After Health and Human Services Secretary Robert F. Kennedy Jr. fired Centers for Disease Control and Prevention Director Susan Monarez for refusing what her lawyers called “,” Newsom to help modernize California’s public health system. He also gave a job to Debra Houry, the agency’s former chief science and medical officer, who had resigned in protest hours after Monarez’s firing.

Newsom also teamed up with fellow Democratic governors Tina Kotek of Oregon, Bob Ferguson of Washington, and Josh Green of Hawaii to form the , a regional public health agency, whose guidance would “uphold scientific integrity in public health as Trump destroys” the CDC’s credibility. Newsom argued establishing the independent alliance was vital as Kennedy leads the Trump administration’s rollback of national vaccine recommendations.

More recently, California became the a global outbreak response network coordinated by the World Health Organization, followed by Illinois and New York. Colorado and Wisconsin signaled they plan to join. They did so after President Donald Trump officially from the agency on the grounds that it had “strayed from its core mission and has acted contrary to the U.S. interests in protecting the U.S. public on multiple occasions.” Newsom said joining the WHO-led consortium would enable California to respond faster to communicable disease outbreaks and other public health threats.

Although other Democratic governors and public health leaders have openly criticized the federal government, few have been as outspoken as Newsom, who is considering a run for president in 2028 and is in his second and final term as governor. Members of the scientific community have praised his effort to build a public health bulwark against the Trump administration’s slashing of funding and scaling back of vaccine recommendations.

What Newsom is doing “is a great idea,” said Paul Offit, an outspoken critic of Kennedy and a vaccine expert who formerly served on the Food and Drug Administration’s vaccine advisory committee but was removed under Trump in 2025.

“Public health has been turned on its head,” Offit said. “We have an anti-vaccine activist and science denialist as the head of U.S. Health and Human Services. It’s dangerous.”

The White House did not respond to questions about Newsom’s stance and HHS declined requests to interview Kennedy. Instead, federal health officials criticized Democrats broadly, arguing that blue states are participating in fraud and mismanagement of federal funds in public health programs.

HHS spokesperson Emily Hilliard said the administration is going after “Democrat-run states that pushed unscientific lockdowns, toddler mask mandates, and draconian vaccine passports during the covid era.” She said those moves have “completely eroded the American people’s trust in public health agencies.”

Public Health Guided by Science

Since Trump returned to office, Newsom has criticized the president and his administration for engineering policies that he sees as an affront to public health and safety, labeling federal leaders as “extremists” trying to “weaponize the CDC and spread misinformation.” He has for erroneously linking vaccines to autism, the administration is endangering the lives of infants and young children in scaling back childhood vaccine recommendations. And he argued that the White House is unleashing “chaos” on America’s public health system in backing out of the WHO.

The governor declined an interview request. Newsom spokesperson Marissa Saldivar said it’s a priority of the governor “to protect public health and provide communities with guidance rooted in science and evidence, not politics and conspiracies.”

The Trump administration’s moves have triggered financial uncertainty that local officials said has reduced morale within public health departments and left states unprepared for disease outbreaks and . The White House last year proposed cutting HHS spending , including . Congress largely rejected those cuts last month, although funding for programs focusing on social drivers of health, such as access to food, housing, and education, .

The Trump administration announced that it would claw back in public health funds from California, Colorado, Illinois, and Minnesota, arguing that the Democratic-led states were funding “woke” initiatives that didn’t reflect White House priorities. Within days, and a judge the cut.

“They keep suddenly canceling grants and then it gets overturned in court,” said Kat DeBurgh, executive director of the Health Officers Association of California. “A lot of the damage is already done because counties already stopped doing the work.”

Federal funding has accounted for of state and local health department budgets nationwide, with money going toward fighting HIV and other sexually transmitted infections, preventing chronic diseases, and boosting public health preparedness and communicable disease response, according to a 2025 analysis by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Federal funds account for $2.4 billion of California’s $5.3 billion public health budget, making it difficult for Newsom and state lawmakers to backfill potential cuts. That money helps fund state operations and is vital for local health departments.

Funding Cuts Hurt All

Los Angeles County public health director Barbara Ferrer said if the federal government is allowed to cut that $600 million, the county of nearly 10 million residents would lose an estimated $84 million over the next two years, in addition to other grants for prevention of HIV and other sexually transmitted infections. Ferrer said the county depends on nearly $1 billion in federal funding annually to track and prevent communicable diseases and combat chronic health conditions, including diabetes and high blood pressure. Already, the the closure of that provided vaccinations and disease testing, largely because of funding losses tied to federal grant cuts.

“It’s an ill-informed strategy,” Ferrer said. “Public health doesn’t care whether your political affiliation is Republican or Democrat. It doesn’t care about your immigration status or sexual orientation. Public health has to be available for everyone.”

A single case of measles requires public health workers to track down 200 potential contacts, Ferrer said.

The U.S. but is close to losing that status as a result of vaccine skepticism and misinformation spread by vaccine critics. The U.S. had , the most since 1991, with 93% in people who were unvaccinated or whose vaccination status was unknown. This year, the highly contagious disease has been reported at , , and .

Public health officials hope the West Coast Health Alliance can help counteract Trump by building trust through evidence-based public health guidance.

“What we’re seeing from the federal government is partisan politics at its worst and retaliation for policy differences, and it puts at extraordinary risk the health and well-being of the American people,” said Georges Benjamin, executive director of the American Public Health Association, a coalition of public health professionals.

Robust Vaccine Schedule

Erica Pan, California’s top public health officer and director of the state Department of Public Health, said the West Coast Health Alliance is defending science by recommending a vaccine schedule than the federal government. California is part of a coalition over its decision to rescind recommendations for seven childhood vaccines, including for hepatitis A, hepatitis B, influenza, and covid-19.

Pan expressed deep concern about the state of public health, particularly the uptick in measles. “We’re sliding backwards,” Pan said of immunizations.

Sarah Kemble, Hawaii’s state epidemiologist, said Hawaii joined the alliance after hearing from pro-vaccine residents who wanted assurance that they would have access to vaccines.

“We were getting a lot of questions and anxiety from people who did understand science-based recommendations but were wondering, ‘Am I still going to be able to go get my shot?’” Kemble said.

Other states led mostly by Democrats have also formed alliances, with Pennsylvania, New York, New Jersey, Massachusetts, and several other East Coast states banding together to create the .

HHS’ Hilliard said that even as Democratic governors establish vaccine advisory coalitions, the federal “remains the scientific body guiding immunization recommendations in this country, and HHS will ensure policy is based on rigorous evidence and gold standard science, not the failed politics of the pandemic.”

Influencing Red States

Newsom, for his part, has approved a recurring annual infusion of nearly $300 million to support the state Department of Public Health, as well as the 61 local public health agencies across California, and last year authorizing the state to issue its own immunization guidance. It requires health insurers in California to provide patient coverage for vaccinations the state recommends even if the federal government doesn’t.

Jeffrey Singer, a doctor and senior fellow at the libertarian Cato Institute, said decentralization can be beneficial. That’s because local media campaigns that reflect different political ideologies and community priorities may have a better chance of influencing the public.

A KFF analysis found some red states are joining blue states in decoupling their vaccine recommendations from the federal government’s. Singer said some doctors in his home state of Arizona are looking to more liberal California for vaccine recommendations.

“Science is never settled, and there are a lot of areas of this country where there are differences of opinion,” Singer said. “This can help us challenge our assumptions and learn.”

This <a target="_blank" href="/public-health/gavin-newsom-california-public-health-fight-west-coast-alliance-trump-hhs-rfk/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

LISTEN: In this audio portrait of homeless people displaced by the Trump administration’s crackdown on encampments in the nation’s capital, ºÚÁϳԹÏÍø News senior correspondent Angela Hart tells of residents living outside this winter and their search for medical care and shelter.

January’s extreme cold has put a spotlight on the conditions homeless people face. They get sicker and die younger than housed people, often because health problems go untreated. The Trump administration’s removal of homeless tent encampments in Washington, D.C., has made it more difficult for health workers to reach that vulnerable population this winter.

ºÚÁϳԹÏÍø News senior correspondent Angela Hart takes WAMU “Health Hub” listeners to Washington’s streets to hear how homeless people are juggling their health and shelter after the Trump administration’s crackdown.

This <a target="_blank" href="/public-health/homeless-crackdown-washington-dc-wamu-health-hub-winter-listen/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

“Police want us out of the way,” he said, dressed in a gray jacket and carrying none of his possessions. “Out of sight, out of mind.”

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no ‘MR. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is — he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, ‘We don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

This <a target="_blank" href="/mental-health/washington-dc-homelessness-crackdown-hiding-plain-sight-street-medicine/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Democratic Gov. Gavin Newsom and state lawmakers have tried to bolster the state’s health care workforce, in part by implementing recommendations from the California Future Health Workforce Commission, a 24-member panel of state, labor, academic, and industry representatives. The state in recent years has expanded the for nurse practitioners, allowing them to practice medicine — ordering tests and prescribing medication, for instance — without traditional doctor supervision, and has academic nursing slots and training programs.

Still, California’s shortage of registered nurses is expected to grow from 3.7% in 2024 to 16.7% by 2033, or more than 61,000 nurses, due to inadequate recruitment, training, and retention, according to Kathryn Phillips, associate director of the Improving Access team at the California Health Care Foundation, a nonprofit philanthropic organization specializing in health care research and education.

Regional shortages, particularly in the Central Valley and rural North, are expected to swell. “There are major deficits and those could get even worse,” Phillips said.

Researchers say the gap between nursing supply and demand is exacerbated by inadequate career pathways and high turnover in a labor-intensive industry, but nurses and argue the problem is driven primarily by a management-induced and poor working conditions. Nurses say nursing remains a noble calling, but many report feeling pressured to turn over beds and take on more patients, stress that can dissuade young people from entering the field and drive experienced nurses to .

Industry representatives cast those concerns as union talking points to drive up labor costs, but nurses say they are losing benefits while being overworked, hobbling morale and hampering their ability to provide even basic health care in hospitals, clinics, and nursing homes around the state.

Lorena Burkett, a registered nurse at Emanuel Medical Center in Turlock, an agricultural city in the heart of the Central Valley, recounted being so overloaded last year that she didn’t promptly log a medical chart after administering a psychiatric patient’s medication, a critical step for ensuring proper drug doses.

“I was being told get him out, and I forgot to scan his opioid medication; I missed it,” said Burkett, a 12-year veteran, who later updated the patient’s record. “After that I said no more. We have to prioritize patient care, but we are under a lot of pressure to get patients out and turn profits.”

Tenet Healthcare, the Dallas-based for-profit hospital system that owns Emanuel, declined to respond to Burkett’s claim, as well as questions about staffing levels. In a statement, Tenet spokesperson Rob Dyer said that the hospital provides “quality and compassionate care” and broadly disputed nurses’ concerns.

“We are currently in contract negotiations with the union which represents our nurses,” he said, “and suspect that this is what is behind these false claims.”

Improving Conditions for Nurses

Two years ago, state lawmakers approved to help hospitals maintain operations, which can include retaining nurses. Lawmakers are also trying to improve nurses’ work conditions in hospitals and to protect patient care by at health care facilities. Some also call for investing in a more robust nursing workforce.

“Nurses are working in hospitals and other places that are severely understaffed,” said Michelle Mahon, director of nursing practice for National Nurses United, a union that represents 225,000 nurses.

Phillips said the reasons vary. In the San Francisco Bay Area, nurses must contend with a high cost of living, a lack of affordable housing, and expensive child care. In the Central Valley, there’s insufficient education, training, and mentoring. And the rural North has a hard time attracting enough nurses to replace those who are retiring and to meet the needs of an aging population.

University of California-San Francisco researchers who have say although people are still seeking jobs in nursing, student enrollments and graduations have declined.

The California Board of Registered Nursing shows nearly 552,000 active licensed registered nurses in California as of Oct. 1. Yet the California Nurses Association says significantly fewer were practicing, pointing to 2024 data indicating only 350,850 were working in the field. The same problem persists nationally, according to National Nurses United, which reported that, as of May 2024, licensed nurses were not working in the field.

California Hospital Association spokesperson Jan Emerson-Shea said hospitals around the state are facing “skyrocketing costs” for labor, pharmaceuticals, medical equipment, and compliance with government mandates. Patient care costs have soared 30% in the past five years and continue to rise, she said. Meanwhile, 53% of hospitals in the state “lose money every day caring for patients,” she said.

And it could get worse.

Under the GOP tax-and-spending bill that President Donald Trump called the “One Big Beautiful Bill,” the state estimates roughly Californians could lose health coverage due in part to major Medicaid cuts and new rules like work requirements that narrow eligibility for low-income and disabled residents. California is at risk of losing in annual funding, and hospitals will be hit particularly hard because they rely on federal reimbursements and need enough insured patients to remain solvent.

Emerson-Shea said California hospitals stand to lose up to $128 billion over 10 years due to the law.

“This projection does not include the likely increases in uncompensated care due to Medicaid work requirements, coverage losses due to the elimination of the Affordable Care Act subsidies, more frequent Medi-Cal redeterminations, and coverage losses for those with unsatisfactory immigration status,” Emerson-Shea said.

While some California hospitals lose money on patient care, financial data shows the industry is making money, earning about $11.5 billion in net income, or profit, in 2024, said Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, pointing to preliminary state data comparing 365 hospitals. “The industry as a whole has returned to pre-covid profitability levels,” Stremikis said.

He acknowledged, though, that Medicaid cuts will reduce revenue for all facilities.

Hospitals will be burdened as uninsured patients, who often arrive with prolonged illness or injuries that can make treatment more expensive, increase in number. That will exacerbate health care challenges in high-poverty communities with large Medi-Cal populations, since the safety net program generally pays hospitals and providers less than private insurance or Medicare.

Already, some hospitals are closing due to financial struggles, before the impacts of the federal health care cuts are felt, and others are limiting access to care, including by shuttering maternity wards and emergency rooms. Officials at Glenn Medical Center, about 85 miles north of Sacramento, reported that it would be its ER at the due to staffing shortages.

Pandemic-Era Burnout Persists

Front-line nurses said the well-documented from the covid-19 pandemic, mixed with growing hospital demands, is still being felt today as many part ways with the industry. That is prompting some hospitals to hire more traveling nurses from out of state.

