Afterward, though, use of Sturgis Hospital’s emergency department fell, according to data collected at the state level. In June, three years after taking the federal lifeline, the hospital closed, leaving residents of Sturgis, a town of about 11,000 people, without critical healthcare. Its leaders had tried “every reasonable option” to remain open, including seeking a buyer, according to a

The closure “could be kind of a canary in the coal mine” for rural healthcare, said Lauren LaPine-Ray, the vice president of policy and rural health at the Michigan Health & Hospital Association.

Federal leaders have spent decades trying to prop up rural hospitals, which face persistent staffing shortages, low federal payment rates, and declining patient numbers.

About 1,700 hospitals nationwide are eligible to convert to the stripped-down Rural Emergency Hospital model. So far, more than 50 rural hospitals in over 20 states have signed on, but LaPine-Ray and other hospital leaders nationwide fear Sturgis’ failure is a sign the new model won’t be enough to keep doors open when the anticipated federal funding losses arrive from President Donald Trump’s signature One Big Beautiful Bill Act.

Last year, the survival of rural hospitals became as Congress debated the massive tax and spending law, which is expected to reduce Medicaid funding by more than $900 billion over 10 years. The reductions are expected to have a substantial impact in rural areas that often have high Medicaid enrollment. Republicans added the new $50 billion Rural Health Transformation Program to win votes from a few holdouts in their ranks.

Sturgis’ facility is the only rural U.S. hospital to in 2026. The day before it shuttered, four senators — including Maine Republican Susan Collins, an architect of the rural health fund — sent a letter to Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services. said the way his agency structured the fund “may unintentionally disadvantage many of the rural hospitals and clinics the program was intended to support.”

Congress created the emergency hospital model, which took effect in 2023, as “a whole new way of providing care,” said George Pink, a senior research fellow at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. The Sheps Center tracks rural hospital closures and conversions, and Pink recently released early research showing converted hospitals reporting improved finances, though some are not yet in the black.

Hospitals that convert to the emergency model get a 5% boost in Medicare payments plus an extra monthly facility payment, totaling about $3.6 million a year, according to the Rural Health Redesign Center. In return, the hospitals must offer emergency services and give up their inpatient beds. They can continue offering outpatient services.

Janice Walters, CEO of the Rural Health Redesign Center, which has received federal funding to help hospitals change to the new model, said dozens of hospitals had reached out about converting during the first five months of 2026. It’s reasonable, she said, to presume that 10 or 11 might convert this year.

‘No Easy Answers’

More than 40% of all rural hospitals lose money, and hundreds have eliminated obstetrics, general surgery, and chemotherapy services, the healthcare consulting group Chartis.

Sen. Chuck Grassley (R-Iowa) sponsored the legislation that created the emergency hospital model. He touted the program last fall, pointing to hospitals such as Landmann-Jungman Memorial Hospital Avera in South Dakota, which he said would be able to use the model to enhance local health services.

Melissa Gale, the chief executive of the Scotland, South Dakota, hospital, said the facility averaged less than one inpatient a day and was “a little above or below break-even year-over-year for decades.”

Today, with additional federal funding from the emergency model, Gale said, the hospital could try to draw in more patients for mammograms and may add a wound care program. In the past year, the hospital has improved employee benefits and reinvested in the building, upgrading plumbing and the heating and air conditioning, she said.

“No one wants to see rural health fail,” Gale said, adding, “There’s no easy answers.”

Federal lawmakers have tried, and thus far failed, to update the emergency hospital model. One proposal, which is expected to be reintroduced, would allow converted hospitals to offer new services, such as beds for patients who need short-term recovery and in-house obstetric labor and delivery units. Another, which is in committee, would allow hospitals to use a federal drug discount program that many facilities use to generate revenue.

The current law is a “critical start, but it must evolve,” said Carrie Cochran-McClain, the chief policy officer for the National Rural Health Association, whose members include hospitals and clinics.

Residents of the southeastern Iowa town of Keokuk continue to hope their shuttered hospital will reopen under the program. The effort has been plagued by delays.

The Keokuk hospital went out of business in 2022 and was later purchased by a Michigan company that pledged to reopen it.

“It’s been a slower process than we envisioned,” said Insight Health Systems Vice President Dayne Walling. Many of the delays have been related to improvements needed to the aging building, he said. Without the emergency hospital model, Walling said, his company would not see a realistic path to reviving the hospital.

Walling said the emergency model would be even better if Congress approved the bill that would allow hospitals to make extra income from prescription medications.

Dierdra Sorrell, the CEO of Clifton-Fine Hospital in Star Lake, New York, said converting to an emergency hospital was not a “silver-bullet, magic pill.” But it “put us in a much better place.”

The 20-bed hospital lost more than $2.5 million annually before 2024, when it became New York’s first emergency hospital, Sorrell said. While converting, the hospital shut down inpatient beds and cut 20 employees.

The first year, Clifton-Fine lost only $600,000, and its emergency patient visits were “rock solid,” Sorrell said. The hospital also won state grant money to update its two-bed emergency room and pay for additions that could house visiting specialty doctors or new lines of services, such as a dental hygienist.

If Clifton-Fine had not converted, Sorrell said, anticipated Medicaid losses could have “put us under.”

