen venganza, opinó Paris Davis, director de programas de intervención de Youth Alive.

“Puede ser ayudarlos a mudarse a otra zona o facilitarles que consigan una vivienda. También colaborar para que puedan canalizar esa energía hacia la educación o el trabajo o, por ejemplo, iniciar una terapia familiar. Sean cuales fueren las necesidades en cada caso y en cada individuo en particular, nos aseguramos de brindarles el apoyo que necesitan”, dijo Davis.

El equipo de AIM que trabaja directamente con la comunidad visita a las víctimas de disparos en sus camas de hospital para tener lo que Morgan, el principal encargado de esta área del programa, describe como una conversación difícil pero libre de prejuicios respecto de cómo los pacientes llegaron a esa situación.

AIM utiliza esa información para ayudar a las personas a acceder a los recursos que necesitan para afrontar los grandes desafíos que los esperan después de que les den el alta, dijo Morgan. Esos desafíos pueden incluir volver a la escuela o al trabajo, o encontrar una nueva vivienda.

Los trabajadores comunitarios de AIM también pueden asistir a los procedimientos judiciales y ayudar con el transporte para que los pacientes acudan a las citas de atención médica.

“Tratamos de ayudar en la medida de lo posible, pero depende de lo que necesita el beneficiario”, dijo Morgan.

Desde 2010, AIM ha pasado de tener tres a tener nueve trabajadores sociales a tiempo completo, y este año ha abierto la REACH Clinic en el barrio Five Points de Denver. La clínica comunitaria ofrece kits para el cuidado de heridas, fisioterapia y atención de salud conductual, mental y ocupacional. En los próximos meses, tiene previsto agregar a sus servicios la extracción de balas.

El programa forma parte de un movimiento creciente de clínicas comunitarias centradas en lesiones violentas, como la Bullet Related Injury Clinic, en St. Louis.

Ginny McCarthy, profesora adjunta del Departamento de Cirugía de la Universidad de Colorado, describió REACH como una extensión del trabajo hospitalario, que ofrece un tratamiento integral en un solo lugar y fomenta la confianza entre los proveedores de salud y las comunidades minoritarias que históricamente han padecido prejuicios raciales en la atención médica.

Caught in the Crossfire, creado en 1994 y dirigido por Youth Alive en Oakland, es mencionado como el primer programa de la nación de intervención de violencia vinculado a un hospital; desde entonces ha inspirado a otros.

La Health Alliance for Violence Intervention, una red nacional iniciada por Youth Alive para promover soluciones de salud pública a la violencia con armas de fuego, en enero de este año contaba entre sus miembros con 74 programas de intervención de violencia vinculados a hospitales.

La directora ejecutiva de la alianza, Fatimah Loren Dreier, comparó el papel de la medicina en la lucha contra la violencia armada con el de la prevención de una enfermedad infecciosa como el cólera. “Esa enfermedad se propaga si no se cuenta con buenas condiciones sanitarias en los lugares donde se concentra la gente”, argumentó.

Dreier, que también es directora ejecutiva del Kaiser Permanente Center for Gun Violence Research and Education, dijo que la medicina identifica y rastrea los patrones que conducen a la propagación de una enfermedad o, en este caso, a la propagación de la violencia.

“Eso es lo que la atención sanitaria puede hacer realmente bien para cambiar la sociedad. Cuando lo implementamos, obtenemos mejores resultados para todos”, dijo Dreier.

La alianza, de la que AIM es miembro, ofrece asistencia técnica y formación para programas de intervención contra la violencia vinculados a hospitales y ha solicitado con éxito que sus servicios sean reconocidos para recibir reembolso de los seguros tradicionales.

En 2021, el presidente Joe Biden emitió una orden ejecutiva que abrió la puerta para que los estados utilizaran Medicaid para la prevención de la violencia. Varios estados, entre ellos California, Nueva York y Colorado, han aprobado leyes que establecen un beneficio de Medicaid para los programas de intervención contra la violencia vinculados a hospitales.

El verano pasado, el entonces cirujano general de los Estados Unidos, Vivek Murthy, declaró la violencia armada como una crisis de salud pública, y la Ley Bipartidista de Comunidades más Seguras de 2022 destinó $1.400 millones en fondos para una amplia gama de programas de prevención de la violencia hasta el próximo año.

Pero a principios de febrero, Trump emitió una orden ejecutiva en la que ordenaba al fiscal general de los Estados Unidos que llevara a cabo una revisión de 30 días de varias políticas de Biden sobre la violencia armada.

La Oficina de Prevención de la Violencia Armada de la Casa Blanca parece estar inactiva, y las recientes medidas para congelar las subvenciones federales han creado incertidumbre entre los programas de prevención que reciben financiación federal.

Según Li, AIM recibe el 30% de su financiación de su acuerdo operativo con la Oficina de Soluciones a la Violencia Comunitaria de Denver. El resto proviene de subvenciones, incluida la financiación de la Ley de Víctimas del Crimen, que llega a través del Departamento de Justicia. A mediados de febrero, las órdenes ejecutivas de Trump no habían afectado a la financiación actual de AIM.

Algunas de las personas que trabajan con los programas de prevención de la violencia vinculados a hospitales en Colorado confían en que un nuevo impuesto especial sobre las armas de fuego y las municiones, ya aprobado por los votantes en el estado, pueda ser una fuente adicional de financiación.

Se espera que genere unos $39 millones anuales y apoye a los servicios para las víctimas, pero no es probable que los ingresos del impuesto fluyan por completo hasta 2026, y no está claro cómo se asignará ese dinero.

Catherine Velopulos, cirujana de traumatología e investigadora de salud pública, que es la directora médica de AIM en el hospital de la Universidad de Colorado en Aurora, dijo que cualquier interrupción en la financiación federal, aunque sea durante unos meses, sería “muy difícil para nosotros”. Pero aseguró que la tranquilizaba el apoyo bipartidista al tipo de trabajo que hace AIM.

“La gente quiere simplificar demasiado el problema y dice: ‘Si nos deshacemos de las armas, todo se detendrá’ o ‘No importa lo que hagamos, porque de todos modos van a conseguir armas’”, afirmó. “Lo que realmente tenemos que pensar es por qué la gente siente tanto miedo que tiene que armarse”.

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DENVER — Seven years ago, Erica Green learned through a Facebook post that her brother had been shot.

She rushed to check on him at a hospital run by Denver Health, the city’s safety-net system, but she was unable to get information from emergency room workers, who complained that she was creating a disturbance.

“I was distraught and outside, crying, and Jerry came out of the front doors,” she said.

Jerry Morgan is a familiar face from Green’s Denver neighborhood. He had rushed to the hospital after his pager alerted him to the shooting. As a violence prevention professional with the At-Risk Intervention and Mentoring program, or AIM, Morgan supports gun-violence patients and their families at the hospital — as he did the day Green’s brother was shot.

“It made the situation of that traumatic experience so much better. After that, I was, like, I want to do this work,” Green said.

Today, Green works with Morgan as the program manager for AIM, a hospital-linked violence intervention program launched in 2010 as a partnership between Denver Health and the nonprofit Denver Youth Program. It since has expanded to include Children’s Hospital Colorado and the University of Colorado Hospital.

AIM is one of dozens of hospital-linked violence intervention programs around the country. The programs aim to uncover the social and economic factors that contributed to someone ending up in the ER with a bullet wound: inadequate housing, job loss, or feeling unsafe in one’s neighborhood, for example.

Such programs that take a public health approach to stopping gun violence have had success — one in San Francisco reported a fourfold reduction in violent injury recidivism rates over six years. But President Donald Trump’s executive orders calling for the review of the Biden administration’s gun policies and trillions of dollars in federal grants and loans have created uncertainty around the programs’ long-term federal funding. Some organizers believe their programs will be just fine, but others are looking to shore up alternative funding sources.

“We’ve been worried about, if a domino does fall, how is it going to impact us? There’s a lot of unknowns,” said John Torres, associate director for Youth Alive, an Oakland, California-based nonprofit.

Federal data shows that gun violence became a leading cause of death among children and young adults at the start of this decade and was tied to more than 48,000 deaths among people of all ages in 2022. New York-based pediatric trauma surgeon Chethan Sathya, a National Institutes of Health-funded firearms injury prevention researcher, believes those statistics show that gun violence can’t be ignored as a health care issue. “It’s killing so many people,” Sathya said.

Research shows that a violent injury puts someone at heightened risk for future ones, and the risk of death goes up significantly by the third violent injury, according to a 2006 study published in The Journal of Trauma: Injury, Infection and Critical Care.

Benjamin Li, an emergency medicine physician at Denver Health and the health system’s AIM medical director, said the ER is an ideal setting to intervene in gun violence by working to reverse-engineer what led to a patient’s injuries.

“If you are just seeing the person, patching them up, and then sending them right back into the exact same circumstances, we know it’s going to lead to them being hurt again,” Li said. “It’s critical we address the social determinants of health and then try to change the equation.”

That might mean providing alternative solutions to gunshot victims who might otherwise seek retaliation, said Paris Davis, the intervention programs director for Youth Alive.

“If that’s helping them relocate out of the area, if that’s allowing them to gain housing, if that’s shifting that energy into education or job or, you know, family therapy, whatever the needs are for that particular case and individual, that is what we provide,” Davis said.

AIM outreach workers meet gunshot wound victims at their hospital bedsides to have what Morgan, AIM’s lead outreach worker, calls a tough, nonjudgmental conversation on how the patients ended up there.

