The routine is familiar for most people: When checking in for an appointment with a doctor or other health care provider, patients typically complete and sign a pile of paperwork, including a form that contains some version of the statement, “I agree to pay for all charges not covered by my insurance company.”

Patients may not feel comfortable making that financial promise, often before they have any idea what the charges will be. But they generally sign the form anyway, because the alternative is often not to get the services they’re seeking.

As a result, consumers may be responsible for unexpected bills and at risk for medical debt.

In New York, state officials, advocates, and the health care provider community have been engaged in a policy tug-of-war over efforts to protect consumers. Their advocates don’t want them to get stuck signing “blank check” forms that put them in financial jeopardy. Doctors, hospitals, and other providers don’t want to disrupt their practices’ workflow and payment logistics with cost discussions and paperwork, especially after services have been provided. State officials’ efforts to find a satisfying compromise have so far fallen short.

At the center is a state law that took effect last fall to prohibit requiring patients to sign such consent-to-pay forms before they’ve received treatment and discussed the costs.

Legal analysts described it as the first such law in the country. Physician groups cried foul, saying it would raise payment issues and other significant logistical problems.

Those concerns found traction. Shortly before the law’s start date, the state’s Department of Health delayed its implementation indefinitely. In addition, Democratic Gov. Kathy Hochul’s proposed fiscal year 2026 budget would let providers go back to requiring patients to agree to pay for care in advance of receiving treatment. It also clarified that the consent requirements would not apply to emergency care.

A key provision of the new law would remain in place, however: Doctors and other providers would still be obligated to have the cost discussion with patients before the patient is asked to sign the form agreeing to pay for the service. Some consider this a significant step.

“Providers having an affirmative obligation to discuss treatment costs is unique,” said Gregory Mitchell, a partner in the health and life sciences practice group at McDermott Will & Emery law firm who specializes in managed care. Clients from around the country have been reaching out to the law firm with questions.

Requiring providers to discuss costs with patients, whether before or after services are provided, would pose a “significant burden,” he said. Doctors and other providers typically don’t know specifics about patient deductibles, cost sharing, or other insurance coverage details until after a claim is submitted to a health plan.

Health care services are different than refrigerators or other goods that people buy, doctors say. If a patient gets a colonoscopy and doesn’t want to pay for it, “it’s not possible to take the service back,” said Jerome Cohen, a gastroenterologist and the president of the Medical Society of the State of New York, which represents physicians. As for the proposed changes in the 2026 budget, Cohen said the medical society “very much appreciates the governor’s efforts to try to fix this problematic financial consent requirement.”

But patient advocates are pushing back. The current practice is “unfair and it’s wrong,” said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit that has successfully pushed for passage of several medical debt-related laws in recent years. No patient should ever have to preemptively agree to pay whatever a provider charges, Benjamin said.

In a written response to questions, Danielle De Souza, a spokesperson for the state Department of Health, said that the proposed law change is justified, “given the burden of this requirement on both patients and providers.” De Souza didn’t respond to a request for clarification about what those patient burdens are.

Helen Krim walked out of a doctor’s office in the Bronx borough of New York City a few years ago rather than sign an open-ended form agreeing to pay for any services recommended by the doctor.

It was the first time that Krim, who is covered by Medicare, had visited that primary care practice. When she told them she didn’t want to sign the form, she was told they wouldn’t serve her unless she did.

“I’m one of those annoying people who actually reads the forms,” the retired bank project manager said. “It’s kind of like signing a consent to be scammed.” She found another practice that didn’t ask her to sign a similar form.

There are other consumer medical debt protections at the federal and state level. The federal No Surprises Act restricts providers from billing consumers for out-of-network services in certain instances. It also requires providers to give good-faith cost estimates for self-pay patients. The Consumer Financial Protection Bureau released a final rule in January that would have removed medical debt from people’s credit reports, but the rule’s implementation has been frozen by the Trump administration. Several states besides New York have also taken steps to protect consumers with medical debt.

Benjamin said that simply requiring an unspecified “discussion” about costs doesn’t address patients’ potential unlimited financial liability. Under a bill that Benjamin’s organization has drafted, providers would have to give patients a written good-faith estimate of their expected costs before the patient receives services and patients could not be held liable for unlimited or unspecified costs beyond that estimate.

“Let’s be the first state to really have fair rules of engagement for both the providers and the patients about what is it that you’re agreeing to be financially liable for at the point, beforehand,” Benjamin said.

The measure was introduced in the Senate this month.

Providers are taking a wait-and-see attitude, Mitchell said, because the budget plan must still move through the legislative process.

Another New York medical debt-related law that took effect in October takes aim at the use of credit cards to pay for medical services. The Hochul administration has not proposed changing it. The law prohibits providers from requiring pre-authorization of credit cards or keeping a patient’s card on file. It also requires providers to notify patients of the risks of paying for medical care with credit cards, which may lack medical debt protections. In addition, providers aren’t allowed to help patients complete credit card applications under the law.

The laws are aimed at stopping unfair billing practices and reducing medical debt for New Yorkers. Earlier laws ban credit reporting of all medical debt and prohibit hospitals from suing patients with incomes under 400% of the poverty level, among other things.

New York providers don’t like the credit card law either, though it hasn’t generated the pushback seen with the consent-to-pay law.

In a statement, Brian Conway, a spokesperson for the Greater New York Hospital Association, said, “It’s important to clarify that hospitals do not oppose the goals of the hospital financial assistance law reforms overall, but rather the operational burdens and patient disclosure overload that a few specific provisions create.”

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The Trump administration’s crackdown on DEI programs could exacerbate an unexpectedly steep drop in diversity among medical school students, even in states like California, where public universities have been navigating bans on affirmative action for decades. Education and health experts warn that, ultimately, this could harm patient care.

Since taking office, President Donald Trump has issued a handful of executive orders aimed at terminating all diversity, equity, and inclusion, or DEI, initiatives in federally funded programs. And in his March 4 address to Congress, he described the Supreme Court’s 2023 decision banning the consideration of race in college and university admissions as “brave and very powerful.”

Last month, the Education Department’s Office for Civil Rights — which lost about 50% of its staff in mid-March — directed schools, including postsecondary institutions, to end race-based programs or risk losing federal funding. The “Dear Colleague” letter cited the Supreme Court’s decision.

Paulette Granberry Russell, president and CEO of the National Association of Diversity Officers in Higher Education, said that “every utterance of ‘diversity’ is now being viewed as a violation or considered unlawful or illegal.” Her organization filed a lawsuit challenging Trump’s anti-DEI executive orders.

While California and eight other states — Arizona, Florida, Idaho, Michigan, Nebraska, New Hampshire, Oklahoma, and Washington — had already implemented bans of varying degrees on race-based admissions policies well before the Supreme Court decision, schools bolstered diversity in their ranks with equity initiatives such as targeted scholarships, trainings, and recruitment programs.

But the court’s decision and the subsequent state-level backlash — 29 states have since introduced bills to curb diversity initiatives, according to data published by the Chronicle of Higher Education — have tamped down these efforts and led to the recent declines in diversity numbers, education experts said.

After the Supreme Court’s ruling, the numbers of Black and Hispanic medical school enrollees fell by double-digit percentages in the 2024-25 school year compared with the previous year, according to the Association of American Medical Colleges. Black enrollees declined 11.6%, while the number of new students of Hispanic origin fell 10.8%. The decline in enrollment of American Indian or Alaska Native students was even more dramatic, at 22.1%. New Native Hawaiian or other Pacific Islander enrollment declined 4.3%.

“We knew this would happen,” said Norma Poll-Hunter, AAMC’s senior director of workforce diversity. “But it was double digits — much larger than what we anticipated.”

The fear among educators is the numbers will decline even more under the new administration.

At the end of February, the Education Department launched an online portal encouraging people to “report illegal discriminatory practices at institutions of learning,” stating that students should have “learning free of divisive ideologies and indoctrination.” The agency later issued a “Frequently Asked Questions” document about its new policies, clarifying that it was acceptable to observe events like Black History Month but warning schools that they “must consider whether any school programming discourages members of all races from attending.”

“It definitely has a chilling effect,” Poll-Hunter said. “There is a lot of fear that could cause institutions to limit their efforts.”

Numerous requests for comment from medical schools about the impact of the anti-DEI actions went unreturned. University presidents are staying mum on the issue to protect their institutions, according to reporting from The New York Times.

Utibe Essien, a physician and UCLA assistant professor, said he has heard from some students who fear they won’t be considered for admission under the new policies. Essien, who co-authored a study on the effect of affirmative action bans on medical schools, also said students are worried medical schools will not be as supportive toward students of color as in the past.

“Both of these fears have the risk of limiting the options of schools folks apply to and potentially those who consider medicine as an option at all,” Essien said, adding that the “lawsuits around equity policies and just the climate of anti-diversity have brought institutions to this place where they feel uncomfortable.”

In early February, the Pacific Legal Foundation filed a lawsuit against the University of California-San Francisco’s Benioff Children’s Hospital Oakland over an internship program designed to introduce “underrepresented minority high school students to health professions.”

Attorney Andrew Quinio filed the suit, which argues that its plaintiff, a white teenager, was not accepted to the program after disclosing in an interview that she identified as white.

“From a legal standpoint, the issue that comes about from all this is: How do you choose diversity without running afoul of the Constitution?” Quinio said. “For those who want diversity as a goal, it cannot be a goal that is achieved with discrimination.”

UC Health spokesperson Heather Harper declined to comment on the suit on behalf of the hospital system.

Another lawsuit filed in February accuses the University of California of favoring Black and Latino students over Asian American and white applicants in its undergraduate admissions. Specifically, the complaint states that UC officials pushed campuses to use a “holistic” approach to admissions and “move away from objective criteria towards more subjective assessments of the overall appeal of individual candidates.”

The scrutiny of that approach to admissions could threaten diversity at the UC-Davis School of Medicine, which for years has employed a “race-neutral, holistic admissions model” that reportedly tripled enrollment of Black, Latino, and Native American students.

“How do you define diversity? Does it now include the way we consider how someone’s lived experience may be influenced by how they grew up? The type of school, the income of their family? All of those are diversity,” said Granberry Russell, of the National Association of Diversity Officers in Higher Education. “What might they view as an unlawful proxy for diversity equity and inclusion? That’s what we’re confronted with.”

California Attorney General Rob Bonta, a Democrat, recently joined other state attorneys general to issue guidance urging that schools continue their DEI programs despite the federal messaging, saying that legal precedent allows for the activities. California is also among several states suing the administration over its deep cuts to the Education Department.

If the recent decline in diversity among newly enrolled students holds or gets worse, it could have long-term consequences for patient care, academic experts said, pointing toward the vast racial disparities in health outcomes in the U.S., particularly for Black people.

A higher proportion of Black primary care doctors is associated with longer life expectancy and lower mortality rates among Black people, according to a 2023 study published by the JAMA Network.

Physicians of color are also more likely to build their careers in medically underserved communities, studies have shown, which is increasingly important as the AAMC projects a shortage of up to 40,400 primary care doctors by 2036.

“The physician shortage persists, and it’s dire in rural communities,” Poll-Hunter said. “We know that diversity efforts are really about improving access for everyone. More diversity leads to greater access to care — everyone is benefiting from it.”

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

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

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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.

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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As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.

That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.

“It would be a tremendous hit,” she said.

The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.

But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.

Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.

During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.

The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.

Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.

James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.

American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News.

A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.

The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.

HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.

Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.

“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.

State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.

Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.

President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.

The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.

The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.

Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.

The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

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

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In 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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“Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1. … We need to stand up to these Medicare cuts.”

Rep. Ro. Khanna (D-Calif.), in a TikTok video posted Feb. 20, 2025

Rep. Ro Khanna (D-Calif.) posted a Tiktok video on Feb. 20 saying he had “breaking news” about the fate of Medicare coverage for telehealth visits, which allow patients to see health care providers remotely from their homes.

“Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1,” Khanna said. “We need to stand up to these Medicare cuts.”

The same day, the Centers for Medicare & Medicaid Services posted a document online titled “Telehealth” that said, “Through March 31, 2025, you can get telehealth services at any location in the U.S., including your home. Starting April 1, 2025, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services.”

CMS did not respond to requests for comment about the post. The White House also did not respond to requests for comment.

The telehealth benefit was first put in place as a temporary Trump-era addition to Medicare coverage during the covid-19 public health emergency.

Khanna’s statement took on more significance leading up to the threat of a government shutdown, but late last week Congress averted one by approving a stopgap spending bill.

The expiration date for the benefit has been known since December, when Congress extended coverage around telehealth through March 31. The roughly 90-day reprieve was part of a compromise after then-President-elect Donald Trump and his ally Elon Musk criticized a sweeping, end-of-year legislative package that would have, among other things, continued those benefits for two years.

Their opposition forced Congress to pass a stripped-down version of the end-of-year bill. Telehealth’s two-year extension, included in the initial bill, became collateral damage.

Last week, just as the clock was ticking down, House Republicans passed a spending bill for the rest of the fiscal year that includes another extension of telehealth flexibilities — this one lasting through September. The Senate then cleared the bill for Trump’s signature, with the support of 10 Democrats, including Senate Minority Leader Chuck Schumer.

Regardless, the two-year extension proposed in December — or a permanent extension, as Khanna has urged — looks unlikely.