‘One Important Tool’

Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, said the emergency model is “one important tool” for rural hospitals, “but each facility must determine whether this care model is appropriate.” Foster also said that the new five-year, $50 billion rural health fund was created to support “innovative, system-wide reforms” that strengthen the rural healthcare delivery system.

Of the 56 hospitals that have converted to the rural emergency model, two have closed, and three remain open but have changed what services they offer, according to Sheps.

In Holly Springs, Mississippi, Alliance HealthCare System was one of the first to convert to the emergency hospital designation, laying off staff and shutting down inpatient beds.

Then, federal officials said they and required the hospital to recertify as a new hospital, a delay that cost an estimated $1.5 million in federal reimbursement, CEO Kenneth Williams said.

The hospital is “a shell of what it once was,” Williams said. The ER remains closed.

“We have survived, but survival has come at a tremendous cost,” he said.

Williams said he is closely watching the impact of upcoming Medicaid changes because cuts in insurance coverage or payments “ultimately affect patient access,” he said.

Sen. Josh Hawley (R-Mo.), who voted for the One Big Beautiful Bill Act — which included both the rural health fund and the Medicaid spending reductions — has asked for more support for rural hospitals. Ten full-service rural hospitals in Missouri have closed in the past 12 years, according to the Sheps Center.

Last year, Hawley introduced legislation to . This June, he to announce that he wanted to pay rural hospitals $1 million annually, or more if needed, to keep emergency rooms operating. A spokesperson said the bill would apply to all rural hospitals, including those using the emergency model.

Michigan’s Sturgis Hospital faced “some significant challenges” in 2023 when it converted to the emergency hospital model, said LaPine-Ray, of the state hospital association. In the news release, hospital officials said the closure was due to declining reimbursement rates, rising costs, and declining patient numbers. Bobby Morin, a former chief operating and financial officer at the hospital, declined to comment.

The hospital’s ER patient volume dropped 13% in the two years after it converted, LaPine-Ray said. Five rural hospitals have closed in the past 20 years in Michigan, and LaPine-Ray said she doubts the rural health fund Congress approved last year will stop the closures. The association, which worked with the governor’s office on the funding, expects less than 10% of Michigan’s $173 million in first-year rural health funding to trickle down to rural hospitals.

That money will pay for “very specific programs where rural hospitals have to create basically a new program and implement it with no funding on the front end,” LaPine-Ray said.

At the same time, she said, the association expects Michigan hospitals to lose $6 billion in Medicaid payments over the next decade because of the One Big Beautiful Bill Act.

“What’s it going to look like in the coming years?” LaPine-Ray said.

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Enrollment in Affordable Care Act plans fell by nearly 3 million this year to about 19.2 million, following steep premium increases by insurers and the Republican-led Congress’ unwillingness to extend more generous premium subsidies. On average, ACA customers in premium payments this year, a 58% increase from 2025, according to KFF, while their deductibles — the amount consumers must pay annually before insurers pick up their share — have climbed 37% to nearly $3,800 a year.

“These are real people who are now forced to make impossible choices,” said Annalyse Keller, a spokesperson for a large coalition of lobby organizations for the healthcare industry, including insurers and patient advocacy groups.

But a released in June, written mostly by President Donald Trump’s political appointees and allies, asserts that 5.6 million people were fraudulently enrolled in ACA plans in 2025, and that the Trump administration removed 2.9 million of them — the same number as the 2026 drop in enrollment.

There’s little dispute that the ACA suffers from some fraud, as do most government programs. The administration said it has taken actions to tighten the enrollment process to thwart brokers who fraudulently enroll people without their knowledge.

For example, the administration in August 2025 halted a Biden-era initiative that allowed low-income people to sign up for coverage year-round. Regulators 1.5 million people since 2025 for reasons such as not meeting a requirement to file their taxes over two years or being concurrently enrolled in another health program, such as Medicaid, which is not allowed.

But health policy experts say that the administration is overstating the extent of ACA fraud and that the HHS report relies on debatable assumptions, such as that all sign-ups under the year-round enrollment program for low-income people were potentially fraudulent. ACA enrollment fell off a cliff because of escalating prices for insurance plans, policy analysts say, which the administration’s done nothing to stem.

“The top-level claim” that all the decline in enrollment since 2025 is because of improper or fraudulent enrollees leaving the market “is not remotely credible,” said , a senior fellow at the Brookings Institution. “We know that lots of people have seen higher premiums, and there’s really good evidence that when premiums go up, people drop coverage.”

Healthcare costs are a big concern for voters ahead of November’s midterm elections, and both Democrats and Republicans are trying to spin the issue to their advantage. Democrats argue more needs to be done to make insurance less expensive for consumers, while Republicans are trying to focus on the need to save taxpayer dollars from fraud.

found that voters trust Democrats over Republicans to address healthcare costs (37% vs. 26%). The poll also found, though, that 55% of Republican voters consider it extremely important for candidates to address healthcare fraud, more than any other issue, showing that the White House’s effort to shift focus from costs has had some success with its own supporters.

But Jonathan Oberlander, a professor of health policy and management at the University of North Carolina, questioned whether the fraud narrative will hold up as voters continue to struggle with rising costs.

“It will be cold comfort to the very real persons who could no longer afford coverage and dropped their plans,” he said in an email to ºÚÁϳԹÏÍø News.