AIM uses that information to help patients access the resources they need to navigate their biggest challenges after they’re discharged, Morgan said. Those challenges can include returning to school or work, or finding housing. AIM outreach workers might also attend court proceedings and assist with transportation to health care appointments.

“We try to help in whatever capacity we can, but it’s interdependent on whatever the client needs,” Morgan said.

Since 2010, AIM has grown from three full-time outreach workers to nine, and this year opened the REACH Clinic in Denver’s Five Points neighborhood. The community-based clinic provides wound-care kits; physical therapy; and behavioral, mental and occupational health care. In the coming months, it plans to add bullet removal to its services. It’s part of a growing movement of community-based clinics focused on violent injuries, including the Bullet Related Injury Clinic in St. Louis.

Ginny McCarthy, an assistant professor in the Department of Surgery at the University of Colorado, described REACH as an extension of the hospital-based work, providing holistic treatment in a single location and building trust between health care providers and communities of color that have historically experienced racial biases in medical care.

Caught in the Crossfire, created in 1994 and run by Youth Alive in Oakland, is cited as the nation’s first hospital-linked violence intervention program and has since inspired others. The Health Alliance for Violence Intervention, a national network initiated by Youth ALIVE to advance public health solutions to gun violence, counted 74 hospital-linked violence intervention programs among its membership as of January.

The alliance’s executive director, Fatimah Loren Dreier, compared medicine’s role in addressing gun violence to that of preventing an infectious disease, like cholera. “That disease spreads if you don’t have good sanitation in places where people aggregate,” she said.

Dreier, who also serves as executive director of the Kaiser Permanente Center for Gun Violence Research and Education, said medicine identifies and tracks patterns that lead to the spread of a disease or, in this case, the spread of violence.

“That is what health care can do really well to shift society. When we deploy this, we get better outcomes for everybody,” Dreier said.

The alliance, of which AIM is a member, offers technical assistance and training for hospital-linked violence intervention programs and successfully petitioned to make their services eligible for traditional insurance reimbursement.

In 2021, President Joe Biden issued an executive action that opened the door for states to use Medicaid for violence prevention. Several states, including California, New York, and Colorado, have passed legislation establishing a Medicaid benefit for hospital-linked violence intervention programs.

Last summer, then-U.S. Surgeon General Vivek Murthy declared gun violence a public health crisis, and the 2022 Bipartisan Safer Communities Act earmarked $1.4 billion in funding for a wide array of violence-prevention programs through next year.

But in early February, Trump issued an executive order instructing the U.S. attorney general to conduct a 30-day review of a number of Biden’s policies on gun violence. The White House Office of Gun Violence Prevention now appears to be defunct, and recent moves to freeze federal grants created uncertainty among the gun-violence prevention programs that receive federal funding.

AIM receives 30% of its funding from its operating agreement with Denver’s Office of Community Violence Solutions, according to Li. The rest is from grants, including Victims of Crime Act funding, through the Department of Justice. As of mid-February, Trump’s executive orders had not affected AIM’s current funding.

Some who work with the hospital-linked violence prevention programs in Colorado are hoping a new voter-approved firearms and ammunition excise tax in the state, expected to generate about $39 million annually and support victim services, could be a new source of funding. But the tax’s revenues aren’t expected to fully flow until 2026, and it’s not clear how that money will be allocated.

Trauma surgeon and public health researcher Catherine Velopulos, who is the AIM medical director at the University of Colorado hospital in Aurora, said any interruption in federal funding, even for a few months, would be “very difficult for us.” But Velopulos said she was reassured by the bipartisan support for the kind of work AIM does.

“People want to oversimplify the problem and just say, ‘If we get rid of guns, it’s all going to stop,’ or ‘It doesn’t matter what we do, because they’re going to get guns, anyway,’” she said. “What we really have to address is why people feel so scared that they have to arm themselves.”

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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BOLIGEE, Ala. — Green lights flickered on the wireless router in Barbara Williams’ kitchen. Just one bar lit up — a weak signal connecting her to the world beyond her home in the Alabama Black Belt.

Next to the router sat medications, vitamin D pills, and Williams’ blood glucose monitor kit.

“I haven’t used that thing in a month or so,” said Williams, 72, waving toward the kit. Diagnosed with diabetes more than six years ago, she has developed nerve pain from neuropathy in both legs.

Williams is one of nearly 3 million Americans who live in mostly rural counties that lack both health care and reliable high-speed internet, according to an analysis by KFF Health News, which showed that these people tend to live sicker and die younger than others in America.

Compared with those in other regions, patients across the rural South, Appalachia, and remote West are most often unable to make a video call to their doctor or log into their patient portals. Both are essential ways to participate in the U.S. medical system. And Williams is among those who can do neither.

This year, more than $42 billion allocated in the 2021 Infrastructure Investment and Jobs Act is expected to begin flowing to states as part of a national “Internet for All” initiative launched by the Biden administration. But the program faces uncertainty after Commerce Department Secretary Howard Lutnick last week announced a “rigorous review” asserting that the previous administration’s approach was full of “woke mandates.”

High rates of chronic illness and historical inequities are hallmarks of many of the more than 200 U.S. counties with poor services that KFF Health News identified. Dozens of doctors, academics, and advocates interviewed for this article unanimously agreed that limited internet service hinders medical care and access.

Without fast, reliable broadband, “all we’re going to do is widen health care disparities within telemedicine,” said Rashmi Mullur, an endocrinologist and chief of telehealth at VA Greater Los Angeles. Patients with diabetes who also use telemedicine are more likely to get care and control their blood sugar, Mullur found.

Diabetes requires constant management. Left untreated, uncontrolled blood sugar can cause blindness, kidney failure, nerve damage, and eventually death.

Williams, who sees a nurse practitioner at the county hospital in the next town, said she is not interested in using remote patient monitoring or video calls.

“I know how my sugar affects me,” Williams said. “I get a headache if it’s too high.” She gets weaker when it’s down, she said, and always carries snacks like crackers or peppermints.

Williams said she could even drink a soda pop — orange, grape — when her sugar is low but would not drink one when she felt it was high because she would get “kind of goozie-woozy.”

‘This Is America’

Connectivity dead zones persist in American life despite at least $115 billion lawmakers have thrown toward fixing the inequities. Federal broadband efforts are fragmented and overlapping, with more than 133 funding programs administered by 15 agencies, according to a 2023 federal report.

“This is America. It’s not supposed to be this way,” said Karthik Ganesh, chief executive of Tampa, Florida-based OnMed, a telehealth company that in September installed a walk-in booth at the Boligee Community Center about 10 minutes from Williams’ home. Residents can call up free life-size video consultations with an OnMed health care provider and use equipment to check their weight and blood pressure.

OnMed, which partnered with local universities and the Alabama Cooperative Extension System, relies on SpaceX’s Starlink to provide a high-speed connection in lieu of other options.

A short drive from the community center, beyond Boligee’s Main Street with its deserted buildings and an empty railroad depot and down a long gravel drive, is the 22-acre property where Williams lives.

Last fall, Williams washed a dish in her kitchen, with its unforgiving linoleum-topped concrete floors. A few months earlier, she said, a man at the community center signed her up for “diabetic shoes” to help with her sore feet. They never arrived.

As Williams spoke, steam rose from a pot of boiling potatoes on the stove. Another pan sizzled with hamburger steak. And on a back burner simmered a mix of Velveeta cheese, diced tomatoes, and peppers.

She spent years on her feet as head cook at a diner in Cleveland, Ohio. The oldest of nine, Williams returned to her family home in Greene County more than 20 years ago to care for her mother and a sister, who both died from cancer in the back bedroom where she now sleeps.

Williams looked out a window and recalled when the landscape was covered in cotton that she once helped pick. Now three houses stand in a carefully tended clearing surrounded by tall trees. One belongs to a brother and the other to a sister who drives with her daily to the community center for exercise, prayers, and friendship with other seniors.

All the surviving siblings, Williams said, have diabetes. “I don’t know how we became diabetic,” she said. Neither of their parents had been diagnosed with the illness.

In Greene County, an estimated quarter of adults have diabetes — twice the national average. The county, which has about 7,600 residents, also has among the nation’s highest rates for several chronic diseases such as high blood pressure, stroke, and obesity, Centers for Disease Control and Prevention data shows.

The county’s population is predominately Black. The federal CDC reports that Black Americans are more likely to be diagnosed with diabetes and are 40% more likely than their white counterparts to die from the condition. And in the South, rural Black residents are more likely to lack home internet access, according to the Joint Center for Political and Economic Studies, a Washington-based think tank.

To identify counties most lacking in reliable broadband and health care providers, KFF Health News used data from the Federal Communications Commission and George Washington University’s Mullan Institute for Health Workforce Equity. Reporters also analyzed U.S. Census Bureau, CDC, and other data to understand the health status and demographics of those counties.

The analysis confirms that internet and care gaps are “hitting areas of extreme poverty and high social vulnerability,” said Clese Erikson, deputy director of the health workforce research center at the Mullan Institute.

Digital Haves vs. Have-Nots

Just over half of homes in Greene County have access to reliable high-speed internet — among the lowest rates in the nation. Greene County also has some of the country’s poorest residents, with a median household income of about $31,500. Average life expectancy is less than 72 years, below the national average.

By contrast, the KFF Health News analysis found that counties with the highest rates of internet access and health care providers correlated with higher life expectancy, less chronic disease, and key lifestyle factors such as higher incomes and education levels.

One of those is Howard County, Maryland, between Baltimore and Washington, D.C., where nearly all homes can connect to fast, reliable internet. The median household income is about $147,000 and average life expectancy is more than 82 years — a decade longer than in Greene County. A much smaller share of residents live with chronic conditions such as diabetes.