At Hazel Hawkins Memorial Hospital, a public facility in San Benito County near the Central Coast, the California Nurses Association said the hospital is employing 22 traveling nurses, although the hospital put the number at 16. Local nurses said temporary workers can ease workloads, but they worry hospitals are using traveling nurses to avoid labor contracts that require higher pay and benefits. They say hospitals should invest in well-trained, local staff familiar with the community.

ER nurse Ariahnna Sanchez said workers at Hazel Hawkins, a , are pressured to discharge patients quickly so more patients can be seen. As union contracts come up for renegotiation, union officials say, hospitals have slashed benefits and haven’t offered adequate raises to keep up with the cost of living. Salaries vary by region but the average annual wage for California registered nurses was $148,330 in 2024, according to the U.S. Bureau of Labor Statistics.

“The morale is so bad right now,” Sanchez said. “We’re trying to fight the good fight but we’re constantly holding people in the emergency room who should be admitted due to the hospital being at max capacity.”

State data shows San Benito County has an of nurses and needs about 180 more to accommodate the local population. But Hazel Hawkins disputes it has a shortage. The California Nurses Association said 40 nurses have left since last year, whereas the hospital said it has replaced 15 of 21 departing nurses.

Hazel Hawkins spokesperson Marcus Young said nurses are conflating staffing levels with protocols for handling ER patients when there aren’t enough beds. “There is no material shortage of nurses and hospital operations are not being impacted today,” Young said. “We are in full compliance with state-mandated nurse-to-patient ratios at all times.”

staffing minimums at hospitals, ranging from one nurse for every three patients to one nurse for every five patients, depending on the level of care the patients require. Research has shown that clinical errors can increase in hospitals and other health care workplaces when nurses are stressed and overwhelmed. that burnout related to work overload, career satisfaction, and patient satisfaction is a major concern and can lead to mistakes.

The state has issued 32 citations to California hospitals since 2020 for violating these minimum nurse staffing levels, financial penalties totaling $840,000, according to the . Neither Hazel Hawkins nor the Turlock hospital Emanuel had any citations. Spokesperson Mark Smith said the agency could not provide information on any “potential, pending or ongoing investigations” into health care facilities alleged to be in violation of state nursing ratios.

Burkett, the nurse in Turlock, said though she can see up to five patients at a time, she exceeded her ratio twice in the past year. In its , Tenet reported $288 million in net income, up from $259 million over the same period last year.

“I’ve taken that assignment against my will,” Burkett said, noting that the union distributes forms protecting nurses from repercussions if mistakes happen on their watch when they take on more patients than the state allows. “It says I’m taking these patients against my better judgment and I’m protected because I am not agreeing to this, but the hospital is making me do it,” she added. “It’s tough. I mean, you just have to juggle and do what you can and hope you’re not going to miss something important. It’s not safe.”

State Sen. Caroline Menjivar, a Democrat representing part of the Los Angeles region, has to strengthen the state’s nurse-to-patient ratio law by requiring hospitals to work harder to identify available nurses to meet staffing mandates.

“Hospitals for years have been getting a pass on minimum nurse staffing,” said Menjivar, a former emergency medical technician. “If we do not provide more support to our nurses, then we do not get the quality care that is needed.”

Menjivar’s niece Megan Noguera-DeLeon is excited about becoming a nurse, despite workplace challenges. A nursing student who expects to graduate next year from West Coast University in Southern California, she said relatives who work as nurses have warned her how tough the job can be. She’s worried about burning out but remains committed to the mission.

“I think taking care of people is a beautiful thing,” Noguera-DeLeon said. “I know this job can be really hard and a lot of nurses are experiencing burnout, but honestly I’ve seen firsthand how much nurses can help people even on the darkest of days, and I want to help people.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/health-industry/california-nursing-shortage-medicaid-funding-management-profit-unions-burnout/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The Centers for Medicare & Medicaid Services is scouring payments covering health care for immigrants without legal status to ensure there isn’t any waste, fraud, or abuse, according to public records obtained by ºÚÁϳԹÏÍø News and The Associated Press. While acknowledging that states can bill the federal government for Medicaid emergency and pregnancy care for immigrants without legal status, federal officials have sent letters notifying state health agencies in California, Colorado, Illinois, Minnesota, Oregon, and Washington that they are reviewing federal and state payments for medical services such as prescription drugs and specialty care.

The federal agency told the states it is reviewing claims as part of its commitment to maintain Medicaid’s fiscal integrity. California is the biggest target after the state self-reported overcharging the federal government for health care services delivered to immigrants without legal status, determined to be at least $500 million, spurring the threat of a lawsuit.

“If CMS determines that California is using federal money to pay for or subsidize healthcare for individuals without a satisfactory immigration status for which federal funding is prohibited by law,” according to a letter dated March 18, “CMS will diligently pursue all available enforcement strategies, including, consistent with applicable law, reductions in federal financial participation and possible referrals to the Attorney General of the United States for possible lawsuit against California.”

The investigations come as the White House and a Republican-controlled Congress slashed taxpayer spending on immigrant health care in President Donald Trump’s spending-and-tax law passed this summer. The administration is also living in the U.S. without authorization off Medicaid rolls. Health policy experts say these moves could hamper care and leave safety net hospitals, clinics, and other providers . Some Democratic-led states — — have already had to end or slim down their Medicaid programs for immigrants due to ballooning costs. Colorado is also considering cuts due to cost overruns.

At the same time, 20 states are pushing back on Trump’s immigration crackdown the administration for on millions of enrollees to deportation officials. A federal judge the move. California’s attorney general, Rob Bonta, who led that challenge, says the Trump administration is launching a political attack on states that embrace immigrants in Medicaid programs.

“The whole idea that there’s waste, fraud, and abuse is contrived,” Bonta said. “It’s manufactured. It’s invented. It’s a catchall phrase that they use to justify their predetermined anti-immigrant agenda.”

Trump Targets Immigrants

Immigrants lacking permanent legal status are not eligible to enroll in comprehensive Medicaid coverage. However, states bill the federal government for emergency and pregnancy care provided to anyone.

Fourteen states and Washington, D.C., expanded their Medicaid programs with their own funds to cover low-income children without legal status. Seven of those states, plus Washington, D.C., have also provided full-scope coverage to some adult immigrants living in the country without authorization.

The Trump administration appears to be targeting only states with full Medicaid coverage for both kids and adults without legal status. Utah, Massachusetts, and Connecticut, which provide Medicaid coverage , have not received letters, for instance. CMS declined to provide a full list of states it is targeting.

Federal officials say it is their legal right and responsibility to scrutinize states for misspending on immigrant health coverage and are taking “decisive action to stop that.”

“It is a matter of national concern that some states have pushed the boundaries of Medicaid law to offer extensive benefits to individuals unlawfully present in the United States,” CMS spokesperson Catherine Howden said about the agency’s probe of selected states. The oversight is intended to “ensure federal funds are reserved for legally eligible individuals, not for political experiments that violate the law,” she said.

Health policy researchers and economists say providing Medicaid coverage to immigrants for preventive services and treatment of chronic health conditions staves off more costly care for patients down the road. It also tamps down insurance premium increases and the amount of uncompensated care for hospitals and clinics.

Francisco Silva, president and CEO of the , said the Trump administration is threatening to drive up health care costs and make it more difficult to access care.

“The impact is emergency rooms would get so crowded that ambulances have to be diverted away and people in a real emergency can’t get into the hospital, and public health threats like disease outbreaks,” Silva said.

California has taken a approach, providing coverage to 1.6 million immigrants without legal status. The expansion, which was rolled out from 2016 to 2024, is estimated to cost $12.4 billion this year. Of that, $1.3 billion is paid by the federal government for emergency and pregnancy-related care.

As California rolled out its expansion, the state erroneously billed the federal government for care provided to immigrants without legal status — details that have not previously been reported and that former state officials shared with ºÚÁϳԹÏÍø News and the AP. The state improperly billed for services such as mental health and addiction services, prescription drugs, and dental care.

Jacey Cooper, who served as California’s Medicaid director from 2020 to 2023, said she discovered the error and reported it to federal regulators. Cooper said the state had been working to pay back at least $500 million identified by the federal government.

“Once I identified the problem, I thought it was really important to report it and we did,” Cooper said. “We take waste, fraud, and abuse very seriously.”

It’s not clear whether that money has been repaid. The state’s Medicaid agency says it does not know how CMS calculated the overpayments or “what is included in that amount, what time period it covers, and if or when it was collected,” said spokesperson Tony Cava.

California has an enormously complicated Medicaid program: It serves the largest population in the nation — nearly — with a budget of nearly this fiscal year.

Matt Salo, a national Medicaid expert, said these types of mistakes happen in states throughout the country because the program is rife with overlapping federal and state rules. Salo and other policy analysts agreed that states have the authority to administer their Medicaid programs as they see fit and root out misuse of federal funds.

And Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Trump administration’s actions “persecute a minority that’s unpopular with the powers that be.”

“The Trump administration cannot maintain that this effort has anything to do with maintaining the fiscal integrity of the Medicaid program,” Cannon said. “There are so much bigger threats to Medicaid’s fiscal integrity, that that argument just doesn’t wash.”

Immigrants’ Medicaid Under Attack

National Republicans have targeted health spending on immigrants in different ways. The GOP spending law, which Trump calls the “One Big Beautiful Bill,” will lower reimbursement to states in October 2026. In California, for example, federal reimbursement for immigrants without legal status will go to 50% for emergency services, down from 90% for the Medicaid expansion population, according to Cava.

The Trump administration is also scaling back Medicaid coverage to immigrants with temporary legal status who were previously covered and that it would provide states with monthly reports pointing out enrollees whose legal status could not be confirmed by the Department of Homeland Security.

“Every dollar misspent is a dollar taken away from an eligible, vulnerable individual in need of Medicaid,” CMS Administrator Mehmet Oz said in a statement. “This action underscores our unwavering commitment to program integrity, safeguarding taxpayer dollars, and ensuring benefits are strictly reserved for those eligible under the law.”

States under review say they are following the law.

“Spending money on a congressionally authorized medical benefit program that helps people get emergency treatments for cancer, dialysis, and anti-rejection medications for organ transplants is decidedly not waste, fraud and abuse,” said Mike Faulk, deputy communications director for Washington state Attorney General Nick Brown.

Records show Washington Medicaid officials have been inundated with questions from CMS about federal payments covering emergency and pregnancy care for immigrants without legal status.

Emails show Illinois officials met with CMS and sought an extension to share its data. CMS denied that request and federal regulators told the state that its funding could be withheld.

“Thousands of Illinois residents rely on these programs to lawfully seek critical health care without fear of deportation,” said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services, noting that any federal cut would be “impossible” for the state to backfill.

Shastri reported from Milwaukee.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/insurance/trump-administration-cms-medicaid-waste-fraud-abuse-immigrants-states/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The Skid Row Care Campus officially opened this spring with ample offerings for people living on the streets of this historically downtrodden neighborhood. Pop-up fruit stands and tent encampments lined the sidewalks, as well as dealers peddling meth and fentanyl in open-air drug markets. Some people, sick or strung out, were passed out on sidewalks as pedestrians strolled by on a recent afternoon.

For those working toward sobriety, clinicians are on site to offer mental health and addiction treatment. Skid Row’s first methadone clinic is set to open here this year. For those not ready to quit drugs or alcohol, the campus provides clean syringes to more safely shoot up, glass pipes for smoking drugs, naloxone to prevent overdoses, and drug test strips to detect fentanyl contamination, among other supplies.

As many Americans have grown increasingly intolerant of street homelessness, cities and states have returned to tough-on-crime approaches that penalize people for living outside and for substance use disorders. But the Skid Row facility shows Los Angeles County leaders’ embrace of the principle of harm reduction, a range of more lenient strategies that can include helping people more safely use drugs, as they contend with a homeless population estimated — among of any county in the nation. the approach can help individuals enter treatment, gain sobriety, and end their homelessness, while addiction experts and county health officials note it has the added benefit of improving public health.

“We get a really bad rap for this, but this is the safest way to use drugs,” said Darren Willett, director of the Center for Harm Reduction on the new Skid Row Care Campus. “It’s an overdose prevention strategy, and it prevents the spread of infectious disease.”

Despite in overdose deaths, drug and alcohol use continues to be the among homeless people in the county. Living on the streets or in sordid encampments, homeless people saddle the health care system with high costs from uncompensated care, emergency room trips, inpatient hospitalizations, and, for many of them, their deaths. Harm reduction, its advocates say, allows homeless people the opportunity to obtain jobs, taxpayer-subsidized housing, health care, and other social services without being forced to give up drugs. Yet it’s hotly debated.

Politicians around the country, including in California, are reluctant to adopt harm reduction techniques, such as needle exchanges or supervised places to use drugs, in part because they can be seen by the public as condoning illicit behavior. Although Democrats are more supportive than Republicans, this year found lukewarm support across the political spectrum for such interventions.

Los Angeles is defying President Donald Trump’s agenda as he advocates for forced mental health and addiction treatment for homeless people — and locking up those who refuse. The city has also been the scene of large protests against Trump’s immigration crackdown, which the president has fought by deploying National Guard troops and Marines.

Trump’s on homelessness and substance use disorder came during his campaign, when he attacked people who use drugs as criminals and said that homeless people “have no right to turn every park and sidewalk into a place for them to squat and do drugs.” Health and Human Services Secretary Robert F. Kennedy Jr. reinforced Trump’s focus on treatment.

“Secretary Kennedy stands with President Trump in prioritizing recovery-focused solutions to address addiction and homelessness,” said agency spokesperson Vianca Rodriguez Feliciano. “HHS remains focused on helping individuals recover, communities heal, and help make our cities clean, safe, and healthy once again.”

A led by Margot Kushel, a professor of medicine at the University of California-San Francisco, this year found that nearly half of California’s homeless population had a complex behavioral health need, defined as regular drug use, heavy drinking, hallucinations, or a recent psychiatric hospitalization.

The chaos of living outside, she said — marked by violence, sexual assault, sleeplessness, and lack of housing and health care — can make it nearly impossible to get sober.

Skid Row Care Campus

The new care campus is funded by about $26 million a year in local, state, and federal homelessness and health care money, and initial construction was completed by a Skid Row landlord, Matt Lee, who made site improvements on his own, according to Anna Gorman, chief operating officer for community programs at the Los Angeles County Department of Health Services. Operators say the campus should be able to withstand potential federal spending cuts because it is funded through a variety of sources.

