DOJ, HHS, ED, and GSA Announce Initial Cancellation of Grants and Contracts to Columbia University Worth $400 Million

DOJ, HHS, ED, and GSA Announce Initial Cancelation of Grants and Contracts to Columbia University Worth $400 Million

In Washington’s debate over enacting steep funding cuts to Medicaid, words are a central battleground.

Many Republican lawmakers and conservative policy officials who want to scale back the joint state-federal health program are using charged language to describe it. Language experts and advocates for Medicaid enrollees say their word choice is misleading and aims to sway public opinion against the popular, 60-year-old government program in a bid to persuade Congress to cut funding.

Republicans such as Sen. Bill Cassidy of Louisiana, chair of the Senate Health, Education, Labor and Pensions Committee, are deploying provocative terms such as “money laundering,” rebranding a decades-old — and legal — practice known as provider taxes, which most states use to gain additional federal Medicaid funds.

They say it’s “discrimination” that the federal government matches state funding at a higher rate for adults covered by the Affordable Care Act’s Medicaid expansion than it does for other enrollees, including children, pregnant women, and disabled people.

And many Republicans, including House Speaker Mike Johnson and the director of the Office of Management and Budget, Russell Vought, have described adults who gained Medicaid coverage through the ACA expansion as “able-bodied” as they push for federal work requirements.

The term implies they have less need for government assistance than other Medicaid recipients — even though some have health conditions or caregiving responsibilities that make holding full-time jobs difficult.

“Able-bodied adults without dependents are better off with jobs than with hand-outs, and so are their communities and American taxpayers,” Sen. John Kennedy (R-La.) said in a press release in February.

To be sure, political spin is a practice older than Washington, and Democrats are no spectators in the war of words. But what’s striking about the latest GOP effort is that it is focused on cutting a health program for the nation’s poorest residents to pay, in part, for tax cuts for wealthier Americans.

A KFF poll conducted last month and released Friday found that support for proposed changes to Medicaid can wax or wane depending on what individuals are told about the program.

For example, the poll found about 6 in 10 adults support work requirements, with the same portion of respondents believing incorrectly that most working-age adults on Medicaid are unemployed. In fact, about two-thirds work.

KFF’s poll also showed that support for work requirements drops to about 3 in 10 adults when those who initially supported them hear that most Medicaid enrollees are already working and that, if the requirements were implemented, many would risk losing coverage because of the burden of proving eligibility.

When respondents initially opposed to work requirements were told they could allow Medicaid to be reserved for groups like the elderly, people with disabilities, and low-income children, support for them increased to 77%.

Steven Mintz, a history professor at the University of Texas, said the Medicaid debate likely will be won not on the facts, but instead on which party can describe it in terms that gain the most public support. “Words are wielded as weapons,” he said.

Republicans’ word choices are designed to appeal to people’s prejudices about Medicaid, he said, adding that “loaded” terms help divert attention from a detailed policy discussion.

“Words help reinforce a position that people already lean toward,” he said.

Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said conservatives who have long tried to shrink Medicaid have an obvious motivation.

“These people spend their lives trying to ruin the program by searching for the newest slogans, the newest quips, and the newest nonsensical monikers that they think somehow will persuade Congress to completely upend the program and take benefits away from tens of millions of people,” she said.

Medicaid and the closely related Children’s Health Insurance Program cover nearly 80 million low-income and disabled people — roughly 1 in 5 Americans. Enrollment and spending soared in the past decade due largely to the covid pandemic and the decision by more states to expand Medicaid under the ACA. Polling shows the program is nearly as popular as Medicare, the health program primarily for those 65 or older — with about 3 in 4 Americans holding a favorable opinion of Medicaid.

The House of Representatives’ budget resolution, a blueprint that narrowly passed Feb. 25 with no Democratic support, calls for cuts of at least $880 billion over a decade largely from federal health and energy programs. A separate Senate resolution with no such cuts — so far — is also in play. Any proposal would need to pass both chambers.

Democrats fear most of those cuts will come from Medicaid. Trump has vowed not to touch Medicare, leaving few if any alternatives. He has said he would “cherish” Medicaid and go after only waste, fraud, and abuse in the program without offering details on how those would be interpreted — and he endorsed the House’s blueprint calling for cuts.

States and the federal government share in the financing of Medicaid, with the federal government paying from 50% to 77% of the cost of providing services to most beneficiaries. The rate is 90% for beneficiaries receiving coverage through their state’s Medicaid expansion program.

The federal matching rate varies based on a state’s per capita income relative to the national average; states with lower per capita incomes have higher matching rates. The remaining share of program funding comes from state and local sources.