One is 78-year-old Sam Wilderson, a retired electrical engineer who has managed his Type 2 diabetes for more than a decade. He has fiber-optic internet at his home, which is a few miles from a cafe he dines at every week after Bible study. On a recent day, the cafe had a guest Wi-Fi download speed of 104 megabits per second and a 148 Mbps upload speed. The speeds are fast enough for remote workers to reliably take video calls.

Americans are demanding more speed than ever before. Most households have multiple devices — televisions, computers, gaming systems, doorbells — in addition to phones that can take up bandwidth. The more devices connected, the higher minimum speeds are needed to keep everything running smoothly.

To meet increasing needs, federal regulators updated the definition of broadband last year, establishing standard speeds of 100/20 Mbps. Those speeds are typically enough for several users to stream, browse, download, and play games at the same time.

Christopher Ali, professor of telecommunications at Penn State, recommends minimum standard speeds of 100/100 Mbps. While download speeds enable consumption, such as streaming or shopping, fast upload speeds are necessary to participate in video calls, say, for work or telehealth.

At the cafe in Howard County, on a chilly morning last fall, Wilderson ordered a glass of white wine and his usual: three-seeded bread with spinach, goat cheese, smoked salmon, and over-easy eggs. After eating, Wilderson held up his wrist: “This watch allows me to track my diabetes without pricking my finger.”

Wilderson said he works with his doctors, feels young, and expects to live well into his 90s, just as his father and grandfather did.

Telehealth is crucial for people in areas with few or no medical providers, said Ry Marcattilio, an associate director of research at the Institute for Local Self-Reliance. The national research and advocacy group works with communities on broadband access and reviewed KFF Health News’ findings.

High-speed internet makes it easier to use video visits for medical checkups, which most patients with diabetes need every three months.

Being connected “can make a huge difference in diabetes outcomes,” said Nestoras Mathioudakis, an endocrinologist and co-medical director of Johns Hopkins Medicine Diabetes & Education Program, who treats patients in Howard County.

Paying More for Less

At Williams’ home in Alabama, pictures of her siblings and their kids cover the walls of the hallway and living room. A large, wood-framed image of Jesus at the Last Supper with his disciples hangs over her kitchen table.

Williams sat down as her pots simmered and sizzled. She wasn’t feeling quite right. “I had a glass of orange juice and a bag of potato chips, and I knew that wasn’t enough for breakfast, but I was cooking,” Williams said.

Every night Williams takes a pill to control her diabetes. In the morning, if she feels as if her sugar is dropping, she knows she needs to eat. So, that morning, she left the room to grab a peppermint, walking by the flickering wireless router.

The router’s download and upload speeds were 0.03/0.05 Mbps, nearly unusable by modern standards. Williams’ connection on her house phone can sound scratchy, and when she connects her cellphone to the router, it does not always work. Most days it’s just good enough for her to read a daily devotional website and check Facebook, though the stories don’t always load.

Rural residents like Williams paid nearly $13 more a month on average in late 2020 for slow internet connections than those in urban areas, according to Brian Whitacre, an agricultural economics professor at Oklahoma State University.

“You’re more likely to have competition in an urban area,” Whitacre said.

In rural Alabama, cellphone and internet options are limited. Williams pays $51.28 a month to her wireless provider, Ring Planet, which did not respond to calls and emails.

In Howard County, Maryland, national fiber-optic broadband provider Verizon Communications faces competition from Comcast, a hybrid fiber-optic and cable provider. Verizon advertises a home internet plan promising speeds of 300/300 Mbps starting at $35 a month for its existing mobile customers. The company also offers a discounted price as low as $20 a month for customers who participate in certain federal assistance programs.

“Internet service providers look at the economics of going into some of these communities and there just isn’t enough purchasing power in their minds to warrant the investment,” said Ross DeVol, chief executive of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

Conexon, a fiber-optic cable construction company, estimates it costs $25,000 per mile to build above-ground fiber lines on poles and $60,000 to $70,000 per mile to build underground.

Former President Joe Biden’s 2021 infrastructure law earmarked $65 billion with a goal of connecting all Americans to high-speed internet. Money was designated to establish digital equity programs and to help low-income customers pay their internet bills. The law also set aside tens of billions through the Broadband Equity Access and Deployment Program, known as BEAD, to connect homes and businesses.

That effort prioritizes fiber-optic connections, but federal regulators recently outlined guidance for alternative technologies, including low Earth orbit satellites like SpaceX’s Starlink service.

Funding the use of satellites in federal broadband programs has been controversial inside federal agencies. It has also been a sore point for Elon Musk, who is chief executive of SpaceX, which runs Starlink, and is a lead adviser to President Donald Trump.

After preliminary approval, a federal commission ruled that Starlink’s satellite system was “not reasonably capable” of offering reliable high speeds. Musk tweeted last year that the commission had “illegally revoked” money awarded under the agency’s Trump-era Rural Digital Opportunity Fund.

In February, Trump nominated Arielle Roth to lead the federal agency overseeing the infrastructure act’s BEAD program. Roth is telecommunications policy director for the Senate Committee on Commerce, Science, and Transportation. Last year, she criticized the program’s emphasis on fiber and said it was beleaguered by a “woke social agenda” with too many regulations.

Commerce Secretary Lutnick last week said he will get rid of “burdensome regulations” and revamp the program to “take a tech-neutral approach.” Republicans echoed his positions during a U.S. House subcommittee hearing the same day.

When asked about potentially weakening the program’s required low-cost internet option, former National Telecommunications and Information Administration official Sarah Morris said such a change would build internet connections that people can’t afford. Essentially, she said, they would be “building bridges to nowhere, building networks to no one.”

'That Hurt’

Over a lunch of tortilla chips with the savory sauce that had been simmering on the stove, Williams said she hadn’t been getting regular checkups before her diabetes diagnosis.

“To tell you the truth, if I can get up and move and nothing is bothering me, I don’t go to the doctor,” Williams said. “I’m just being honest.”

Years ago, Williams recalled, “my head was hurting me so bad I had to just lay down. I couldn’t stand up, walk, or nothing. I’d get so dizzy.”

Williams thought it was her blood pressure, but the doctor checked for diabetes. “How did they know? I don’t know,” Williams said.

As lunch ended, she pulled out her glucose monitor. Williams connected the needle and wiped her finger with an alcohol pad. Then she pricked her finger.

“Oh,” Williams said, sucking air through her teeth. “That hurt.”

She placed the sample in the machine, and it quickly displayed a reading of 145 — a number, Williams said, that meant she needed to stop eating.

Click to open the Methodology Methodology

Here’s how KFF Health News did its analysis for the “Dead Zone” series, which pinpointed counties that lag behind the rest of the United States in access to broadband service and health care providers.

To identify “dead zones,” KFF Health News consulted two main data sources.

• The Federal Communications Commission National Broadband Map was used to identify broadband deserts as of June 2024. We used the FCC’s minimum speed standard of 100 Mbps download and 20 Mbps upload, and followed its definition of reliable broadband: service accessible via wired (fiber optics, cable, DSL) or licensed fixed wireless technology. It’s the standard for grants awarded through the federal Broadband Equity, Access, and Deployment Program, known as BEAD. The FCC data shows whether such service is available, and not necessarily whether households subscribe to it.
• Data from George Washington University’s Fitzhugh Mullan Institute for Health Workforce Equity was used to determine counties with health provider shortages. GWU’s data on primary care providers (family and internal medicine doctors, pediatricians, obstetricians and gynecologists, physician assistants, and nurse practitioners) reflects providers who serve at least one person enrolled in Medicaid. We used the most recent years available: 2020 for 44 states, and 2019 data for Texas. Five states — Delaware, Florida, Maine, Minnesota, and New Hampshire — were excluded from analysis because they lacked reliable data for either year.

GWU’s data for behavioral health providers reflects psychiatrists, psychologists, counselors, therapists, and addiction medicine specialists, regardless of whether their patients receive Medicaid. We used data from 2021, the most recent year available.

We classified counties as “dead zones” if they met these criteria:

• Fewer than 70% of homes had access to fast, reliable broadband.
• They ranked in the bottom third of Medicaid primary care providers, defined as the number of Medicaid enrollees per provider.
• They ranked in the bottom third of behavioral health providers, defined as the number of residents per provider.

A total of 210 counties met those criteria. At the other extreme, we defined 203 counties as “most served” if they had the most residences with broadband access (at least 96.7%) and ranked in the top third of Medicaid primary care and behavioral health provider ratios.

We also compared the health outcomes and demographics of dead zone counties relative to others using several data sources:

• U.S. Census Bureau, for data on household income, education levels, and other demographics.
• County Health Rankings & Roadmaps, part of the University of Wisconsin Population Health Institute, for data on life expectancy and the percentage of residents living in rural areas.
• U.S. Centers for Disease Control and Prevention, for data on diabetes, high blood pressure, and other chronic health conditions.

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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Joseph Shea, who sells athletic wear in Myrtle Beach, South Carolina, wonders and worries about the food he eats.

The chemical ingredients with mystifying names. The references on product labels to unspecified natural or artificial flavors. The junk food that fits his budget but feels addictive and makes him feel unwell.

Shea, one of 1,310 people who responded to a poll the health policy research group KFF conducted on health care priorities, said he assumes the FDA is making sure the ingredients are safe.

In many cases, it is not.

The FDA’s restraints on food ingredients are limited and relatively feeble, especially compared with those in Europe, a KFF Health News examination found. There are at least 950 substances in our food that are not permitted in Europe, according to one expert’s estimate, and chemicals linked to health concerns show up in hundreds of products that line the shelves of American supermarkets.