Glass front doors lead to an atrium inside the yellow-and-orange complex. It was designed with input from homeless people, who advised the county not just on the layout but also on the services offered on-site. There are 22 recovery beds and 48 additional beds for mostly older homeless people, arts and wellness programs, a food pantry, and pet care. Even bunnies and snakes are allowed.

John Wright, 65, who goes by the nickname Slim, mingled with homeless visitors one afternoon in May, asking them what they needed to be safe and comfortable.

“Everyone thinks we’re criminals, like we’re out robbing everyone, but we aren’t,” said Wright, who is employed as a harm reduction specialist on the campus and is trying, at his own pace, to stop using fentanyl. “I’m homeless and I’m a drug addict, but I’m on methadone now so I’m working on it,” he said.

Nearby on Skid Row, Anthony Willis rested in his wheelchair while taking a toke from a crack pipe. He’d just learned about the new care campus, he said, explaining that he was homeless for roughly 20 years before getting into a taxpayer-subsidized apartment on Skid Row. He spends most of his days and nights on the streets, using drugs and alcohol.

The drugs, he said, help him stay awake so he can provide companionship and sometimes physical protection for homeless friends who don’t have housing. “It’s tough sometimes living down here; it’s pretty much why I keep relapsing,” said Willis, who at age 62 has asthma and arthritic knees. “But it’s also my community.”

Willis said the care campus could be a place to help him kick drugs, but he wasn’t sure he was ready.

Research shows harm reduction helps prevent death and can build long-term recovery for people who use substances, said Brian Hurley, an addiction psychiatrist and the medical director for the Bureau of Substance Abuse Prevention and Control at the Los Angeles County Department of Public Health. The techniques allow health care providers and social service workers to meet people when they’re ready to stop using drugs or enter treatment.

“Recovery is a learning activity, and the reality is relapse is part of recovery,” he said. “People go back and forth and sometimes get triggered or haven’t figured out how to cope with a stressor.”

Swaying Public Opinion

Under harm reduction principles, officials acknowledge that people will use drugs. Funded by taxpayers, the government provides services to use safely, rather than forcing people to quit or requiring abstinence in exchange for government-subsidized housing and treatment programs.

Los Angeles County is spending to , while also launching a multiyear “” campaign to build public support, fight stigma, and encourage people to use services and seek treatment. Officials have hired a nonprofit, , to conduct the campaign including social media advertising and billboards to promote the expansion of both treatment and harm reduction services for people who use drugs.

The organization led a national and is working on overdose prevention and public health campaigns in using roughly $70 million donated by Michael Bloomberg, the former mayor of New York.

“We don’t believe people should die just because they use drugs, so we’re going to provide support any way that we can,” said Shoshanna Scholar, director of harm reduction at the Los Angeles County Department of Health Services. “Eventually, some people may come in for treatment but what we really want is to prevent overdose and save lives.”

Los Angeles also finds itself at odds with California’s Democratic governor. Newsom has spearheaded stricter laws targeting homelessness and addiction and has backed treatment requirements for people with mental illness or who use drugs. Last year, California voters , which allows felony charges for some drug crimes, requires courts to warn people they could be charged with murder for selling or providing illegal drugs that kill someone, and makes it easier to order treatment for people who use drugs.

Even San Francisco approved a measure last year that requires welfare recipients to participate in treatment to continue receiving cash aid. Mayor Daniel Lurie recently ordered city officials to stop handing out free drug supplies, including , and instead to require participation in drug treatment to receive services. Lurie signed a recovery-first ordinance, which prioritizes “” from substance use, and the city is also while funding new sober-living sites and treatment centers for people recovering from addiction.

‘Harm Encouragement’

State Sen. Roger Niello, a Republican who represents conservative suburbs outside Sacramento, says the state needs to improve the lives of homeless people through stricter drug policies. He argues that providing drug supplies or offering housing without a mandate to enter treatment enables homeless people to remain on the streets.

Proposition 36, he said, needs to be implemented forcefully, and homeless people should be required to enter treatment in exchange for housing.

“I think of it as tough love,” Niello said. “What Los Angeles is doing, I would call it harm encouragement. They’re encouraging harm by continuing to feed a habit that is, quite frankly, killing people.”

Keith Humphreys, who worked in the George W. Bush and Barack Obama administrations and practices across the nation, said that communities should find a balance between leniency and law enforcement.

“Parents need to be able to walk their kids to the park without being traumatized. You should be able to own a business without being robbed,” he said. “Harm reduction and treatment both have a place, and we also need prevention and a focus on public safety.”

Just outside the Skid Row Care Campus, Cindy Ashley organized her belongings in a cart after recently leaving a local hospital ER for a deep skin infection on her hand and arm caused by shooting heroin. She also regularly smokes crack, she said.

She was frantically searching for a home so she could heal from two surgeries for the infection. She learned about the new care campus and rushed over to get her name on the waiting list for housing.

“I’m not going to make it out here,” she said, in tears.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/mental-health/los-angeles-skid-row-care-campus-drug-use-addiction-harm-reduction-mental-illness/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Some poor and disabled Medicaid patients became , including security deposits and first month’s rent for housing, rides to medical appointments, wheelchair ramps, and even prescriptions for fresh fruits and vegetables.

Such experimental initiatives to improve the health of vulnerable Americans while saving taxpayers on costly medical procedures and expensive emergency room care are booming nationally. Without homes or healthy food, people risk getting sicker, becoming homeless, and experiencing even more trouble controlling chronic conditions such as diabetes and heart disease.

Former President Joe Biden on new benefits, and the availability of social services exploded in states red and blue. Since North Carolina’s launch, have followed by expanding social service benefits covered by Medicaid, the health care program for low-income and disabled Americans — a national shift that’s turning a system focused on sick care into one that prioritizes prevention. And though Trump was pivotal to the expansion, he’s now reversing course regardless of whether evidence shows it works.

In Trump’s second term, his administration is throwing participating states from California to Arkansas into disarray, arguing that social services should not be paid for by government health insurance. Officials at the Centers for Medicare & Medicaid Services, which grants states permission to experiment, have rescinded its previous , arguing that the Biden administration went too far.

“This administration believes that the health-related social needs guidance distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans,” CMS spokesperson Catherine Howden said in a statement.

“This decision prevents the draining of resources from Medicaid for potentially duplicative services that are already provided by other well-established federal programs, including those that have historically focused on food insecurity and affordable housing,” Howden added, referring to food stamps and low-income housing vouchers provided through other government agencies.

Trump, however, has also proposed axing funding for low-income housing and food programs administered by agencies including the departments of and — on top of Republican proposals for broader .

The pullback has led to chaos and confusion in states that have expanded their Medicaid programs, with both liberal and conservative leaders worried that the shift will upend multibillion-dollar investments already underway. Social problems such as homelessness and food insecurity can cause — or worsen — physical and behavioral health conditions, leading to sky-high health care spending. Medical care delivered in hospitals and clinics, for instance, accounts for only roughly 15% of a person’s overall health, while a staggering 85% is influenced by social factors such as access to healthy food and shelter for sleep, said Anthony Iton, a policy expert on .

Health care experts warn the disinvestment will come at a price.

“It will just lead to more death, more suffering, and higher health care costs,” said Margot Kushel, a primary care doctor in San Francisco and on homelessness and health care.

The Trump administration announced in a that it was rescinding Biden-era guidance dramatically expanding experimental benefits known as . Federal waivers are required for states to use Medicaid funds for most nontraditional social services outside of hospitals and clinics.

Last month, the administration told states that these services, which can also include high-speed internet and storage units, should .

Future waiver requests allowing Medicaid to provide social services — a liberal philosophy — will be considered on a “case-by-case basis,” the administration said. Rather, it has signaled a conservative shift toward requiring most Medicaid beneficiaries to prove that they’re working or trying to find jobs, which puts an estimated Americans at risk of losing their health coverage.

“What they’re arguing is Medicaid has been expanded far beyond basic health care and it needs to be cut back to provide only basic coverage to those most desperately in need,” said Mark Peterson, a health policy expert at UCLA. “They’re making the case, which is not widely shared by specialists in the health care field, that it’s not the job of taxpayers and Medicaid to pay for all this stuff outside the traditional heath care system.”

Although states have not received formal guidance to end their social experiments, Peterson and other health policy researchers expect the administration not to renew waivers, which typically run in five-year intervals. Worse, legal experts say programs underway could be halted early.

Evidence supporting by Medicaid is still nascent. An expansion in Massachusetts that provided food benefits , for instance. But often,

California is , investing $12 billion over five years to provide , from intensive case management to help people with severe behavioral health conditions to through a . The most popular benefits provided by health insurers are those that help homeless people on Medicaid by placing them in apartments or securing beds in recovery homes, covering up to $5,000 for security deposits, and preventing eviction.

Since the launched in 2022, it has served only a small fraction of the state’s Medicaid beneficiaries, with . Yet it has improved and even saved the lives of some of those lucky enough to get help, including Eric Jones, a 65-year-old Los Angeles resident.

“When I got diabetes, I didn’t know what to do and I had a hard time getting to my medical appointments,” said Jones, who lost his housing this year when his mom died but received services through his Medi-Cal insurer, L.A. Care. “My case manager got me rides to my appointments and also helped me get into an apartment.”

California is considering making some of its social services permanent after the CalAIM waivers expire at the end of 2026. Gov. Gavin Newsom’s administration is adding more housing services, including up to six months of free rent under a third waiver approved by the Biden administration. Medi-Cal officials contended early evidence shows CalAIM has led to better care coordination and fewer hospital and ER visits.

“We are fully committed,” , a deputy director for the state Department of Health Care Services, which administers the program. “We have invested so much.”

Health insurers, which deliver Medicaid coverage and receive greater funding to cover these additional benefits, say they’re worried the Trump administration will end or curtail the programs. “If we do things the same old way, we’re just going to generate the same old results — people getting sicker and health care costs continuing to rise,” said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents insurers.

Industry leaders say the expansion is already changing lives.

“We believe wholeheartedly that housing is health, food is health, so seeing these programs disappear would be devastating,” said Kelly Bruno-Nelson, executive director of Medi-Cal for CalOptima Health, a health insurance provider in Orange County.

Oregon is low-income Medicaid patients with a range of , including home-delivered healthy meals and rental payment assistance. Residents for air conditioners, heaters, air filters, power generators, and mini fridges. State Medicaid officials say they remain committed to providing the benefits but worry about federal cuts.

“Climate change and housing instability are huge indicators of poor health,” said Josh Balloch, vice president of health policy and communications at AllCare Health, a Medicaid insurer in Oregon. “We hope to prove to the federal government that this is a good return on their investment.”

But even as the Trump administration curtails waivers, it is retaining discretion to provide social services in Medicaid, just on a smaller scale. Supporters say it’s fair to scrutinize where to draw the line on taxpayer spending, arguing that there isn’t always a direct health connection.

“We’re seeing these things increase, with the free rent, and we’re seeing some states pay for free internet, paying for furniture,” said Kody Kinsley, who previously served as North Carolina’s top health official. “We know there’s evidence for food and housing, but with all of these new benefits, we need to look closely at the evidence and the linkage to what actually drives health.”

Current North Carolina officials say they’re confident the new social services Medicaid provides in their state have resulted in better health and lower overall spending on expensive and acute care. Medicaid recipients there can even use the program to buy farm-fresh produce.

While it’s too soon to know whether these experiments have been effective elsewhere in the United States, early evidence in North Carolina shows promise: The state had saved a year into its experiment — operating in mostly rural counties — by reducing ER trips and hospitalizations.

State health officials also touted the economic benefits of driving business to family farms, home improvement contractors, and community-based organizations providing housing and social services.

“I welcome the challenge of demonstrating the effectiveness of our programs. It’s making for healthier people and healthier budgets,” said Jay Ludlam, deputy secretary for North Carolina’s Medicaid program. “Family farms that were on the verge of collapse after Hurricane Helene are now benefiting from a steady income while they also serve their community.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/medicaid/medicaid-medi-cal-social-determinants-health-california-guidance-trump-cms/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

In March, as President Donald Trump and congressional Republicans escalated a nationwide debate over whether to slash health care for poor and disabled Americans, the Democratic governor had to tell state lawmakers that California’s health care costs had spiraled out of control due to he backed — including the nation’s largest expansion of taxpayer-financed health care for immigrants living in the U.S. without legal permission.

His top officials at the state Department of Finance quietly disclosed to California lawmakers in a letter that the state had to pay health insurers, doctors, and hospitals caring for patients enrolled in California’s Medicaid program, known as Medi-Cal. Facing rising health care costs amid a , Newsom now must contemplate rolling back coverage and benefits.

The second-term governor faces a tough political decision: renege on his promise to achieve and strip coverage from millions of immigrants who lack legal status or look elsewhere for budget cuts. With nearly 15 million low-income or disabled residents enrolled in Medi-Cal, California has on health care than any other state. Yet even as Newsom has condemned Trump’s approach to tariffs and environmental policies, he has been tight-lipped on health policy.

Complicating his political tightrope: that providing health care coverage for immigrants without legal status has tepid support. And any resulting budget trouble could harm his political legacy should he run for president in 2028.

“We all know that the cuts are definitely coming,” said Carlos Alarcon, a health and public benefits analyst with the California Immigrant Policy Center, which has helped spearhead a decade-long campaign in California to expand Medicaid to eligible immigrants without legal status. “The governor should keep his commitment — we’ll be very disappointed if we see cuts and rollbacks. When times get hard, it’s always our marginalized and underserved communities that lose out.”

California in Medi-Cal if they earn level, or , regardless of immigration status. But the costs have been dramatically higher than expected.

Democratic Gov. Jerry Brown expanded Medi-Cal to people age 19 and younger without legal status, but he expressed because of potential costs. Newsom signed bills into law adding people age 20 and older. An estimated 1.6 million immigrants without legal status are now covered, and costs have soared to $9.5 billion per year, up from $6.4 billion estimated in November. The federal government chips in roughly $1.1 billion of that total for pregnancy and emergency care.

“We can expand out of the graciousness of our heart to everywhere and anywhere, but the moment these resources run out, now everybody loses. We’re hitting that breaking point,” said California Assembly member David Tangipa, a Fresno Republican. “Either we get fiscally responsible, or there’s not going to be services for anybody — and that includes the Californian and the undocumented immigrant.”