The words “discrimination” and “money laundering” have been used in reports from the Paragon Health Institute, a conservative think tank led by a former Trump adviser, Brian Blase. Two former Paragon executives now advise Trump, and a former Paragon analyst advises Johnson.

Blase said there’s no ulterior motive in the group’s word choices. “This is us trying to describe the issue in a way that makes the most sense to members of Congress and policymakers,” he said.

Paragon analysts have argued for ending the federal government’s “discrimination” in matching state dollars for those covered under the ACA’s Medicaid expansion at a higher rate than for other enrollees. They also propose giving states a set amount of federal money per year for the program, rather than the open-ended federal funds that always have been a hallmark of Medicaid.

One way states raise funds for their share of Medicaid spending is through provider taxes that hospitals or nursing homes pay. States often reimburse the providers through the extra federal money.

Blase acknowledges that provider taxes used by states to draw down more federal money — which Paragon has referred to as “money laundering” — are legal. He said calling the practice a “tax” is misleading because the providers financially benefit from it.

“Money laundering is the best term we can think of for the schemes providers and states come up with to get federal reimbursement for artificial expenditures that benefits states and providers,” he said.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, defended provider taxes as a legal way states raise money to cover low-income people. She noted most states with provider taxes are controlled at least partly by Republicans.

Alker rejected the notion that enhanced funding to expand enrollment is “discrimination.” The ACA included the higher rates for covering more low-income enrollees because that was the only way states could afford it, she said.

Without providing a specific example, Blase said advocates have said cuts would “leave people dying in the streets.”

During a brief funding freeze to Medicaid providers in January, Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee, said, “This is a blatant attempt to rip away health insurance from millions of Americans overnight and will get people killed.”

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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Panelists at a covid conference last fall were asked to voice their regrets — policies they had supported during the pandemic but had come to see as misguided. Covid contact tracing, one said. Closing schools, another said. Vaccine mandates, a third said.

When Marty Makary’s turn came, the Johns Hopkins University surgeon said, “I can’t think of anything,” adding, “The entire covid policy of three to four years felt like a horror movie I was forced to watch.”

It was a characteristic response for Makary, President Donald Trump’s nominee to lead the Food and Drug Administration, who looks set to be confirmed after a Senate committee hearing on Thursday. A decorated doctor and a brash critic of many of his medical colleagues, Makary drew Trump’s attention during the pandemic with frequent appearances on Fox News shows such as “Tucker Carlson Tonight,” in which he excoriated public health officials over their handling of covid.

Many former FDA officials and scientists with knowledge of the agency are optimistic about Makary — to a degree.

“He’s a world-class surgeon, and he has health policy expertise,” said Jennifer Nuzzo, a Brown University professor of epidemiology and former colleague of Makary’s at Johns Hopkins. “If you have pancreatic cancer, he’s the person you want to operate on you. The university is probably losing a lot of money to not have him doing that work.”

His critics say he at times exaggerated the harms of the covid vaccine and undersold the dangers of the virus, contributing to a pandemic narrative that led many Americans to shun the shots and other practices intended to curb transmission and reduce hospitalizations and deaths.

Should he take the reins at the FDA, transitioning from gadfly to the head of an agency that regulates a fifth of the U.S. economy, Makary would have to engage in the thorny challenges of governing.

“Makary spent the pandemic raving against the medical establishment as if he were an outsider, which he wasn’t,” said Jonathan Howard, a New York City neurologist and the author of “We Want Them Infected,” a book that criticizes Makary and other academics who opposed government policies. “Now he really is the establishment. Everything that happens is going to be his responsibility.”

At his confirmation hearing, Makary sounded a lower-key tone, extolling the FDA’s professional staff and promising to apply good science and common sense in the service of attacking chronic disease in the U.S., including by studying food additives and chemicals that could be contributing to poor health.

“We need more humility in the medical establishment. You have to be willing to evolve your position as new data comes in,” he testified. What makes a great doctor “is not how much you know; it’s your humility and your willingness to learn, as you go, from patients.”

Colleagues have applauded Makary’s skill and intelligence as a surgeon and medical policy thinker. He contributed to a 2009 surgery checklist believed to have prevented thousands of mistakes and infections in operating rooms. He wrote a widely cited 2016 paper claiming that medical errors were the third-leading cause of death in the United States, although some researchers said the assertion was overblown. He’s also founded or been a director for companies and said in the hearing that a surgical technique he invented eventually could help cure diabetes.

Humility, however, has not been Makary’s most obvious trait.

During the pandemic, he took to op-eds and conservative media with controversial positions on public health policy. Some proved astute, while others look less prescient in hindsight.