Robert F. Kennedy Jr., the new head of the Department of Health and Human Services, has railed about the risks of food additives for years and has said he wants to end “the mass poisoning of American children.” At a March 6 confirmation hearing, Marty Makary, President Donald Trump’s nominee to head the FDA, expressed concern about foods “with a lot of molecules that do not appear in nature.”

“These are chemicals that the industry insists are safe, a subset of which are concerning,” he said.

But the Trump administration’s initial moves to reduce staff at the FDA led the director of its food safety unit, Jim Jones, to resign last month and raised fears among food safety specialists that the administration could weaken oversight.

To a great extent, the FDA leaves it to food companies to determine whether their ingredients and additives are safe. Companies don’t have to tell the FDA about those decisions, and they don’t have to list all ingredients on their product labels.

Though pharmaceutical companies are required to share research on humans with the FDA, the agency is largely blind to what food-makers know about their products.

“The food industry does massive amounts of research that we have no access to,” Robert Califf told a Senate committee in December on his way out as FDA commissioner.

As a result: The FDA’s oversight of food additives is much weaker than its oversight of prescription drugs.

“There is good reason to be concerned about the chemicals that are routinely included in much of our food,” Califf testified.

Food is a big business. American consumers spend almost $1.7 trillion annually on food and beverages, according to Circana, a research and advisory firm.

Yet American food companies keep secret much of what they put in their products.

KFF Health News asked nine of the largest food manufacturers — The Coca-Cola Co., Conagra Brands, General Mills, Kellanova (successor to Kellogg), The Kraft Heinz Co., Mondelēz International, Nestlé, PepsiCo, and Unilever — for the number of ingredients, if any, that go unnamed on their product labels and the names of those ingredients deemed safe without involvement by the FDA, and substances used in their products in the United States but not in Europe, and vice versa.

None provided answers to those questions.

“We focus on the quality of the ingredients that we use, and all comply with applicable regulatory requirements,” Nestlé spokesperson Dana Stambaugh said.

Chemicals such as titanium dioxide and potassium bromate, whose safety has been debated, are allowed in foods in the United States but not in Europe.

Corporations may turn a blind eye to potential dangers, a July 2024 FDA-funded report warned.

Potentially harmful ingredients “are not necessarily required to be named on a product label,” the Reagan-Udall Foundation for the FDA, an adjunct to the agency, said in the report, which was based largely on interviews with representatives of companies across the food supply chain.

“Companies may choose not to track the presence of these ingredients/compounds due to concern about future litigation,” the report said.

Some additives can remain hidden from the public behind such catchall terms as “spices” and “artificial flavors,” as the Center for Science in the Public Interest has reported, or shrouded by other exemptions from disclosure requirements.

And some ingredients that should have been listed on product labels — potential allergens such as milk, wheat, eggs, and dyes — have at times gone undisclosed, according to a series of food recalls. Gaps in oversight have alarmed political leaders on both sides of the aisle, the U.S. Government Accountability Office, watchdog groups such as the CSPI, and academic researchers.

Adding to the concern: the profusion of ultra-processed foods, which use a wide array of chemicals to add flavor and color, extend shelf life, reduce cost, control texture or consistency, and generally tempt people to eat more. Ultra-processed foods now make up 73% of the U.S. food supply, researchers have estimated. Sen. Bernie Sanders of Vermont, the ranking member of the Senate Health, Education, Labor and Pensions Committee, has said there’s growing evidence they are “deliberately designed to be addictive,” contributing to an epidemic of obesity — a rare point of agreement between him and Kennedy.

At his confirmation hearing, Makary said some ingredients cause a chronic, low-grade inflammatory reaction in the gastrointestinal tract. “And what are we doing? We are drugging our nation’s children at scale,” he said.

The KFF poll found that 58% of respondents want the Trump administration to prioritize setting stricter limits on chemicals in the U.S. food supply.

The Consumer Brands Association, which represents many of the largest food-makers, defends the regulatory system as “rigorous,” “evidence-based,” and “proven.” The system enables companies “to innovate to meet consumer demand,” Sarah Gallo, the association’s senior vice president of product policy, said in a statement to KFF Health News.

“Food manufacturers attest to the safety of an ingredient through the development of extensive scientific evidence and third-party expert review,” Gallo added.

More than a decade ago, Pew Charitable Trusts estimated that there were about 10,000 additives allowed in food in the United States — and that the FDA had not reviewed the safety of about 3,000 of them.

“The system is fundamentally broken,” said Thomas Neltner, one of the authors of the Pew study. “It’s so bad, nobody knows — not even FDA knows — what’s in our food.”

Banned Abroad

The FDA allows titanium dioxide to be used to enhance the appearance of foods, among other purposes. According to an Environmental Working Group database, it’s listed as an ingredient in more than 1,900 products, including many candies.

The European Union takes a more cautious approach. In 2021, an EU regulatory panel concluded that titanium dioxide “can no longer be considered as safe when used as a food additive.” The panel said it couldn’t rule out the possibility that titanium dioxide could damage chromosomes.

The FDA allows potassium bromate to be used in baking, and, according to the EWG database, it’s listed as an ingredient in more than 200 products, including bread, buns, and bagels.

Potassium bromate has been banned from food in many countries, including those of the European Union, Canada, India, and Peru. In 2023, California banned it from food effective in 2027. The United Kingdom prohibited it in 1990. The International Agency for Research on Cancer identified it as possibly carcinogenic more than 25 years ago. A joint committee of the United Nations and the World Health Organization identified it as a “genotoxic carcinogen” in 1992.

On its website, the FDA says it has worked with industry to minimize potassium bromate levels and is reviewing the chemical, among others.

The EWG says that it created the database to help consumers make healthier choices and that the raw data on product labels is supplied by Label Insight — which is owned by NielsenIQ, a major provider of data to industry. The EWG has called for tighter regulation of foods.

Based on a review of FDA and European Commission databases, it appears that at least 950 more additives are used in foods in the United States than are allowed in the European Union, said Erik Millstone, an emeritus professor at the University of Sussex in England who has been studying food safety policy since the 1970s.

Direct comparisons are difficult because the two regulatory systems and the way they keep their records differ greatly.

A definitive count is elusive because the FDA doesn’t require industry to inform it of everything used in foods in the United States.

“That kind of casual neglect totally would be unacceptable in Europe,” Millstone said.

‘Several Decades Behind Europeans’

When the FDA formally approves substances for use in food, it can let decades pass without reassessing them — even when subsequent research raises doubts about their safety.

In January, when the FDA banned Red Dye No. 3 from foods, it cited research published in 1987. (The FDA said it had no evidence the dye puts people at risk; invoking one of the stricter consumer protections, it said a law from 1960 prohibits the use of additives found to induce cancer in animals.)

In the European Union, substances used in foods must pass regulatory approval before being introduced. The EU has also required that its regulators reassess all additives that were on the market before Jan. 20, 2009, a process that is ongoing.

“In the FDA, although we have authorization to do post-market reviews, there’s no statutory mandate to do them,” Jones, the former deputy commissioner of the FDA’s Human Foods Program, told a Senate committee in December. “We are several decades behind Europeans and our Canadian counterparts because they have legal mandates to reevaluate chemicals that have been authorized at some point in the past.”

The FDA website lists 19 post-market determinations since 2010 that substances were not “generally recognized as safe.” Four involve chemical constituents of one mushroom and the mushroom itself. Others include an anabolic steroid, caffeinated alcoholic beverages, cannabidiol (CBD), Ginkgo biloba, melatonin, and partially hydrogenated oils.

Meanwhile, trichloroethylene, banned by the Environmental Protection Agency in December as “an extremely toxic chemical known to cause liver cancer, kidney cancer, and non-Hodgkin’s lymphoma,” is still allowed under FDA rules for use as a solvent in the production of foods.

FDA spokesperson Enrico Dinges said the agency will work with new leadership at HHS “to safeguard the food supply through pre-market and post-market safety evaluations of chemicals in the food supply.”

‘The Loophole Swallowed the Law’

The biggest gap in the FDA’s oversight of foods goes back generations.

In 1958, Congress mandated that, before additives could be used in foods, manufacturers had to prove they were safe and get FDA approval. However, Congress carved out an exception for substances “generally recognized as safe,” which came to be known simply as GRAS.

As conceived, GRAS promised regulatory relief for standard ingredients like salt, sugar, vinegar, and baking powder — along with many chemicals.

Over time, “the loophole swallowed the law,” said a 2014 report by Neltner and Maricel Maffini for the Natural Resources Defense Council.

Companies can unilaterally decide their ingredients are already recognized as safe and use them without asking the FDA for permission or even informing the agency.

A better translation of GRAS would be “Generally Recognized as SECRET,” the Natural Resources Defense Council report said.

A federal watchdog reached a similar conclusion. “GRAS substances can be marketed without FDA’s approval or even its knowledge,” the Government Accountability Office warned in 2010.

That spared the FDA from spending time reviewing countless substances.

For advice on whether ingredients are GRAS, companies may convene panels of specialists. The FDA has noted that panel members could be paid by the companies commissioning the review, but, in guidance to industry, it says “such compensation is not itself an unacceptable conflict.”

About 3,000 flavoring ingredients have been deemed GRAS by a panel of scientists working for an industry group, the Flavor and Extract Manufacturers Association of the United States, known as FEMA, said George Southworth, the organization’s executive director.

The scientists on the FEMA panel “adhere to stringent conflict-of-interest policies,” and their GRAS determinations are submitted to the FDA, which includes them in an online database, Southworth said.