“President Trump and Elon Musk blew up the continuing resolution last December that would have extended these telehealth authorities by two years,” Khanna told us via email. “Trump should work with Congress to extend telehealth coverage for Medicare beneficiaries.”

It wouldn’t come free. Permanently extending telehealth for medical care under Medicare could cost taxpayers about $25 billion over 10 years, the Congressional Budget Office has estimated. The CBO calculated five months of expanded telehealth coverage as costing $663 million, and calculated that that would total almost $25 billion through fiscal year 2031 if spending remained level, which it may not do.

Also, the agency and the Government Accountability Office have raised concerns about fraud and overuse of the benefit, among other potential issues.

Congress made Medicare coverage of behavioral health services delivered remotely permanent in December 2020, but left other telehealth benefits hanging on by a string. Instead, lawmakers extended them for short periods during the nearly two years since the public health emergency officially ended in May 2023.

“Now, once again, we’ve got another deadline where, if Congress doesn’t act, our flexibilities go away,” said Kyle Zebley, senior vice president of public policy for the American Telemedicine Association.

And if, at some point, the telehealth benefits aren’t extended, is it fair to describe the policy change as a cut? Khanna, for instance, plans to introduce the Telehealth Coverage Act, which would require Medicare to cover seniors’ telehealth services.

Politically speaking, it’s a powerful question when trying to leverage public support — and politicians in both parties often accuse their opponents of “cutting” federal benefits when they make changes to programs.

“Khanna is overly dramatic,” said Joseph Antos, a senior fellow emeritus at the American Enterprise Institute, a conservative think tank.

If the provision expires, Antos said, “this is not a Trump cut.”

But beneficiaries might have a different experience. Since the early days of the pandemic — five years now — millions of patients have come to rely on telehealth for their medical services. That benefit, even with another temporary reprieve, would still be at risk.

According to CMS, more than 1 in 10 Medicare beneficiaries used virtual care services as of 2023. And, after the Trump administration green-lighted telehealth for Medicare recipients in 2020, many private insurers did the same.

Overall telehealth claims in Medicare rose from fewer than 1% of all claims before the covid pandemic to a peak of 13% in April 2020. Now they stand at close to 5%, according to Fair Health, a nonprofit that tracks health care costs.

Those in the telehealth industry are optimistic about the current extension. The Trump administration, they say, has been sending encouraging signals — even highlighting its previous support of telemedicine in its fact sheet on the launch of the President’s Make America Healthy Again Commission.

“We’ve been sweating bullets,” Zebley said. “But it’s been nerve-wracking before. I think we’re going to get it done.”

Antos said, however, that after the extension in the House-passed spending bill, Medicare’s telemedicine benefits could be dead.

Our Ruling

Khanna said, “Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1. … We need to stand up to these Medicare cuts.”

The statement is partially accurate, because the Trump administration announced the March 31 sunset of Medicare telehealth visits, and some beneficiaries who were using that benefit could see it as a “cut.” But the claim lacks key context that the expiration date was set by Congress, not the Trump administration.

After Khanna’s claim, Congress extended access to telehealth coverage through September.

Based on information that was available at the time, we rate Khanna’s statement Half True.

Our Sources:

Rep. Ro Khanna’s Feb. 20, 2025 TikTok video.

The American Relief Act, 2025.

Vice President J.D. Vance’s X post on behalf of himself and President Donald Trump on the year-end legislative package, Dec. 18, 2024.

One of a flurry of Elon Musk’s X posts deriding the government’s year-end legislative package, Dec. 20, 2024.

Email interview with Rep. Ro Khanna’s office, March 3, 2025.

H.R.1968 — Full-Year Continuing Appropriations and Extensions Act, 2025.

H.R.133 — Consolidated Appropriations Act, 2021

Phone interview and follow-up texts with Kyle Zebley, senior vice president of public policy for the American Telemedicine Association and executive director of ATA Action, March 3, 2025.

Email interview with Joseph Antos, senior fellow emeritus for public policy research at the think tank the American Enterprise Institute, March 8, 2025.

A Centers for Medicare & Medicaid Services post CMS post titled “Telehealth” that includes information to recipients about Medicare telehealth benefits ending April 1, 2025.

The journal Primary Care, “The State of Telehealth Before and After the COVID-19 Pandemic,” April 25, 2022.

CMS, “Medicare Telehealth Trends,” Jan. 1, 2020 and June 30, 2024.

“Fiscal Considerations for the Future of Telehealth,” Committee for a Responsible Federal Budget, April 21, 2022.

H.R. 2471, the Consolidated Appropriations Act, 2022, Congressional Budget Office, March 14, 2022.

“Medicare and Medicaid: COVID-19 Program Flexibilities and Considerations for Their Continuation,” U.S. Government Accountability Office, May 19, 2021.

Preprint: “Telehealth and Outpatient Utilization: Trends in Evaluation and Management Visits Among Medicare Fee-For-Service Beneficiaries, 2019-2024,” March 6, 2025.

Preprint: “Association Between Telehealth Use and Downstream 30-Day Medicare Spending,” Feb. 11, 2025.

Ro Khanna’s press release on the telehealth bill he’s introducing.

“Annual Number of Users of Online Doctor Consultations Worldwide From 2017 to 2028,” Statista Market Insights, March 15, 2024.

ATA Action letter to Congress, Jan. 13, 2025.

Make America Healthy Again fact sheet, Feb. 13, 2025.

CMS, “Medicare Telehealth Trends Report,” October 2024.

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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HHS’ Civil Rights Office found Maine in violation of Title IX by allowing males in women’s sports.

When the FDA announced in January, before President Joe Biden’s term ended, that it would ban a dye called red dye No. 3 in food and ingested drugs, the federal agency cited just one 1987 study on rats to support its action.

The industry-funded study, based on data from two prior studies, was led by a Virginia toxicologist who said then — and still believes today, decades after concerns first arose that the chemical could be carcinogenic — that his research found the petroleum-derived food coloring doesn’t cause cancer in humans.

“If I thought there was a problem, I would have stated it in the paper,” Joseph Borzelleca, 94, a professor emeritus of pharmacology and toxicology at Virginia Commonwealth University, told KFF Health News after the FDA’s announcement. “I have no problem with my family — my kids and grandkids — consuming Red 3. I stand by the conclusions in my paper that this is not a problem for humans.”

Soon after Borzelleca’s paper was published in a scientific journal, Food and Chemical Toxicology, the FDA examined the data his team had collected and reached its own conclusion: that the dye caused cancer in male lab rats. In 1990, the FDA cited the study in banning Red 3 in cosmetics.

In 1992, the FDA said it wanted to revoke approval of Red 3 in food and drugs. But the agency didn’t act at the time, citing a lack of resources.

More than 30 years later, after a renewed push by consumer advocates, the Biden administration announced the ban in its last days in power. The move came just weeks before the Senate confirmed Robert F. Kennedy Jr., President Donald Trump’s nominee to head the Department of Health and Human Services, which oversees the FDA.

Kennedy has been a vocal critic of food additives, including Red 3. On March 10 he met with top food industry executives and told them if they don’t eliminate artificial food dyes from their products, the federal government will force them to do so, Food Fix reported.

Consumer advocacy groups cheered the Red 3 ban, even as the FDA said there is no evidence that the dye is dangerous to people. “Importantly, the way that FD&C Red No. 3 causes cancer in male rats does not occur in humans,” Jim Jones, FDA deputy commissioner for human foods, said in a statement.

Jones resigned from FDA in February, criticizing Trump administration cuts that he said hobbled his office.

The FDA did not respond to a request for comment, but Marty Makary, Trump’s nominee to lead the agency, said at his Senate confirmation hearing on March 6 that he is concerned about whether food additives such as Red 3 harm children.

“It did not make sense that red dye No. 3 was banned in cosmetics but allowed in the food supply,” Makary told Sen. Tommy Tuberville, who questioned why the FDA ban doesn’t take effect until 2027.

“We want to kill people for two more years?” the Alabama Republican said. “I would hope that you would, if you’re confirmed, you’d go in and look at it very quickly and say, ‘Why do we want to put our people in harm’s way?’”

The International Association of Color Manufacturers says Red 3 is safe in the tiny levels typically consumed by humans. The dye was approved for use in foods in the U.S. in 1907, and today it’s an ingredient in thousands of products including cereals, candy, beverages, and cake toppings.

Thomas Galligan, principal scientist for food additives and supplements at the Center for Science in the Public Interest, which petitioned the FDA for a ban, said that a federal regulation known as the Delaney Clause prohibits any ingredient that causes cancer in animals from being included in foods. (The publisher of KFF Health News, David Rousseau, is on the CSPI board.)

“At the end of the day, this is an unnecessary additive,” he said. “It’s a marketing tool for the industry to make foods look more appealing so consumers will buy them. But federal law is clear: No amount of cancer risk is acceptable in foods.”

Galligan said he was not surprised Borzelleca’s opinion on Red 3 had not changed or that the food dye industry has played down the risk.

In October 2023, California became the first state to ban Red 3 in food starting in 2027, superseding the FDA’s earlier rule allowing small amounts in foods as a color additive. The state legislature acted after a state analysis concluded the dye could cause hyperactivity in children.

The European Union and Australia are among the locations that already ban the chemical in most foods. The EU also requires food makers to include a warning that certain other food dyes may “have an adverse effect on activity and attention in children.”

The IACM points to research by scientific committees operated by the World Health Organization, including a 2018 review that affirmed the safety of Red 3 in food.

Some food manufacturers have already reformulated products to remove Red 3. In its place they use beet juice; carmine, a dye made from insects; or pigments from foods such as purple sweet potato, radish, and red cabbage.

It isn’t clear how the FDA determined that Red 3 can cause cancer in male rats. Borzelleca’s paper said some rats that were fed Red 3 developed polyps in their thyroid gland but doesn’t mention cancer.

Borzelleca, whose study was funded by the IACM, then known as the Certified Color Manufacturers Association, said he was stunned the FDA banned the dye and used his research to back the move.

“I am surprised all this time has gone by and it’s been safe for human use, and now it’s being pulled from the market due to concerns not supported by the data,” Borzelleca said. “Our study did not find this was a carcinogen.”

His study was a response to the FDA’s requirement in the 1980s for additional long-term feeding studies in rats and mice as a condition for the continued provisional approval of several color additives, including Red 3.

Over decades, Borzelleca published dozens of research papers on the toxicology of food additives, pesticides, and water contaminants. He also served on advisory boards for the tobacco industry and represented cigarette maker R.J. Reynolds in negotiations with the Department of Health and Human Services about cigarette additives, according to a 1984 corporate memo. Borzelleca is a former president of the Society of Toxicology and consulted for the National Academy of Sciences and the World Health Organization.

The commonwealth of Virginia gave him a lifetime achievement award in 2001 for his work helping assess dangers in foods, drugs, and pesticides.

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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Los recortes de gastos, la inmigración y Medicaid están bien arriba en la lista de prioridades en la agenda de Washington. Este clima politico ofrece un terreno fértil para que la desinformación y los mitos se multipliquen en las redes sociales. Algunos de los más comunes se enfocan en los inmigrantes, los latinos y Medicaid.

En las plataformas circulan posts afirmando que los latinos beneficiarios de Medicaid —el programa de salud federal gerenciado por los estados para personas de bajos ingresos o con discapacidades —, “no trabajan” y exageraciones sobre el porcentaje de personas con Medicaid que son latinas.

El 25 de febrero, la Cámara de Representantes de Estados Unidos votó por un estrecho margen a favor de un plan presupuestario que podría llevar a recortes de Medicaid de hasta $880 mil millones a lo largo de una década.

Medicaid y el Programa de Seguro de Salud Infantil (CHIP) son parte de la red de seguridad nacional, que cubre a unas 80 millones de personas. La inscripción a Medicaid aumentó bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) y después del inicio de la pandemia de covid-19, pero luego comenzó a caer durante los dos últimos años de la administración Biden.

El impacto de los inmigrantes en el sistema de atención médica nacional puede exagerarse en medio de la retórica política acalorada. El actual vicepresidente JD Vance dijo durante la campaña electoral de 2024 que “estamos llevando a la quiebra a muchos hospitales al obligarlos a ofrecer atención a personas que no tienen el derecho legal de estar en nuestro país”. PolitiFact calificó esa declaración como “falsa”.

KFF Health News, en alianza con Factchequeado, recopiló cinco mitos que circulan en las redes sociales y los analizó con expertos.

1. ¿Trabajan los latinos que reciben Medicaid?

La mayoría sí. Un análisis de los datos de Medicaid realizado por KFF reveló que el 67% de los latinos que reciben Medicaid trabajan, “lo que representa la proporción mayor de adultos que reciben Medicaid que trabajan en comparación con otros grupos raciales y étnicos”, dijo Jennifer Tolbert, subdirectora del Programa de Medicaid y Personas sin Seguro de KFF.

“Para muchas personas de bajos ingresos, el mito es que no están trabajando, aunque sabemos por muchos datos recopilados que muchas personas trabajan pero no tienen acceso a un seguro asequible patrocinado a través del empleador”, dijo Timothy McBride, codirector del Centro para el Avance de los Servicios de Salud, Políticas e Investigación Económica, parte del Instituto de Salud Pública de la Universidad de Washington en St. Louis.