In December 2020, Makary defied established scientific knowledge and said that vaccination of 20% of the population would be enough to create “herd immunity.” In a February 2021 Wall Street Journal piece, he predicted that covid would virtually disappear by April because so many people would have become immune through infection or vaccination. The U.S. death toll from covid stood at 560,000 that April, with an additional 650,000 deaths to come. In June 2021, he said he had been unable to find evidence of a single covid death of a previously healthy child. By then there were many reports of such deaths, although children were much less likely than older people to suffer severe disease.

In February 2023, Makary testified in Congress that the lab-leak theory of covid’s origin was a “no brainer,” a surprisingly unequivocal statement for a scientist discussing a scientifically unresolved issue.

Some public health officials felt Makary gratuitously attacked authorities working in difficult circumstances.

“He went from being a pretty reasonable person to saying a lot of things that were over the top and unnecessary,” said Ashish Jha, dean of the Brown University School of Public Health, who was the White House covid-19 response coordinator under President Joe Biden.

And while almost everyone involved in fighting covid has admitted to getting things wrong during the pandemic, Jha said, “I never had any sense from Marty that he did.”

Makary did not respond to requests for comment.

Makary accused Biden administration officials of ignoring emerging evidence that previous infection with covid could be as or more effective against future infection than vaccination. While he was probably right, Nuzzo said, his statements seemed to encourage people to get infected.

“It’s reasonable to say that vaccine mandates weren’t the right approach,” she said. “But you can also understand that people were trying to blindly stumble our way out of the situation, and some people thought vaccine mandates would be expedient.”

At Johns Hopkins, for example, Nuzzo opposed a booster mandate for the campus in 2022 but understood the final decision to require it. School authorities were intent on bringing students back to campus and worried that outbreaks would force them to shut down again, she said.

“You can argue that seat belt laws are bad because they impinge on civil rights,” Howard said. “But a better thing to do would be to urge people to wear seat belts.”

Makary’s statements had “no grace,” he said. “These were people dealing with an overwhelming virus, and he constantly accused them of lying.”

Several public health officials were particularly upset by the way Makary cast aspersions on the Centers for Disease Control and Prevention’s vaccine safety program. In a Jan. 16, 2023, appearance on Tucker Carlson’s Fox News show, Makary said the CDC had “tried to quickly downplay” evidence of an increased risk of stroke in Medicare beneficiaries who got a covid booster. In fact, the CDC had detected a potential signal for additional strokes in one database, and in the interest of transparency it released that information, Nuzzo said. Further investigation found that there was no actual risk.

During Thursday’s hearing, Makary’s pandemic views were mostly left unexplored, but Democratic and Republican senators repeatedly probed for his views on the abortion drug mifepristone, which became easier to use without direct medical supervision because of a 2021 FDA ruling. Many Republicans want to reverse the FDA ruling; Democrats say there are reams of evidence that support the drug’s safety when taken by a woman at home.

Makary tried to satisfy both parties. He told Sen. Maggie Hassan (D-N.H.) he would be led by science and had no preconceived ideas about mifepristone’s safety. Questioned by Republican Bill Cassidy, chair of the Health, Education, Labor and Pensions Committee and an abortion foe, he said he would examine ongoing data on the drug from the FDA’s risk evaluation system, which gathers reports from the field.

The abortion pill question exemplifies the kind of dilemmas Makary will face at the FDA, Jha said.

“He’s going to have to decide whether he listens to the scientists in his administration, or his boss, who often disagrees with science,” he said. “He’s a smart, thoughtful guy and my hope is he’ll find his way through.”

“The two most important organs for the FDA commissioner are the brain and the spine,” said former FDA deputy commissioner Joshua Sharfstein. “The spine because there’s attempted influence coming from many directions, not just political but also commercial and from multiple advocacy communities. It’s very important to stand up for the agency’s success.”

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

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

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

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

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HHS OCR impose a $200,000 CMP against Oregon Health & Science University for failure to provide timely access to patient records.

TUSTIN, California — Cynthia Williams está furiosa con los republicanos de la Cámara de Representantes de Estados Unidos que están dispuestos a recortar Medicaid, el programa de salud dirigido por el gobierno para personas de bajos ingresos o con discapacidades.

La residente de Anaheim, de 61 años, cuida de su hija adulta, que es ciega, y de su hermana, una veterana militar con trastorno de estrés postraumático grave y otras afecciones de salud mental. Medi-Cal, la versión estatal de Medicaid, le paga a Williams para que las cuide, y ella depende de ese ingreso, al igual que su hermana y su hija dependen de ella.