How We Got Here

Under President Joe Biden, Congress that included more generous tax subsidies for people enrolled in Obamacare, starting in 2021. Those enhanced subsidies lowered premium payments, for a large enough tax credit to reduce their monthly payment to zero. The Biden-era law also allowed wealthier households to get assistance.

ACA coverage essentially doubled, from just over 11 million Americans in 2021 to more than 22 million in 2025, according to the HHS report.

Republicans and conservative groups argue that the growth wasn’t driven only by people newly enrolling because of lower premiums. Instead, they say, the enhanced subsidies, along with other Biden-era policies — including easing income verification requirements for some enrollees — invited fraud. Unscrupulous, commission-seeking insurance brokers found it easier to sign people up for coverage, often without their knowledge, while ordinary consumers could more easily fudge their income and qualify for the largest subsidy possible.

The conservative Paragon Health Institute’s president, Brian Blase, wrote that the HHS report’s conclusion on the scope of improper enrollment is likely an undercount. He remains unconvinced by the arguments that rising premiums are to blame for the sharp drop in ACA enrollment, saying subsidies remain generous for many people.

The Administration’s Current Targets

The debate will continue as more enrollment data emerges from the federal marketplace and the exchanges run by states. Some policy experts — including the consulting group Wakely — expect the year to end with the number of ACA policyholders down by .

Trump’s regulators will likely connect further drops with anti-fraud efforts. The HHS report alleges there are potentially millions more who remain improperly enrolled. The report’s authors noted that some of the administration’s anti-fraud proposals have been blocked by court rulings.

HHS released June 27, HHS Secretary Robert F. Kennedy Jr. pats Mehmet Oz, the head of the Centers for Medicare & Medicaid Services, on the back for the number of canceled ACA plans so far. Oz threatens potential ACA hucksters: “Don’t walk away from us, run! Because we are going to find you.”

In an email responding to ºÚÁϳԹÏÍø News’ questions, CMS spokesperson Christopher Krepich said his agency this summer will block ACA applications made by brokers that lack a Social Security number. By open enrollment this fall, CMS plans to require more identify-proofing when brokers enroll people and will limit a broker’s access to accounts until that person “has been authorized by the consumer to work on their behalf.”

How some suspicious enrollments will be removed is spelled out in emails sent in June to insurance carriers and obtained by ºÚÁϳԹÏÍø News.

CMS told insurers that the agency will send them files for ACA accounts it believes are potentially unauthorized. Each flagged consumer account will have used a sales broker to enroll, be in a zero-premium plan, and lack a Social Security or an immigration documentation number — which Kennedy said in the video is a glaring sign of fraud.

Insurers must try to contact the enrollees to verify that they signed up for coverage. After 60 days, insurers must report policies they were unable to verify to CMS, which will cancel them.

Krepich wrote that carriers are cooperating with efforts to investigate accounts with missing or unverified information.

Policy experts, including Fiedler, note that the absence of a Social Security number doesn’t automatically prove fraud. While it could indicate a fake enrollee, a missing Social Security number might also be a simple oversight by the consumer or their broker, for example, or a newborn added to a parent’s account at birth, before they’ve received a number.

“That the administration put it in a report and did not summarily terminate these enrollments suggests they believe there is some mix of different circumstances,” Fiedler said.

The administration report singles out another segment of enrollments as suspicious: very low-income, subsidy-eligible people who shifted to plans that carry no monthly premium, suggesting “fraudulent agents and brokers are moving them to keep gaining commissions and avoid detection.” The report also cites ACA enrollees who file no medical claims as suspicious.

Policy experts question the assumptions behind those concerns.

Younger or lower-income people use healthcare less often, for example, which can explain why they may make no claims — particularly when they must first spend thousands of dollars out-of-pocket to meet high deductibles.

And very low-income people may switch to plans with higher deductibles in exchange for making no premium payment because they struggle to come up with the $50 or $80 monthly share that other plans might require.

“People are hurting for money,” said Florida insurance agent Jason Fine. “I literally have people who can’t afford to pay $15. I would not immediately assume that a person who went from a silver plan to a bronze plan, that it’s fraud,” referring to two types of ACA plans.

Fine said the administration needs to focus on better enforcement of existing rules, saying he has reported to regulators dozens of unscrupulous agents who have switched clients without authorization, yet none were barred from selling ACA policies.

He and other agents continue to push for adding multifactor identification, as banks and other financial institutions use, to the federal ACA marketplace. Some states that run their own exchanges have two-factor authentication or other types of ID verification and have not reported problems with unauthorized switching.

CMS — under both Biden and Trump — has not added two-factor authentication to the federal marketplace, healthcare.gov.

Rep. Glenn Grothman (R-Wis.) to require it in June, but its prospects are murky.

“It will help reduce fraud,” said Ronnell Nolan, who leads Health Agents for America, a lobbying group that has long urged CMS to add the feature. Grothman’s legislation, she said, might “encourage CMS to do it themselves.”

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That could change. In June, the Department of Justice issued saying federal disability rights laws don’t require states to provide services that allow people with disabilities to remain in their homes rather than institutions.

It’s a sharp reversal from 1999, when a held that unjustified institutionalization constituted discrimination under the Americans with Disabilities Act. Previous administrations have relied on that ruling to enforce civil rights for disabled people, but the Trump administration says that long-held interpretation is wrong.

Advocacy groups say legal protections for about and 5 million children who have disabilities could be undermined, and they worry that the new interpretation may herald a return to forced institutionalization.