Ni la Oficina de Salud de las Minorías del Departamento de Salud y Servicios Humanos (HHS) ni los Centros de Servicios de Medicare y Medicaid (CMS) respondieron a las solicitudes de comentarios.

2. ¿Son los latinos el grupo más grande inscrito en Medicaid?

No. Los blancos no hispanos son el grupo demográfico más grande en Medicaid.

La inscripción en los programas es de un 42% de blancos no hispanos, un 28% de latinos y un 18% de negros no hispanos, con pequeños porcentajes de otras minorías, según indica un documento de los CMS.

La proporción de latinos en la inscripción total de Medicaid “se ha mantenido bastante estable durante muchos años, entre el 26 y el 30% desde al menos 2008”, dijo Gideon Lukens, director de investigación y análisis de datos del equipo de políticas de salud del Center on Budget and Policy Priorities.

En una publicación en un blog del 18 de febrero, Alex Nowrasteh y Jerome Famularo, del libertario Cato Institute, escribieron: “El mayor mito en el debate sobre el uso de la asistencia social por parte de los inmigrantes es que los no ciudadanos, que incluyen a los inmigrantes ilegales y a los que se encuentran legalmente en el país con diversas visas temporales y tarjetas de residencia, utilizan desproporcionadamente la asistencia social. Ese no es el caso”. Incluyeron Medicaid en el término “asistencia social”.

Aunque los latinos no son el grupo más grande en Medicaid, son el grupo demográfico con el mayor porcentaje de personas que reciben Medicaid. Hay alrededor de 65,2 millones de hispanos en el país, lo que representa el 19,5% de la población total de Estados Unidos.

Y aproximadamente el 31% de esa población está inscrita en Medicaid, en parte porque los latinos empleados a menudo tienen trabajos que no ofrecen beneficios como un seguro de salud.

La elegibilidad para Medicaid se basa en factores como los ingresos, la edad y el estatus de embarazo o discapacidad, y varía de un estado a otro, dijo Kelly Whitener, profesora asociada de Prácticas en el Centro para Niños y Familias de la Escuela de Políticas Públicas McCourt de la Universidad de Georgetown.

“La elegibilidad para Medicaid no se basa en la raza o la etnia”, agregó Whitener.

3. ¿La mayoría de los latinos indocumentados utilizan Medicaid?

No. Según la ley federal, los inmigrantes que carecen de estatus legal no son elegibles para los beneficios federales de Medicaid.

A enero, 14 estados y el Distrito de Columbia habían utilizado sus propios fondos para ampliar la cobertura a los niños en el país sin importar su estatus migratorio. De ellos, siete estados y el Distrito de Columbia expandieron la cobertura a algunos adultos sin importar su estatus migratorio.

Los estados cubren en su totalidad el costo de ofrecer atención médica a estos beneficiarios. El gobierno federal no pone ni un centavo.

El gobierno federal sí paga el llamado Medicaid de Emergencia, que reembolsa a los hospitales por la atención de emergencias médicas para personas que, debido a su estatus migratorio u otros factores, normalmente no califican para el programa.

El Medicaid de Emergencia comenzó en 1986 bajo el Emergency Medical Treatment and Labor Act, firmado por el presidente republicano Ronald Reagan.

En 2023, el Medicaid de Emergencia representó el 0,4% del gasto total de Medicaid.

Algunos legisladores conservadores dicen que los inmigrantes que están en el país sin papeles no deberían recibir ningún beneficio de Medicaid.

“Medicaid está destinado a los ciudadanos estadounidenses que más lo necesitan: personas mayores, niños, mujeres embarazadas y discapacitados”, dijo Dan Crenshaw, representante republicano por Texas, en las redes sociales. “Pero los estados liberales están encontrando formas de jugar con el sistema y hacer que los contribuyentes cubran la atención médica de los inmigrantes ilegales”.

4. ¿Los latinos permanecen en Medicaid por décadas?

Expertos dicen que no hay un análisis por raza o etnia del tiempo que las personas usan el programa.

“Las personas que permanecen en Medicaid por más tiempo son aquellas que tienen Medicaid debido a una discapacidad y que viven con una situación médica que no cambia”, dijo Tolbert.

Los beneficiarios que usan los servicios de apoyo de Medicaid a largo plazo representan el 6% del número total de personas en el programa.

Muchos beneficiarios están en el programa temporalmente, dijo McBride. “Algunos estudios indican que hasta la mitad de las personas en Medicaid lo abandonan en un corto período de tiempo”, dijo, como en un año.

5. ¿Son los latinos en Medicaid el grupo que más usa los servicios médicos?

Los latinos no usan significativamente más servicios de Medicaid que otros, dicen expertos. Reciben servicios preventivos (como mamografías, pruebas de Papanicolaou y colonoscopías), atención primaria y atención de salud mental menos que otros grupos, según documentos de los CMS y la Comisión de Pago y Acceso a Medicaid y CHIP, una organización no partidista que proporciona análisis de políticas y datos.

Los latinos sí utilizan más los servicios de parto y alumbramiento de Medicaid. Las familias latinas y las familias blancas no hispanas representan cada una alrededor del 35% de los nacimientos de Medicaid, aunque los blancos no hispanos constituyen una proporción mayor de la población general.

Si bien los latinos conforman el 28% de todos los inscritos en Medicaid, representan el 37% de los miembros con beneficios limitados, que cubren solo servicios específicos.

“En realidad, utilizan los servicios de atención médica menos que otros grupos, debido a barreras sistémicas como el dominio limitado del inglés y la dificultad para navegar por el sistema”, dijo Arturo Vargas Bustamante, profesor de la Escuela Fielding de Salud Pública de UCLA y director de investigación en el Latino Policy and Politics Institute de la universidad.

Los latinos también evitan utilizar los servicios por temor a la regla de “carga pública” y otras políticas, apuntó Vargas Bustamante. El presidente Donald Trump amplió la política de carga pública y la aplicó con firmeza durante su primer mandato, aunque se suavizó bajo el presidente Joe Biden. La regla tenía como objetivo dificultar que los inmigrantes que utilizan Medicaid o programas de asistencia social obtuvieran la residencia permanente o se convirtieran en ciudadanos estadounidenses.

“El efecto amedrentador de la carga pública persiste, pero órdenes recientes como la deportación masiva o la eliminación de la ciudadanía por nacimiento han generado sus propios efectos aterradores”, agregó Vargas Bustamante.

Esta historia es producto de una colaboración entre Factchequeado y KFF Health News.

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

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The Senate Finance Committee got its chance March 14 to question Mehmet Oz, President Donald Trump’s nominee to lead the vast Centers for Medicare & Medicaid Services, the largest agency within the Department of Health and Human Services. Oz, with his long history in television, was as polished as one would expect, brushing off even some more controversial parts of his past with apparent ease. In this special bonus episode of “What the Health?,” KFF Health News’ Rachana Pradhan and Stephanie Armour join host Julie Rovner to recap the Oz hearing. They also provide an update on the progress of nominees to lead the National Institutes of Health, the Food and Drug Administration, and the Centers for Disease Control and Prevention.

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

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When the FDA announced in January, before President Joe Biden’s term ended, that it would ban a dye called red dye No. 3 in food and ingested drugs, the federal agency cited just one 1987 study on rats to support its action.

The industry-funded study, based on data from two prior studies, was led by a Virginia toxicologist who said then — and still believes today, decades after concerns first arose that the chemical could be carcinogenic — that his research found the petroleum-derived food coloring doesn’t cause cancer in humans.

“If I thought there was a problem, I would have stated it in the paper,” Joseph Borzelleca, 94, a professor emeritus of pharmacology and toxicology at Virginia Commonwealth University, told KFF Health News after the FDA’s announcement. “I have no problem with my family — my kids and grandkids — consuming Red 3. I stand by the conclusions in my paper that this is not a problem for humans.”

Soon after Borzelleca’s paper was published in a scientific journal, Food and Chemical Toxicology, the FDA examined the data his team had collected and reached its own conclusion: that the dye caused cancer in male lab rats. In 1990, the FDA cited the study in banning Red 3 in cosmetics.

In 1992, the FDA said it wanted to revoke approval of Red 3 in food and drugs. But the agency didn’t act at the time, citing a lack of resources.

More than 30 years later, after a renewed push by consumer advocates, the Biden administration announced the ban in its last days in power. The move came just weeks before the Senate confirmed Robert F. Kennedy Jr., President Donald Trump’s nominee to head the Department of Health and Human Services, which oversees the FDA.

Kennedy has been a vocal critic of food additives, including Red 3. On March 10 he met with top food industry executives and told them if they don’t eliminate artificial food dyes from their products, the federal government will force them to do so, Food Fix reported.

Consumer advocacy groups cheered the Red 3 ban, even as the FDA said there is no evidence that the dye is dangerous to people. “Importantly, the way that FD&C Red No. 3 causes cancer in male rats does not occur in humans,” Jim Jones, FDA deputy commissioner for human foods, said in a statement.

Jones resigned from FDA in February, criticizing Trump administration cuts that he said hobbled his office.

The FDA did not respond to a request for comment, but Marty Makary, Trump’s nominee to lead the agency, said at his Senate confirmation hearing on March 6 that he is concerned about whether food additives such as Red 3 harm children.

“It did not make sense that red dye No. 3 was banned in cosmetics but allowed in the food supply,” Makary told Sen. Tommy Tuberville, who questioned why the FDA ban doesn’t take effect until 2027.

“We want to kill people for two more years?” the Alabama Republican said. “I would hope that you would, if you’re confirmed, you’d go in and look at it very quickly and say, ‘Why do we want to put our people in harm’s way?’”

The International Association of Color Manufacturers says Red 3 is safe in the tiny levels typically consumed by humans. The dye was approved for use in foods in the U.S. in 1907, and today it’s an ingredient in thousands of products including cereals, candy, beverages, and cake toppings.

Thomas Galligan, principal scientist for food additives and supplements at the Center for Science in the Public Interest, which petitioned the FDA for a ban, said that a federal regulation known as the Delaney Clause prohibits any ingredient that causes cancer in animals from being included in foods. (The publisher of KFF Health News, David Rousseau, is on the CSPI board.)

“At the end of the day, this is an unnecessary additive,” he said. “It’s a marketing tool for the industry to make foods look more appealing so consumers will buy them. But federal law is clear: No amount of cancer risk is acceptable in foods.”

Galligan said he was not surprised Borzelleca’s opinion on Red 3 had not changed or that the food dye industry has played down the risk.

In October 2023, California became the first state to ban Red 3 in food starting in 2027, superseding the FDA’s earlier rule allowing small amounts in foods as a color additive. The state legislature acted after a state analysis concluded the dye could cause hyperactivity in children.

The European Union, Australia, and Japan are among the locations that already ban the chemical in foods. The EU’s ban also cites hyperactivity in children. The EU requires food makers to include a warning that food dyes that are still allowed may “have an adverse effect on activity and attention in children.”

The IACM points to research by scientific committees operated by the World Health Organization, including a 2018 review that affirmed the safety of Red 3 in food.

Some food manufacturers have already reformulated products to remove Red 3. In its place they use beet juice; carmine, a dye made from insects; or pigments from foods such as purple sweet potato, radish, and red cabbage.

It isn’t clear how the FDA determined that Red 3 can cause cancer in male rats. Borzelleca’s paper said some rats that were fed Red 3 developed polyps in their thyroid gland but doesn’t mention cancer.

Borzelleca, whose study was funded by the IACM, then known as the Certified Color Manufacturers Association, said he was stunned the FDA banned the dye and used his research to back the move.

“I am surprised all this time has gone by and it’s been safe for human use, and now it’s being pulled from the market due to concerns not supported by the data,” Borzelleca said. “Our study did not find this was a carcinogen.”

His study was a response to the FDA’s requirement in the 1980s for additional long-term feeding studies in rats and mice as a condition for the continued provisional approval of several color additives, including Red 3.

Over decades, Borzelleca published dozens of research papers on the toxicology of food additives, pesticides, and water contaminants. He also served on advisory boards for the tobacco industry and represented cigarette maker R.J. Reynolds in negotiations with the Department of Health and Human Services about cigarette additives, according to a 1984 corporate memo. Borzelleca is a former president of the Society of Toxicology and consulted for the National Academy of Sciences and the World Health Organization.

The commonwealth of Virginia gave him a lifetime achievement award in 2001 for his work helping assess dangers in foods, drugs, and pesticides.

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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HELENA, Mont. — Montana lawmakers are grappling with how — if at all — the state should rein in kratom, an unregulated plant-derived substance with addictive properties sold mainly as a mood and energy booster at gas stations, vape shops, and elsewhere.

Kratom, which originates from the leaves of a tree native to Southeast Asia, is also touted for helping relieve pain and opioid withdrawal symptoms. But it can have wide-ranging mental and bodily effects, according to the federal Drug Enforcement Administration, addiction medicine experts, and kratom researchers. Reports of deadly kratom overdoses have surfaced in recent years, though often in combination with other substances.

But the drug is in a gray federal regulatory area: It’s designated by the DEA as a “drug and chemical of concern,” but it is not considered a controlled substance. Legislation introduced in Congress in 2023 to study kratom has not advanced.

The lack of federal regulation and congressional action has left it to states to step into the complex debate over how to clean up supply chains and protect users.