“Seamos realistas. No deberíamos tener que estar aquí esta noche”, dijo Williams a una ruidosa multitud de más de 200 personas en una junta comunitaria. “Deberíamos estar en casa, pasando tiempo con nuestros seres queridos y nuestras familias, pero estamos aquí. Y estamos aquí para luchar, porque cuando los políticos intentan quitarnos nuestra atención médica, no tenemos la opción de quedarnos de brazos cruzados y dejar que ocurra”.

La primera semana de marzo, la Cámara de Representantes aprobó un plan presupuestario republicano que podría reducir el gasto de Medicaid en $880.000 millones a lo largo de 10 años.

Un recorte de gastos de esa magnitud tendría un enorme impacto en California, con casi 15 millones de personas (más de un tercio de la población) en Medi-Cal. Más del 60% del presupuesto de $161.000 millones de Medi-Cal proviene de Washington.

Williams estaba entre una docena de proveedores, defensores de pacientes, personas que viven con discapacidades y familiares que se pusieron de pie uno tras otro para contar sus historias. La representante Young Kim, republicana cuyo distrito incluye esta ciudad relativamente rica del condado de Orange, rechazó una invitación para que ella o un miembro del personal asistieran. Pero sus electores le transmitieron su mensaje alto y claro, a ella y a los demás republicanos en el Congreso: no toquen Medicaid.

Josephine Ríos, asistente de enfermería en un centro quirúrgico de Kaiser Permanente en Irvine, dijo que su nieto de 7 años, Elijah, ha recibido tratamientos indispensables a través de Medi-Cal, incluyendo un medicamento de $5.000 al mes que controla sus convulsiones, que pueden ser mortales. Elijah tiene parálisis cerebral y se encuentra entre más del 50% de los niños de California cubiertos por Medi-Cal.

“Recortar Medicaid, Medi-Cal, es como decir que no puede vivir. No puede prosperar. Se quedará en la cama y no hará nada”, dijo Ríos. “¿Quiénes son ellos para juzgar quién vive y quién no?”.

Dos tercios de los californianos de todos los partidos se oponen a los recortes a Medi-Cal, según una nueva encuesta de la California Health Care Foundation y NORC en la Universidad de Chicago.

El foro fue uno de los tres que organizó a fines de febrero “Fight for Our Health”, una coalición de sindicatos y grupos de defensa de la salud, para atacar a los miembros republicanos de la Cámara de Representantes cuyos distritos de California se consideran políticamente competitivos.

Los otros dos se realizarán en Bakersfield, parte de la cual está representada por el representante David Valadao, y Corona, donde vive el representante Ken Calvert. En las últimas semanas, han surgido otros foros y protestas en todo el país.

La coalición ha retomado una campaña (parte de un movimiento nacional más amplio) que luchó contra el intento fallido del Partido Republicano de derogar la Ley de Cuidado de Salud a Bajo Precio (ACA) en 2017.

La pérdida del control de la Cámara por parte de los republicanos en las elecciones de medio término de 2018 se ha atribuido ampliamente a su postura sobre la atención médica. Valadao estuvo entre los miembros del Partido Republicano que perdieron sus escaños en 2018, aunque lo recuperó dos años después.

Aun así, votó a favor de la propuesta presupuestaria de la Cámara a principios de marzo, a pesar de que aproximadamente dos tercios de la población de su distrito está en Medicaid (la cifra más alta del estado) y a pesar de que es uno de los ocho miembros republicanos de la Cámara que enviaron una carta al voceru de la Cámara Mike Johnson advirtiéndole sobre las “graves consecuencias” de los profundos recortes a Medicaid.

La oficina de Valadao no respondió a las solicitudes de comentarios.

Calvert, que ha estado en la Cámara por 32 años y logró la reelección el pasado noviembre, también votó a favor del presupuesto, como Kim. Los nueve miembros republicanos de la delegación del Congreso de California lo apoyaron, al igual que todos los republicanos de la Cámara excepto uno.

Los críticos del plan presupuestario dicen que ayuda a los ricos a expensas de los más vulnerables de la sociedad, un argumento que se repitió vigorosamente en la junta de Tustin. Pero los partidarios del plan dicen que extender los recortes impositivos, cuyas disposiciones clave expirarán a fines de este año, evitaría un gran aumento de impuestos para los estadounidenses promedio y beneficiaría más a las familias de bajos ingresos.

“Las familias estadounidenses se enfrentan a un aumento masivo de impuestos a menos que el Congreso actúe antes de fin de año”, dijo Calvert en una declaración a KFF Health News antes de la votación. Prometió que el Partido Republicano no tocaría la Seguridad Social (Social Security) ni Medicare.

No ofreció garantías similares sobre Medicaid, pero dijo: “No estamos interesados ​​en recortar la red de seguridad social y sanitaria para los niños, los discapacitados y los estadounidenses de bajos ingresos. Estamos centrados en eliminar el despilfarro, el fraude y el abuso”.