Democratic leaders responsible for approving the state budget declined interviews. In a statement, state Sen. María Elena Durazo, a Los Angeles Democrat, who championed the expansion in the legislature, said, “Rolling back this progress would be a harmful and shortsighted decision.”

Lawmakers are considering freezing enrollment for immigrants without legal status, imposing cost-sharing measures such as drug copays or premiums, or restricting benefits, according to people familiar with the matter, who asked not to be identified to protect relationships at the state Capitol.

However, it’s unlikely Newsom will slash funding in his budget revision set for release on May 14. Instead, cuts would follow if congressional Republicans approve a budget deal with major reductions in federal spending on Medicaid.

“This is going to be very problematic for the governor. Budget cuts will disrupt the lives of millions of immigrants who just got health care, but the governor has got to do something, because this is not sustainable,” said Mark Peterson, an expert on health care and national politics at UCLA. “The prospect of cutting other places in order to support immigrants living in the country illegally would be a hard political sale; I don’t see that happening.”

Should Newsom, along with the Democratic-controlled legislature, be forced to make cuts, he could argue he had no choice. Trump and congressional Republicans have threatened states like California with the cutting Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status.For Newsom, political analysts say, Trump could make an easy scapegoat.

“He can blame Trump — there’s only so much money to go around,” said Mike Madrid, an anti-Trump Republican political analyst in California who specializes in Latino issues. “It’s making people look at the health care that they can’t afford and ask, ‘Why the hell are we giving it for free to people who are here illegally?’”

The exorbitant cost has come as somewhat of a surprise.

In as governor — in which he called for expanding Medi-Cal to young adults without legal status — his administration estimated it would cost roughly $2.4 billion annually to extend benefits to all eligible people regardless of status. But the latest figure reported to legislators was nearly four times as much.

Newsom declined to respond to questions from ºÚÁϳԹÏÍø News, instead referencing previous comments that leave the door open to scaling back Medi-Cal. The governor noted “sober” discussions with lawmakers and said cutting Medi-Cal is “an open-ended question” that the president will heavily influence.

“What’s the impact of Donald Trump on a lot of these things? What’s the impact of federal vandalism to a lot of these programs?” Newsom asked , suggesting it’s unclear whether he’ll be able to sustain the expansion to immigrants without legal status in future years.

Newsom expanded Medi-Cal in three phases, starting with immigrants ages 19 to 25, who became eligible in 2020, resisting pressure from health care advocates for one big, costly expansion. He argued doing it incrementally would ultimately save California money.

“It is the right thing morally and ethically,” . “It is also the financially responsible thing to do.”

Record budget surpluses in recent years allowed Democrats to continue. Older adults ages became eligible in 2022, and Newsom closed the gap the following year, approving coverage starting in 2024 for the biggest group, those ages .

But the costs have grown tremendously while the budget picture has soured, according to a ºÚÁϳԹÏÍø News analysis of the most recent 2023 records available from the state Department of Health Care Services, which administers Medi-Cal.

Aside from children, it was more expensive to provide Medicaid coverage to immigrants without legal status than to legal residents. For instance, Medi-Cal paid L.A. Care, a major health insurer in Los Angeles, an average of $495.32 monthly to provide care for a childless adult without legal status and $266.77 for a legal resident without kids.

Not only were immigrants without legal status more expensive, California footed most of the cost. The state paid roughly between 60% and 70% of health care costs for a childless adult immigrant covered by L.A. Care, and about 10% for a legal resident without kids. Those costs don’t encapsulate the entire cost of providing care, which can vary depending on where Medi-Cal patients live, and grow higher when filling prescriptions, going to the dentist, or seeking mental health care.

These payments also differ by insurer, but the trend holds across the state’s Medi-Cal health insurance plans. Patients in most of the state can choose from more than one health plan.

Children without legal status in many cases were cheaper to cover than children who were legal residents. Generally, kids are healthier and require less care.

Mike Genest, who served as finance director under former Republican Gov. Arnold Schwarzenegger, argued that the state should have planned for the immense price tag.

“The idea that we’d be able to afford in the long run paying for health care for all these undocumented people — it’s beyond unsustainable,” Genest said.

While costs are high now, the expansion of Medi-Cal will result in long-term savings to taxpayers and the health care system, said Anthony Wright, who previously lobbied for the expansion as the head of the nonprofit Health Access and is now fighting Medicaid cuts as the executive director of , based in Washington, D.C.

“They’re going to be showing up in our health care system regardless,” Wright said. “Leaving them without health insurance is just going to end in more crowded emergency rooms, and it’s going to cost even more. It doesn’t make any sense economically for them to be uninsured; that takes critical revenue from clinics and hospitals, just causing more problems.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/health-care-costs/california-governor-newsom-medicaid-universal-health-care-immigrant-coverage-trump-political-tightrope/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Researchers say housing is the most important intervention to end homelessness, and now a from the University of California-San Francisco sheds deeper insight: While California’s high housing costs and low incomes drive people into homelessness, those with behavioral health conditions face added risk of becoming homeless. And once people lose housing, homelessness makes them more likely to use drugs or experience a mental health problem. 

The report found that of homeless adults in California have a serious mental health condition or use drugs or alcohol, and 42% of people who regularly use drugs began doing so after becoming homeless. 

“Complex behavioral health needs, including substance and mental health problems, increase the risk of becoming homeless, and homelessness exacerbates these problems,” said Margot Kushel, director of the Benioff Homelessness and Housing Initiative at UCSF. 

Kushel and others argue that housing and supportive services are critical. Instead, President Donald Trump is pushing a treatment-first approach. 

During his campaign, Trump called for relocating homeless people to large camps and forcing treatment, a punitive approach that he says will come with jail time if people refuse. 

Now in office, Trump has launched a broad assault on “Housing First.” 

The nationwide anti-homelessness policy, aimed at getting people into permanent housing, was created under President George W. Bush and for decades has steered federal funding into housing and social service programs. 

Already, city and county officials are being told that the federal Department of Housing and Urban Development “” homelessness contracts if they follow the Housing First model. And as Trump officials seek major funding cuts, the president this month shrinking the U.S. Interagency Council on Homelessness, which was established under President Ronald Reagan to coordinate homelessness initiatives around the nation. 

The focus has been on offering housing and voluntary treatment, even if those promises elude too many people. Now, those programs will be eroded. 

Democratic U.S. Rep. Maxine Waters of Los Angeles warns: “Make no mistake that Trump’s reckless attacks across the federal government will supercharge the housing and homelessness crisis in communities across the country.”Ìý

This <a target="_blank" href="/mental-health/the-week-in-brief-trump-homelessness-treatment-over-housing/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“Our once-great cities have become unlivable, unsanitary nightmares,” Trump said in a . “For those who are severely mentally ill and deeply disturbed, we will bring them to mental institutions, where they belong, with the goal of reintegrating them back into society once they are well enough to manage.”

Now that he’s in office, the assault on “” has begun.

White House officials haven’t announced a formal policy but are opening the door to a treatment-first agenda, while engineering a major overhaul of the housing and social service programs that form the backbone of the homelessness response system that cities and counties across the nation depend on. Nearly alone. But now, Scott Turner, who heads Trump’s Department of Housing and Urban Development — the agency responsible for administering housing and homelessness funding — has outlined massive funding cuts and called for a .

“Thanks to President Trump’s leadership, we are no longer in a business-as-usual posture and the DOGE task force will play a critical role in helping to identify and eliminate waste, fraud and abuse and ultimately better serve the American people,” in a statement.

Staffing cuts already proposed the part of the agency overseeing homelessness spending and Housing First initiatives particularly hard. Trump outlined his vision during his campaign, calling for new treatment facilities to be opened on large parcels of government land — “tent cities where the homeless can be relocated and their problems identified.” They could receive treatment and rehabilitation or face arrest. Now in office, he has begun to turn his attention to street homelessness, in March ordering Washington, D.C., , potentially separating homeless people from their case managers and social service providers, derailing their path to housing.

The administration is discouraging local governments from following the federal policy, telling them it homelessness contracts “to the extent that they require the project to use a housing first program model.” And, “reducing the scope of the federal bureaucracy,” Trump slashed the U.S. Interagency Council on Homelessness, shrinking the agency responsible for coordinating funding and initiatives between the federal government, states, and local agencies, known as .

“Make no mistake that Trump’s reckless attacks across the federal government will supercharge the housing and homelessness crisis in communities across the country,” Democratic U.S. Rep. Maxine Waters of Los Angeles said in response to the order.

Support Without Forced Treatment

was implemented nationally in 2004 under the George W. Bush administration to combat chronic homelessness, having lived on the streets with a disabling condition for a long period of time. It was expanded under President Barack Obama as America’s plan of attack on homelessness and broadened by President Joe Biden, who argued that housing was a basic need, critical to health.

The policy aims to stabilize homeless people in permanent housing and provide them with case management support and social services without forcing treatment, imposing job requirements, or demanding sobriety. Once housed, the theory goes, homeless people escape the chaos of the streets and can then work on finding a job, taking care of chronic health conditions, or getting sober.

“When you’re on the streets, all you’re doing every day is figuring out how to survive,” said Ann Oliva, CEO of the National Alliance to End Homelessness. “Housing is the most important intervention that brings a sense of safety and stability, where you’re not just constantly trying to find food or a safe place to sleep.”

But Trump wants to gut taxpayer-subsidized housing initiatives. He is pushing for a punitive approach that would impose fines and potentially jail time on homeless people. And he wants to mandate sobriety and mental health treatment as the primary homelessness intervention — a stark reversal from Housing First.

The shift has ignited fear and panic among homelessness experts and front-line service providers, who argue that forcing treatment and criminalizing homeless people through fines and jail time simply doesn’t work.

“It’s only going to make things much worse,” said Donald Whitehead Jr., executive director of the National Coalition for the Homeless. “Throwing everybody into treatment programs just isn’t an effective strategy. The real problem is we just don’t have enough affordable housing.”

Trump got close to ending Housing First during his first term when he tapped Robert Marbut to lead the U.S. Interagency Council on Homelessness . Marbut mandating treatment and reducing reliance on social services, while curtailing taxpayer-subsidized housing. He argued that forcing homeless people to get sober and enter treatment would help them achieve self-sufficiency and end their homelessness. But covid-19 stalled those plans.

Now, Marbut said, he believes the president will finish the job.

“Trump knows that what we need to do is get funding back to treatment and recovery,” Marbut said. “The Trump administration is laser-focused on ending Housing First. They realized it was wrong the first time and that’s why I was selected to change it. They still realize it’s wrong.”

Trump and administration officials did not respond to questions from ºÚÁϳԹÏÍø News. A request to interview Turner was not granted. Project 2025’s “,” a conservative policy blueprint from some of Trump’s closest advisers, explicitly calls for an end to Housing First.

Under Attack

Housing First is under attack not only from Republicans who have long criticized taxpayer-subsidized housing for homeless people, but also from Democrats responding to public frustration over homeless encampments multiplying around the nation. Last year, the federal government estimated that people in the U.S. were homeless, a record high. That was up 18% from 2023. And while housing grows increasingly unaffordable, homeless camps have exploded, spilling into city parks, crowding sidewalks, and polluting sensitive waterways, despite unprecedented public spending.

Already, cities and states, liberal and conservative, are cracking down on street homelessness and targeting the mental health and addiction crisis. This is true even in deep-blue states like California, where Gov. Gavin Newsom has created a “” initiative that can mandate treatment even though housing isn’t always available and threatened to withhold funding from cities and counties that don’t aggressively clear encampments.

San Francisco Mayor Daniel Lurie has proposed for drug users. Los Angeles Mayor Karen Bass is prioritizing encampment sweeps even though the promise of housing or shelter is elusive. And San Jose Mayor Matt Mahan for plans to who refuse shelter three times in 18 months and to to pay for an expansion of homeless shelters.

Mahan believes liberals and advocates have been too “purist” because housing isn’t being built fast enough, while investments in shelter and treatment have been inadequate. “It can’t only be about Housing First,” he said.

Homelessness crackdowns have exploded since the U.S. Supreme Court made it easier for elected officials and law enforcement agencies to fine and arrest people for living outside. Since June, roughly 150 laws imposing fines or jail time have been passed, with about 45 in California alone, said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

Rabinowitz and other experts say both Republicans and Democrats are undermining Housing First by criminalizing homelessness and conducting encampment sweeps that hinder the ability of front-line workers to get people into housing and services.

However, there’s disagreement on whether to entirely dismantle the policy. Liberal leaders want to maintain existing streams of housing and homelessness funding while expanding shelters and moving people off the streets. Conservatives blame Housing First for the rise in homelessness and are instead pushing for mandatory treatment and cutting housing subsidies.

“I used to think it was just a waste of taxpayer money because it wasn’t treatment-based, but now I think it actually enables people to remain homeless and addicted,” Marbut said of the Housing First approach. He favors requiring behavioral health treatment as a prerequisite to housing.

Evidence shows Housing First has been successful in moving vulnerable, chronically homeless people into permanent housing. For instance, of 26 studies indicated that, compared with treatment-first, “Housing First programs decreased homelessness by 88%.”And the approach has shown in health, reducing costly hospital and emergency room care.

Experts say Housing First has been and implemented unevenly, with some homelessness agencies taking federal money but not providing appropriate services or housing placements.

“Making it the broad policy to all homelessness leaves it vulnerable to being attacked the way it’s currently being attacked,” said Philip Mangano, a Republican who spearheaded the development of Housing First as the lead homelessness adviser to George W. Bush. “The truth is it’s a mixed bag. For some people like those who are using substances, the evidence just isn’t there yet.”

Others say it has been ineffective in some places because of rampant misspending, abuse, and a .

“This works when it’s done right,” said Marc Dones, a policy director for homelessness initiatives at the University of California-San Francisco, arguing that housing can save lives and lower spending on costly health care. “But I think we have been too polite and too nice for too long about some real incompetence.”

Jeff Olivet, who succeeded Marbut at the U.S. Interagency Council on Homelessness under Biden, said Marbut and Trump’s positions are misguided. He argues that Housing First has worked for those who have gotten indoors, yet the number of people falling into homelessness outpaces those getting housing. And he says there was never enough money to provide housing and supportive services for everyone in need.