The kratom industry itself wants to help address this regulatory void. A bill drafted by the American Kratom Association, a national industry lobbying group, is pending in the Montana Legislature. In its current form, the industry-dubbed “Kratom Consumer Protection Act” would ban sales to people under 18 and restrict which products can be labeled as “kratom” based on the amount and potency of two chemical components, mitragynine, and 7-hydroxymitragynine.

Similar industry-backed bills have passed in 14 states, including Oregon, Texas, Kentucky, and Maryland, according to the American Kratom Association website. Other states, including Wisconsin and Arkansas, have enacted kratom bans by listing it as a Schedule I controlled substance.

Oliver Grundmann, a University of Florida researcher who has studied kratom since 2016, said industry-written bills often hinge on producers accurately representing what’s in their products. Lawmakers and the public in Montana may not be convinced that the proposed legislation will put public health considerations above commercial interests.

“Naturally, a company is driven by profits and making sure that they can retain their profits,” Grundmann said. “I’m skeptical of self-regulation.”

Whether the Montana bill will be effective hinges on the state’s having enough resources to regulate the industry, as well as industry retailers honestly testing and marketing their products, he said.

The bill’s sponsor, Republican Rep. Nelly Nicol, said she’s trying to bring her fellow lawmakers up to speed on a substance that few people understand. Nicol said she delayed House Bill 407’s first committee hearing to give herself more time to speak with legislators and to hear from groups that support and disagree with the industry’s suggested approach. She indicated she’s open to amending the bill, though it has not yet been rescheduled for a committee hearing.

“We’re going to be changing our minds and learning things and molding this as we’re going,” Nicol said in a February interview.

Researchers and addiction medicine experts have struggled in recent years to pin down kratom’s health effects and patterns of use. A federal survey from 2021 estimated that 1.7 million Americans age 12 and older used the substance in some way the year before the study.

Medical providers and addiction researchers in Montana say patients often don’t disclose their kratom use to health care providers. Some consider it an herbal supplement, a perception driven by its accessibility in gas stations and vape shops, rather than a mind-altering and potentially addictive drug.

Megan Zawacki, a physician assistant and addiction medicine specialist in Helena, said many of her patients seek help for misuse of other substances and aren’t easily convinced of kratom’s negative side effects.

“The majority of my patients that are using it can’t even quantify to me how much they’re using,” Zawacki said.

But if their use spirals into addiction, she said, the consequences of the substance become clearer. At her clinic in Helena, Zawacki said, more of her patients are currently being treated for kratom addiction than for opioid use disorder.

“I’ve had two patients specifically in the last calendar year tell me, ‘We need to bring legislation against kratom,’” she said. “Because it is so readily available and so misunderstood that it just is wreaking havoc on their lives.”

Depending on how it’s manufactured and how much users consume, kratom can function as a stimulant or a sedative. Though not an opioid, its key chemical components can target opioid receptors in the brain, leading some advocates to cite its potential for helping opioid users manage withdrawal.

Zawacki and other Montana providers say they have prescribed buprenorphine to help patients stop using kratom — the same treatment often used to manage opioid addiction.

Some Montana advocacy groups that work to prevent substance misuse have also flagged concerns about kratom use among minors. Beth Price Morrison, with the Alliance for Youth in Great Falls, said her organization has pressured gas stations in the area to stop carrying kratom products or at least keep them behind the counter.

“Our youth are really struggling with mental health right now, and they turn to substances to cope. And this stuff is easily accessible,” Price Morrison said.

Price Morrison and Nicol expressed support for raising the age limit on kratom sales to users 21 and older, rather than 18, which is in the current draft of the American Kratom Association bill.

The legislation would allow state regulators to screen kratom products coming on the market in Montana and create a registry of permitted distributors. Vendors would be banned from selling or promoting kratom products whose concentration of 7-hydroxymitragynine exceeds 2% of the total alkaloid content.

The American Kratom Association and other supporters say that such a restriction would help weed out natural forms of kratom from synthetic, higher-potency concoctions. Some kratom researchers have endorsed this type of market regulation, citing the chaotic array of products currently allowed to sport kratom labels.

Grundmann, the University of Florida researcher, said there has been an “evolution” in the United States of products being labeled and sold as kratom.

“The kratom that was on the market then was basically ground-up leaf powder that was not further concentrated,” Grundmann said. “What we have seen in recent years is even stronger extracts that focus specifically on mitragynine and 7-hydroxymitragynine. These should not be seen as ‘kratom’ any longer.”

Grundmann, who supported a similar version of legislation in Arizona in 2019, said Montana’s bill is a starting point for regulation. He said other states, including Colorado, began with a common framework and put more guardrails in place in recent years.

Price Morrison, the youth prevention advocate, said she has broader misgivings about any bill that normalizes the sale of kratom in Montana. In an ideal world, she said, she would like to see the product banned completely.

“We know that availability drives use. And when a product is marketed as regulated, it gains legitimacy,” Price Morrison said. “And more people, including those who are vulnerable, end up using it.”

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Spending cuts, immigration, and Medicaid are at the top of the Washington agenda. That climate provides fertile ground for misinformation and myths to multiply on social networks. Some of the most common are those surrounding immigrants, Latinos, and Medicaid.

These claims include assertions that Latinos who use Medicaid, the federal-state program for low-income people and those with disabilities, “do not work” and exaggerations of the percentage of people with Medicaid who are Latinos.

The U.S. House voted narrowly on Feb. 25 in favor of a budget blueprint that could lead to Medicaid cuts of up to $880 billion over a decade.

Medicaid and the Children’s Health Insurance Program are part of the national safety net, covering about 80 million people. Medicaid enrollment grew under the Affordable Care Act and after the start of the covid-19 pandemic but then started falling during the final two years of the Biden administration.

Immigrants’ impact on the nation’s health care system can be overstated in heated political rhetoric. Now-Vice President JD Vance said on the campaign trail last year that “we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.” PolitiFact rated that statement “False.”

KFF Health News, in partnership with Factchequeado, compiled five myths circulating on social media and analyzed them with experts in the field.

1. Do Latinos who receive Medicaid work?

Most do. A KFF analysis of Medicaid data found that almost 67% of Latinos on Medicaid work, “which is a higher share of Medicaid adults who are working compared to other racial and ethnic groups,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured. KFF is a health information nonprofit that includes KFF Health News.

“For many low-income people, the myth is that they are not working, even though we know from a lot of data that many people work but don’t have access to affordable employer-sponsored insurance,” said Timothy McBride, co-director at the Center for Advancing Health Services, Policy and Economics Research, part of the Institute for Public Health at Washington University in St. Louis.

Neither the Department of Health and Human Services Office of Minority Health nor the Centers for Medicare & Medicaid Services responded to requests for comment.

2. Are Latinos the largest group enrolled in Medicaid?

No. White people who are not Hispanic represent the biggest demographic group in Medicaid and CHIP. The programs’ enrollment is 42% non-Hispanic white, 28% Latinos, and 18% non-Hispanic Black, with small percentages of other minorities, according to a CMS document.

Latinos’ share of total Medicaid enrollment “has remained fairly stable for many years — hovering between 26 and 30% since at least 2008,” said Gideon Lukens, research and data analysis director on the health policy team at the left-leaning Center on Budget and Policy Priorities, a research organization.

In a Feb. 18 blog post, Alex Nowrasteh and Jerome Famularo of the libertarian Cato Institute wrote: “The biggest myth in the debate over immigrant welfare use is that noncitizens — which includes illegal immigrants and those lawfully present on various temporary visas and green cards — disproportionately consume welfare. That is not the case.” They included Medicaid in the term “welfare.”

Although Latinos are not the biggest group in Medicaid, they are the demographic group with the greatest percentage of people receiving Medicaid. There are about 65.2 million Hispanics in the country, representing 19.5% of the total U.S. population.

Approximately 31% of the Latino population is enrolled in Medicaid, in part because employed Latinos often have jobs that do not offer affordable insurance.

Eligibility for Medicaid is based on factors such as income, age, and pregnancy or disability status, and it varies from state to state, said Kelly Whitener, associate professor of practice at the Center for Children and Families at Georgetown University’s McCourt School of Public Policy.

“Medicaid eligibility is not based on race or ethnicity,” Whitener said.

3. Do most Latinos living in the country without legal permission use Medicaid?

No. Under federal law, immigrants lacking legal status are not eligible for federal Medicaid benefits.

As of January, 14 states and the District of Columbia had used their own funds to expand coverage to children in the country without regard to immigration status. Of those, seven states and D.C. expanded coverage to some adults regardless of immigration status.

The cost of providing health care to these beneficiaries is covered entirely by the states. The federal government does not put up a penny.

The federal government does pay for Emergency Medicaid, which reimburses hospitals for medical emergencies for people who, because of their immigration status or other factors, do not normally qualify for the program.

Emergency Medicaid began in 1986 under the Emergency Medical Treatment and Labor Act, signed by President Ronald Reagan, a Republican.

In 2023, Emergency Medicaid accounted for 0.4% of total Medicaid spending.

Some conservative lawmakers say immigrants in the country illegally should not get any Medicaid benefits.

“Medicaid is meant for American citizens who need it most — seniors, children, pregnant women, and the disabled,” Rep. Dan Crenshaw (R-Texas) said on social media. “But liberal states are finding ways to game the system and make taxpayers cover healthcare for illegal immigrants.”

4. Do Latinos stay on Medicaid for decades?

Experts say there is no analysis by race or ethnicity of the length of time people use the program.

“The people who stay on Medicaid the longest are people who have Medicaid due to a disability and who live with a medical situation that does not change,” Tolbert said.

People who use long-term Medicaid support services represent 6% of the total number of people in the program.

Many beneficiaries are in the program temporarily, McBride said.

“Some studies indicate that as many as half of the people on Medicaid churn off of Medicaid within a short period of time,” he said, such as within a year.

5. Are Latinos on Medicaid the group that uses medical services the most?

Latinos do not use significantly more Medicaid services than others, experts say. Latinos receive preventive services (such as mammograms, pap smears, and colonoscopies), primary care and mental health care less than other groups, according to documents from CMS and the Medicaid and CHIP Payment and Access Commission, a nonpartisan organization that provides policy and data analysis.

Latinos do account for a disproportionate share of Medicaid labor and delivery services. Latino families and white families each represent about 35% of Medicaid births, although white people make up a bigger share of the overall population.

While Latinos represent 28% of all Medicaid and CHIP enrollees, they account for 37% of beneficiaries with limited benefits that cover only specific services.

“They actually use health care services less than other groups, because of systemic barriers such as limited English proficiency and difficulty navigating the system,” said Arturo Vargas Bustamante, a professor at UCLA’s Fielding School of Public Health and the faculty research director at the university’s Latino Policy and Politics Institute.

Latino people also avoid using services out of fear of the “public charge” rule and other policies, Vargas Bustamante said. President Donald Trump expanded the public charge policy and strongly enforced it during his first term, though it was softened under President Joe Biden. The policy was intended to make it harder for immigrants who use Medicaid or welfare programs to obtain green cards or become U.S. citizens.

“The chilling effect of public charge persists, but recent orders such as mass deportation or the elimination of birthright citizenship have generated their own chilling effects,” Vargas Bustamante added.

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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When patients walked into Planned Parenthood clinics, a consumer data company sold their precise locations to anti-abortion groups for targeted ads.

When patients picked up prescriptions for testosterone replacement therapy, law enforcement retrieved their names and addresses without a warrant.

And when a father was arrested by immigration authorities, agents allegedly accessed his personal information from a medical clinic where he received diabetes treatment.

Progressive California lawmakers have proposed a number of bills aimed at bolstering privacy protections for women, transgender people, and immigrants in response to such intrusions by anti-abortion groups, conservative states, and federal law enforcement agencies as President Donald Trump declares the nation “will be woke no longer” and flexes his executive power to roll back rights.

Democrats have supermajorities in the state legislature, but even if they pass the proposals, they may first need to lobby one of their own: Gov. Gavin Newsom, who has noticeably tempered his once harsh criticism of Trump.

Last month, the Democratic governor issued a rare veto threat against a bill that would expand the state’s sanctuary law to limit cooperation between state prisons and federal immigration agents. And Newsom recently called transgender athletes’ participation in women’s sports “deeply unfair” on his new podcast with guest Charlie Kirk, a founder of the conservative group Turning Point USA. Newsom went on to tell Kirk that he had a “hard time with” the way the right talks about transgender people.

Billions of dollars are also on the line for California. Newsom visited the White House last month seeking unconditional aid for wildfire victims in Los Angeles, and the state relies on Washington for over 60% of its Medicaid budget, which is vulnerable to significant cuts under the GOP’s budget blueprint.

“California’s leaders have not been as aggressive, out of recognition that there are many things that the state needs federal cooperation on,” said Thad Kousser, a political science professor at the University of California-San Diego.

A Newsom spokesperson declined to comment on pending legislation. He has a track record of supporting abortion, transgender, and immigrant rights.

Since taking office, Trump has granted the Elon Musk-controlled Department of Government Efficiency — created through a Trump executive order — access to previously restricted data, including medical information, raising concerns that sensitive information could be exposed without proper safeguards. 

The White House did not respond to requests for comment.

While most Americans are familiar with the Health Insurance Portability and Accountability Act, known as HIPAA, it offers only narrow protection for patients in health care settings. There’s no comprehensive federal law protecting data privacy.