El documento que recibió luz verde hace pocos días no especifica detalles sobre los recortes, aunque instruye al Comité de Energía y Comercio, que supervisa el gasto en Medicaid y Medicare, a recortar $880.000 millones, una gran parte de los $2.000 millones en recortes totales.

La angosta mayoría del Partido Republicano significa que Johnson tendrá un camino estrecho para conseguir la aprobación de un presupuesto más detallado. El apoyo republicano, ya sea de los halcones fiscales que quieren recortes más profundos del gasto o de los miembros de la Cámara de Representantes preocupados por recortar Medicaid, podría fluctuar a medida que se definan los detalles.

Además, la Cámara de Representantes debe llegar a un compromiso con el Senado, que ha aprobado una resolución presupuestaria mucho más limitada que, por ahora, deja fuera los grandes recortes de impuestos.

Al igual que Kim, Valadao y Calvert rechazaron las invitaciones para asistir o enviar personal a las reuniones comunitarias en sus regiones. En la reunión de Tustin, varios oradores reprendieron a Kim por su ausencia. En un momento, la gran pantalla detrás del podio mostró una imagen de una silla vacía con las palabras, en letras grandes, “Congresista Kim, le reservamos un asiento”.

La vocera de Kim, Callie Strock, dijo en un correo electrónico que Kim y su personal local tenían compromisos preexistentes esa noche. Agregó que Kim está “comprometida a proteger y fortalecer nuestro sistema de atención médica”.

Pero los asistentes estaban claramente preocupados.

“Es una obligación moral para todos nosotros mirar a las personas más desfavorecidas de nuestro país y cuidarlas bien”, dijo Beth Martinko, cuyo hijo de 33 años, Josh, tiene autismo y depende de Medi-Cal para su atención. “Esto no tiene lugar en la política”.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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A dozen people seated around folding tables clap heartily for a beaming woman: She’s donated two 13-gallon garbage bags full of clothes, including several Christmas sweaters and a couple of pantsuits, to a Presbyterian church.

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

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

These unsafe conditions can also lead to strained relationships.

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

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

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

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

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

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

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

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

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

Clutter Catches Up to Baby Boomers

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

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

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

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

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

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

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

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

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

Health Hazards of Hoarding

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

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

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

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

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

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

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

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

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

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

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

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

Lack of Treatment Leaves Few Options

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

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

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

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

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

Could Changes to Federal Policy Help?

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

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

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

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

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

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

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

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

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

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

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

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

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TUSTIN, Calif. — Cynthia Williams is furious with U.S. House Republicans willing to slash Medicaid, the government-run insurance program for people with low incomes or disabilities.

The 61-year-old Anaheim resident cares for her adult daughter, who is blind, and for her sister, a military veteran with severe post-traumatic stress disorder and other mental health conditions. Medi-Cal, the state’s version of Medicaid, pays Williams to care for them, and she relies on that income, just as her sister and daughter depend on her.

“Let’s be real. We shouldn’t have to be here tonight,” Williams told a raucous standing-room crowd of over 200 people at a recent town hall. “We should be home, spending time with our loved ones and our families, but we’re here. And we’re here to fight, because when politicians try to take away our health care, we don’t have the option to sit back and let it happen.”

The House last week approved a Republican budget plan that could shrink Medicaid spending by $880 billion over 10 years, only partially paying for an extension of expiring tax cuts from President Donald Trump’s first term, plus some new ones he has promised, totaling as much as $4.5 trillion.

A spending cut of that magnitude would have a huge impact in California, with nearly 15 million people — more than a third of the population — on Medi-Cal. Over 60% of Medi-Cal’s $161 billion budget comes from Washington.

Williams was among about a dozen providers, patient advocates, disabled people, and family members who stood up one after the other to tell their stories. Rep. Young Kim, a Republican whose district includes this relatively affluent Orange County city, declined an invitation for her or a staff member to attend. But her constituents delivered their message loud and clear to her and the other Republicans in Congress: Hands off Medicaid.

Josephine Rios, a certified nursing assistant at a Kaiser Permanente surgical center in Irvine, said her 7-year-old grandson, Elijah, has received indispensable treatments through Medi-Cal, including a $5,000-a-month medication that controls his seizures, which can be life-threatening. Elijah, who has cerebral palsy, is among the more than 50% of California children covered by Medi-Cal.

“To cut Medicaid, Medi-Cal, that’s like saying he can’t live. He can’t thrive. He’s going to lie in bed and do nothing,” Rios said. “Who are they to judge who lives and who doesn’t?”