The stage is also now set for a legal fight between advocates, states, and the federal government. Some states with ongoing lawsuits challenging disability rights requirements are already citing the DOJ opinion in hopes it will help them prevail.

In a case in Texas, for example, that a rule instituting a 1973 civil rights law that led to community and home integration of people with disabilities is costly and infringes on states’ rights.

People like DeSimone-Shabrack are especially worried because, they say, the opinion follows a spate of White House and Republican-led initiatives that have already begun eroding hard-won protections for people with disabilities.

“I’m worried. Am I going to have to put him in an institution, and what’s that going to be like for him?” said DeSimone-Shabrack, whose personal home care help was recently reduced from 30 to 18 hours a week by the state. “As he gets older, am I going to be able to care for him without this support?”

The Department of Health and Human Services remains steadfast in enforcing federal civil rights laws, agency spokesperson Emily Hilliard said in an email.

“Our commitment to ensuring that individuals with disabilities are treated with dignity, afforded equal opportunity, and are able to meaningfully access community services remains unchanged,” she said.

But advocacy groups say the DOJ opinion could have sweeping repercussions. The opinion doesn’t change existing law, but advocates worry that HHS and the DOJ could begin that mandate integration for people with disabilities.

They’re concerned that agencies will stop enforcing disability laws that ensure people aren’t. HHS, for example, has historically investigated disability discrimination claims at hospitals and in states that get federal funding, enforcing compliance with home and community integration through . Disability rights experts say those agreements could now be imperiled.

And some states facing financial pressures may roll back Medicaid services that enable people with disabilities to stay in their homes and communities — a trend that’s already happening following last year’s passage of the One Big Beautiful Bill Act, which cuts a projected from the safety net program over a decade.

Democrats are seizing on the opinion, which was released in a DOJ memo, to portray President Donald Trump and Republicans as a threat to people with disabilities. Sen. Tammy Duckworth (D-Ill.) and other Senate Democrats led the calling on the DOJ to rescind the opinion.

“The Trump Administration’s memo is an outrageous attack on the rights and independence of the disability community,” Duckworth said in a statement.

The DOJ didn’t return emails seeking comment.

According to the DOJ’s interpretation, regulations that give disabled people the right to demand certain services for daily living — bathing, mental health counseling, and financial budgeting help, for instance — and that require states to extend to mentally disabled individuals are unlawful, a view the agency acknowledged “is out of step with the common understanding of that decision within the federal courts.”

States may have legitimate reason to treat mentally disabled people in institutions, “including resource constraints, capacity limitations in community-based facilities, and safety concerns for both the patient and the community,” the memo reads.

The Supreme Court case, Olmstead v. L.C., has long shaped federal policy. And while it remains to be seen how courts will respond to the DOJ, some states seeking to curtail disability protections see the opinion as significant.

Consider the in federal court in the Northern District of Texas by Republican-led states arguing that an HHS rule about the integration mandate is unlawful. The lawsuit began with broader claims and 17 state plaintiffs. Following significant advocacy from the disability community, only Texas, Alaska, and Florida remain.

Following the new DOJ interpretation, the states filed documentation to inform the court about the memo as a new and relevant development. Similar documentation citing the memo has been filed in disability rights cases in Florida and New Hampshire, according to The Arc of the United States, a disability advocacy group.

Advocates for people with disabilities say the speed at which plaintiffs are citing the opinion underscores how it may be used to justify the erosion of protections.

“The administration’s attempt to dismantle decades of progress in community integration is alarming and inconsistent with federal disability rights laws and Supreme Court precedent as well as the critical enforcement work of prior administrations,” said , senior executive officer of legal advocacy and general counsel at The Arc.

Forced institutionalization led to human rights violations, segregation, and a eugenics movement in the late 19th and early 20th centuries that included involuntary sterilization.

Exposure of the abuses, legal battles, and an caused a major shift toward integration. Fewer than 1% of people with intellectual or developmental disabilities lived in state-run facilities in 2021, down from almost 30% in 1967, from the University of Minnesota’s , which maintains metrics on such long-term services and supports.

The Trump administration has already taken steps to reverse that trend, advocates say.

Trump signed that addresses homelessness by expanding involuntary treatment and institutionalization, reversing a championed by the Biden administration.

Much of the special education program office is moving from the Department of Education to HHS, raising concerns among advocates that the administration is reverting to a view that disabilities are a medical issue to be fixed rather than differences that can be accommodated.

And cuts in federal funding for Medicaid, a federal-state insurance program for people with low incomes or disabilities, also portend fewer resources and services. States have responded by reducing some optional benefits such as home health aides and support. In addition, qualifying for an exemption from the program’s work requirements, which take effect Jan. 1 in most states, will pose significant hurdles for people with disabilities.

The June DOJ opinion, advocates say, could accelerate the shift and result in court rulings that chip away at disability rights.

“While it doesn’t overnight change the law, it’s very troubling and very dangerous,” said , director of the Disability Rights Program at the American Civil Liberties Union. “It reflects a really deeply held disrespect for disabled people from this administration and a total lack of awareness of the lived experiences of people with disabilities who are living in their homes.”

Data shows there can be benefits to involuntary institutionalization. Relative to those voluntarily admitted, people with psychiatric illness who were involuntarily admitted “experienced greater improvements in symptoms and function,” according to a in Psychiatry, Psychology and Law, a peer-reviewed academic journal.