Health care information has increasingly become a tool of surveillance and enforcement, and in states that have banned certain medical treatments or toughened immigration laws, vulnerable populations are at greater risk, said Suzanne Bernstein, a health privacy rights expert with the Electronic Privacy Information Center.

Progressive Democrats are concerned that personal information and people’s medical decisions could be used to monitor or criminalize patients, facilitate arrests in or near health care facilities, or jeopardize access to health care services.

They and health privacy advocates say now is the time to shore up protections for the nearly 2 million immigrants living in California without authorization, the more than 200,000 transgender adults in the state, and thousands of people — living in the state or out of state — in need of abortion care in California each year. Some of these laws could take effect immediately if signed.

“This is about making sure that people are able to access critical health care in California and to take the politics out of our hospitals and health clinics,” said state Sen. Jesse Arreguín, who hopes the governor would sign his bill to protect immigrants.

The bills are expected to be debated in Sacramento in the coming months.

Since the Supreme Court overturned the constitutional right to abortion, anti-abortion groups have purchased location information from consumer data companies to target people seeking abortion care with anti-abortion ads. And authorities in states with abortion bans have used cellphone data to enforce laws beyond their borders.

A bill introduced by state Assembly member Rebecca Bauer-Kahan, AB 45, would make geofencing, the collection of phone location by data brokers, illegal around health care facilities that provide in-person services. It would also prevent reproductive health information collected during research from being disclosed in response to out-of-state requests.

Conservative organizations said the proposal would single them out by restricting their ability to inform women about alternatives to abortion, including services offered by crisis pregnancy centers.

“I think that could very well be a First Amendment violation,” said Jonathan Keller, president of the California Family Council, a statewide anti-abortion nonprofit. “It doesn’t seem like the bill would be prohibiting or putting any restrictions on a group like Planned Parenthood if they wanted to market or target to a local high school or college.”

So far this year, lawmakers in 49 states have introduced more than 700 anti-transgender bills, seeking to ban gender-affirming care, prohibit gender identity education in schools, or restrict transgender students from participating in sports, according to the Trans Legislation Tracker, a national research organization tracking bills affecting transgender people. Transgender adults represent less than 1% of the U.S. population.

And some states with bans or restrictions on gender-affirming care have been targeting health care data. In 2023, Republican Gov. Ron DeSantis requested that Florida universities release data on the number of individuals who have been diagnosed with gender dysphoria or received treatment at campus clinics. That same year, Missouri’s Republican attorney general, Andrew Bailey, submitted 54 requests to one hospital seeking information about gender-affirming care procedures.

Trump has issued a series of executive orders to ban access to gender-affirming care for minors. Federal judges have temporarily blocked some portions of his orders.

To guard against other states that criminalize or ban gender-affirming care, California state Sen. Scott Wiener wants to expand current protections for minors to include adults.

His bill, SB 497, would require law enforcement to obtain a warrant to access state databases on gender-affirming care and make it a misdemeanor to release the data to unauthorized parties. It would also prohibit health care providers, employers, and insurers from releasing information about a person who seeks or obtains gender-affirming physical and mental health care to an agency or individual from another state.

“We want to make sure that we are as comprehensively as possible shielding trans people from hate emanating from the federal government, other states, and private parties,” Wiener said.

Keller countered that authorities in states with bans on abortion or gender-affirming care should have access to medical information as they investigate providers who could harm patients or coerce them into procedures against their will. He cited a lawsuit against Kaiser Permanente over a teenager who detransitioned after undergoing gender-affirming care. A 2015 survey found it was uncommon for people undergoing gender-affirming care to decide to permanently detransition.

“The only way that you’re able to uncover that level of widespread malpractice and malfeasance is if these health care records are able to be accessed,” Keller said.

The California Family Council plans to oppose both bills.

Earlier this year, Trump rescinded a long-standing policy of not making immigration arrests near hospitals, schools, or churches. The decision has providers fearful that Immigration and Customs Enforcement agents will disrupt their work at health facilities and prompt immigrants to skip medical care — for themselves or, of particular concern, their children.

Anticipating the move, California’s Democratic attorney general, Rob Bonta, issued guidance in December advising health care providers how best to respond if ICE comes to their doorstep. But while private entities are encouraged to follow these policies, only state-run facilities are required to adopt them.

“Some health care providers have implemented them, but not everyone has,” Arreguín said.

Arreguín’s SB 81 would require all health care facilities, including hospitals and community-based clinics, to follow state guidance to limit cooperation with immigration authorities. It would also prohibit providers from granting access to private areas or places where a patient is actively receiving treatment or care, unless there’s a warrant.

Another immigration bill, AB 421, would limit the sharing of local law enforcement information if agents plan to make an arrest within a one-mile radius of a hospital or medical office, a child care or day care facility, a religious institution, or a place of worship. California law enforcement has some discretion to share information with immigration agents when an individual has been convicted of a serious crime or felony.

Kousser said immigration is more complicated for California politicians than health privacy. Although a February poll by the Public Policy Institute of California found that 7 in 10 Californians think immigrants are a benefit to the state, Kousser said that lawmakers, especially those who won by narrow margins in contested districts, still have to make tough political choices.

Senate Republican leader Brian Jones, who represents a predominantly Democratic district in San Diego, is proposing to change California’s sanctuary policies to require law enforcement to share information with ICE when a person has been convicted of a serious crime.

“When these violent felons are released from local custody, they go right back into the communities that they came from to re-victimize those same immigrant communities,” Jones said.

But Jones acknowledged the need for nuance when it comes to health privacy.

“Look, the bottom line for me on this immigration reform in America is it needs to be humanitarian and it needs to make sense,” Jones said. “And so, if there are areas that we need to protect folks, it might make sense.”

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

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

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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.

Health and Human Services Secretary Robert F. Kennedy Jr. is already acting on his anti-vaccine views, ordering an end of research into why people become vaccine-hesitant and requesting new research on the long-debunked theory that vaccines can cause autism in children. Coincidentally, the Trump administration at the last minute pulled the nomination of former GOP congressman and vaccine skeptic Dave Weldon to head the Centers for Disease Control and Prevention, perhaps signaling that Republicans in the Senate are growing uncomfortable with the issue.

Meanwhile, Congress continues to contemplate how to cut as much as $880 billion in spending — possibly from Medicaid — at a time when more beneficiaries of the government health program for those with low incomes and disabilities have become Republican voters.

 This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists Anna Edney Bloomberg @annaedney Read Anna's stories. Shefali Luthra The 19th @shefalil Read Shefali's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories.

Among the takeaways from this week’s episode:

• The Trump administration’s last-minute decision to pull the nomination of Dave Weldon to head the CDC — shortly before his confirmation hearing before the Senate Health, Education, Labor and Pensions Committee was set to begin Thursday morning — has fueled speculation that Weldon’s anti-vaccine views meant he didn’t have enough Senate support to win confirmation. Weldon, a physician and former Florida congressman, has advanced debunked theories about vaccines and autism.
• Senate Democrats threatened to vote against a continuing resolution, or CR, to fund the government through Sept. 30. The measure passed narrowly in the House, with just one Democrat, Jared Golden of Maine, voting for it. Senate Democrats oppose the stopgap spending bill on many fronts, including its proposed cuts to medical research and its lack of a “fix” to prevent payment cuts to doctors who accept Medicare patients. The Democrats propose a 30-day government funding bill to allow negotiations on a bipartisan measure. The House adjourned after passing the CR on Tuesday and is not scheduled to return to Washington until March 24.
• The Medicaid program may be garnering more support as Republicans continue to debate how to cut federal spending to finance a major tax cut package. The impact of Medicaid funding cuts on rural hospitals and on the Medicaid expansion population that gained coverage as part of the Affordable Care Act are two areas of discussion as House Republicans deliberate.
• Continued staffing reductions at federal agencies are stoking concerns about lower levels of service to constituents and worsening mental health in the federal workforce. If federal workers are dismissed for poor performance — a charge many federal employees have called false because they received positive job performance reviews — then they don’t receive severance and cannot collect unemployment. With 8 in 10 federal workers employed outside the Washington, D.C., area, the sweeping impacts of reductions in the federal workforce are being felt far beyond the Beltway.
• The Trump administration’s decision to cancel $250 million in National Institutes of Health grants to Columbia University is the latest in an ongoing campaign to cut federal research funding. The uncertainty in federal funding has caused several schools to freeze hiring and rescind some graduate student admissions, raising concerns that the Trump administration’s policies are disrupting scientific research. Recent moves from HHS to allow new rules and regulations without public comment and new restrictions from the National Cancer Institute on what topics require review before publication (vaccines, fluoride, and autism are now on the list) are raising concerns that politics is playing a larger role in federal health policy.

Also this week, Rovner interviews Jeff Grant, who recently retired from CMS after 41 years in government service.

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

Julie Rovner: NBC News’ “‘You Lose All Hope’: Federal Workers Gripped by Mental Health Distress Amid Trump Cuts,” by Natasha Korecki.

Shefali Luthra: The New York Times’ “15 Lessons Scientists Learned About Us When the World Stood Still,” by Claire Cain Miller and Irineo Cabreros.

Alice Miranda Ollstein: The Atlantic’s “His Daughter Was America’s First Measles Death in a Decade,” by Tom Bartlett.

Anna Edney: Bloomberg News’ “India Trade Group Blasts Study Linking Drugs to Safety Risks,” by Satviki Sanjay.

Also mentioned in this week’s podcast:

• ProPublica’s “National Cancer Institute Employees Can’t Publish Information on These Topics Without Special Approval,” by Annie Waldman and Lisa Song.
• WIRED’s “Social Security Workers Aren’t Allowed To Read This Story,” by David Gilbert.
• Stat’s “Former NIH Director Francis Collins, Once Beloved in Washington, Now Worries for His Safety There,” by Anil Oza and Katherine MacPhail.

click to open the transcript Transcript: The Cutting Continues

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 13, at 10 a.m. As always, news happens fast — really fast, as you’ll hear in a moment — and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Later in this episode we’ll have my interview with Jeff Grant, formerly of the Centers for Medicare & Medicaid Services. Recently retired after 41 years in the government, he has thoughts about the way the Trump administration is handling the downsizing of that agency. But first, this week’s news. 

As we sit down to tape, we have some breaking news. The White House has reportedly pulled the nomination of former Republican Congressman Dave Weldon of Florida to lead the Centers for Disease Control and Prevention. 

Weldon was scheduled for his confirmation hearing this very morning at 10 a.m. before the Senate Health, Education, Labor and Pensions Committee. The hearing cancellation notice came out at 9:24 a.m. We obviously don’t know any real details yet about why this nomination was pulled, but somebody remind us why Dave Weldon was a controversial pick to head this agency. 

Edney: He was holding on to some anti-vax theories that do align with some who have already been approved by these senators, but he— 

Rovner: Notably the secretary of health and human services. 

Edney: Exactly. But he was still claiming that there’s mercury in vaccines and that’s the reason for autism. I don’t know if that made him a bit of a step too far for some of these people, particularly Sen. [Bill] Cassidy, who chairs the HELP Committee and is probably already frustrated by what’s going on when he thought that he had some promises from RFK [Robert F. Kennedy] Jr., the HHS [Department of Health and Human Services] secretary, to not be going after vaccines in different ways. 

Rovner: And we will get to that later in the podcast. Also, I should note that Weldon was also a big anti-abortion voice when he was in Congress. Although, again, I doubt that that’s what got his nomination pulled. I mean, obviously what got his nomination pulled was that he didn’t have enough votes to be confirmed. 

Ollstein: Sure. But like Anna said and like you said, Julie, there seems to be some inconsistency of criteria across the Cabinet nominations. Saying that this is about his anti-vax views, well, that didn’t stop RFK Jr. from getting confirmed, and if this is related to his anti-abortion views, that hasn’t stopped many of the nominees from getting confirmed. And so that leads me to believe that it’s about something else. I think we’ve seen this before. Matt Gaetz’s nomination was pulled. He had this history of sexual misconduct allegations, but other nominees who also had a history of sexual misconduct allegations sailed through their confirmations. And so that leaves me to believe there’s something else going on, some other shoe that was going to drop or some other issue at play. 

Rovner: We will definitely see. And just a note here, tomorrow, Friday, after the confirmation hearing at the Finance Committee for Mehmet Oz to head the Centers for Medicare & Medicaid Services, I’m going to sit down with a couple of my KFF Health News colleagues to wrap up that hearing as well as the other HHS nominations, and that will appear in your podcast feeds as well, as a bonus podcast episode. 

All right, moving on to the next-biggest news. As we tape, the government is less than 48 hours away from a potential shutdown. Friday after midnight is when the three-month funding patch Congress passed just before Christmas expires. The House on Tuesday barely passed a bill that was advertised as a clean CR [continuing resolution], meaning it just continues current funding for the rest of the fiscal year, but it would actually cut billions of dollars from domestic programs and add billions of dollars for defense and immigration enforcement. 

Among the little surprises in that bill are a more than 50% cut in medical research funded by the Defense Department. And while the bill does include a bunch of so-called health extenders, like continuing authority for Medicare telehealth, funding for community health centers, and delaying a cut to hospitals that serve large populations of people with low incomes, it rather pointedly does not include relief for doctors from a Medicare pay cut, much to the dismay of the American Medical Association. What are the prospects for this to become law? Or is the government going to shut down in addition to all the people who’ve been fired? 