Two thirds of Californians across party lines oppose cuts to Medi-Cal, according to a new survey by the California Health Care Foundation and NORC at the University of Chicago.

The town hall here was one of three organized late last month by “Fight for Our Health,” a coalition of health advocacy groups and unions, to target Republican House members whose California districts are considered politically competitive. The other two were in Bakersfield, part of which is represented by Rep. David Valadao, and Corona, home to Rep. Ken Calvert. Multiple other town halls and protests have sprung up across the country in recent weeks.

The coalition has reprised a campaign — part of a broader national movement — that fought against the GOP’s unsuccessful 2017 effort to repeal the Affordable Care Act.

The Republicans’ loss of House control in the 2018 midterm elections has been widely attributed to their stance on health care. Valadao was among the GOP members who lost their seats in 2018, though he took his back two years later.

Still, he voted for the House budget proposal last week, despite the fact that about two-thirds of the population in his district is on Medicaid — the highest in the state — and even though he is one of eight GOP House members who sent a letter to Speaker Mike Johnson warning about the “serious consequences” of deep cuts to Medicaid. Valadao’s office did not respond to requests for comment.

Calvert, who’s been in the House for 32 years and eked out reelection last November, also voted for the budget, as did Kim. All nine GOP members of California’s congressional delegation supported it, as did all House Republicans except one.

Critics of the budget plan say it helps the rich at the expense of society’s most vulnerable — an argument that was vigorously repeated at the Tustin town hall. But supporters of the plan say that extending the tax cuts, key provisions of which are set to expire at the end of this year, would avoid a large tax hike for average Americans and benefit low-income families the most.

“American families are facing a massive tax increase unless Congress acts by the end of the year,” Calvert said in a statement to KFF Health News before the vote. He vowed the GOP would not touch Social Security or Medicare. He did not offer similar assurances on Medicaid, but said, “We are not interested in cutting the social and healthcare safety net for children, disabled, and low-income Americans. We are focused on eliminating waste, fraud, and abuse.”

The document greenlit last Tuesday does not specify spending cut details, though it instructs the Energy and Commerce Committee, which oversees Medicaid and Medicare spending, to cut $880 billion — a large chunk of the up to $2 trillion in total cuts. The GOP’s razor-thin majority means Johnson will have a narrow path to get a more detailed budget passed. Republican support, whether from fiscal hawks who want deeper spending cuts or House members worried about slashing Medicaid, could ebb and flow as the details are hashed out.

Moreover, the House must reach a compromise with the Senate, which has passed a much narrower budget resolution that leaves the big tax cuts out for now.

Like Kim, Valadao and Calvert declined invitations to attend or send staffers to the town hall meetings in their regions. At the Tustin meeting, multiple speakers chided Kim for her absence. At one point, the large screen behind the podium flashed a picture of an empty chair with the words, in large block letters, “Congresswoman Kim, we saved you a seat.”

Kim spokesperson Callie Strock said in an email that Kim and her local staff had preexisting commitments that night. She added that Kim is “committed to protecting and strengthening our health care system.”

But those in attendance were clearly worried.

“It’s a moral obligation for all of us to look at the most disadvantaged people in our country and take good care of them,” said Beth Martinko, whose 33-year-old son, Josh, has autism and relies on Medi-Cal for his care. “This has no place in politics.”

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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More than three years ago, health insurance giant Centene Corp. settled allegations that it overcharged Medicaid programs in Ohio and Mississippi related to prescription drug billing.

Now at least 20 states have settled with Centene over its pharmacy benefit manager operation that coordinated the medications for Medicaid patients. Arizona was among the most recent to join the ranks, settling for an undisclosed payout, Richie Taylor, a spokesperson for the state’s attorney general, told KFF Health News in December.

All told, Centene has agreed to pay more than $1 billion in settlements, according to Cohen Milstein, one of the law firms representing states in the agreements. Meanwhile, St. Louis-based Centene reported $163 billion in revenue in 2024, largely proceeds from government health programs for Medicaid, Medicare, and the Affordable Care Act. The health care company has admitted no wrongdoing in the settlements.

Two state holdouts appear to remain: Georgia has yet to settle with Centene, even though the administration of Gov. Brian Kemp hired law firm Liston & Deas in 2019 to investigate state pharmacy benefit operations.

Florida hired the same law firm in 2021 to pursue overbilling allegations involving Centene, but state officials declined to answer a reporter’s questions about whether Florida has dropped the case, reached an undisclosed settlement, or is still discussing the issue.

Neither state has publicly disclosed what’s standing in the way of potentially tens of millions of dollars in Centene payouts, or whether negotiations are taking place. Because the deals are largely occurring outside the court system, the process between the private law firms hired by states and Centene remains generally out of public view.