Deinstitutionalization has created new challenges. More hospitals have been forced to board people with psychiatric illness in emergency rooms because of a dearth of available beds. And moving people into home- and community-based living was supposed to be accompanied by an increase in outpatient care and treatment that never materialized, creating gaps in support.

But advocates for the disabled community say involuntary institutionalization and poses a higher risk of neglect and abuse.

, 57, of Cleveland, spent two years in a nursing home. She has spinal muscular atrophy, a genetic disease that kills motor neurons, leaving her able to move only part of her left arm and her head.

At the institution, she said, she felt bored and trapped and developed intense itching from scabies, which is caused by microscopic mites.

For more than a decade, however, she has lived in an apartment with the help of caregivers who come in the morning to get her dressed and ready and return to put her to bed. She works at a disability rights group, and her care is covered by Medicaid.

“The two years I lived in the nursing home, it was the most horrible time in my life,” said Kucera, who worries about the DOJ opinion on Olmstead. “My future is a shaking floor beneath me. With the stroke of a pen, they could get rid of everything I’ve built for myself.”

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Céline Gounder, ºÚÁϳԹÏÍø News’ editor-at-large for public health, discussed how children’s caffeine consumption is affecting their health on CBS News’ CBS Mornings on July 30.

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ºÚÁϳԹÏÍø News senior correspondent Arthur Allen discussed the recent Anthony Fauci Senate hearing on CBS News 24/7 on July 29.

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ºÚÁϳԹÏÍø News chief Washington correspondent Julie Rovner discussed the Fauci hearing on WBUR’s Here & Now on July 29. Rovner also discussed exceptional Affordable Care Act enrollment in New Mexico on KJZZ’s The Show on July 29.

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ºÚÁϳԹÏÍø News national public health correspondent Amy Maxmen discussed the FDA potentially easing restrictions on peptide drugs on CBS News 24/7 on July 24.

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ºÚÁϳԹÏÍø News Georgia correspondent Briah Lumpkins discussed the local impact of the loss of Environmental Protection Agency grant money on WUGA’s The Georgia Health Report on July 24.

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• Read Lumpkins’ “Public Health Improvements Stall Amid Trump’s DEI Crackdown.”

ºÚÁϳԹÏÍø News HawaiÊ»i correspondent Ashley Mizuo discussed the challenge of finding placement for prisoners after their compassionate release from detention on HawaiÊ»i Public Radio’s The Conversation on July 22.

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• Read Mizuo’s “Severely Ill Prisoners Granted Early Release Are Left Stuck Behind Bars.”

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But behind the house, the 44-year-old’s backyard garden showcases her goals for the future, one that involves a long, healthy life with her kids: collard greens, bell peppers, onions, tomatoes, red and white potatoes, kale.

Like Lowery, many in the small towns of Lumberton and nearby Pembroke are citizens of the Lumbee Tribe who have dealt with heart conditions. The mother of four struggled with obesity and had to take insulin pills and shots daily. By when her first grandchild was born, in 2024, Lowery imagined her own life ending the way her biological father’s did: Daily insulin shots for diabetes. Kidney dialysis treatments at home. Dead of a heart attack at 63. She wanted her grandkids to remember her.

“If I don’t get this weight off me, if I don’t change my eating habits, it’s going to take me over,” she recalled thinking.

So, she expanded her garden. She cut fatty foods and sugary drinks out of her diet, stopped eating fried and fast food, and started moving more. She lost 120 pounds in two years and weaned herself off the daily insulin pills.

The Lumbee Tribe of North Carolina late last year became the 575th tribe to secure federal recognition as a sovereign nation, a milestone that leaders and citizens celebrated in tears. The designation provides federal funding for an array of services, including for healthcare. , chairman of the tribe and a state representative, “the biggest benefit” would be access to the Indian Health Service — its clinics and hospitals, as well as funding that it could provide for the tribe to .

But Lumbee researchers and healthcare providers say that money won’t be enough. For decades, IHS has been , with the agency’s budget workgroup estimating that of what it needs this year. And that was before the Trump administration’s cuts to other federal agencies further pinched IHS. Slashes to the Centers for Disease Control and Prevention last year initially included laying off nearly , and President Donald Trump’s proposed 2027 budget cuts more than $150 million for a in Native American tribes.

The nearest IHS facility is more than a two-hour drive to another state for most of the 55,000 Lumbee citizens in Robeson County. The county is one of the and has some of the .

The Congressional Budget Office in 2022 estimated that the tribe could increase IHS spending by .

The tribe will have to rely on other revenue sources that are now allowed through recognition, such as a casino, to reverse the health disparities their people have faced for decades, Lumbee researchers said.

“None of us can depend on IHS alone, because we just don’t have the resources within that system,” said , a physician, a researcher at the Johns Hopkins Center for Indigenous Health, and a member of the Oglala Lakota tribe. “But it’s a great starting point.”

The IHS did not respond to questions about plans for the tribe’s health system. John Lowery did not respond to requests for an interview or a list of questions, but he said on a June podcast that he expected healthcare to be the .

‘Not Just Statistics’

Eighteen years ago, , a doctor in Lumberton and a citizen of the tribe, was working at a nearby medical center. There, she said, she was taught that patients with certain last names “are often referred directly to cardiac catheterization,” a procedure to diagnose heart conditions.