Ollstein: The situation is very fluid. It barely passed the House, and Democratic senators are making noises about blocking it and putting forward a very short-term, actually clean CR because, as you noted, what they’re claiming is a clean CR is sort of more like an omnibus that makes a bunch of changes that only Republicans want to see. And not even all Republicans — just some Republicans want to see. And so I think because of the math here, the very narrow majority Republicans have in the House, they can really only lose a tiny handful of votes on this. 

I think you get into both policy and political dangerous territory when you make decisions that piss off some Republicans as well as Democrats, such as not including the so-called doc fix that would prevent doctors who serve people on Medicare from getting hit. That is a priority for some Republican members of Congress, and they can’t afford to lose their votes. And so there’s a lot of back-and-forth. There’s talk about a stand-alone health bill that scoops up some of the things that were abandoned at the end of last year. Who knows? Congress is very good at not getting things done. So I’m always skeptical. 

Rovner: We should point out that the House did kind of leave it all on the Senate’s doorstep by leaving and won’t be back until March 24. So even if the Senate were able to pass this 30-day clean CR, there’s no House to pass it, so the government would shut down anyway, which is what the House likes to do. It’s like: We’re going to do this. We’re not going to negotiate with you. We’re going to do this and leave, and you take it or you shut the government down. And that’s basically where we are at the moment. 

So, well, moving on to Medicaid and a reminder that the possibly impending Medicaid cuts are not part of this fight to keep the government open. I know reporters tend to refer to both the spending bill and the not-yet-written reconciliation bill as, quote, “the budget.” But the spending bill is something that’s left over from last year, while the budget resolution is something intended to lead to a bill that will be written this year. Anyway, regular listeners will know that the budget resolution approved by the House in February calls for $880 billion in mandatory spending reduction from the House Energy and Commerce Committee, which cannot be done without cutting from Medicare or Medicaid or both. 

But Medicaid is in a much different place politically now than it was even in 2017, when it was surprisingly popular and it helped defeat the Republican efforts to repeal the Affordable Care Act. How much more politically volatile are Medicaid cuts for Republicans now than they were? Alice, you’ve been following this, right? 

Ollstein: Yeah. So we did a story about all of the states that have expanded Medicaid by popular vote, and I think that’s a very different political dynamic than the states that did it through the legislature. This is something that a majority of folks in these states overwhelmingly voted for very recently. They said, Yes, we do want this. They said it directly. And I think that makes it more politically precarious for lawmakers to then come and basically override the will of the people and say, We’re going to make cuts. Especially because a lot of the cuts that are being discussed would hit the expansion population pretty squarely. 

There’s a lot of rhetoric recently sort of setting up different constituencies of Medicaid beneficiaries and sort of ranking them and implying that some are deserving and some are undeserving. And the expansion population in the eyes of many conservatives are undeserving, people who are low-income but not so low-income that they qualify for traditional Medicaid. They’re not parents, they don’t have disabilities, but they have not been able to afford insurance if not for this program. And so I think that as lawmakers in Washington discuss policies that would in many states automatically get rid of the expansion, a lot of these states have these trigger policies where if the federal level of support and funding goes down, then the expansion, poof, goes away. 

And I think that would upset a lot of people. And so this is a new dynamic. And these states only went the popular-vote ballot measure route because it was impossible to get it passed through the legislature and signed by their governors, who in many circumstances opposed it. And so it’s a very expensive, time-consuming route, but it’s something that a bunch of states pursued, and these are overwhelmingly states that voted for [Donald] Trump that are represented by Republicans in Congress. 

Edney: I also think that since 2017 we’ve seen more and more news articles, discussion, we’ve been paying attention more to rural hospitals and how they are impacted by Medicaid. This stat that really stuck out to me is that half of them are operating in a deficit, and so they need that Medicaid money, and threatening it threatens closing them down in places that wouldn’t have any other options. 

Luthra: The other component that I think is worth adding is I think what Alice pointed out about these hierarchies of deserving recipients is really astute and really important. And it also is a point that critics of Medicaid like to lean on without considering necessarily how interconnected these groups are. And an example of that I think about a lot is pregnant Americans. People love to provide insurance for people when they’re pregnant. It is very popular. You are seen as much more deserving when it is insurance not just for you but for your pregnancy. 

But one thing that we know is that your health in pregnancy is better if you have access to health care before you get pregnant as well and after you get pregnant. And there is a large body of research that shows that expanding eligibility for Medicaid actually does improve one’s health during pregnancy and improves long-term outcomes. And so I think it’s really important for us to underscore that if the kinds of cuts that we’re talking about do in fact take effect, there will be very meaningful implications, including for the people who Republicans claim would be protected. 

Rovner: So why aren’t we hearing more from lobbyists on this? You’d think the hospitals and the drug companies and other big for-profit parts of the health system would be shouting from the rafters by now. It seems that most of the emails and claims and things, ads, that I’m seeing are coming from consumer protection groups, not so much from the sort of big stakeholders in the health industry. 

Edney: I think there is a lot going on. So I think that this can be said in so many situations right now, but there’s only an ability to focus on so much. And you mentioned the doctors cut earlier. There are things that these groups have right in front of them. Medicaid, we all know that cuts are, in some way, are coming but maybe don’t have the picture yet exactly of how that will happen. So it might be tougher to fight quite yet. And they’re focusing on the things that are happening immediately in front of their face, which seems to be all anyone’s able to do with the onslaught of changes and cuts and things going on. 

Rovner: I feel like, move fast and break things, that’s why it works is that it doesn’t let people, there’s just not enough time to react before they’re on to the next thing. 

Well, we will move on to the next thing, which is Trump administration news, which is, obviously, there’s more than we can possibly get to. As you’ll hear more in our interview with Jeff Grant, key people are losing their jobs at CMS. Everyone left at HHS was offered a $25,000 cash buyout to quit, and there’s likely more to come with reorganization proposals due to DOGE [the Department of Government Efficiency] today. 

Social Security and the Department of Veterans Affairs are cutting thousands of workers as well and clearly jeopardizing services, even though the administration insists that’s not its goal. Many of these workers are being fired for poor performance, even the ones who have stellar performance records. That’s important because not only are they not getting any severance, people fired for cause aren’t generally eligible for unemployment insurance, either. It does seem like one campaign promise being met is the one by OMB [Office of Management and Budget] Director Russell Vought to put federal workers, quote, “in trauma.” Right? 

Luthra: I was going to say there is really compelling reporting that has shown exactly that. There are very severe mental health consequences we are seeing for these federal workers who are losing their jobs in a situation that will obviously lead to reduced services and where they may not be eligible for things like severance, like unemployment. It’s really pretty alarming to see the mental health degradation that’s been reported on. 

You hear about former federal employees contemplating self-harm as a result. And I think we are going to be continuing to see the impact for a very long time — and not just in the Washington, D.C., area, because federal employees work and live all around the country. 

Rovner: Eighty percent of federal employees are outside the Washington, D.C., metro area, which they seem to keep forgetting. I kept wondering why there hasn’t been more pushback on this, and now I’m starting to hear that the lack of pushback isn’t just people worried about future jobs or their careers. Some of it is about actual personal safety. Francis Collins, the former NIH [National Institutes of Health] director and White House science adviser who retired from his own NIH lab last month, told Stat News that he’s worried for his and his family’s safety and that he’s had to hire personal security. 

Are you all hearing that kind of story, too? I mean, is there literal concern for physical safety as much as for, Oh my goodness, if I speak out I’ll be blacklisted? 

Ollstein: Well, for some high-level people, also high-level former administration officials, the Trump administration has been stripping them of publicly funded security, and so they feel they’ve had to hire their own. And so those folks who are more recognizable feel even more at risk. But I think what Shefali was saying, too, it’s just hard to, even as we say that most federal workers are outside of D.C., it has been hard for me to convey to people outside of D.C. just how grim the mood has been. And just so many people we know are suffering, out of work, don’t know how they’re going to support their families. 

This is going to have repercussions for D.C.’s tax revenue, the ability to keep running our local schools and public transit and public safety and libraries. So it’s just going to continue to have these ripple effects. 

Rovner: And I should point out, I mean, I was born in Washington, D.C. I grew up here. I’ve lived here all of my adult life. Administrations change, and people come and go. That’s not unusual. This is unusual. Trying to sort of shut down entire agencies is definitely much more unusual than anything I have seen before. 

Well, meanwhile, at the helm of the Department of Health and Human Services, Secretary Robert F. Kennedy Jr. is behaving pretty much like you’d expect. He says the measles outbreak in Texas, which has now spread to New Mexico and to Oklahoma, is due at least in part to poor nutrition and exercise habits, which is a link not established by science. 

NIH is shutting down research into why people become vaccine-hesitant and how to increase vaccine uptake. And the CDC has announced a large-scale study to once again examine whether there’s a connection between vaccines and autism, even though there are reams of studies saying that there is not. Is anybody actually surprised by all of this? Maybe Sen. Cassidy, who I think was promised that this wouldn’t happen? 

Edney: No, not surprised. I can’t imagine he’s surprised, either. I think it was maybe just sort of a dance for them, where Cassidy knew he needed to make that vote and said the things he said. But, no, not surprised that it’s going this way. I think that there are a lot of people out there, a lot of groups who do want to know the cause of autism, and that is something that could be looked at more. Focusing it on vaccines, doing more damage than actually being helpful, doesn’t seem to be the way to do it, but it’s certainly the hypothesis this administration is going with, and they seem to refuse to look at any other direction. 

Rovner: Do you think sort of the growing measles outbreak in Texas—? I mean we’re obviously speculating here, though. You were saying earlier with the pulling of the Weldon nomination, might’ve had something to do with that. I mean, this is the biggest measles outbreak that we’ve had I think I saw in 10 years. It is unusual. I mean despite what RFK said, which we have measles every year, we don’t have outbreaks like this every year. And I’m wondering if that’s sort of making some of the Republicans who were sort of swallowing the fact that there is going to be a real anti-vaxxer at the helm of HHS giving them a little bit more pause. 

Edney: Yeah, I mean, the timing is, there’s no good word for it. I mean the fact that this measles outbreak happened when a vaccine skeptic, an anti-vaxxer basically, has gotten into the HHS secretary position. I’m sure they thought that, and I feel like I had a lot of conversations with people like this, not necessarily lawmakers but who said, Well, I really like a lot of things RFK Jr.’s doing, and I don’t think the vaccine thing’s really going to come up or matter that much. Guess what. It did. And they have to deal with that now. And I think particularly people who have been out very prominently in the news, like Sen. Cassidy, is going to have to try to reconcile that somehow, and maybe not having Weldon come before his committee and draw more attention to this was one way of digging in. 

Rovner: Yes, I think that’s definitely one of the possibilities. Well, the dismantling of science and medicine continues outside the federal government’s buildings as well. This week NIH canceled $250 million in grants to Columbia University, citing the university’s, quote, “continued inaction in the face of persistent harassment of Jewish students.” Meanwhile, in December, The Wall Street Journal reported that incoming NIH director Jay Bhattacharya wants to base funding at least in part on campus academic freedom-of-speech rankings, except the group that does those rankings said this week that they are, quote, “not the right tool for this particular job.” Is NIH just going to become another way for this administration to reward its friends and punish its enemies? 

Luthra: That’s what it seems like so far. We’ve seen hiring freezes take effect at a lot of universities, even as recently as this week. We are seeing a lot of universities that are politically more liberal in their members, in their general inclination, also reporting that they are under investigation for purported antisemitism. And I think we should know that often this framing is simply that protests existed on campus some, and there’s some debate over whether the term is being used a little liberally, but this is having real consequences for people’s ability to do research, to build a research pipeline, and as a result to improve our health. 

And I think it’s really striking that, yet again, this effort to use a federal funding institution as part of a political agenda is having real implications for how we live and our ability to become a healthier society. 

Rovner: And I would point out that Columbia University’s biomedical research establishment is nowhere near Columbia University’s main campus. It’s a totally different part of Manhattan. So it’s not about things that happen, quote-unquote, “on campus,” even though it is obviously all part of the same university. But we have seen a lot of universities getting grants pulled in the middle of them. It’s not like, We’re not going to renew your grant. It’s like, We’re just going to stop giving you money now, and you’re going to have to either fire all of your lab workers or see if you can figure out where else you can get money. I mean, it does seem to be really disrupting the practice of science right now. 

Luthra: And one other thing I think is worth noting is, I mean, this is very similar to what we saw with the USAID [U.S. Agency for International Development] grants that were suddenly canceled, and sometimes often it is more expensive to cancel things midway as opposed to not renewing them, because you’re paying for broken leases, you have already invested in things that will not yield results. Maybe there is severance that you have to pay. And all of these sort of sunk costs and new costs incurred by abrupt termination come without the benefits of the gains that one hopes to reap. 

Ollstein: Yeah, I mean, to Shefali’s point, so not only is it more costly in the short term, but it’s absolutely more costly in the long term. These research grants generate way more economic revenue than they cost, and they support tons of jobs all around the country. And so this will absolutely have detrimental economic effects in the long term as well. 

Rovner: Well, finally this week I have a heading I’m calling “Your Government Is No Longer Any of Your Business.” This is pretty much the opposite of the radical transparency this administration was promising. First, the good news: The administration apparently will still issue rules and regulations under the legal process known as the Administrative Procedure Act, which I talked about with law professor Nick Bagley earlier this year. How do we know this? Because HHS has put out a policy statement that it will no longer take public comment on a broad array of rules for which public comment had been required since 1971. 