Southworth described the panel as independent, and the FEMA website says panel members have never been employees of companies in the food industry.

Asked how many times FEMA’s panel found that a flavoring didn’t meet the test, Southworth wouldn’t say. He indicated that some reviews are called off before a conclusion is reached.

“Publicly reporting these numbers without full context could lead to misinterpretations about the safety of substances,” he added.

Another Way

Food companies have another option: They can voluntarily notify the FDA that they believe their product is GRAS for its intended use and lay out their reasons — giving the FDA a heads up and essentially seeking its blessing.

If they take that route, they don’t have to wait for an answer from the FDA to begin marketing the product, the agency has said.

And they don’t risk much. If the FDA spots weaknesses in a company’s argument or reasons to worry about a chemical’s safety, it routinely calls off its review instead of declaring the substance unsafe.

FDA records posted on the agency’s website show that the FDA often coaches companies to ask the agency to cease its evaluation. That, too, leaves the company free to sell the product, food watchdogs said.

For companies that voluntarily run their products past the FDA, victory is a letter saying the agency has no questions.

But if companies market products as “generally recognized as safe” without firm grounds, they run the risk that the FDA could one day take enforcement action, such as issuing a warning or stopping sales. That’s if the FDA notices.

Psyched Out

On March 8, 2022, a Canadian company, Psyched Wellness, issued a news release saying it had a green light to market products in the United States.

An “independent review panel of scientific experts” concluded that an extract the company developed, AME-1, was “Generally Recognized As Safe,” paving the way for it to be sold in bulk and used as an ingredient, the company said.

The company described the panel’s judgment as a successful “certification” and “a key milestone.” The extract was derived from a hallucinogenic mushroom, Amanita muscaria, which the company said “has incredible healing and medicinal powers.” As the company later put it in a news release, it had obtained “self-Gras status.”

In June 2024, the company announced that it would soon release Amanita muscaria watermelon gummies.

However, the FDA later took issue with the company and its product.

In a memo dated Sept. 9, 2024, an FDA toxicologist said Psyched Wellness’ claim of GRAS certification was false. The firm failed to show that its extract was generally recognized as safe, the FDA memo said.

Speaking of the mushroom, its extracts, and its known “pharmacologically active constituents,” the FDA memo posted on the agency’s website said they have “potential for serious harm and adverse effects on the central nervous system.”

The FDA was focusing on the mushroom against the backdrop of a spate of medical problems linked to another company’s “Diamond Shruumz” brand chocolate bars, gummies, and infused cones. When it recalled those products in June 2024, that other company announced that a chemical found in Amanita mushrooms was a possible cause of symptoms, including seizures and loss of consciousness.

The FDA memo discussed that recall and said one death and 30 hospitalizations might have been related.

The memo did not connect Psyched Wellness to the outbreak or the Diamond Shruumz products.

The chief executive of Psyched Wellness, Jeffrey Stevens, did not respond to an interview request or written questions.

As recently as Feb. 1, Psyched Wellness said in a securities filing that it will “continue to market its products in the U.S. using the Self-GRAS designation.”

‘Probably Poisoning Us’

If food ingredients cause acute reactions — sending people to emergency rooms, for example — the potential dangers may be relatively easy to identify, and regulatory action might naturally follow. Some critics of the system say they worry more about health effects that could take years or decades to develop.

Then, when it’s too late, it could be hard to trace the harm to any particular ingredient.

All that leaves Joseph Shea of Myrtle Beach in a tough spot.

For a while, Shea tried shopping at a market that has a lot of organic offerings, he said in an interview. That proved too expensive.

Shea said the entire picture is “incredibly frustrating.”

“They’re probably poisoning us, and we don’t know,” he said. “We’ll figure it out 30 years down the road when we get sick.”

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

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

Can the Trump administration refuse to spend money appropriated through Congress by firing federal workers and canceling existing contracts? And if the courts say it cannot, will the administration obey those directives? That key confrontation crept closer this week as the Supreme Court weighed in, suggesting the federal government could not refuse to pay for services already provided.

 Meanwhile, the measles outbreak that started in Texas continues to expand, while the secretary of Health and Human Services, Robert F. Kennedy Jr., a longtime anti-vaccine activist, offers a less-than-full-throated endorsement of the vaccine that has long checked the spread of measles in the U.S.

 This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Joanne Kenen of the Johns Hopkins University School of Public Health and Politico Magazine, and Lauren Weber of The Washington Post.

 Also this week, Rovner interviews Sandy West, who reported and wrote the latest KFF Health News’ “Bill of the Month” feature, about a runner hit by a car — and then by a very expensive ambulance bill.

Panelists Stephanie Armour KFF Health News @StephArmour1 Read Stephanie's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen Read Joanne's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• The Supreme Court rejected the Trump administration’s attempt to continue its freeze on foreign aid. One notable lesson of the administration’s efforts to shutter the U.S. Agency for International Development is that health spending abroad not only supports foreign communities but also helps protect Americans from infectious diseases.
• Meanwhile, Jay Bhattacharya, Trump’s pick to lead the National Institutes of Health, appeared before a Senate committee this week as big changes at the agency rippled through the nation. NIH grants pump key research funding into every state, and turning off funding is expected to have significant economic ramifications. Some universities are pausing or revoking graduate student acceptances, potentially shutting down research avenues and a key source of future educators.
• As expected, the Trump administration said it would no longer pursue a legal effort to block Idaho’s abortion ban for its lack of compliance with the federal Emergency Medical Treatment and Active Labor Act, known as EMTALA. But the state ban remains on hold because the state’s largest hospital system has stepped in to replace the federal government in challenging it.

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

Julie Rovner: KFF Health News’ “Future of Cancer Coverage for Women Federal Firefighters Uncertain Under Trump,” by Kylie Mohr. 

Joanne Kenen: ProPublica’s “How Illinois’ Hands-Off Approach to Homeschooling Leaves Children at Risk,” by Molly Parker and Beth Hundsdorfer, Capitol News Illinois. 

Stephanie Armour: The New York Times’ “Organ Transplant System ‘in Chaos’ as Waiting Lists Are Ignored,” by Brian M. Rosenthal, Mark Hansen, and Jeremy White. 

Lauren Weber: The Washington Post’s “Amid West Texas Measles Outbreak, Vaccine Resistance Hardens,” by Fenit Nirappil and Elana Gordon. 

Also mentioned in this week’s podcast:

• Fox News’ “Robert F. Kennedy Jr.: Measles Outbreak Is Call To Action for All of Us,” by Robert F. Kennedy Jr.
• CBS News’ “USAID Freeze Hits American Manufacturer of Product That Saves Babies’ Lives,” by Graham Kates and Dan Ruetenik.
• The Atlantic’s “Inside the Collapse at the NIH,” by Katherine J. Wu.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

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A dozen people seated around folding tables clap heartily for a beaming woman: She’s donated two 13-gallon garbage bags full of clothes, including several Christmas sweaters and a couple of pantsuits, to a Presbyterian church.

A closet cleanout might not seem a significant accomplishment. But as the people in this Sunday-night class can attest, getting rid of stuff is agonizing for those with hoarding disorder.

People with the diagnosis accumulate an excessive volume of things such as household goods, craft supplies, even pets. In extreme cases, their homes become so crammed that moving between rooms is possible only via narrow pathways.

These unsafe conditions can also lead to strained relationships.

“I’ve had a few relatives and friends that have condemned me, and it doesn’t help,” said Bernadette, a Pennsylvania woman in her early 70s who has struggled with hoarding since retiring and no longer allows guests in her home.

People who hoard are often stigmatized as lazy or dirty. NPR, Spotlight PA, and KFF Health News agreed to use only the first names of people with hoarding disorder interviewed for this article because they fear personal and professional repercussions if their condition is made public.

As baby boomers age into the group most affected by hoarding disorder, the psychiatric condition is a growing public health concern. Effective treatments are scarce. And because hoarding can require expensive interventions that drain municipal resources, more funding and expertise is needed to support those with the diagnosis before the issue grows into a crisis.

For Bernadette, the 16-week course is helping her turn over a new leaf.

The program doubles as a support group and is provided through Fight the Blight. The Westmoreland County, Pennsylvania, organization started offering the course at a local Masonic temple after founder Matt Williams realized the area lacked hoarding-specific mental health services.

Fight the Blight uses a curriculum based on cognitive behavioral therapy to help participants build awareness of what fuels their hoarding. People learn to be more thoughtful about what they purchase and save, and they create strategies so that decluttering doesn’t become overwhelming.

Perhaps more importantly, attendees say they’ve formed a community knitted together through the shared experience of a psychiatric illness that comes with high rates of social isolation and depression.

“You get friendship,” said Sanford, a classmate of Bernadette’s.

After a lifetime of judgment, these friendships have become an integral part of the changes that might help participants eventually clear out the clutter.

Clutter Catches Up to Baby Boomers

Studies have estimated that hoarding disorder affects around 2.5% of the general population — a higher rate than schizophrenia.

The mental illness was previously considered a subtype of obsessive-compulsive disorder, but in 2013 it was given its own diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5.

The biological and environmental factors that may drive hoarding are not well understood. Symptoms usually appear during the teenage years and tend to be more severe among older adults with the disorder. That’s partly because they have had more time to acquire things, said Kiara Timpano, a University of Miami psychology professor.

“All of a sudden you have to downsize this huge home with all the stuff and so it puts pressures on individuals,” she said. In Bernadette’s case, her clutter includes a collection of VHS tapes, and spices in her kitchen that she said date back to the Clinton administration.

But it’s more than just having decades to stockpile possessions; the urge to accumulate strengthens with age, according to Catherine Ayers, a psychiatry professor at the University of California-San Diego.