“Housing First is not just about sticking somebody in an apartment and hoping for the best,” Olivet said. “It’s really about providing stable housing and access to health care, mental health and substance use treatment, and to support people, but not forcing it on people.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/public-health/trump-homelessness-policy-housing-first-forced-treatment/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

After Health and Human Services Secretary Robert F. Kennedy Jr. fired Centers for Disease Control and Prevention Director Susan Monarez for refusing what her lawyers called “,” Newsom to help modernize California’s public health system. He also gave a job to Debra Houry, the agency’s former chief science and medical officer, who had resigned in protest hours after Monarez’s firing.

Newsom also teamed up with fellow Democratic governors Tina Kotek of Oregon, Bob Ferguson of Washington, and Josh Green of Hawaii to form the , a regional public health agency, whose guidance would “uphold scientific integrity in public health as Trump destroys” the CDC’s credibility. Newsom argued establishing the independent alliance was vital as Kennedy leads the Trump administration’s rollback of national vaccine recommendations.

More recently, California became the a global outbreak response network coordinated by the World Health Organization, followed by Illinois and New York. Colorado and Wisconsin signaled they plan to join. They did so after President Donald Trump officially from the agency on the grounds that it had “strayed from its core mission and has acted contrary to the U.S. interests in protecting the U.S. public on multiple occasions.” Newsom said joining the WHO-led consortium would enable California to respond faster to communicable disease outbreaks and other public health threats.

Although other Democratic governors and public health leaders have openly criticized the federal government, few have been as outspoken as Newsom, who is considering a run for president in 2028 and is in his second and final term as governor. Members of the scientific community have praised his effort to build a public health bulwark against the Trump administration’s slashing of funding and scaling back of vaccine recommendations.

What Newsom is doing “is a great idea,” said Paul Offit, an outspoken critic of Kennedy and a vaccine expert who formerly served on the Food and Drug Administration’s vaccine advisory committee but was removed under Trump in 2025.

“Public health has been turned on its head,” Offit said. “We have an anti-vaccine activist and science denialist as the head of U.S. Health and Human Services. It’s dangerous.”

The White House did not respond to questions about Newsom’s stance and HHS declined requests to interview Kennedy. Instead, federal health officials criticized Democrats broadly, arguing that blue states are participating in fraud and mismanagement of federal funds in public health programs.

HHS spokesperson Emily Hilliard said the administration is going after “Democrat-run states that pushed unscientific lockdowns, toddler mask mandates, and draconian vaccine passports during the covid era.” She said those moves have “completely eroded the American people’s trust in public health agencies.”

Public Health Guided by Science

Since Trump returned to office, Newsom has criticized the president and his administration for engineering policies that he sees as an affront to public health and safety, labeling federal leaders as “extremists” trying to “weaponize the CDC and spread misinformation.” He has for erroneously linking vaccines to autism, the administration is endangering the lives of infants and young children in scaling back childhood vaccine recommendations. And he argued that the White House is unleashing “chaos” on America’s public health system in backing out of the WHO.

The governor declined an interview request. Newsom spokesperson Marissa Saldivar said it’s a priority of the governor “to protect public health and provide communities with guidance rooted in science and evidence, not politics and conspiracies.”

The Trump administration’s moves have triggered financial uncertainty that local officials said has reduced morale within public health departments and left states unprepared for disease outbreaks and . The White House last year proposed cutting HHS spending , including . Congress largely rejected those cuts last month, although funding for programs focusing on social drivers of health, such as access to food, housing, and education, .

The Trump administration announced that it would claw back in public health funds from California, Colorado, Illinois, and Minnesota, arguing that the Democratic-led states were funding “woke” initiatives that didn’t reflect White House priorities. Within days, and a judge the cut.

“They keep suddenly canceling grants and then it gets overturned in court,” said Kat DeBurgh, executive director of the Health Officers Association of California. “A lot of the damage is already done because counties already stopped doing the work.”

Federal funding has accounted for of state and local health department budgets nationwide, with money going toward fighting HIV and other sexually transmitted infections, preventing chronic diseases, and boosting public health preparedness and communicable disease response, according to a 2025 analysis by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Federal funds account for $2.4 billion of California’s $5.3 billion public health budget, making it difficult for Newsom and state lawmakers to backfill potential cuts. That money helps fund state operations and is vital for local health departments.

Funding Cuts Hurt All

Los Angeles County public health director Barbara Ferrer said if the federal government is allowed to cut that $600 million, the county of nearly 10 million residents would lose an estimated $84 million over the next two years, in addition to other grants for prevention of HIV and other sexually transmitted infections. Ferrer said the county depends on nearly $1 billion in federal funding annually to track and prevent communicable diseases and combat chronic health conditions, including diabetes and high blood pressure. Already, the the closure of that provided vaccinations and disease testing, largely because of funding losses tied to federal grant cuts.

“It’s an ill-informed strategy,” Ferrer said. “Public health doesn’t care whether your political affiliation is Republican or Democrat. It doesn’t care about your immigration status or sexual orientation. Public health has to be available for everyone.”

A single case of measles requires public health workers to track down 200 potential contacts, Ferrer said.

The U.S. but is close to losing that status as a result of vaccine skepticism and misinformation spread by vaccine critics. The U.S. had , the most since 1991, with 93% in people who were unvaccinated or whose vaccination status was unknown. This year, the highly contagious disease has been reported at , , and .

Public health officials hope the West Coast Health Alliance can help counteract Trump by building trust through evidence-based public health guidance.

“What we’re seeing from the federal government is partisan politics at its worst and retaliation for policy differences, and it puts at extraordinary risk the health and well-being of the American people,” said Georges Benjamin, executive director of the American Public Health Association, a coalition of public health professionals.

Robust Vaccine Schedule

Erica Pan, California’s top public health officer and director of the state Department of Public Health, said the West Coast Health Alliance is defending science by recommending a vaccine schedule than the federal government. California is part of a coalition over its decision to rescind recommendations for seven childhood vaccines, including for hepatitis A, hepatitis B, influenza, and covid-19.

Pan expressed deep concern about the state of public health, particularly the uptick in measles. “We’re sliding backwards,” Pan said of immunizations.

Sarah Kemble, Hawaii’s state epidemiologist, said Hawaii joined the alliance after hearing from pro-vaccine residents who wanted assurance that they would have access to vaccines.

“We were getting a lot of questions and anxiety from people who did understand science-based recommendations but were wondering, ‘Am I still going to be able to go get my shot?’” Kemble said.

Other states led mostly by Democrats have also formed alliances, with Pennsylvania, New York, New Jersey, Massachusetts, and several other East Coast states banding together to create the .

HHS’ Hilliard said that even as Democratic governors establish vaccine advisory coalitions, the federal “remains the scientific body guiding immunization recommendations in this country, and HHS will ensure policy is based on rigorous evidence and gold standard science, not the failed politics of the pandemic.”

Influencing Red States

Newsom, for his part, has approved a recurring annual infusion of nearly $300 million to support the state Department of Public Health, as well as the 61 local public health agencies across California, and last year authorizing the state to issue its own immunization guidance. It requires health insurers in California to provide patient coverage for vaccinations the state recommends even if the federal government doesn’t.

Jeffrey Singer, a doctor and senior fellow at the libertarian Cato Institute, said decentralization can be beneficial. That’s because local media campaigns that reflect different political ideologies and community priorities may have a better chance of influencing the public.

A KFF analysis found some red states are joining blue states in decoupling their vaccine recommendations from the federal government’s. Singer said some doctors in his home state of Arizona are looking to more liberal California for vaccine recommendations.

“Science is never settled, and there are a lot of areas of this country where there are differences of opinion,” Singer said. “This can help us challenge our assumptions and learn.”

This <a target="_blank" href="/public-health/gavin-newsom-california-public-health-fight-west-coast-alliance-trump-hhs-rfk/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

LISTEN: In this audio portrait of homeless people displaced by the Trump administration’s crackdown on encampments in the nation’s capital, ºÚÁϳԹÏÍø News senior correspondent Angela Hart tells of residents living outside this winter and their search for medical care and shelter.

January’s extreme cold has put a spotlight on the conditions homeless people face. They get sicker and die younger than housed people, often because health problems go untreated. The Trump administration’s removal of homeless tent encampments in Washington, D.C., has made it more difficult for health workers to reach that vulnerable population this winter.

ºÚÁϳԹÏÍø News senior correspondent Angela Hart takes WAMU “Health Hub” listeners to Washington’s streets to hear how homeless people are juggling their health and shelter after the Trump administration’s crackdown.

This <a target="_blank" href="/public-health/homeless-crackdown-washington-dc-wamu-health-hub-winter-listen/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

“Police want us out of the way,” he said, dressed in a gray jacket and carrying none of his possessions. “Out of sight, out of mind.”

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no ‘MR. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is — he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, ‘We don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

This <a target="_blank" href="/mental-health/washington-dc-homelessness-crackdown-hiding-plain-sight-street-medicine/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Democratic Gov. Gavin Newsom and state lawmakers have tried to bolster the state’s health care workforce, in part by implementing recommendations from the California Future Health Workforce Commission, a 24-member panel of state, labor, academic, and industry representatives. The state in recent years has expanded the for nurse practitioners, allowing them to practice medicine — ordering tests and prescribing medication, for instance — without traditional doctor supervision, and has academic nursing slots and training programs.

Still, California’s shortage of registered nurses is expected to grow from 3.7% in 2024 to 16.7% by 2033, or more than 61,000 nurses, due to inadequate recruitment, training, and retention, according to Kathryn Phillips, associate director of the Improving Access team at the California Health Care Foundation, a nonprofit philanthropic organization specializing in health care research and education.

Regional shortages, particularly in the Central Valley and rural North, are expected to swell. “There are major deficits and those could get even worse,” Phillips said.

Researchers say the gap between nursing supply and demand is exacerbated by inadequate career pathways and high turnover in a labor-intensive industry, but nurses and argue the problem is driven primarily by a management-induced and poor working conditions. Nurses say nursing remains a noble calling, but many report feeling pressured to turn over beds and take on more patients, stress that can dissuade young people from entering the field and drive experienced nurses to .

Industry representatives cast those concerns as union talking points to drive up labor costs, but nurses say they are losing benefits while being overworked, hobbling morale and hampering their ability to provide even basic health care in hospitals, clinics, and nursing homes around the state.

Lorena Burkett, a registered nurse at Emanuel Medical Center in Turlock, an agricultural city in the heart of the Central Valley, recounted being so overloaded last year that she didn’t promptly log a medical chart after administering a psychiatric patient’s medication, a critical step for ensuring proper drug doses.

“I was being told get him out, and I forgot to scan his opioid medication; I missed it,” said Burkett, a 12-year veteran, who later updated the patient’s record. “After that I said no more. We have to prioritize patient care, but we are under a lot of pressure to get patients out and turn profits.”

Tenet Healthcare, the Dallas-based for-profit hospital system that owns Emanuel, declined to respond to Burkett’s claim, as well as questions about staffing levels. In a statement, Tenet spokesperson Rob Dyer said that the hospital provides “quality and compassionate care” and broadly disputed nurses’ concerns.

“We are currently in contract negotiations with the union which represents our nurses,” he said, “and suspect that this is what is behind these false claims.”

Improving Conditions for Nurses

Two years ago, state lawmakers approved to help hospitals maintain operations, which can include retaining nurses. Lawmakers are also trying to improve nurses’ work conditions in hospitals and to protect patient care by at health care facilities. Some also call for investing in a more robust nursing workforce.

“Nurses are working in hospitals and other places that are severely understaffed,” said Michelle Mahon, director of nursing practice for National Nurses United, a union that represents 225,000 nurses.

Phillips said the reasons vary. In the San Francisco Bay Area, nurses must contend with a high cost of living, a lack of affordable housing, and expensive child care. In the Central Valley, there’s insufficient education, training, and mentoring. And the rural North has a hard time attracting enough nurses to replace those who are retiring and to meet the needs of an aging population.

University of California-San Francisco researchers who have say although people are still seeking jobs in nursing, student enrollments and graduations have declined.

The California Board of Registered Nursing shows nearly 552,000 active licensed registered nurses in California as of Oct. 1. Yet the California Nurses Association says significantly fewer were practicing, pointing to 2024 data indicating only 350,850 were working in the field. The same problem persists nationally, according to National Nurses United, which reported that, as of May 2024, licensed nurses were not working in the field.

California Hospital Association spokesperson Jan Emerson-Shea said hospitals around the state are facing “skyrocketing costs” for labor, pharmaceuticals, medical equipment, and compliance with government mandates. Patient care costs have soared 30% in the past five years and continue to rise, she said. Meanwhile, 53% of hospitals in the state “lose money every day caring for patients,” she said.

And it could get worse.

Under the GOP tax-and-spending bill that President Donald Trump called the “One Big Beautiful Bill,” the state estimates roughly Californians could lose health coverage due in part to major Medicaid cuts and new rules like work requirements that narrow eligibility for low-income and disabled residents. California is at risk of losing in annual funding, and hospitals will be hit particularly hard because they rely on federal reimbursements and need enough insured patients to remain solvent.

Emerson-Shea said California hospitals stand to lose up to $128 billion over 10 years due to the law.

“This projection does not include the likely increases in uncompensated care due to Medicaid work requirements, coverage losses due to the elimination of the Affordable Care Act subsidies, more frequent Medi-Cal redeterminations, and coverage losses for those with unsatisfactory immigration status,” Emerson-Shea said.

While some California hospitals lose money on patient care, financial data shows the industry is making money, earning about $11.5 billion in net income, or profit, in 2024, said Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, pointing to preliminary state data comparing 365 hospitals. “The industry as a whole has returned to pre-covid profitability levels,” Stremikis said.

He acknowledged, though, that Medicaid cuts will reduce revenue for all facilities.

Hospitals will be burdened as uninsured patients, who often arrive with prolonged illness or injuries that can make treatment more expensive, increase in number. That will exacerbate health care challenges in high-poverty communities with large Medi-Cal populations, since the safety net program generally pays hospitals and providers less than private insurance or Medicare.

Already, some hospitals are closing due to financial struggles, before the impacts of the federal health care cuts are felt, and others are limiting access to care, including by shuttering maternity wards and emergency rooms. Officials at Glenn Medical Center, about 85 miles north of Sacramento, reported that it would be its ER at the due to staffing shortages.

Pandemic-Era Burnout Persists

Front-line nurses said the well-documented from the covid-19 pandemic, mixed with growing hospital demands, is still being felt today as many part ways with the industry. That is prompting some hospitals to hire more traveling nurses from out of state.