Centene spokespeople did not return multiple phone calls and emails asking for updates. In 2022, the company said it was working on settlements with Georgia and eight other states, having reached deals with 13 others. And in a Securities and Exchange Commission filing in October, Centene said it had reached settlements with “the vast majority of states impacted” over the operations of its former pharmacy benefits manager.

Georgia has “taken disproportionately long compared to other states,” said Greg Reybold, a vice president of the American Pharmacy Cooperative, which represents independent pharmacies.

Meanwhile, Centene’s Georgia Medicaid plan, the Peach State Health Plan, lost its bid last year to continue its longtime participation in a Georgia Medicaid program in which companies cover the care for Medicaid recipients for a set fee from the government rather than for each medical service provided. The company, which has been part of the contract since the managed-care program began in 2006, filed a protest over the contract awards, saying that the process was “mismanaged, rife with errors and reckless practices.”

Nationally, pharmacy benefit managers, or PBMs, have come under increased scrutiny over accusations of pocketing discounts on medications or inflating costs in the years since Centene started settling its Medicaid-related allegations. Members of Congress have proposed major policy constraints on PBMs. Centene has since overhauled its PBM operation.

Still, a possible settlement in Georgia could bring in significant money to the state. California had the largest publicly disclosed settlement at $215 million, split with the federal government, but a settlement with Georgia could be in the range of the $88 million that Centene agreed to pay in the Ohio dispute, Reybold said.

The state should aggressively pursue a settlement with Centene, said Roland Behm, co-founder of the Georgia Mental Health Policy Partnership, who is a critic of Centene and its Georgia Medicaid plan. Behm said state Attorney General Chris Carr should take “the same tenacious prosecutorial action” against Centene that Carr’s agency takes against individuals involved in fraud against Medicaid, the federal-state program that provides health insurance coverage for those with low incomes or disabilities.

Carr’s office said in 2022 that it stood ready to represent Georgia in settlement negotiations with Centene. Carr, a Republican who has announced he’s running for governor in 2026, received tens of thousands of dollars in campaign contributions from Centene, its subsidiaries, and its executives, as did Kemp, a fellow Republican, KFF Health News reported in 2022. Contributions to the Kemp and Carr campaigns were part of more than $26.9 million that Centene, its subsidiaries, its top executives, and their spouses donated to state politicians in 33 states, to their political parties, and to nonprofit fundraising groups from 2015 through 2022.

Since 2022, the company and its political action committee have contributed, combined, at least $2 million more to the campaigns of Florida and Georgia candidates of both political parties, along with state party organizations and political committees, according to state campaign finance records.

When asked about a possible settlement, a spokesperson for Carr, Kara Murray, directed a reporter to the Georgia Department of Community Health, which administers Medicaid.

Fiona Roberts, a spokesperson for that agency, then told KFF Health News that the department “is actively pursuing options to ensure regulatory compliance with the state’s contract.” She declined to comment further.

Florida’s attorney general’s office directed a reporter to the state agency that oversees Medicaid, the Florida Agency for Health Care Administration. But that agency did not respond to multiple phone calls and emails requesting comment.

Rebecca Grapevine of Healthbeat contributed to this article.

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 Trump administration’s sudden firing of Centers for Disease Control and Prevention employees gutted training programs across the nation whose participants bolstered the workforce of state and local public health departments that for decades have been starved of resources.

The programs are designed to cultivate a new generation of public health leaders, many of whom have gone on to work at the CDC. That was far from its only purpose. Local and state officials said the departures threaten to undermine the nation’s constant effort to identify and control infectious disease outbreaks.

The terminated CDC employees helped prevent and respond to outbreaks such as dengue fever and the flu. They worked with local officials to quickly test for viruses and ensure that testing in public health labs complies with federal regulations. Others monitored potential cases of tuberculosis or provided health education to adolescents to prevent sexually transmitted infections, according to interviews with fired workers and local public health officials.

As a CDC public health adviser, Gaël Cruanes had been working at New York City’s Department of Health and Mental Hygiene to detect cases of tuberculosis, a serious illness that spreads through the air and usually attacks the lungs.

The Public Health Associate Program deploys recent college graduates and other early-career workers for two years. After starting his job in October, Cruanes said, he contacted newly arrived immigrants and refugees potentially at risk of spreading TB in hopes of getting them into the city’s clinics for screening.

“It’s purely for the safety of the public at the end of the day,” Cruanes said. He and other trainees were fired in mid-February.

“It’s unconscionable,” he said.

A spokesperson for the Department of Health and Human Services, Andrew Nixon, declined to comment. The White House and CDC didn’t respond to requests for comment.