Researchers are working to discern why. Ayers and Timpano theorize that age-related cognitive changes — particularly in the frontal lobe, which regulates impulsivity and problem-solving — might exacerbate the disorder.

“It is the only mental health disorder, besides dementia, that increases in prevalence and severity with age,” Ayers said.

As the U.S. population ages, hoarding presents a growing public health concern: Some 1 in 5 U.S. residents are baby boomers, all of whom will be 65 or older by 2030.

This population shift will require the federal government to address hoarding disorder, among other age-related issues that it has not previously prioritized, according to a July report by the Democratic staff of the U.S. Senate Special Committee on Aging, chaired then by former Sen. Bob Casey (D-Pa.).

Health Hazards of Hoarding

Clutter creates physical risks. A cramped and disorderly home is especially dangerous for older adults because the risk of falling and breaking a bone increases with age. And having too many things in one space can be a fire hazard.

Last year, the National Fallen Firefighters Foundation wrote to the Senate committee’s leadership that “hoarding conditions are among the most dangerous conditions the fire service can encounter.” The group also said that cluttered homes delay emergency care and increase the likelihood of a first responder being injured on a call.

The Bucks County Board of Commissioners in Pennsylvania told Casey that hoarding-related mold and insects can spread to adjacent households, endangering the health of neighbors.

Due to these safety concerns, it might be tempting for a family member or public health agency to quickly empty someone’s home in one fell swoop.

That can backfire, Timpano said, as it fails to address people’s underlying issues and can be traumatic.

“It can really disrupt the trust and make it even less likely that the individual is willing to seek help in the future,” she said.

It’s more effective, Timpano said, to help people build internal motivation to change and help them identify goals to manage their hoarding.

For example, at the Fight the Blight class, a woman named Diane told the group she wanted a cleaner home so she could invite people over and not feel embarrassed.

Sanford said he is learning to keep his documents and record collection more organized.

Bernadette wants to declutter her bedroom so she can start sleeping in it again. Also, she’s glad she cleared enough space on the first floor for her cat to play.

“Because now he’s got all this room,” she said, “he goes after his tail like a crazy person.”

Ultimately, the home of someone with hoarding disorder might always be a bit cluttered, and that’s OK. The goal of treatment is to make the space healthy and safe, Timpano said, not to earn Marie Kondo’s approval.

Lack of Treatment Leaves Few Options

A 2020 study found that hoarding correlates with homelessness, and those with the disorder are more likely to be evicted.

Housing advocates argue that under the Fair Housing Act, tenants with the diagnosis are entitled to reasonable accommodation. This might include allowing someone time to declutter a home and seek therapy before forcing them to leave their home.

But as outlined in the Senate aging committee’s report, a lack of resources limits efforts to carry out these accommodations.

Hoarding is difficult to treat. In a 2018 study led by Ayers, the UCSD psychiatrist, researchers found that people coping with hoarding need to be highly motivated and often require substantial support to remain engaged with their therapy.

The challenge of sticking with a treatment plan is exacerbated by a shortage of clinicians with necessary expertise, said Janet Spinelli, the co-chair of Rhode Island’s hoarding task force.

Could Changes to Federal Policy Help?

Casey, the former Pennsylvania senator, advocated for more education and technical assistance for hoarding disorder.

In September, he called for the Substance Abuse and Mental Health Services Administration to develop training, assistance, and guidance for communities and clinicians. He also said the Centers for Medicare & Medicaid Services should explore ways to cover evidence-based treatments and services for hoarding.

This might include increased Medicare funding for mobile crisis services to go to people’s homes, which is one way to connect someone to therapy, Spinelli said.

Another strategy would involve allowing Medicaid and Medicare to reimburse community health workers who assist patients with light cleaning and organizing; research has found that many who hoard struggle with categorization tasks.

Williams, of Fight the Blight, agrees that in addition to more mental health support, taxpayer-funded services are needed to help people address their clutter.

When someone in the group reaches a point of wanting to declutter their home, Fight the Blight helps them start the process of cleaning, removing, and organizing.

The service is free to those earning less than 150% of the federal poverty level. People making above that threshold can pay for assistance on a sliding scale; the cost varies also depending on the size of a property and severity of the hoarding.

Also, Spinelli thinks Medicaid and Medicare should fund more peer-support specialists for hoarding disorder. These mental health workers draw on their own life experiences to help people with similar diagnoses. For example, peer counselors could lead classes like Fight the Blight’s.

Bernadette and Sanford say courses like the one they enrolled in should be available all over the U.S.

To those just starting to address their own hoarding, Sanford advises patience and persistence.

“Even if it’s a little job here, a little job there,” he said, “that all adds up.”

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

Spotlight PA is an independent, nonpartisan, and nonprofit newsroom producing investigative and public-service journalism that holds power to account and drives positive change in Pennsylvania. Sign up for its free newsletters.

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

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KFF Health News editor-at-large for public health Céline Gounder discussed a mysterious illness in Congo that has claimed dozens of lives on CBS’ “CBS Mornings” on Feb. 26.

• Click here to watch Gounder on “CBS Mornings”

KFF Health News chief Washington correspondent Julie Rovner discussed moves by Secretary of Health and Human Services Robert F. Kennedy Jr. on WNYC’s “The Brian Lehrer Show” on Feb. 25.

• Click here to hear Rovner on “The Brian Lehrer Show”

KFF Health News senior correspondent Aneri Pattani discussed how Connecticut has used its opioid settlement funds on Connecticut Public Radio on Feb. 21.

• Click here to hear Pattani on Connecticut Public Radio
• Read Pattani’s series, “Payback: Tracking the Opioid Settlement Cash

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

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On a bright October day, high schoolers from Francis L. Cardozo Education Campus piled into a boat on the Anacostia River in Washington, D.C. Most had never been on the water before.

Their guide, Trey Sherard of the Anacostia Riverkeeper, started the tour with a well-rehearsed safety talk. The nonprofit advocates for the protection of the river.

A boy with tousled black hair casually dipped his fingers in the water.

“Don’t touch it!” Sherard yelled.

Why was Sherard being so stern? Was it dangerously cold? Were there biting fish?

Because of the sewage.

“We get less sewage than we used to. Sewage is a code word for what?” Sherard asked the teenagers.

“Poop!” one student piped up.

“Human poop,” Sherard said. “Notice I didn’t say we get none. I said we get what? Less.”

Tours like this are designed to get young people interested in the river’s ecology, but it’s a fine line to tread — interacting with the water can make people sick. Because of the health risks, swimming hasn’t been legal in the Anacostia for more than half a century. The polluted water can cause gastrointestinal and respiratory illnesses, as well as eye, nose, and skin infections.

The river is the cleanest it’s been in years, according to environmental experts, but they still advise you not to take a dip in the Anacostia — not yet, at least.

About 40 million people in the U.S. live in a community with a combined sewer system, where wastewater and stormwater flow through the same pipes. When pipe capacities are reached after heavy rains, the overflow sends raw wastewater into the rivers instead of to a treatment plant.

Federal regulations, including sections of the Clean Water Act, require municipalities such as Washington to reduce at least 85% of this pollution or face steep fines.

To achieve compliance, Washington launched a $2.6 billion infrastructure project in 2011. DC Water’s Clean Rivers Project will eventually build multiple miles-long underground storage basins to capture stormwater and wastewater and pump it to treatment plants once heavy rains have subsided.

The Anacostia tunnel is the first of these storage basins to be completed. It can collect 190 million gallons of bacteria-laden wastewater for later treatment, said Moussa Wone, vice president of the Clean Rivers Project.

Climate change is causing more intense rainstorms in Washington, so even after construction is complete in 2030, Wone said, untreated stormwater will be discharged into the river, though much less frequently.

“On the Anacostia, we’re going to be reducing the frequency of overflows from 82 to two in an average year,” Wone said.

But while the Anacostia sewershed covers 176 square miles, he noted, only 17% is in Washington.

“The other 83% is outside the district,” Wone said. “We can do our part, but everybody else has to do their part also.”

Upstream in Maryland’s Montgomery and Prince George’s counties, miles of sewer lines are in the process of being upgraded to divert raw sewage to a treatment plant instead of the river.

The data shows that poop is a problem for river health — but knowing what kind of poop it is matters. Scientists monitor E. coli to indicate the presence of feces in river water, but since the bacteria live in the guts of most warm-blooded animals, the source is difficult to determine.

“Is it human feces? Or is it deer? Is it gulls’? Is it dogs’?” said Amy Sapkota, a professor of environmental and occupational health at the University of Maryland.

Bacterial levels can fluctuate across the river even without rainstorms. An Anacostia Riverkeeper report found that in 2023 just three of nine sites sampled along the Washington portion of the watershed had consistently low E. coli levels throughout the summer season.

Sapkota is heading a new bacterial monitoring program measuring the amount of E. coli that different animal species deposit along the river.

The team uses microbial source tracking to analyze samples of river water taken from different locations each month by volunteers. The molecular approach enables scientists to target specific gene sequences associated with fecal bacteria and determine whether the bacteria come from humans or wildlife. Microbial source tracking also measures fecal pollution levels by source.

“We can quantify the levels of different bacterial targets that may be coming from a human fecal source or an animal fecal source,” Sapkota said.

Her team expects to have preliminary results this year.

The health risk to humans from river water will never be zero, Sapkota said, but based on her team’s research, smart city planning and retooled infrastructure could lessen the level of harmful bacteria in the water.