Blackburn said she realized that common Lumbee surnames carried an expectation of disease.

“Nearly two decades later, I can tell you that reality has not changed,” she told assembled tribal leadership and citizens at a public hearing.

Robeson County’s rates of heart disease, diabetes, and continue to rank among the highest in the state, Blackburn noted. In 2025, were Medicaid enrollees, the highest percentage of all counties in the state.

“But these are not just statistics to me,” she said. “These are my patients. These are our families.”

For Angie Lowery, breaking free from those statistics meant taking her health into her own hands.

She hopes a healthy diet is the answer to breaking her family’s cycle and living long enough to form relationships with her grandkids. And she brought the rest of the family with her. Her teenage daughter lost about 35 pounds. Two of her other children are now “health fanatics,” Lowery said.

Her granddaughter will be 2 in November. One Sunday morning in March, Lowery served up macaroni, cauliflower, and chickpeas for her as they spent the day together.

Lowery had supported building a casino, believing it would provide better education, infrastructure, and healthcare for her family.

“That vote, I’m thinking of my children’s future,” she said.

Casino Dreams in Limbo

Tribal citizens are deeply divided over how to reverse decades of economic decline that have led to poor living conditions, unaffordable health services, and chronic disease.

Four months after Trump signed the Lumbee Fairness Act — “I love the Lumbee Tribe” — tribal leaders gathered at a business meeting to take the first steps toward building a casino and establishing gaming as a new revenue source. Hundreds of federally recognized tribes across 29 states have used gaming as a source of revenue, in fiscal 2024, according to the latest report from the National Indian Gaming Commission.

The approach has been popular among tribal nations looking for more dollars to build up healthcare. The Choctaw Nation of Oklahoma in 1999 to build its own hospital, using roughly $25 million in gaming money, and the Eastern Band of Cherokee Indians in western North Carolina funded its own hospital in 2015 mostly with $82 million in gaming funds.

But the Lumbee Tribe’s effort to establish a casino collapsed in June.

rejected a Lumbee constitutional amendment that would have allowed tribal leaders to create infrastructure needed for a gaming business. John Lowery said that he doesn’t plan on bringing back the initiative now that it was rejected “by the majority of Lumbee voters.” His term as chairman ends in two years.

Other funding sources to provide health services for the tribe could include gas stations or hotels, he said in a call with citizens before the vote.

Lumbee and other Native health researchers said they believe a twofold system — using IHS money and additional revenue — is necessary. Funds from gaming could compensate for what IHS can’t support.

Casinos’ impact on tribal health has been debated in research for decades. that the money from gaming helps tribes build more facilities, hire more doctors, and improve social services, but unhealthy substance use and smoking increase.

“There’s going to be negative impacts,” , a social work professor at the University of North Carolina and citizen of the Lumbee Tribe, said at a June panel discussion on gaming.

, 62, a Lumbee citizen and a researcher studying Native health at UNC, said the community has felt ripple effects from systemic racism, having not been acknowledged as a tribal nation for so long, and the economic downturn following the loss of Robeson County’s manufacturing and tobacco jobs.

That history plays a part in the health statistics in Robeson today, Bell said. But with federal recognition, he said, the Lumbee people have achieved a victory they’ve fought for since 1888.

“I think about the resilience of the Lumbee people and how they’ve gone through this 100-plus-year fight for federal recognition,” Bell said. “I sort of see that as a continuation of this resilience, and how now we have this opportunity with federal recognition to bring in resources to help address those issues.”

Resolution and Uncertainty

Jada Brooks, a Lumbee citizen and UNC researcher who studies Indigenous health and lives in Robeson County, is conducting a study about heart health among Lumbee women. The initiative includes classes in which Lumbee women ages 18 to 50 signed up to discuss their health. That’s where she met Angie Lowery, who talked about her lifestyle changes with the group.

“I was just floored by, like, just the extent to which she went,” Brooks said.

She and other Lumbee researchers said federal recognition allows Lumbee citizens to be set apart in census data, paving a way to get clear information on heart health, cancer rates, diabetes diagnoses, and mental health risks.

“There’s challenges in even understanding the nuances of these complex health disparities, because a lot of data isn’t out there,” said Ryan Dial, a public health researcher at UNC and a member of the Lumbee Tribe.

But access and confidence may be the biggest barriers Lumbee people will have to overcome, Brooks said.

“I think what really matters is people feeling like they can trust the healthcare system.”

Brooks said she worried that a casino would encourage bad health habits, such as smoking and drinking.

“Let’s not create more problems for ourselves than we already have,” she said. She voted against the casino.

Like others in the tribe, Angie Lowery believes in her people’s power to help themselves, regardless of whether government steps in to help.

“Just because we’re federally recognized don’t mean that the doors are going to open up and money’s going to fall through the door like dirt,” she said.

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The officials, all Democrats, are running at a time when the Trump administration is reducing government funding for scientific research, restricting access to some vaccines, and making it more difficult for some Americans to obtain health insurance.

Shaughnessy Naughton, president of 3.14 Action, a political action committee that recruits Democratic candidates with science and health backgrounds, said it is unusual to see so many public health leaders running for office.

“But it’s not surprising given the moment we are living in, with an arsonist running HHS working to undermine the vaccine schedule and public health at large,” she said.