At Hazel Hawkins Memorial Hospital, a public facility in San Benito County near the Central Coast, the California Nurses Association said the hospital is employing 22 traveling nurses, although the hospital put the number at 16. Local nurses said temporary workers can ease workloads, but they worry hospitals are using traveling nurses to avoid labor contracts that require higher pay and benefits. They say hospitals should invest in well-trained, local staff familiar with the community.

ER nurse Ariahnna Sanchez said workers at Hazel Hawkins, a , are pressured to discharge patients quickly so more patients can be seen. As union contracts come up for renegotiation, union officials say, hospitals have slashed benefits and haven’t offered adequate raises to keep up with the cost of living. Salaries vary by region but the average annual wage for California registered nurses was $148,330 in 2024, according to the U.S. Bureau of Labor Statistics.

“The morale is so bad right now,” Sanchez said. “We’re trying to fight the good fight but we’re constantly holding people in the emergency room who should be admitted due to the hospital being at max capacity.”

State data shows San Benito County has an of nurses and needs about 180 more to accommodate the local population. But Hazel Hawkins disputes it has a shortage. The California Nurses Association said 40 nurses have left since last year, whereas the hospital said it has replaced 15 of 21 departing nurses.

Hazel Hawkins spokesperson Marcus Young said nurses are conflating staffing levels with protocols for handling ER patients when there aren’t enough beds. “There is no material shortage of nurses and hospital operations are not being impacted today,” Young said. “We are in full compliance with state-mandated nurse-to-patient ratios at all times.”

staffing minimums at hospitals, ranging from one nurse for every three patients to one nurse for every five patients, depending on the level of care the patients require. Research has shown that clinical errors can increase in hospitals and other health care workplaces when nurses are stressed and overwhelmed. that burnout related to work overload, career satisfaction, and patient satisfaction is a major concern and can lead to mistakes.

The state has issued 32 citations to California hospitals since 2020 for violating these minimum nurse staffing levels, financial penalties totaling $840,000, according to the . Neither Hazel Hawkins nor the Turlock hospital Emanuel had any citations. Spokesperson Mark Smith said the agency could not provide information on any “potential, pending or ongoing investigations” into health care facilities alleged to be in violation of state nursing ratios.

Burkett, the nurse in Turlock, said though she can see up to five patients at a time, she exceeded her ratio twice in the past year. In its , Tenet reported $288 million in net income, up from $259 million over the same period last year.

“I’ve taken that assignment against my will,” Burkett said, noting that the union distributes forms protecting nurses from repercussions if mistakes happen on their watch when they take on more patients than the state allows. “It says I’m taking these patients against my better judgment and I’m protected because I am not agreeing to this, but the hospital is making me do it,” she added. “It’s tough. I mean, you just have to juggle and do what you can and hope you’re not going to miss something important. It’s not safe.”

State Sen. Caroline Menjivar, a Democrat representing part of the Los Angeles region, has to strengthen the state’s nurse-to-patient ratio law by requiring hospitals to work harder to identify available nurses to meet staffing mandates.

“Hospitals for years have been getting a pass on minimum nurse staffing,” said Menjivar, a former emergency medical technician. “If we do not provide more support to our nurses, then we do not get the quality care that is needed.”

Menjivar’s niece Megan Noguera-DeLeon is excited about becoming a nurse, despite workplace challenges. A nursing student who expects to graduate next year from West Coast University in Southern California, she said relatives who work as nurses have warned her how tough the job can be. She’s worried about burning out but remains committed to the mission.

“I think taking care of people is a beautiful thing,” Noguera-DeLeon said. “I know this job can be really hard and a lot of nurses are experiencing burnout, but honestly I’ve seen firsthand how much nurses can help people even on the darkest of days, and I want to help people.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/health-industry/california-nursing-shortage-medicaid-funding-management-profit-unions-burnout/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The Centers for Medicare & Medicaid Services is scouring payments covering health care for immigrants without legal status to ensure there isn’t any waste, fraud, or abuse, according to public records obtained by ºÚÁϳԹÏÍø News and The Associated Press. While acknowledging that states can bill the federal government for Medicaid emergency and pregnancy care for immigrants without legal status, federal officials have sent letters notifying state health agencies in California, Colorado, Illinois, Minnesota, Oregon, and Washington that they are reviewing federal and state payments for medical services such as prescription drugs and specialty care.

The federal agency told the states it is reviewing claims as part of its commitment to maintain Medicaid’s fiscal integrity. California is the biggest target after the state self-reported overcharging the federal government for health care services delivered to immigrants without legal status, determined to be at least $500 million, spurring the threat of a lawsuit.

“If CMS determines that California is using federal money to pay for or subsidize healthcare for individuals without a satisfactory immigration status for which federal funding is prohibited by law,” according to a letter dated March 18, “CMS will diligently pursue all available enforcement strategies, including, consistent with applicable law, reductions in federal financial participation and possible referrals to the Attorney General of the United States for possible lawsuit against California.”

The investigations come as the White House and a Republican-controlled Congress slashed taxpayer spending on immigrant health care in President Donald Trump’s spending-and-tax law passed this summer. The administration is also living in the U.S. without authorization off Medicaid rolls. Health policy experts say these moves could hamper care and leave safety net hospitals, clinics, and other providers . Some Democratic-led states — — have already had to end or slim down their Medicaid programs for immigrants due to ballooning costs. Colorado is also considering cuts due to cost overruns.

At the same time, 20 states are pushing back on Trump’s immigration crackdown the administration for on millions of enrollees to deportation officials. A federal judge the move. California’s attorney general, Rob Bonta, who led that challenge, says the Trump administration is launching a political attack on states that embrace immigrants in Medicaid programs.

“The whole idea that there’s waste, fraud, and abuse is contrived,” Bonta said. “It’s manufactured. It’s invented. It’s a catchall phrase that they use to justify their predetermined anti-immigrant agenda.”

Trump Targets Immigrants

Immigrants lacking permanent legal status are not eligible to enroll in comprehensive Medicaid coverage. However, states bill the federal government for emergency and pregnancy care provided to anyone.

Fourteen states and Washington, D.C., expanded their Medicaid programs with their own funds to cover low-income children without legal status. Seven of those states, plus Washington, D.C., have also provided full-scope coverage to some adult immigrants living in the country without authorization.

The Trump administration appears to be targeting only states with full Medicaid coverage for both kids and adults without legal status. Utah, Massachusetts, and Connecticut, which provide Medicaid coverage , have not received letters, for instance. CMS declined to provide a full list of states it is targeting.

Federal officials say it is their legal right and responsibility to scrutinize states for misspending on immigrant health coverage and are taking “decisive action to stop that.”

“It is a matter of national concern that some states have pushed the boundaries of Medicaid law to offer extensive benefits to individuals unlawfully present in the United States,” CMS spokesperson Catherine Howden said about the agency’s probe of selected states. The oversight is intended to “ensure federal funds are reserved for legally eligible individuals, not for political experiments that violate the law,” she said.

Health policy researchers and economists say providing Medicaid coverage to immigrants for preventive services and treatment of chronic health conditions staves off more costly care for patients down the road. It also tamps down insurance premium increases and the amount of uncompensated care for hospitals and clinics.

Francisco Silva, president and CEO of the , said the Trump administration is threatening to drive up health care costs and make it more difficult to access care.

“The impact is emergency rooms would get so crowded that ambulances have to be diverted away and people in a real emergency can’t get into the hospital, and public health threats like disease outbreaks,” Silva said.

California has taken a approach, providing coverage to 1.6 million immigrants without legal status. The expansion, which was rolled out from 2016 to 2024, is estimated to cost $12.4 billion this year. Of that, $1.3 billion is paid by the federal government for emergency and pregnancy-related care.

As California rolled out its expansion, the state erroneously billed the federal government for care provided to immigrants without legal status — details that have not previously been reported and that former state officials shared with ºÚÁϳԹÏÍø News and the AP. The state improperly billed for services such as mental health and addiction services, prescription drugs, and dental care.

Jacey Cooper, who served as California’s Medicaid director from 2020 to 2023, said she discovered the error and reported it to federal regulators. Cooper said the state had been working to pay back at least $500 million identified by the federal government.

“Once I identified the problem, I thought it was really important to report it and we did,” Cooper said. “We take waste, fraud, and abuse very seriously.”

It’s not clear whether that money has been repaid. The state’s Medicaid agency says it does not know how CMS calculated the overpayments or “what is included in that amount, what time period it covers, and if or when it was collected,” said spokesperson Tony Cava.

California has an enormously complicated Medicaid program: It serves the largest population in the nation — nearly — with a budget of nearly this fiscal year.

Matt Salo, a national Medicaid expert, said these types of mistakes happen in states throughout the country because the program is rife with overlapping federal and state rules. Salo and other policy analysts agreed that states have the authority to administer their Medicaid programs as they see fit and root out misuse of federal funds.

And Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Trump administration’s actions “persecute a minority that’s unpopular with the powers that be.”

“The Trump administration cannot maintain that this effort has anything to do with maintaining the fiscal integrity of the Medicaid program,” Cannon said. “There are so much bigger threats to Medicaid’s fiscal integrity, that that argument just doesn’t wash.”

Immigrants’ Medicaid Under Attack

National Republicans have targeted health spending on immigrants in different ways. The GOP spending law, which Trump calls the “One Big Beautiful Bill,” will lower reimbursement to states in October 2026. In California, for example, federal reimbursement for immigrants without legal status will go to 50% for emergency services, down from 90% for the Medicaid expansion population, according to Cava.

The Trump administration is also scaling back Medicaid coverage to immigrants with temporary legal status who were previously covered and that it would provide states with monthly reports pointing out enrollees whose legal status could not be confirmed by the Department of Homeland Security.

“Every dollar misspent is a dollar taken away from an eligible, vulnerable individual in need of Medicaid,” CMS Administrator Mehmet Oz said in a statement. “This action underscores our unwavering commitment to program integrity, safeguarding taxpayer dollars, and ensuring benefits are strictly reserved for those eligible under the law.”

States under review say they are following the law.

“Spending money on a congressionally authorized medical benefit program that helps people get emergency treatments for cancer, dialysis, and anti-rejection medications for organ transplants is decidedly not waste, fraud and abuse,” said Mike Faulk, deputy communications director for Washington state Attorney General Nick Brown.

Records show Washington Medicaid officials have been inundated with questions from CMS about federal payments covering emergency and pregnancy care for immigrants without legal status.

Emails show Illinois officials met with CMS and sought an extension to share its data. CMS denied that request and federal regulators told the state that its funding could be withheld.

“Thousands of Illinois residents rely on these programs to lawfully seek critical health care without fear of deportation,” said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services, noting that any federal cut would be “impossible” for the state to backfill.

Shastri reported from Milwaukee.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/insurance/trump-administration-cms-medicaid-waste-fraud-abuse-immigrants-states/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The Skid Row Care Campus officially opened this spring with ample offerings for people living on the streets of this historically downtrodden neighborhood. Pop-up fruit stands and tent encampments lined the sidewalks, as well as dealers peddling meth and fentanyl in open-air drug markets. Some people, sick or strung out, were passed out on sidewalks as pedestrians strolled by on a recent afternoon.

For those working toward sobriety, clinicians are on site to offer mental health and addiction treatment. Skid Row’s first methadone clinic is set to open here this year. For those not ready to quit drugs or alcohol, the campus provides clean syringes to more safely shoot up, glass pipes for smoking drugs, naloxone to prevent overdoses, and drug test strips to detect fentanyl contamination, among other supplies.

As many Americans have grown increasingly intolerant of street homelessness, cities and states have returned to tough-on-crime approaches that penalize people for living outside and for substance use disorders. But the Skid Row facility shows Los Angeles County leaders’ embrace of the principle of harm reduction, a range of more lenient strategies that can include helping people more safely use drugs, as they contend with a homeless population estimated — among of any county in the nation. the approach can help individuals enter treatment, gain sobriety, and end their homelessness, while addiction experts and county health officials note it has the added benefit of improving public health.

“We get a really bad rap for this, but this is the safest way to use drugs,” said Darren Willett, director of the Center for Harm Reduction on the new Skid Row Care Campus. “It’s an overdose prevention strategy, and it prevents the spread of infectious disease.”

Despite in overdose deaths, drug and alcohol use continues to be the among homeless people in the county. Living on the streets or in sordid encampments, homeless people saddle the health care system with high costs from uncompensated care, emergency room trips, inpatient hospitalizations, and, for many of them, their deaths. Harm reduction, its advocates say, allows homeless people the opportunity to obtain jobs, taxpayer-subsidized housing, health care, and other social services without being forced to give up drugs. Yet it’s hotly debated.

Politicians around the country, including in California, are reluctant to adopt harm reduction techniques, such as needle exchanges or supervised places to use drugs, in part because they can be seen by the public as condoning illicit behavior. Although Democrats are more supportive than Republicans, this year found lukewarm support across the political spectrum for such interventions.

Los Angeles is defying President Donald Trump’s agenda as he advocates for forced mental health and addiction treatment for homeless people — and locking up those who refuse. The city has also been the scene of large protests against Trump’s immigration crackdown, which the president has fought by deploying National Guard troops and Marines.

Trump’s on homelessness and substance use disorder came during his campaign, when he attacked people who use drugs as criminals and said that homeless people “have no right to turn every park and sidewalk into a place for them to squat and do drugs.” Health and Human Services Secretary Robert F. Kennedy Jr. reinforced Trump’s focus on treatment.

“Secretary Kennedy stands with President Trump in prioritizing recovery-focused solutions to address addiction and homelessness,” said agency spokesperson Vianca Rodriguez Feliciano. “HHS remains focused on helping individuals recover, communities heal, and help make our cities clean, safe, and healthy once again.”

A led by Margot Kushel, a professor of medicine at the University of California-San Francisco, this year found that nearly half of California’s homeless population had a complex behavioral health need, defined as regular drug use, heavy drinking, hallucinations, or a recent psychiatric hospitalization.

The chaos of living outside, she said — marked by violence, sexual assault, sleeplessness, and lack of housing and health care — can make it nearly impossible to get sober.

Skid Row Care Campus

The new care campus is funded by about $26 million a year in local, state, and federal homelessness and health care money, and initial construction was completed by a Skid Row landlord, Matt Lee, who made site improvements on his own, according to Anna Gorman, chief operating officer for community programs at the Los Angeles County Department of Health Services. Operators say the campus should be able to withstand potential federal spending cuts because it is funded through a variety of sources.