“Let’s say that we’re finding that actually there’s a lot of deer fecal signatures in our results,” Sapkota said. “Maybe this points to the fact that we need more green buffers along the river that can help prevent fecal contaminants from wildlife from entering the river during stormwater events.”

Washington is hoping to recoup some of the cost of building green spaces and other river cleanup. In January, the office of D.C. Attorney General Brian Schwalb filed a lawsuit seeking unspecified damages from the federal government over decades of alleged pollution of the Anacostia River.

Brenda Lee Richardson, coordinator of the Anacostia Parks & Community Collaborative, said the efforts to cut down on trash and sewage are paying off. She sees a river on the mend, with more plant and animal life sprouting up.

“The ecosystem seems a lot greener,” she said. “There’s stuff in the river now that wasn’t there before.”

But any changes to the waterfront need to be done with residents of both sides of the river in mind, she said.

“We want there to be some sense of equity as it relates to who has access,” she said. “When I look at who is recreating, it’s not people who look like me.”

Richardson has lived for 40 years in Ward 8 — a predominantly Black area on the east side of the river whose residents are generally less affluent than those on the west side. She and her neighbors don’t consider the Anacostia a place to get out and play, she said.

As the water quality slowly improves, Richardson said, she hopes the Anacostia’s reputation is also rehabilitated. Even if it’s not safe to swim in, Richardson enjoys boating trips like the one with the Anacostia Riverkeeper.

“To see all those creatures along the way and the greenery. It was comforting,” she said. “So rather than take a pill to settle my nerves, I can just go down the river.”

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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Like many Americans who voted for Donald Trump, Jason Rouse hopes the president’s return will mean lower prices for gas, groceries, and other essentials.

But Rouse is looking to the federal government for relief from one particular pain point: high health care costs. “The prices are just ridiculous,” said Rouse, 53, a retired Michigan firefighter and paramedic who has voted for Trump three times. “I’d like to see a lower cap on what I have to pay out-of-pocket.”

Government regulation of health care prices used to be heresy for most Republicans. GOP leaders fiercely opposed the 2010 Affordable Care Act, which included government limits on patients’ costs. More recently, the party fought legislation signed by former President Joe Biden to cap prescription drug prices.

But as Trump begins his second term, many of the voters who sent him back to the White House welcome more robust government action to rein in a health care system many Americans perceive as out of control, polls show.

“That idea that government should just keep its hands off, even when things are tough for people, has kind of lost its sheen,” said Andrew Seligsohn, president of Public Agenda, a nonprofit that has studied public attitudes about government and health care.

“We’re wandering around the country with a set of old, outdated frameworks about what ordinary Democrats and ordinary Republicans like,” he said.

Republican voters strongly back federal limits on the prices charged by drug companies and hospitals, caps on patients’ medical bills, and restrictions on how health care providers can pursue people over medical debt.

Even Medicaid, the state-federal insurance program that Republican congressional leaders are eyeing to dramatically cut, is viewed favorably by many GOP voters, like Ashley Williamson.

Williamson, 37, a mother of five in eastern Tennessee who voted for Trump, said Medicaid provided critical assistance when her mother-in-law needed nursing home care. “We could not take care of her,” Williamson said. “It stepped in. It made sure she was taken care of.”

Williamson, whose own family gets coverage through her husband’s employer, said she would be very concerned by large cuts in Medicaid funding that could jeopardize coverage for needy Americans.

For years, Republican ideas about health care reflected a broad skepticism about government and fears that government would threaten patients’ access to physicians or lifesaving medicines.

“The discussions 10 to 15 years ago were all around choice,” said Christine Matthews, a Republican pollster who has worked for numerous GOP politicians, including former Maryland governor Larry Hogan. “Free market, not having the government limit or take over your health care.”

Matthews and fellow pollster Mike Perry recently convened and paid for several focus groups with Trump voters, including Rouse and Williamson, which KFF Health News observed.

Skepticism about government lingers among rank-and-file Republicans. And ideas such as shifting all Americans into a single government health plan, akin to “Medicare for All,” are still nonstarters for many GOP voters.

But as tens of millions of Americans are driven into debt by medical bills they don’t understand or can’t afford, many are reassessing their inclination to look to free markets rather than the government, said Bob Ward, whose firm, Fabrizio Ward, polled for Trump’s 2024 campaign.

“I think most people look at this and say the market is broken, and that’s why they’re willing for someone, anyone, to step in,” he said. “The deck is stacked against folks.”

In a recent national survey, Fabrizio Ward and Hart Research, which for decades has polled for Democratic candidates, found that Trump voters were more likely to blame health insurers, drug companies, and hospital systems than the government for high health care costs.

Sarah Bognaski, 31, an administrative assistant in upstate New York, is among the many Trump voters who say they resent profiteering by the health care industry. “I don’t think there is any reason a lot of the costs should be as high as they are,” Bognaski said. “I think it’s just out of pure greed.”

High health care costs have had a direct impact on Bognaski, who was diagnosed four years ago with Type 1 diabetes, a condition that makes her dependent on insulin. She said she’s ready to have the government step in and cap what patients pay for pharmaceuticals. “I’d like to see more regulation,” she said.

Charles Milliken, a retired auto mechanic in West Virginia, who said he backed Trump because the country “needs a businessman, not a politician,” expects the new president to go even further.

“I think he’s going to put a cap on what insurance companies can charge, what doctors can charge, what hospitals can charge,” said Milliken, 51, who recently had a heart attack that left him with more than $6,000 in medical debt.

Three-quarters of Trump voters back government limits on what hospitals can charge, Ward’s polling found.

And about half of Trump voters in a recent KFF poll said the new administration should prioritize expanding the number of drugs whose price is set through negotiation between the federal Medicare program and drug companies, a program started under the Biden administration.

Perry, who’s convened dozens of focus groups with voters about health care in recent years, said the support for government price caps is all the more remarkable since regulating medical prices isn’t at the top of most politicians’ agenda. “It seems to be like a groundswell,” he said. “They’ve come to this decision on their own, rather than any policymakers leading them there, that something needs to be done.”

Other forms of government regulation, such as limits on medical debt collections, are even more popular.

About 8 in 10 Republicans backed a $2,300 cap on how much patients could be required to pay annually for medical debt, according to a 2023 survey by Perry’s polling firm, PerryUndem. And 9 in 10 favored a cap on interest rates charged on medical debt.

“These are what I would consider no-brainers, from a political perspective,” Ward said.

But GOP political leaders in Washington have historically shown little interest in government limits on what patients pay for medical care. And as Trump and his allies in Congress begin shaping their health care agenda, many Republican leaders have expressed more interest in cutting government than in expanding its protections.

“There is oftentimes a massive disconnect,” Ward said, “between what happens in the caucuses on Capitol Hill and what’s happening at family tables across America.”

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.

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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Some private schools have shut down because of a rapidly escalating measles outbreak in West Texas. Local health departments are overstretched, pausing other important work as they race to limit the spread of this highly contagious virus.

Since the outbreak emerged three weeks ago, the Texas health department has confirmed 90 cases with 16 hospitalizations, as of Feb. 21. Most of those infected are under age 18. Officials suspect that nine additional measles cases reported in New Mexico, across the border from the epicenter of the Texas outbreak in Gaines County, are linked to the Texas outbreak. Ongoing investigations seek to confirm that connection.

Health officials worry they’re missing cases. Undetected infections bode poorly for communities because doctors and health officials can’t contain transmission if they can’t identify who is infected.

“This is the tip of the iceberg,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “I think this is going to get a lot worse before it gets better.”

An unknown number of parents may not be taking sick children to clinics where they could be tested, said Katherine Wells, the public health director in Lubbock, Texas. “If your kids are responding to fever reducers and you’re keeping hydrated, some people may keep them at home,” she said.

Most unvaccinated people will contract measles if they’re exposed to the airborne virus, which can linger for up to two hours indoors. Those infected can spread the disease before they have symptoms. Around 1 in 5 people with measles end up hospitalized, 1 in 10 children develop ear infections that can lead to permanent hearing loss, and about 1 in 1,000 children die from respiratory and neurological conditions.

Gaines has a large Mennonite population, which often shuns vaccinations. “We respect everyone’s right to vaccinate or not get vaccinated,” said Albert Pilkington, CEO of the Seminole Hospital District, in the heart of the county, in an interview with Texas Standard. “That’s just what it means to be an American, right?”

Local health officials have been trying to persuade the parents of unvaccinated children to protect their kids by bringing them to pop-up clinics offering measles vaccines.

“Some people who were on the fence, who thought measles wasn’t something their kids would see, are recalculating and coming forward for vaccination,” Wells said.

Local health departments are also operating mobile testing units outside schools in an attempt to detect infections before they spread. They’re staffing clinics that can provide treatment prophylactically for infants exposed to the virus, who are too young for vaccination. Local health officials are advising day care centers on how to protect young children and babies, and educating school nurses on how to spot signs of the disease.

“I am putting 75% of my staff on this outbreak,” Wells said. Although Lubbock isn’t at the center of the outbreak, people infected have sought treatment there. “If someone infected was in the [emergency room], we need to identify everyone who was in that ER within two hours of that visit, notify them, and find out if they were vaccinated.”

Local health departments in rural areas are notoriously underfunded. Wells said the workload has meant pressing pause on other programs, such as one providing substance abuse education.

Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines, said health officials were following Centers for Disease Control and Prevention guidelines, as of last year, by advising schools to keep unvaccinated children home for 21 days if they shared a classroom or the cafeteria with someone infected. This means that many parents may need to stay home from work to care for their kids.

“A lot of private schools have closed down because of a high number of sick children,” Holbrooks said.