The Trump administration’s swift staff reductions in February targeted probationary employees, many hired in the past two years, who lack civil service protections against firings. The administration on Feb. 26 ordered federal agencies to submit plans by mid-March for large-scale layoffs, a move that could encompass a much broader swath of workers.

After CNN published this article, at least some fired CDC workers in the training programs were notified on March 4 that their terminations had been rescinded.

Affected employees were cleared to work on March 5, according to emails viewed by KFF Health News. “You should return to duty under your previous work schedule. We apologize for any disruption that this may have caused,” said the emails, which were unsigned and sent from an internal CDC email address.

The reversal came less than a week after a federal judge ruled that the Trump administration’s widespread terminations of probationary employees were likely illegal.

Seven CDC employees — including from the associate program — assigned to the New York City health department were originally terminated, Michelle Morse, the agency’s acting commissioner, testified during a City Council hearing Feb. 19.

In an interview, Morse said the health department was exploring how to retain them.

“We’re looking into what the CDC could do,” she said, “but we are really just trying to use our own levers that we have within the health department to see what’s possible for those staff.”

Since its creation in 2007, the Public Health Associate Program has placed 1,800 people in nearly every state and territory, plus the District of Columbia, according to the CDC.

The sudden firings meant “there was no lead time to try to figure out what we’re going to do,” said Anissa Davis, the city health officer at the Long Beach Department of Health and Human Services in California.

Three participants of the associate program worked at the Long Beach department, Davis said. A CDC public health adviser was one of four employees working on sexually transmitted infections and HIV surveillance. Two others were with the 13-person communicable disease control team, which includes staff who respond to outbreaks in nursing homes, hospitals, restaurants, and schools, Davis said.

“They are invaluable,” Davis said. “Public health is always under-resourced so having these people really helps us.”

The U.S. public health system was already under severe strain at the onset of the covid-19 pandemic — tens of thousands of jobs disappeared after the 2007-09 recession hit, and spending also dropped significantly for state and local health departments, according to a KFF Health News investigation. The backlash against pandemic-era restrictions drove many more officials to resign or retire. Others were fired. Still, officials said the pandemic also inspired some to pursue public health careers.

Scientists in the CDC’s Laboratory Leadership Service program were also fired in February. The CDC in 2015 started the two-year training fellowship to improve lab safety and quality following a series of failures, including in 2014 when CDC staff in Atlanta were potentially exposed to anthrax. The program each year recruits a small number of doctorate-level scientists; several work in state or local health departments.

At least 16 of 24 fellows in the program were fired in mid-February, according to two scientists who were terminated and spoke on the condition of anonymity for fear of professional retaliation. “Now we can’t be a resource for these labs anymore,” one of them said.

Public health labs need the CDC scientists “because they’re underfunded, understaffed,” the other said. “They are at their capacity already.”

Lab fellows’ responsibilities included helping with outbreak investigations and responses, including by training local staff on how to safely run tests or analyzing samples to identify the cause of an illness. Fellows were recently involved in setting up a new test in Florida to detect Oropouche, a relatively unknown insect-borne disease that has no vaccine or effective treatment. The World Health Organization in December said more than 11,600 cases had been reported in 2024 in South America, the Caribbean, the U.S., Europe, Canada, and Panama. The Florida Department of Health didn’t respond to a request for comment.

Fellows also helped develop the capacity to test for dengue fever in American Samoa, one of them said.

“When new stuff happens that’s urgent, it’s almost all the time we get pivoted to it,” the person said.

Participants in different training programs received the same form letter notifying them of their terminations, according to documents viewed by KFF Health News.

The letters said that terminated people had shown poor performance: “Unfortunately, the Agency finds that you are not fit for continued employment because your ability, knowledge and skills do not fit the Agency’s current needs, and your performance has not been adequate to justify further employment at the Agency.”

However, the fellows’ supervisors had written memos and emails saying they were in good standing, according to documents viewed by KFF Health News. Cruanes said he had not had a performance evaluation when he was terminated — his first was supposed to be Feb. 18, three days after he received his notice. He was among the CDC staff reinstated on March 4.

In Minneapolis, a CDC public health adviser had been providing sexual and reproductive health education in two high schools, as well as doing citywide work on STI testing, said Barbara Kyle, the city’s school-based clinic manager. The department was trying to shift those responsibilities to remaining personnel. “We’re right now just scrambling,” she said.

The city has relied on trainees through the CDC program for more than a decade, Kyle said.

“These two years of learning public health, on-the-ground experience, has really been such a positive move for our country,” she said. “So that concerns me if we lose that pipeline.”

Healthbeat reporter Eliza Fawcett contributed to this report from New York City.

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

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

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