Is this legal under the APA? Yes, the law allows for exceptions. But not only is this not exactly radically transparent, it could make it a lot easier to do some pretty unpopular things, like, I don’t know, cutting NIH overhead funding to 15%. Anna, you’re nodding. 

Edney: Well, yeah, I think that is the point, is that they want to move quickly and public comment slows that down. But it does it for a reason, because there are consequences, which Shefali and Alice just laid out, for things like cutting grants and things like that that maybe a health care expert in the administration isn’t thinking about when they first post something and groups come in and they say, Hey, this is actually how we’re affected. And so public comment maybe sounds like your aunt and grandma winding up to talk about it, which can also happen, but it’s really educated experts in these areas that are saying, Here’s this one thing you didn’t think about, or there’s a lot of reasons to get public comment. 

I can understand it. It’s something that when I cover the FDA [Food and Drug Administration] that sometimes they’ll complain, not complain but they’ll say, Things go slow because we have to do an advanced notice of proposed rulemaking and then we do a notice of proposed rulemaking. And these are all times when the public can come in and comment, but to not do that, it seems like they want to be able to do unpopular things quickly. 

Ollstein: It’s just struck me how crazy a contrast it is between the two parties on this front. The Democratic Party was criticized for being so cautious and moving so slowly on some pressing priorities when [President Joe] Biden was in office and checking all the boxes and doing the long version of the process to make sure everything was legally on the up-and-up when they could have expedited some things and done interim final rules and taken comment after. So there was a lot of frustration from some groups on that front. Meanwhile, the Republican administration is doing just the opposite, moving as fast as possible with as little public input as possible. 

Rovner: Which leads into my next topic, over at the National Cancer Institute. According to ProPublica, staff have been notified that manuscripts, presentations, or basically any sort of public communications that touch on any of nearly two dozen sensitive, controversial, or high-profile issues must be cleared first by a special NCI clearance team. Now it’s obviously not unusual for political appointees to want to see potentially newsworthy things before they go public, but this list of what has to be specially cleared is pretty comprehensive. 

And it includes not just obvious hot-button things like abortion and stem cell or fetal tissue research but also things like obesity, vaccines, quote “discussion of federal policies” quote, and even peanut allergies. This feels quite a bit more sweeping than your usual Don’t put out stuff that will surprise us in a bad way. Right? 

Luthra: Yeah, it’s very striking. It’s hard for me not to say that this is very strange. I have a peanut allergy, and I would personally like information about peanut allergies to be put out in the world, and I guess that may not always happen anymore. But it is part of this, as we have discussed, ability and interest in amplifying, often, conspiracy theories and taking us away from medically established science. We just saw efforts to restrict fluoride in the water in Utah this week. This is something that is happening at high levels of government and more local levels of government, and it’s something that is going to continue, is trying to leverage our health institutions to promote things that will make us less healthy. 

Rovner: Yeah, well, and finally this week, Wired magazine informs us that a new policy at the Social Security Administration bars workers from looking at news websites on work devices. Now this is obviously aimed at things like making sure employees aren’t watching the NCAA basketball tournament or checking their 401(k)s during work hours or reading Wired, for that matter, except Social Security workers also use news sites for, you know, work, like checking obituaries to make sure the agency isn’t sending checks to people who have died. That seems to be a big issue these days. Is this just another way DOGE is trying to make federal workers feel like grade school children so they’ll quit? 

Ollstein: Well, this is a twofer, because it punishes federal workers and it punishes news outlets who, including myself and my colleagues at Politico. They forced many federal workers to cancel their subscriptions to our Pro news. And so all that does is make sure the lobbyists are better informed than the federal agencies, which is troubling, for sure. 

Rovner: And probably not what the administration wanted. All right, well that is as much news as we have time for this week. Now we will play my interview with Jeff Grant, formerly of CMS, and then we will come back and do our extra credits. 

I am pleased to welcome to the podcast Jeff Grant, most recently the deputy director for operations at CCIIO, the Center for Consumer Information and Insurance Oversight, at the Centers for Medicare & Medicaid Services. Jeff retired last month after 41 years in government, following the firing of 15% of his staff. Now he’s starting a consulting firm that will try to help those being let go from the government find new jobs. Jeff Grant, thank you so much for joining us. 

Jeff Grant: Oh thanks for having me. 

Rovner: So you were a career employee at CMS. Tell us what you did and how that would normally change between administrations. Obviously, you were there 40 years. You’ve seen a lot of administrations come and go. 

Grant: So I was actually at CMS for just under 30 years, and then I had Navy and Navy Reserve experience prior to that and a little bit at Commerce and GAO [the Government Accountability Office], but was all over CMS. My last job was running operations for the Center for Consumer Information and Insurance Oversight. So I was a deputy center director. I reported to the political appointee that ran the center, and I was in charge of our major operations, like HealthCare.gov, getting payments out to health plans that provided care for folks that registered in the private insurance marketplace, running things like the risk adjustment program. 

And then the independent dispute resolution program was also huge out of the No Surprises Act. And we ran that for three Cabinet departments — ourselves, Labor, and Treasury. So we handled all the disputes that came in over surprise bills. 

Rovner: So obviously in your 30 years you’ve had Republican and Democratic administrations come and go. How did things normally change for the career workforce when the administration changes? 

Grant: What we really do, especially at a senior level like I was at at the tail end of my career, is we meet with the new officials coming in. And frankly, we read things about them before they come in, study up on who we’re going to be working with, what their policy priorities are, and then we prepare to move forward on a new policy agenda. And what I found over 30 years of working for Republicans and Democrats, Democrats will move it one direction, Republicans will move it another direction. 

There’s a big wide middle there where policies that tend to make sense to both parties over time, when they see them working, remain. And then you have some shifts around the edges on the rest of the policies. And it’s actually, I think the changes in administrations are usually quite beneficial for the stability of health programs, not taking them too far in one direction or another. 

Rovner: So how important is the career workforce to the operations of this agency? I think people, they just see Medicare and Medicaid, CHIP [the Children’s Health Insurance Program], ACA, and assume that it all runs on its own. 

Grant: It absolutely does not, and the career workforce is absolutely essential to the operations of these programs. I think what people should understand is this is 6,700 people, or it was before they started removing folks, but 6,700 people to handle $1.5 trillion in health insurance. So we’re the largest health insurance agency in the world, and we’re running it with 6,700 people, which is smaller than most federal agencies and probably smaller than most Americans would think. 

Rovner: So who were the people who were let go? We’ve been led to believe they were people who didn’t or couldn’t do their jobs or didn’t bother to come to work or were working on the side elsewhere. 

Grant: That’s absolutely, 100% false in terms of what I think people believe about these workers, if they believe the letters. So the letters informed them that their knowledge, skills, and abilities were insufficient to meet the needs of the agency and that their performance was not adequate to justify retention. Both of those were just blatant falsehoods. The people that had been there long enough to get performance appraisals, many of them had the highest appraisals you could get, and that’s not an automatic. There’s a distribution of performance appraisal numbers. These were really exceptional individuals. 

We had a very rigorous hiring process that’s gotten better over the years, and we’ve really identified top talent to come in and work for us. Some of these folks had been there five weeks, six weeks, three weeks. I don’t know what the shortest amount of time was. I think the shortest amount of time was three weeks. You have to have 90 days on board to make a performance-based judgment. You could make a conduct-based judgment. So if they were not showing up for work, we fire them for that. I’ve actually personally fired an employee for not showing up for work. That was a probationary employee. It’s very easy to do. We did not have that problem. 

They did work a mix of in the office and at home, but all of our recent employees were local to one of our offices. So they all came in the office at times. At times they work remotely. That has always been true of our workforce, that we have employees that work both in office and at home, and it’s actually a very efficient way to do things, because they don’t waste time commuting. And sometimes being quiet at home for activities that require uninterrupted work, you can actually be much more efficient working at home than you are in the office. 

But then you come in the office for activities that it’s beneficial to be around people and work things out. So you organize your days in such a way that makes sense, but you can have some interruption-free workdays where you can be super productive. 

Rovner: Yes. And that’s how, I confess, that’s how I work. Partly I’m home, partly in the office. 

Grant: That is how I work. Now that I’m on my own, I’m 100% remote. And I can assure you, running my own business, I’m not just sitting around doing nothing. 

Rovner: So what do you think people most misunderstand about the way the Trump administration is trying to make the government run more “efficiently”? And I’m putting efficiently in air quotes. 

Grant: Well then, I think, the first thing I would say, especially for an agency like CMS — I can’t speak for all of government, but for an agency like CMS, we’ve got 6,700 workers. They’re managing contractors that in turn manage this ginormous benefit that we are paying out. The money’s in the benefit. Let’s just start there. So if there are inefficiencies that are leading to overspending, it’s not the 6,700 people that are too small a workforce already to effectively run these programs. The smartest thing you could do is probably hire more people into CMS to give you more degrees of freedom to make more changes that actually might transform these programs and make them more efficient. 

I can tell you, personal experience in the Trump administration, I cut costs for the marketplace operations by $100 million per year for three consecutive years. But it took people and contractors to make those cuts. But over time that resulted by the third year we were saving $300 million a year. Those savings carry forward. So every year after that you’re saving that $300 million a year. That’s real money. Tinkering around with 82 probationary employees, that’s about $15 million a year by comparison. 

It is ludicrous to say that you’re taking your cheapest employees, cutting them, and eliminating your degrees of freedom to make transformative change and that’s going to make you more efficient. That’s the least efficient thing you can do. 

Rovner: So what’s your biggest fear about long-term damage to the programs if these kinds of cuts continue? I mean they say they’re not finished yet. The probationary employees were the easy ones to let go. Now they’re going to move into the buyouts and RIFs [reductions in force] and other ways, I guess, of trying to downsize the workforce. 

Grant: Yeah, well, first I think the probationary were easy, but I’m hoping that one of those lawsuits on the way they did it, that points out how wrong their method for doing it was, might still restore those jobs, because I don’t think those were as easy as they thought they were. They should have run a reduction in force. But they’re now talking about a reduction in force. They’re talking about reducing contracts, and I think reduction in force is going to be more randomly distributed. Just the probationary people are random, who happen to be where and be probationary at that time. So it’s not a thoughtful way of saying: We don’t need this function anymore. Let’s get rid of it and save money. 

A RIF would be less thoughtful. And I think the one that’s also really dangerous is the return to workplace with a mandatory five days a week. And at the end of this month, all workers within 50 miles of an HHS office have to be in the workplace. If they cannot be in five days a week without some kind of exceptions process, they’re going to be gone. And that will be really randomly distributed again among who is actually able to do that at the end of April. People that are not within 50 miles of a CMS office are still required to find an office and then go to work. And my component had 75 of those people. 

So I think it would be very hard for those folks to come in. And again, a lot of these are senior people, really talented, and you’re just losing a skill set randomly because they can’t get to the office, yet they’ve been performing superbly without going to an office. 

Rovner: So what happens to these programs? 

Grant: So, I can’t tell you exactly. I know there was one person that we have in during government shutdowns for running the payment process, one of two people that really knows the payment process backwards and forwards. That person cannot get to an office. And without an exceptions process, that person is gone. And that hampers our ability to pay health plans the money they need for covering our insured individuals. And it’d just be these little pockets of people here and there that have advanced expertise. We’re not that big an agency. We don’t have a lot of people that back people up. 

That’s one of the problems with being an underfunded agency, is you do not have more than one or two people that work on any given subject. The redundancy they think is there does not exist. And so you will start losing key capacity to actually operate programs. Did you see that they were also proposing to sell the Woodlawn building [in Maryland]? 

Rovner: I did. 

Grant: It’s the only place that can house 4,000 people. Evidently there may be an administration connection and, who might buy it and then lease it back to the government. You may know that there are some people— 

Rovner: It’s going to be like the private equity thing with the hospitals. We’re going to— 

Grant: This is exactly what I said, that everything that’s being done right now is being done like private equity firms do it. It doesn’t make you run better. It just kind of lightens the cost, and you have a better-looking statement just for a short time. So your financials look good for a very short period of time, then everything starts spiraling downhill, customer service goes down the tubes, and you’re all of a sudden paying twice as much. 

Rovner: And I guess I should have asked you this at the beginning. Is that why you left? I mean, you worked for [President] Trump last time. 

Grant: I did. And I actually liked the person that came in. I left because it was becoming clearer and clearer that the people that they brought in that are very good to run CMS aren’t in charge of these key policies about how many people we will have, how big our contracting budget will be. And I could see us having large-scale loss. I mean, we lost 82 in one day. I’ve mentioned 75. I could get to a number that was easily 200 of 600 employees I had, and I felt I could do more on the outside than I could on the inside. 

And that’s what I’m doing now. And hopefully we can get these people either restored to their jobs, which is one angle I am fighting hard on. And if they can’t get restored to their rightful positions, try to find them a position outside of government. 

Rovner: Great. Jeff Grant, thank you so much. 

Grant: Thank you. 

Rovner: OK, we are back, and it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Shefali, this week is the fifth anniversary of the covid shutdown, which we didn’t even get a chance to talk about, but that’s what your extra credit is. So tell us now. 