The burden of measles outbreaks multiplies as the disease spreads. Curbing a 2018 outbreak in Washington state with 72 cases cost about $2.3 million, in addition to $76,000 in medical costs, and an estimated $1 million in economic losses due to illness, quarantines, and caregiving.

Public health researchers expect such outbreaks to become larger and more common because of scores of laws around the U.S. — pending and recently passed — that ultimately lower vaccine rates by allowing parents to exempt their children from vaccine requirements at public schools and some private schools.

Such policies are coupled with misinformation about childhood vaccination now platformed at the highest levels of government. The new director of the Department of Health and Human Services, Robert F. Kennedy Jr., has erroneously blamed vaccines for autism, pointing to discredited theories shown to be untrue by more than a dozen scientific studies.

In Kennedy’s first week on the job, HHS postponed an important meeting of the CDC’s Advisory Committee on Immunization Practices, without saying when it would resume. In addition, the CDC’s letter template to school principals, advising unvaccinated children to remain home from school for 21 days if they’ve been exposed to the measles virus, is no longer on the agency’s website. An old version remains posted on its archive.

As a rule, at least 95% of people need to be vaccinated against measles for a community to be well protected. That threshold is high enough to protect infants too young for the vaccine, people who can’t take the vaccine for medical reasons, and anyone who doesn’t mount a strong, lasting immune response to it. Last school year, the number of kindergartners exempted from a vaccine requirement was higher than ever reported before, according to the CDC. 

In Gaines, exemptions were far higher than the national average, approaching 20% in 2023-24. Gaines has one of the lowest rates of childhood vaccination in Texas. At a local public school district in the community of Loop, only 46% of kindergarten students have gotten vaccines that protect against measles. 

Amid an outbreak that displays the toll of measles in under-vaccinated pockets of America, Texas lawmakers have filed about 25 bills in this year’s legislative session that could limit vaccination further. Lakshmanan said the public — the majority of whom believe in the benefits of measles vaccination — should contact their representatives about the danger of such decisions. Her group and others offer resources to get involved. 

“We’ve got children winding up in the hospital, and yet lawmakers who’ve got their blinders on,” she said, referring to pending policies that will erode vaccination rates. “It’s just mind-blowing.”

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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Medicaid is under threat — again.

Republicans, who narrowly control Congress, are pushing proposals that could sharply cut funding to the government health insurance program for poor and disabled Americans, as a way to finance President Donald Trump’s agenda for tax cuts and border security.

Democrats, hoping to block the GOP’s plans and preserve Medicaid funding, are rallying support from hospitals, governors, and consumer advocates.

At stake is coverage for roughly 79 million people enrolled in Medicaid and its related Children’s Health Insurance Program. So, too, is the financial health of thousands of hospitals and community health centers — and a huge revenue source to all states.

On Feb. 13, the House Budget Committee voted to seek at least $880 billion in mandatory spending cuts on programs overseen by the House Energy and Commerce Committee. That committee oversees Medicaid, which is expected to bear much of the cuts.

Senate Republicans, working on their own plan, have not proposed similar deep cuts. Sen. Ron Wyden of Oregon, the Finance Committee’s top Democrat, said he expects “an effort to keep the Medicaid cuts hidden behind the curtain, but they’re going to come sooner or later.”

Since Trump took office, Republicans in Washington have discussed making changes to Medicaid, particularly by requiring that enrollees prove they are working. Because most enrollees already work, go to school, or serve as caregivers or have a disability, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.

Other GOP ideas that could gain traction toward meeting budget-cutting goals include reducing the federal government’s share of costs for certain enrollees or for the program overall.

Both Trump and House Speaker Mike Johnson say they are only trying to cut what they describe as “waste, fraud, and abuse” in the program, but have yet to offer examples or specifics.

Trump has said he would “love and cherish” Medicaid along with Medicare. During a Fox News interview that aired Feb. 18, Trump repeated his assurance that Medicaid, along with Social Security and Medicare, was not “going to be touched.”

Known as the workhorse of the U.S. health system, Medicaid covers Americans from the beginning of life to the end — paying for 4 in 10 births and care costs for more than 60% of nursing home residents. The program operates as a state-federal partnership, with the federal government paying most of the money and matching state funds regardless of how many people enroll.

Medicaid, which turns 60 this summer, was created as part of President Lyndon B. Johnson’s “Great Society” strategy to attack poverty along with Medicare, the federal health insurance program for people 65 and older.

In today’s era of extreme partisanship on Capitol Hill, few topics highlight the ideological chasm between the major political parties better than Medicaid.

Unlike Democrats who view Medicaid as a way to ensure health care is affordable and accessible regardless of income, many Republicans in Washington see Medicaid as a broken and wasteful welfare program that’s grown too big and covers millions of adults who don’t deserve the government assistance. Many Republicans in Congress say “able-bodied” adults could get coverage from a job or by purchasing insurance on their own.

Nearly all Republicans opposed the 2010 Affordable Care Act, which expanded Medicaid by offering coverage to millions of low-income adults and helped edge the country closer to Democrats’ long-sought goal of all Americans having health coverage. In exchange for expanding Medicaid, the federal government offered states a larger funding match to cover those individuals.

But while most Republican-controlled states accepted the federal expansion dollars — some only after voters approved ballot initiatives in favor of Medicaid expansion — GOP leaders in Congress have remained steadfastly against the program’s growth.

When Republicans last controlled Congress and the White House, the party sought big cuts to Medicaid as part of efforts in 2017 to repeal and replace the ACA. That campaign failed by a razor-thin margin, partly due to concerns from some congressional Republicans over how it would harm Medicaid and the private industry of health plans and hospitals that benefit from it.

Now, a more conservative GOP caucus has again put a bull’s-eye on Medicaid’s budget, which has grown by at least $300 billion in eight years due largely to the covid pandemic and the decision by more states to expand Medicaid. The House budget plan seeks to free up $4.5 trillion to renew Trump’s 2017 tax cuts, which expire at the end of this year.

“Medicaid is increasingly caught in the middle of partisan polarization in Washington,” said Jonathan Oberlander, a health policy professor at the University of North Carolina and the editor of the Journal of Health Politics, Policy and Law. “This is not just resistance to the ACA’s Medicaid expansion; it is a broader change in the politics of Medicaid that puts the program in a more precarious place.”

Medicaid presents a tempting target for Republicans for several reasons beyond its sheer size, Oberlander said. “The first is fiscal arithmetic: They need Medicaid savings to help pay for the costs of extending the 2017 tax cuts,” he said, noting Trump has taken off the table cuts to Medicare, Social Security, and national defense — the other most costly government programs.

The GOP cuts would also help scale back the program, which covered 93 million people at its apex during the covid pandemic, when states were prohibited for three years from terminating coverage for any enrollee. Oberlander said the cuts also would allow Republicans to strike a blow against the ACA, often called Obamacare.

Republicans’ latest revamping effort comes as Medicaid expansion has become entrenched in most states — and their budgets — over the past decade. Without federal expansion dollars, states would struggle to afford coverage for low-income people on the program without raising taxes, cutting benefits, or slashing spending on other programs such as education.

And since Trump’s first-term effort to cut Medicaid, additional red states such as Utah, Oklahoma, Idaho, and Missouri have expanded the program, helping drop the nation’s uninsured rate to a record low in recent years.

Medicaid is popular. About 3 in 4 Americans view the program favorably, according to a January 2025 KFF poll. That’s similar to polling from 2017.

Here are a few strategies the GOP reportedly is considering to reduce the size of Medicaid:

Cutting ACA Medicaid funding. Through Medicaid expansion, the ACA provided financing for the program to cover adults with incomes up to 138% of the federal poverty level, or $21,597 for an individual. The federal government pays 90% of the cost for adults covered through the expansion, which 40 states and Washington, D.C., have adopted. The GOP could lower that funding to the same match rate the federal government pays states for everyone else in the program, which averages about 60%.Shifting to block or per capita grants. Either of these two proposals could lower federal funding for states to operate Medicaid while giving states more discretion over how to spend the money. Annual block grants would give states a set amount, regardless of the number of enrollees. Per capita grants would pay the states based on the number of enrollees in each state. Currently, the federal government matches a certain percentage of state spending each year with no cap. Limiting the federal funding would hamper Medicaid’s ability to help states during difficult economic times, when demand for coverage rises with falling employment and incomes, while states also have fewer tax dollars to spend.Adding work requirements. Republicans in Washington are looking to insert work requirements into federal law. During Trump’s first term, his administration allowed several states to condition coverage for adults on whether they were working, unless they met exemptions such as caregiving or going to school. Arkansas became the first to implement the measure, leading to 18,000 people losing coverage there. Federal judges ruled in 2018 that Medicaid law does not allow for work requirements in the program, which stopped efforts by Trump and several states to impose them in his first term. Several states are taking steps to add a requirement, including Ohio and Montana.

Lawrence Jacobs, founder and director of the University of Minnesota’s Center for the Study of Politics and Governance, said Republicans will face challenges within their own ranks to make major Medicaid cuts, noting House members may be hesitant to cut Medicaid if warned it could lead to hospital closures in their district.

America’s Essential Hospitals, a trade group representing safety-net hospitals that treat the disadvantaged, is encouraging its members to reach out to their lawmakers to make sure they know not only the cuts’ potential impact on patients, but also how they could lead to job cuts and service reductions affecting entire communities.

“The level of cuts being discussed would be incredibly damaging and catastrophic for our hospitals,” said Beth Feldpush, the group’s senior vice president of policy and advocacy.

Said Jacobs: “The politics of cutting Medicaid is really quite fraught, and it’s hard to make a prediction about what will happen at this point.”

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.

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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