Glass front doors lead to an atrium inside the yellow-and-orange complex. It was designed with input from homeless people, who advised the county not just on the layout but also on the services offered on-site. There are 22 recovery beds and 48 additional beds for mostly older homeless people, arts and wellness programs, a food pantry, and pet care. Even bunnies and snakes are allowed.

John Wright, 65, who goes by the nickname Slim, mingled with homeless visitors one afternoon in May, asking them what they needed to be safe and comfortable.

“Everyone thinks we’re criminals, like we’re out robbing everyone, but we aren’t,” said Wright, who is employed as a harm reduction specialist on the campus and is trying, at his own pace, to stop using fentanyl. “I’m homeless and I’m a drug addict, but I’m on methadone now so I’m working on it,” he said.

Nearby on Skid Row, Anthony Willis rested in his wheelchair while taking a toke from a crack pipe. He’d just learned about the new care campus, he said, explaining that he was homeless for roughly 20 years before getting into a taxpayer-subsidized apartment on Skid Row. He spends most of his days and nights on the streets, using drugs and alcohol.

The drugs, he said, help him stay awake so he can provide companionship and sometimes physical protection for homeless friends who don’t have housing. “It’s tough sometimes living down here; it’s pretty much why I keep relapsing,” said Willis, who at age 62 has asthma and arthritic knees. “But it’s also my community.”

Willis said the care campus could be a place to help him kick drugs, but he wasn’t sure he was ready.

Research shows harm reduction helps prevent death and can build long-term recovery for people who use substances, said Brian Hurley, an addiction psychiatrist and the medical director for the Bureau of Substance Abuse Prevention and Control at the Los Angeles County Department of Public Health. The techniques allow health care providers and social service workers to meet people when they’re ready to stop using drugs or enter treatment.

“Recovery is a learning activity, and the reality is relapse is part of recovery,” he said. “People go back and forth and sometimes get triggered or haven’t figured out how to cope with a stressor.”

Swaying Public Opinion

Under harm reduction principles, officials acknowledge that people will use drugs. Funded by taxpayers, the government provides services to use safely, rather than forcing people to quit or requiring abstinence in exchange for government-subsidized housing and treatment programs.

Los Angeles County is spending to , while also launching a multiyear “” campaign to build public support, fight stigma, and encourage people to use services and seek treatment. Officials have hired a nonprofit, , to conduct the campaign including social media advertising and billboards to promote the expansion of both treatment and harm reduction services for people who use drugs.

The organization led a national and is working on overdose prevention and public health campaigns in using roughly $70 million donated by Michael Bloomberg, the former mayor of New York.

“We don’t believe people should die just because they use drugs, so we’re going to provide support any way that we can,” said Shoshanna Scholar, director of harm reduction at the Los Angeles County Department of Health Services. “Eventually, some people may come in for treatment but what we really want is to prevent overdose and save lives.”

Los Angeles also finds itself at odds with California’s Democratic governor. Newsom has spearheaded stricter laws targeting homelessness and addiction and has backed treatment requirements for people with mental illness or who use drugs. Last year, California voters , which allows felony charges for some drug crimes, requires courts to warn people they could be charged with murder for selling or providing illegal drugs that kill someone, and makes it easier to order treatment for people who use drugs.

Even San Francisco approved a measure last year that requires welfare recipients to participate in treatment to continue receiving cash aid. Mayor Daniel Lurie recently ordered city officials to stop handing out free drug supplies, including , and instead to require participation in drug treatment to receive services. Lurie signed a recovery-first ordinance, which prioritizes “” from substance use, and the city is also while funding new sober-living sites and treatment centers for people recovering from addiction.

‘Harm Encouragement’

State Sen. Roger Niello, a Republican who represents conservative suburbs outside Sacramento, says the state needs to improve the lives of homeless people through stricter drug policies. He argues that providing drug supplies or offering housing without a mandate to enter treatment enables homeless people to remain on the streets.

Proposition 36, he said, needs to be implemented forcefully, and homeless people should be required to enter treatment in exchange for housing.

“I think of it as tough love,” Niello said. “What Los Angeles is doing, I would call it harm encouragement. They’re encouraging harm by continuing to feed a habit that is, quite frankly, killing people.”

Keith Humphreys, who worked in the George W. Bush and Barack Obama administrations and practices across the nation, said that communities should find a balance between leniency and law enforcement.

“Parents need to be able to walk their kids to the park without being traumatized. You should be able to own a business without being robbed,” he said. “Harm reduction and treatment both have a place, and we also need prevention and a focus on public safety.”

Just outside the Skid Row Care Campus, Cindy Ashley organized her belongings in a cart after recently leaving a local hospital ER for a deep skin infection on her hand and arm caused by shooting heroin. She also regularly smokes crack, she said.

She was frantically searching for a home so she could heal from two surgeries for the infection. She learned about the new care campus and rushed over to get her name on the waiting list for housing.

“I’m not going to make it out here,” she said, in tears.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/mental-health/los-angeles-skid-row-care-campus-drug-use-addiction-harm-reduction-mental-illness/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Some poor and disabled Medicaid patients became , including security deposits and first month’s rent for housing, rides to medical appointments, wheelchair ramps, and even prescriptions for fresh fruits and vegetables.

Such experimental initiatives to improve the health of vulnerable Americans while saving taxpayers on costly medical procedures and expensive emergency room care are booming nationally. Without homes or healthy food, people risk getting sicker, becoming homeless, and experiencing even more trouble controlling chronic conditions such as diabetes and heart disease.

Former President Joe Biden on new benefits, and the availability of social services exploded in states red and blue. Since North Carolina’s launch, have followed by expanding social service benefits covered by Medicaid, the health care program for low-income and disabled Americans — a national shift that’s turning a system focused on sick care into one that prioritizes prevention. And though Trump was pivotal to the expansion, he’s now reversing course regardless of whether evidence shows it works.

In Trump’s second term, his administration is throwing participating states from California to Arkansas into disarray, arguing that social services should not be paid for by government health insurance. Officials at the Centers for Medicare & Medicaid Services, which grants states permission to experiment, have rescinded its previous , arguing that the Biden administration went too far.

“This administration believes that the health-related social needs guidance distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans,” CMS spokesperson Catherine Howden said in a statement.

“This decision prevents the draining of resources from Medicaid for potentially duplicative services that are already provided by other well-established federal programs, including those that have historically focused on food insecurity and affordable housing,” Howden added, referring to food stamps and low-income housing vouchers provided through other government agencies.

Trump, however, has also proposed axing funding for low-income housing and food programs administered by agencies including the departments of and — on top of Republican proposals for broader .

The pullback has led to chaos and confusion in states that have expanded their Medicaid programs, with both liberal and conservative leaders worried that the shift will upend multibillion-dollar investments already underway. Social problems such as homelessness and food insecurity can cause — or worsen — physical and behavioral health conditions, leading to sky-high health care spending. Medical care delivered in hospitals and clinics, for instance, accounts for only roughly 15% of a person’s overall health, while a staggering 85% is influenced by social factors such as access to healthy food and shelter for sleep, said Anthony Iton, a policy expert on .

Health care experts warn the disinvestment will come at a price.

“It will just lead to more death, more suffering, and higher health care costs,” said Margot Kushel, a primary care doctor in San Francisco and on homelessness and health care.

The Trump administration announced in a that it was rescinding Biden-era guidance dramatically expanding experimental benefits known as . Federal waivers are required for states to use Medicaid funds for most nontraditional social services outside of hospitals and clinics.

Last month, the administration told states that these services, which can also include high-speed internet and storage units, should .

Future waiver requests allowing Medicaid to provide social services — a liberal philosophy — will be considered on a “case-by-case basis,” the administration said. Rather, it has signaled a conservative shift toward requiring most Medicaid beneficiaries to prove that they’re working or trying to find jobs, which puts an estimated Americans at risk of losing their health coverage.

“What they’re arguing is Medicaid has been expanded far beyond basic health care and it needs to be cut back to provide only basic coverage to those most desperately in need,” said Mark Peterson, a health policy expert at UCLA. “They’re making the case, which is not widely shared by specialists in the health care field, that it’s not the job of taxpayers and Medicaid to pay for all this stuff outside the traditional heath care system.”

Although states have not received formal guidance to end their social experiments, Peterson and other health policy researchers expect the administration not to renew waivers, which typically run in five-year intervals. Worse, legal experts say programs underway could be halted early.

Evidence supporting by Medicaid is still nascent. An expansion in Massachusetts that provided food benefits , for instance. But often,

California is , investing $12 billion over five years to provide , from intensive case management to help people with severe behavioral health conditions to through a . The most popular benefits provided by health insurers are those that help homeless people on Medicaid by placing them in apartments or securing beds in recovery homes, covering up to $5,000 for security deposits, and preventing eviction.

Since the launched in 2022, it has served only a small fraction of the state’s Medicaid beneficiaries, with . Yet it has improved and even saved the lives of some of those lucky enough to get help, including Eric Jones, a 65-year-old Los Angeles resident.

“When I got diabetes, I didn’t know what to do and I had a hard time getting to my medical appointments,” said Jones, who lost his housing this year when his mom died but received services through his Medi-Cal insurer, L.A. Care. “My case manager got me rides to my appointments and also helped me get into an apartment.”

California is considering making some of its social services permanent after the CalAIM waivers expire at the end of 2026. Gov. Gavin Newsom’s administration is adding more housing services, including up to six months of free rent under a third waiver approved by the Biden administration. Medi-Cal officials contended early evidence shows CalAIM has led to better care coordination and fewer hospital and ER visits.

“We are fully committed,” , a deputy director for the state Department of Health Care Services, which administers the program. “We have invested so much.”

Health insurers, which deliver Medicaid coverage and receive greater funding to cover these additional benefits, say they’re worried the Trump administration will end or curtail the programs. “If we do things the same old way, we’re just going to generate the same old results — people getting sicker and health care costs continuing to rise,” said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents insurers.

Industry leaders say the expansion is already changing lives.

“We believe wholeheartedly that housing is health, food is health, so seeing these programs disappear would be devastating,” said Kelly Bruno-Nelson, executive director of Medi-Cal for CalOptima Health, a health insurance provider in Orange County.

Oregon is low-income Medicaid patients with a range of , including home-delivered healthy meals and rental payment assistance. Residents for air conditioners, heaters, air filters, power generators, and mini fridges. State Medicaid officials say they remain committed to providing the benefits but worry about federal cuts.

“Climate change and housing instability are huge indicators of poor health,” said Josh Balloch, vice president of health policy and communications at AllCare Health, a Medicaid insurer in Oregon. “We hope to prove to the federal government that this is a good return on their investment.”

But even as the Trump administration curtails waivers, it is retaining discretion to provide social services in Medicaid, just on a smaller scale. Supporters say it’s fair to scrutinize where to draw the line on taxpayer spending, arguing that there isn’t always a direct health connection.

“We’re seeing these things increase, with the free rent, and we’re seeing some states pay for free internet, paying for furniture,” said Kody Kinsley, who previously served as North Carolina’s top health official. “We know there’s evidence for food and housing, but with all of these new benefits, we need to look closely at the evidence and the linkage to what actually drives health.”

Current North Carolina officials say they’re confident the new social services Medicaid provides in their state have resulted in better health and lower overall spending on expensive and acute care. Medicaid recipients there can even use the program to buy farm-fresh produce.

While it’s too soon to know whether these experiments have been effective elsewhere in the United States, early evidence in North Carolina shows promise: The state had saved a year into its experiment — operating in mostly rural counties — by reducing ER trips and hospitalizations.

State health officials also touted the economic benefits of driving business to family farms, home improvement contractors, and community-based organizations providing housing and social services.

“I welcome the challenge of demonstrating the effectiveness of our programs. It’s making for healthier people and healthier budgets,” said Jay Ludlam, deputy secretary for North Carolina’s Medicaid program. “Family farms that were on the verge of collapse after Hurricane Helene are now benefiting from a steady income while they also serve their community.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/medicaid/medicaid-medi-cal-social-determinants-health-california-guidance-trump-cms/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

In March, as President Donald Trump and congressional Republicans escalated a nationwide debate over whether to slash health care for poor and disabled Americans, the Democratic governor had to tell state lawmakers that California’s health care costs had spiraled out of control due to he backed — including the nation’s largest expansion of taxpayer-financed health care for immigrants living in the U.S. without legal permission.

His top officials at the state Department of Finance quietly disclosed to California lawmakers in a letter that the state had to pay health insurers, doctors, and hospitals caring for patients enrolled in California’s Medicaid program, known as Medi-Cal. Facing rising health care costs amid a , Newsom now must contemplate rolling back coverage and benefits.

The second-term governor faces a tough political decision: renege on his promise to achieve and strip coverage from millions of immigrants who lack legal status or look elsewhere for budget cuts. With nearly 15 million low-income or disabled residents enrolled in Medi-Cal, California has on health care than any other state. Yet even as Newsom has condemned Trump’s approach to tariffs and environmental policies, he has been tight-lipped on health policy.

Complicating his political tightrope: that providing health care coverage for immigrants without legal status has tepid support. And any resulting budget trouble could harm his political legacy should he run for president in 2028.

“We all know that the cuts are definitely coming,” said Carlos Alarcon, a health and public benefits analyst with the California Immigrant Policy Center, which has helped spearhead a decade-long campaign in California to expand Medicaid to eligible immigrants without legal status. “The governor should keep his commitment — we’ll be very disappointed if we see cuts and rollbacks. When times get hard, it’s always our marginalized and underserved communities that lose out.”

California in Medi-Cal if they earn level, or , regardless of immigration status. But the costs have been dramatically higher than expected.

Democratic Gov. Jerry Brown expanded Medi-Cal to people age 19 and younger without legal status, but he expressed because of potential costs. Newsom signed bills into law adding people age 20 and older. An estimated 1.6 million immigrants without legal status are now covered, and costs have soared to $9.5 billion per year, up from $6.4 billion estimated in November. The federal government chips in roughly $1.1 billion of that total for pregnancy and emergency care.

“We can expand out of the graciousness of our heart to everywhere and anywhere, but the moment these resources run out, now everybody loses. We’re hitting that breaking point,” said California Assembly member David Tangipa, a Fresno Republican. “Either we get fiscally responsible, or there’s not going to be services for anybody — and that includes the Californian and the undocumented immigrant.”