Health and Human Services Secretary Robert F. Kennedy Jr. is a longtime anti-vaccine activist who disparaged public health measures implemented during the pandemic, going as far as calling the covid vaccine the “.”

Neither HHS nor the White House responded to requests for comment.

Several of the candidates benefit from name recognition built during the covid pandemic, political science scholars say, when daily news briefings from local health officials became must-see-TV for many citizens sheltering in place from the novel virus. But that cuts two ways.

While many Americans regarded public health officials as offering prudent advice and a steady voice, others criticized them for pushing school closures, mask mandates, and new, quickly created vaccines. The attacks have escalated under President Donald Trump, with Republicans targeting pandemic-era public health leaders such as Anthony Fauci and a former Fauci adviser even facing .

National polls show healthcare is for many voters this year, with Democrats most worried about costs and Republicans about fraud. But that’s no guarantee of victory. Nirav Shah, an epidemiologist who led Maine’s top public health agency through the pandemic, lost a narrow Democratic primary in the state governor’s race in June.

Here are some of the public health officials on the ballot this year:

Xavier Becerra, Running for Governor in California

Becerra, who served as HHS secretary under President Joe Biden, is the highest-ranking former health official running this cycle. He won a crowded and expensive open primary and now faces Republican Steve Hilton, a British-born former Fox News host, in the general election.

Mark Peterson, a public policy professor at the UCLA Luskin School of Public Affairs, said with the pandemic in the rearview mirror, any judgment voters may have about the federal government’s response is more likely to reflect on Biden rather than Becerra, who has no medical background and maintained a low profile as HHS secretary.

Leading the nation’s health department as the pandemic lingered, Becerra focused more on expanding access to the Affordable Care Act and Medicaid, overseeing record numbers of people enrolled in the publicly financed programs during his tenure. He did face criticism over the processing and placement of a massive influx of migrant children at the U.S.-Mexico border, as well as his agency’s response to a baby formula shortage brought on, in part, by major product recalls.

Becerra has said he now wants to be California’s “healthcare governor,” a mantle outgoing Gov. Gavin Newsom tried to claim upon taking office in 2019.

Becerra’s campaign did not respond to a request for comment.

Before becoming HHS secretary, Becerra served as California’s attorney general and sued the first Trump administration more than 100 times, leading a coalition of states against GOP efforts to gut the ACA. He also started a unit in his office focused solely on healthcare. During Becerra’s tenure, his office reached a $575 million antitrust settlement with the California hospital system Sutter Health, pursued pharmaceutical companies that delayed generic drugs, and helped block a Trump administration rule that let employers choose whether to cover .

Voters often regard decades of experience in government as a negative, Peterson said. But for the job of running the nation’s most populous state and the world’s fourth-largest economy, he added, “I think there are a lot of people out there who would like to have somebody who actually has run a big enterprise.”

In , Becerra has said California should maintain state-funded Medicaid coverage for immigrants without legal status. He is also a longtime supporter of implementing single-payer healthcare, though in recent interviews he has said it needs to be addressed at the federal level.

Amy Acton, Running for Governor in Ohio

Acton ran Ohio’s health department from February 2019 to June 2020.

During the first months of the pandemic, Acton appeared at daily news conferences with the state’s Republican governor, Mike DeWine, that were jokingly dubbed “.” She earned fans with her calm and positive demeanor while explaining her approach to keeping covid at bay.

But she also attracted critics with her recommendations to stay at home, mask up, and shut down some businesses to curb the virus’ spread. Protesters even showed up at her home.

Acton’s Republican opponent in the governor’s race, Vivek Ramaswamy, has labeled her “Dr. Lockdown” on social media. His criticism of her role in shutting down businesses could prove effective with the economy at the top of many people’s minds, said Christopher Devine, a University of Dayton political science professor.

“It’s a double-edged sword, because she also really upset some people,” Devine said of Acton’s time as the health director during the pandemic.

He said that is a tricky attack for Ramaswamy to pursue, though, because DeWine — still the sitting governor and a popular conservative figure — endorsed the covid measures Acton recommended, granting her emergency powers to sign the orders, and has since said he takes all responsibility for those actions.

For her part, Acton has done little on the campaign trail to highlight her time as the state’s public health director. Instead, she has focused more on healthcare affordability, highlighting the Trump-led cuts to Medicaid and the scaled-back subsidies for ACA plans that have resulted in dropping coverage in the state.

“I hear from families across Ohio that healthcare costs are rising and they just can’t keep up,” Acton said in an emailed statement. “That’s why I will fight to protect and expand access, reduce the price of prescription drugs, forgive medical debt holding Ohioans back, and lower premiums.”

Abdul El-Sayed, Running for U.S. Senate in Michigan

El-Sayed — who ran the health departments in the city of Detroit and Wayne County, Michigan — is one of two leading Democratic candidates for Senate. The primary is Aug. 4.

El-Sayed, a progressive, is facing off against Haley Stevens, a four-term congresswoman. They are vying to run against Republican nominee Mike Rogers, a former congressman, for the Senate seat held by retiring Democrat Gary Peters.

From 2015 to 2017, El-Sayed ran the Detroit Health Department, which and privatized as part of the city’s 2013 bankruptcy. In his role, he led efforts to test Detroit schools for lead in the wake of the Flint water crisis and provide free eyeglasses to children in public schools.