Luthra: There were a lot of really great pieces this week about the five-year anniversary of the covid shutdown, but I feel like I learned the most and had the most fun with this piece from TheUpshot. It is by Claire Cain Miller and Irineo Cabreros. It is “15 Lessons Scientists Learned About Us When the World Stood Still.” It’s got some great charts. It talks about things we learned that were kind of neat, like we don’t have to have really bad flu seasons, and actually there are ways to improve pregnancy-related health outcomes by letting people rest when they’re pregnant. 

And there are also things we learned that are really bad, like it is actually harder to learn virtually as opposed to in person and that there is no substitute for in-person socialization. And that even during lockdowns, men are less likely to do housework than women in heterosexual couples. But I really loved how this took us back to a time that upended everything we knew and it pulled out some of the most salient facts that we’ve learned for better and for worse. It’s really fun, and I recommend it. 

Rovner: It is really fun. Anna. 

Edney: I did one by my colleague in India called “India Trade Group Blasts Study Linking Drugs to Safety Risks.” And I was glad that she was able to write this, because I thought this was a really interesting study that came out. And it was published in an operations journal, so it was kind of not prominently displayed. But it showed that drugs that are made in India — so these are mostly generics — were 54% more likely to result in a serious adverse event. 

So that includes hospitalization, disability, and death compared to drugs made anywhere else. And the study’s authors think this may be due to a lot of the manufacturing issues that probably listeners of this podcast have heard me talk about before so I don’t have to get into. But I think it’s an interesting story to give a read. 

Rovner: Yes. Anna with the scary drug stories. Alice. 

Ollstein: So I have a very heartbreaking story from The Atlantic called “His Daughter Was America’s First Measles Death in a Decade.” And a Texas-based reporter went to the small rural community where a Mennonite community was really at the epicenter of the recent measles outbreak. And he sort of stumbled upon the father of the child who died. And the piece really illuminates just how challenging a public health crisis this is. A lot of people in that community don’t speak English. They speak Low German. So it’s very hard to communicate. It’s very hard to even know the scope of the problem, because people aren’t testing. 

A lot of folks in that community are not enrolled in public schools or even accredited private schools where vaccination rates are tracked. And so it’s just very, very challenging to communicate and build trust and even have a sense of how bad the situation is. And at the same time, the piece walks through all of the things going on that are not helping, like RFK Jr. not only downplaying the outbreak but also sort of doing some light victim-blaming, implying that if you have good health habits and nutrition, you won’t die of measles. And this was a little child. 

And so not only is that not scientifically proven, but it’s sort of painful to hear when you’re talking about a little child. So I highly recommend this story. 

Rovner: Yeah, I have a different blaming-the-victim story. My extra credit is from NBC News. It’s called “‘You lose all hope’: Federal workers gripped by mental health distress amid Trump cuts,” by Natasha Korecki. And it’s the best roundup I’ve seen of the mental distress on federal workers across agencies being caused by the way the administration is going about this downsizing. Some of these workers voted for Trump. They support cutting waste and fraud in the federal government. But said one former CDC worker, quote: “Taking a sledgehammer approach and having an unelected billionaire in my email is just insane. What are his qualifications for doing this? The government is not a startup; we’ve been in business since 1776.” A really good if depressing read. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer and editor, Francis Ying, and our fill-in editor this week, Mary Agnes Carey. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys mostly these days? Shefali? 

Luthra: I am on Bluesky, @shefali. 

Rovner: Anna. 

Edney: X and Bluesky, @annaedney. 

Rovner: Alice. 

Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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California’s Medicaid program has borrowed $3.4 billion from the state’s general fund — and will likely need even more — to cover ballooning health expenses for 15 million residents with low incomes and disabilities.

The state Department of Finance disclosed the loan to lawmakers in a letter late Wednesday, noting funds were needed to make critical payments to health care providers in Medi-Cal, the state’s version of Medicaid. In recent months, Gov. Gavin Newsom’s administration has warned of skyrocketing health care costs, including higher prescription drug prices and increased enrollment by newly eligible seniors and immigrants without legal status.

Finance spokesperson H.D. Palmer said the loan will cover Medi-Cal obligations through the end of the month. He declined to specify the total of the program’s potential shortfall. However, a document circulated by state Senate leaders warns that additional funding may be needed to cover expenses through June 30, the end of the fiscal year.

The cost overrun adds a new layer of difficulty for Democrats who control the legislature and are already grappling with congressional budget plans that could slash Medicaid funding, which accounts for 60% of Medi-Cal’s $174.6 billion budget. President Donald Trump and Republican lawmakers have also criticized California Democrats for covering residents regardless of their immigration status.

Newsom spokesperson Izzy Gardon downplayed the loan. “Rising Medicaid costs are a national challenge, affecting both red and blue states alike,” Gardon said. “This is not unique to California.”

Health officials last year said the state would spend roughly $6.4 billion in the 2024-25 fiscal year to cover immigrants without legal status, which the Democratic governor has hailed as a key step toward his goal of providing “universal coverage” for Californians. In recent testimony, however, finance staff told legislators that health benefits extended to all income-eligible immigrants without legal status are projected to cost roughly $9.5 billion, of which $8.4 billion will come from the general fund.

Republicans called for fresh scrutiny of the state’s decision to cover residents without legal status. “This program is out of control,” Senate Minority Leader Brian Jones posted on the social platform X. “We are demanding a full hearing and a full cost analysis so the public knows exactly where their tax dollars are going.”

Patient advocates objected to Republicans singling out the expansion for immigrants.

“Health care costs are influenced by many factors including prescription drugs, hospital costs, and more,” said Rachel Linn Gish, a spokesperson for Health Access California, a consumer health advocacy group.

According to a fall update from the Department of Health Care Services, Medi-Cal spending grew due to higher-than-expected enrollment of seniors, fewer Californians losing Medi-Cal coverage than anticipated, and increased pharmaceutical spending, as well as expanding coverage of immigrants. For instance, the state is spending $1.1 billion more on residents who were expected to lose coverage after the covid-19 pandemic, and an additional $2.7 billion more than anticipated to cover unauthorized residents.

Assembly Speaker Robert Rivas said he’s committed to maintaining the state’s expansions of Medi-Cal services.

“There are tough choices ahead, and Assembly Democrats will closely examine any proposal from the Governor,” he said in a statement. “But let’s be clear: We will not roll over and leave our immigrants behind.”

Senate leaders said they were looking closely at the state’s estimated costs and caseloads and would recommend cost containment measures as part of their budget proposal in the coming weeks.

Scott Graves, budget director at the California Budget & Policy Center, said it’s not unusual for the state government to make adjustments when spending doesn’t line up with projections.

Last year, for instance, the state borrowed $1.75 billion against its general fund when revenues from a state provider tax were delayed. Prior to that, Department of Finance officials said, California took out a similar loan in 2018 for $830 million.

“The reality is all of these are just estimates, especially with a very complicated program like Medi-Cal,” Graves said, noting that $3.4 billion is roughly 2% of the state’s overall Medi-Cal budget. “It seems like we’re on the verge of making a mountain out of a molehill.”

Mike Genest, who served as finance director under Republican Gov. Arnold Schwarzenegger, agreed that adjustments can be routine. But he said the magnitude of Medi-Cal’s current overrun was not.

“For this to happen in the middle of the year — we’re only in March — I mean, that’s pretty astounding,” Genest said.

California Democrats continue to characterize Trump and congressional Republicans as the biggest threat, pointing to the House budget plan to shrink Medicaid spending by as much as $880 billion. They say cuts of that magnitude would leave millions of residents uninsured, reducing access to preventive care and driving up costlier emergency room services.

They cautioned that some short-term cost increases could be driven by newly eligible residents seeking long-delayed care, which could level off in coming years. However, some acknowledge difficult decisions ahead.

“We definitely have to ensure that those who are our most vulnerable — our kids, those with chronic conditions — continue to have some sort of coverage,” said Democratic Sen. Akilah Weber Pierson, a San Diego County physician. “The question is, what will that look like? To be quite honest with you, at this point, I don’t know.”

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

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The prospect of deep Medicaid cuts has become a flashpoint in Congress, with leaders of both parties accusing their counterparts of lying.

House Democratic leader Hakeem Jeffries said Feb. 27 that a Republican budget measure would “set in motion the largest cut to Medicaid in American history,” and that Republicans are hiding the consequences.

“The Republicans are lying to the American people about Medicaid,” Jeffries said. “I can’t say it any other way. Republicans are lying. Prove me wrong.”

Republicans said Democrats were distorting the Republican budget. Rep. Steve Scalise (R-La.) said, “The word ‘Medicaid’ is not even in this bill.” House Speaker Mike Johnson said on CNN that Republicans don’t want to cut Medicaid, “and the Democrats have been lying about it.”

Republicans are looking for massive budget savings to meet their goal of fully extending President Donald Trump’s 2017 tax cuts. This is a separate process from Congress’ need to pass a continuing resolution to keep the government running by March 14 or face a federal government shutdown.

Here’s what we know so far about potential Medicaid cuts.

The House GOP Budget Plan Seeks $880 Billion in Cuts

Medicaid serves about 1 in 5 Americans. The health care program for low-income people is paid for by the federal government and partly by states. Louisiana, home to Johnson and Scalise, has one of the highest state proportions of Medicaid enrollees.

The House Republican budget plan adopted Feb. 25 opens the door to slashing Medicaid, even though it doesn’t name the program. The plan directs the House Energy and Commerce Committee to find ways to cut the deficit by at least $880 billion over the next decade.

The committee has jurisdiction over Medicaid, Medicare, and the Children’s Health Insurance Program, in addition to much smaller programs. CHIP offers low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

Republicans ruled out cuts to Medicare, the health insurance program for seniors that leaders cut at their political peril. Medicare is about 15% of the federal budget, and Medicaid is about 8.6%.

When Medicare is set aside, Medicaid accounts for 93% of the funding under the committee’s jurisdiction, the nonpartisan Congressional Budget Office found in a March 5 analysis. That means it is impossible for the committee to find enough cuts that don’t affect Medicaid.

“It’s a fantasy to imply that federal Medicaid assistance won’t be cut very deeply,” said Allison Orris, an expert on Medicaid policy at the Center on Budget and Policy Priorities, a left-leaning think tank.

After Medicaid, the next-largest program under the committee’s jurisdiction is CHIP. Lawmakers don’t appear to be planning to wipe out CHIP, but even if they did, they would be only a “fraction of the way there,” said Joan Alker, an expert on Medicaid and CHIP at Georgetown University.

If Medicare cuts are off the table, the only way to achieve $880 billion in savings is through big Medicaid cuts, said Larry Levitt, executive vice president for health policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

Andy Schneider, a professor at Georgetown University who served in the Obama administration as a senior adviser at the Centers for Medicare & Medicaid Services, said even if the committee eliminated all those “other” programs entirely it could achieve only $381 billion in savings — about 43% of the target.

“In short, if they don’t want to cut Medicaid [or CHIP], and they don’t want to cut Medicare, the goal of cutting $880 billion is impossible,” Schneider said.

The $880 billion cut is not a done deal. House Republicans were able to pass their budget package, but Senate Republicans are taking a different approach, without proposing such significant cuts.

Any finalized budget blueprint would need Senate Republicans’ buy-in. Sen. Josh Hawley (R-Mo.) is among Republicans who have spoken against potential cuts; he told HuffPost, “I would not do severe cuts to Medicaid.”

The numbers are starting points that may lead to negotiation among at least Republicans, said Joseph Antos, a health care expert at the conservative American Enterprise Institute. “We are a long way from final legislation, so it’s not possible to predict how much any program will be cut,” he said.

“If the bill also includes extending the [Trump 2017] tax cuts, we are probably months away from seeing real language,” Antos said.

Once the House and Senate have reached an agreement on language and the resolution passes both chambers, the committees will work on detailed cuts. To enact such cuts, both chambers would need to approve a separate bill and receive Trump’s signature.

Why Eliminating Fraud Doesn’t Solve the Problem

Republican leaders have deflected concerns about Medicaid cuts by talking about a different target: Medicaid fraud.

“I’m not going to touch Social Security, Medicare, Medicaid. Now, we’re going to get fraud out of there,” Trump told Fox News’ Maria Bartiromo on March 9, in keeping with his campaign rhetoric that he would protect those programs.

At the same time, Trump on his Truth Social platform praised the House resolution that would make cuts highly likely: “The House Resolution implements my FULL America First Agenda, EVERYTHING, not just parts of it!”

Would eliminating fraud solve the Medicaid problem? No.

On CNN, Johnson said cutting fraud, waste, and abuse would result in “part of the savings to accomplish this mission.” He said the government loses $50 billion a year in Medicaid payments “just in fraud alone.”

Johnson conflated “fraud” with “improper payments.” The Government Accountability Office, the nonpartisan investigative arm that examines the use of public funds, found about $50 billion in improper payments in Medicaid and the same amount in Medicare in fiscal 2023.

Those improper payments were made in an incorrect amount (overpayment or underpayment), should not have been made at all, or had missing or insufficient documentation. But that doesn’t mean that there was $50 billion in Medicaid fraud, which would involve obtaining something through willful misrepresentation.

The system used to identify improper payments is not designed to measure fraud, so we don’t know what percentage of improper payments were losses due to fraud, said Schneider, the former Obama administration health adviser.

Plus, it’s a drop in the overall bucket of the potential $880 billion in cuts.

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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”.

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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