Democratic leaders responsible for approving the state budget declined interviews. In a statement, state Sen. María Elena Durazo, a Los Angeles Democrat, who championed the expansion in the legislature, said, “Rolling back this progress would be a harmful and shortsighted decision.”

Lawmakers are considering freezing enrollment for immigrants without legal status, imposing cost-sharing measures such as drug copays or premiums, or restricting benefits, according to people familiar with the matter, who asked not to be identified to protect relationships at the state Capitol.

However, it’s unlikely Newsom will slash funding in his budget revision set for release on May 14. Instead, cuts would follow if congressional Republicans approve a budget deal with major reductions in federal spending on Medicaid.

“This is going to be very problematic for the governor. Budget cuts will disrupt the lives of millions of immigrants who just got health care, but the governor has got to do something, because this is not sustainable,” said Mark Peterson, an expert on health care and national politics at UCLA. “The prospect of cutting other places in order to support immigrants living in the country illegally would be a hard political sale; I don’t see that happening.”

Should Newsom, along with the Democratic-controlled legislature, be forced to make cuts, he could argue he had no choice. Trump and congressional Republicans have threatened states like California with the cutting Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status.For Newsom, political analysts say, Trump could make an easy scapegoat.

“He can blame Trump — there’s only so much money to go around,” said Mike Madrid, an anti-Trump Republican political analyst in California who specializes in Latino issues. “It’s making people look at the health care that they can’t afford and ask, ‘Why the hell are we giving it for free to people who are here illegally?’”

The exorbitant cost has come as somewhat of a surprise.

In as governor — in which he called for expanding Medi-Cal to young adults without legal status — his administration estimated it would cost roughly $2.4 billion annually to extend benefits to all eligible people regardless of status. But the latest figure reported to legislators was nearly four times as much.

Newsom declined to respond to questions from ºÚÁϳԹÏÍø News, instead referencing previous comments that leave the door open to scaling back Medi-Cal. The governor noted “sober” discussions with lawmakers and said cutting Medi-Cal is “an open-ended question” that the president will heavily influence.

“What’s the impact of Donald Trump on a lot of these things? What’s the impact of federal vandalism to a lot of these programs?” Newsom asked , suggesting it’s unclear whether he’ll be able to sustain the expansion to immigrants without legal status in future years.

Newsom expanded Medi-Cal in three phases, starting with immigrants ages 19 to 25, who became eligible in 2020, resisting pressure from health care advocates for one big, costly expansion. He argued doing it incrementally would ultimately save California money.

“It is the right thing morally and ethically,” . “It is also the financially responsible thing to do.”

Record budget surpluses in recent years allowed Democrats to continue. Older adults ages became eligible in 2022, and Newsom closed the gap the following year, approving coverage starting in 2024 for the biggest group, those ages .

But the costs have grown tremendously while the budget picture has soured, according to a ºÚÁϳԹÏÍø News analysis of the most recent 2023 records available from the state Department of Health Care Services, which administers Medi-Cal.

Aside from children, it was more expensive to provide Medicaid coverage to immigrants without legal status than to legal residents. For instance, Medi-Cal paid L.A. Care, a major health insurer in Los Angeles, an average of $495.32 monthly to provide care for a childless adult without legal status and $266.77 for a legal resident without kids.

Not only were immigrants without legal status more expensive, California footed most of the cost. The state paid roughly between 60% and 70% of health care costs for a childless adult immigrant covered by L.A. Care, and about 10% for a legal resident without kids. Those costs don’t encapsulate the entire cost of providing care, which can vary depending on where Medi-Cal patients live, and grow higher when filling prescriptions, going to the dentist, or seeking mental health care.

These payments also differ by insurer, but the trend holds across the state’s Medi-Cal health insurance plans. Patients in most of the state can choose from more than one health plan.

Children without legal status in many cases were cheaper to cover than children who were legal residents. Generally, kids are healthier and require less care.

Mike Genest, who served as finance director under former Republican Gov. Arnold Schwarzenegger, argued that the state should have planned for the immense price tag.

“The idea that we’d be able to afford in the long run paying for health care for all these undocumented people — it’s beyond unsustainable,” Genest said.

While costs are high now, the expansion of Medi-Cal will result in long-term savings to taxpayers and the health care system, said Anthony Wright, who previously lobbied for the expansion as the head of the nonprofit Health Access and is now fighting Medicaid cuts as the executive director of , based in Washington, D.C.

“They’re going to be showing up in our health care system regardless,” Wright said. “Leaving them without health insurance is just going to end in more crowded emergency rooms, and it’s going to cost even more. It doesn’t make any sense economically for them to be uninsured; that takes critical revenue from clinics and hospitals, just causing more problems.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/health-care-costs/california-governor-newsom-medicaid-universal-health-care-immigrant-coverage-trump-political-tightrope/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Researchers say housing is the most important intervention to end homelessness, and now a from the University of California-San Francisco sheds deeper insight: While California’s high housing costs and low incomes drive people into homelessness, those with behavioral health conditions face added risk of becoming homeless. And once people lose housing, homelessness makes them more likely to use drugs or experience a mental health problem. 

The report found that of homeless adults in California have a serious mental health condition or use drugs or alcohol, and 42% of people who regularly use drugs began doing so after becoming homeless. 

“Complex behavioral health needs, including substance and mental health problems, increase the risk of becoming homeless, and homelessness exacerbates these problems,” said Margot Kushel, director of the Benioff Homelessness and Housing Initiative at UCSF. 

Kushel and others argue that housing and supportive services are critical. Instead, President Donald Trump is pushing a treatment-first approach. 

During his campaign, Trump called for relocating homeless people to large camps and forcing treatment, a punitive approach that he says will come with jail time if people refuse. 

Now in office, Trump has launched a broad assault on “Housing First.” 

The nationwide anti-homelessness policy, aimed at getting people into permanent housing, was created under President George W. Bush and for decades has steered federal funding into housing and social service programs. 

Already, city and county officials are being told that the federal Department of Housing and Urban Development “” homelessness contracts if they follow the Housing First model. And as Trump officials seek major funding cuts, the president this month shrinking the U.S. Interagency Council on Homelessness, which was established under President Ronald Reagan to coordinate homelessness initiatives around the nation. 

The focus has been on offering housing and voluntary treatment, even if those promises elude too many people. Now, those programs will be eroded. 

Democratic U.S. Rep. Maxine Waters of Los Angeles warns: “Make no mistake that Trump’s reckless attacks across the federal government will supercharge the housing and homelessness crisis in communities across the country.”Ìý

This <a target="_blank" href="/mental-health/the-week-in-brief-trump-homelessness-treatment-over-housing/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“Our once-great cities have become unlivable, unsanitary nightmares,” Trump said in a . “For those who are severely mentally ill and deeply disturbed, we will bring them to mental institutions, where they belong, with the goal of reintegrating them back into society once they are well enough to manage.”

Now that he’s in office, the assault on “” has begun.

White House officials haven’t announced a formal policy but are opening the door to a treatment-first agenda, while engineering a major overhaul of the housing and social service programs that form the backbone of the homelessness response system that cities and counties across the nation depend on. Nearly alone. But now, Scott Turner, who heads Trump’s Department of Housing and Urban Development — the agency responsible for administering housing and homelessness funding — has outlined massive funding cuts and called for a .

“Thanks to President Trump’s leadership, we are no longer in a business-as-usual posture and the DOGE task force will play a critical role in helping to identify and eliminate waste, fraud and abuse and ultimately better serve the American people,” in a statement.

Staffing cuts already proposed the part of the agency overseeing homelessness spending and Housing First initiatives particularly hard. Trump outlined his vision during his campaign, calling for new treatment facilities to be opened on large parcels of government land — “tent cities where the homeless can be relocated and their problems identified.” They could receive treatment and rehabilitation or face arrest. Now in office, he has begun to turn his attention to street homelessness, in March ordering Washington, D.C., , potentially separating homeless people from their case managers and social service providers, derailing their path to housing.

The administration is discouraging local governments from following the federal policy, telling them it homelessness contracts “to the extent that they require the project to use a housing first program model.” And, “reducing the scope of the federal bureaucracy,” Trump slashed the U.S. Interagency Council on Homelessness, shrinking the agency responsible for coordinating funding and initiatives between the federal government, states, and local agencies, known as .

“Make no mistake that Trump’s reckless attacks across the federal government will supercharge the housing and homelessness crisis in communities across the country,” Democratic U.S. Rep. Maxine Waters of Los Angeles said in response to the order.

Support Without Forced Treatment

was implemented nationally in 2004 under the George W. Bush administration to combat chronic homelessness, having lived on the streets with a disabling condition for a long period of time. It was expanded under President Barack Obama as America’s plan of attack on homelessness and broadened by President Joe Biden, who argued that housing was a basic need, critical to health.

The policy aims to stabilize homeless people in permanent housing and provide them with case management support and social services without forcing treatment, imposing job requirements, or demanding sobriety. Once housed, the theory goes, homeless people escape the chaos of the streets and can then work on finding a job, taking care of chronic health conditions, or getting sober.

“When you’re on the streets, all you’re doing every day is figuring out how to survive,” said Ann Oliva, CEO of the National Alliance to End Homelessness. “Housing is the most important intervention that brings a sense of safety and stability, where you’re not just constantly trying to find food or a safe place to sleep.”

But Trump wants to gut taxpayer-subsidized housing initiatives. He is pushing for a punitive approach that would impose fines and potentially jail time on homeless people. And he wants to mandate sobriety and mental health treatment as the primary homelessness intervention — a stark reversal from Housing First.

The shift has ignited fear and panic among homelessness experts and front-line service providers, who argue that forcing treatment and criminalizing homeless people through fines and jail time simply doesn’t work.

“It’s only going to make things much worse,” said Donald Whitehead Jr., executive director of the National Coalition for the Homeless. “Throwing everybody into treatment programs just isn’t an effective strategy. The real problem is we just don’t have enough affordable housing.”

Trump got close to ending Housing First during his first term when he tapped Robert Marbut to lead the U.S. Interagency Council on Homelessness . Marbut mandating treatment and reducing reliance on social services, while curtailing taxpayer-subsidized housing. He argued that forcing homeless people to get sober and enter treatment would help them achieve self-sufficiency and end their homelessness. But covid-19 stalled those plans.

Now, Marbut said, he believes the president will finish the job.

“Trump knows that what we need to do is get funding back to treatment and recovery,” Marbut said. “The Trump administration is laser-focused on ending Housing First. They realized it was wrong the first time and that’s why I was selected to change it. They still realize it’s wrong.”

Trump and administration officials did not respond to questions from ºÚÁϳԹÏÍø News. A request to interview Turner was not granted. Project 2025’s “,” a conservative policy blueprint from some of Trump’s closest advisers, explicitly calls for an end to Housing First.

Under Attack

Housing First is under attack not only from Republicans who have long criticized taxpayer-subsidized housing for homeless people, but also from Democrats responding to public frustration over homeless encampments multiplying around the nation. Last year, the federal government estimated that people in the U.S. were homeless, a record high. That was up 18% from 2023. And while housing grows increasingly unaffordable, homeless camps have exploded, spilling into city parks, crowding sidewalks, and polluting sensitive waterways, despite unprecedented public spending.

Already, cities and states, liberal and conservative, are cracking down on street homelessness and targeting the mental health and addiction crisis. This is true even in deep-blue states like California, where Gov. Gavin Newsom has created a “” initiative that can mandate treatment even though housing isn’t always available and threatened to withhold funding from cities and counties that don’t aggressively clear encampments.

San Francisco Mayor Daniel Lurie has proposed for drug users. Los Angeles Mayor Karen Bass is prioritizing encampment sweeps even though the promise of housing or shelter is elusive. And San Jose Mayor Matt Mahan for plans to who refuse shelter three times in 18 months and to to pay for an expansion of homeless shelters.

Mahan believes liberals and advocates have been too “purist” because housing isn’t being built fast enough, while investments in shelter and treatment have been inadequate. “It can’t only be about Housing First,” he said.

Homelessness crackdowns have exploded since the U.S. Supreme Court made it easier for elected officials and law enforcement agencies to fine and arrest people for living outside. Since June, roughly 150 laws imposing fines or jail time have been passed, with about 45 in California alone, said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

Rabinowitz and other experts say both Republicans and Democrats are undermining Housing First by criminalizing homelessness and conducting encampment sweeps that hinder the ability of front-line workers to get people into housing and services.

However, there’s disagreement on whether to entirely dismantle the policy. Liberal leaders want to maintain existing streams of housing and homelessness funding while expanding shelters and moving people off the streets. Conservatives blame Housing First for the rise in homelessness and are instead pushing for mandatory treatment and cutting housing subsidies.

“I used to think it was just a waste of taxpayer money because it wasn’t treatment-based, but now I think it actually enables people to remain homeless and addicted,” Marbut said of the Housing First approach. He favors requiring behavioral health treatment as a prerequisite to housing.

Evidence shows Housing First has been successful in moving vulnerable, chronically homeless people into permanent housing. For instance, of 26 studies indicated that, compared with treatment-first, “Housing First programs decreased homelessness by 88%.”And the approach has shown in health, reducing costly hospital and emergency room care.

Experts say Housing First has been and implemented unevenly, with some homelessness agencies taking federal money but not providing appropriate services or housing placements.

“Making it the broad policy to all homelessness leaves it vulnerable to being attacked the way it’s currently being attacked,” said Philip Mangano, a Republican who spearheaded the development of Housing First as the lead homelessness adviser to George W. Bush. “The truth is it’s a mixed bag. For some people like those who are using substances, the evidence just isn’t there yet.”

Others say it has been ineffective in some places because of rampant misspending, abuse, and a .

“This works when it’s done right,” said Marc Dones, a policy director for homelessness initiatives at the University of California-San Francisco, arguing that housing can save lives and lower spending on costly health care. “But I think we have been too polite and too nice for too long about some real incompetence.”

Jeff Olivet, who succeeded Marbut at the U.S. Interagency Council on Homelessness under Biden, said Marbut and Trump’s positions are misguided. He argues that Housing First has worked for those who have gotten indoors, yet the number of people falling into homelessness outpaces those getting housing. And he says there was never enough money to provide housing and supportive services for everyone in need.

“Housing First is not just about sticking somebody in an apartment and hoping for the best,” Olivet said. “It’s really about providing stable housing and access to health care, mental health and substance use treatment, and to support people, but not forcing it on people.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/public-health/trump-homelessness-policy-housing-first-forced-treatment/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">