From 2022 until 2025, he ran the health department in Wayne County, the state’s most populous county, which includes Detroit. In that job, he initiated a program to retire medical debt for thousands of residents and make naloxone available in public areas to reverse the effects of opioid overdoses.

In an interview with ºÚÁϳԹÏÍø News, El-Sayed said his public health experience helped him become an effective communicator and challenge corporations and the role they play in healthcare.

“Politics have become overrun by big money and corporations, and my training and background in public health has taught me to think about that and push back against it,” he said.

El-Sayed, who did not practice medicine after completing his residency and is not licensed to do so, has faced criticism from some in his party for calling himself a doctor.  

El-Sayed, who has endorsements from Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Alexandria Ocasio-Cortez (D-N.Y.), supports “Medicare for All,” a policy favored by many progressives that would make more people eligible for the federal health program for people who are 65 and older or disabled.

David Dulio, a professor of political science at Oakland University in Rochester, Michigan, said that the broader economy, Trump’s tariffs, and trade are eclipsing healthcare this year as top concerns for voters in the state. But he added that “progressive stances such as Medicare for All are attractive in the Democratic primary electorate.”

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The ºÚÁϳԹÏÍø News Minute is available every Thursday via direct download or the RSS feed.

July 30

Zach Dyer [DYE-er] reads this week’s news: Health insurance companies promised to make it easier to get doctor-ordered care, but patients are still waiting. Plus, a common surgery might not be the best way to solve knee pain.

Can’t see the audio player? Visit kffhealthnews.org to listen.

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A passed in 2024 forced hospitals to remove a key drug — misoprostol — from the medical cart and keep it locked in a secure room designated for controlled substances.

For physicians like New Orleans obstetrician-gynecologist Nicole Freehill, misoprostol is the go-to medication to treat hemorrhages. The drug is uniquely cheap, safe, and shelf-stable, she said.

But it’s also the second in a two-pill procedure that millions of people have used to have medical abortions. Because of that use, Louisiana lawmakers reclassified misoprostol as a controlled substance, a category typically reserved for addictive drugs.

Now, physicians like her have gone from reaching over to the cart to grab misoprostol to waiting at least two minutes while a nurse sprints to retrieve the medication, Freehill said.

“ You could literally have someone lose, like, a liter of blood or more in that time frame,” Freehill said. “You could have a significantly worse hemorrhage for literally someone running to this medicine and running back because it can’t be on that cart 2 feet from you while you’re treating the hemorrhage.”

She said the reclassification of misoprostol as a controlled substance has set back progress to decrease the frequency of postpartum hemorrhage and blood transfusions. Under the law, her preliminary research found, hemorrhage rates have worsened statewide, she said.

Although the cart includes alternative drugs to treat hemorrhages, they can’t be used if a patient has certain preexisting conditions like asthma or high blood pressure. They’re also more costly.

“ There’s unfortunately a lot of patients nowadays that have these conditions that we might be forced to go straight to misoprostol first without any other real good option because of their medical history,” Freehill said.

Misoprostol has other uses in reproductive healthcare. It prepares women’s cervixes ahead of common, sometimes painful procedures such as inserting an IUD. It also plays a critical role in inducing labor and managing failed pregnancies.

In medication abortions, misoprostol is combined with a medication called mifepristone, which Louisiana also reclassified as a controlled substance. Both mifepristone and misoprostol have uses outside reproductive healthcare, including treating Cushing’s syndrome and preventing stomach ulcers caused by anti-inflammatory drugs.

When Louisiana passed a near-total ban on abortions after Roe v. Wade was overturned in 2022, the number of abortion procedures performed in the state dropped from 7,444 in 2021 to . Similar trends occurred in other states that largely banned abortions that year.

However, in the years since, the number of abortions has largely remained the same in Louisiana and nationally as people receive medication abortions through telemedicine and pills sent across state lines. More than 7,500 Louisianans received medication abortions in 2024, the year the law passed, according to the .

Since then, states with abortion bans have tried to to medication abortions prescribed in telehealth appointments and shipped by mail, looking to close what they saw as a loophole through legislation and lawsuits.

Kimya Forouzan, the state policy adviser for the Guttmacher Institute, a nonprofit reproductive rights advocacy group, said the assault on medication abortions comes as more states that have maintained abortion rights pass laws to shield prescribing providers from prosecution.

“This has been a really important lifeline for a lot of people in states with total bans who are looking to access abortion,” Forouzan said. “However, I think a lot of the restrictive states know that this is happening, and they have wanted to increase the threat and the threat of liability to providers who are doing this.”

Louisiana’s controlled-substance law became one way to do so, though it was originally passed to ensure strict penalties for coerced abortions. Republican state Sen. Thomas Pressly of Shreveport, who introduced the bill, said he did so after his brother-in-law fed his sister the pills to cause an abortion . She gave birth to the baby, and the husband was sentenced to six months in prison after the failed attempt.

The bill was later amended in the legislature to add more restrictions and monitoring of mifepristone and misoprostol by classifying them as controlled substances.

Last October, Louisiana also tried to halt medication abortions by telehealth with a against the FDA. The case is pending before the U.S. Supreme Court.

The New Orleans Health Department called for the repeal of the law in a last September, based on surveys of patients, doctors, and pharmacists. Patients reported delays in treatment while hemorrhaging after birth. Fewer pharmacies filled prescriptions for misoprostol, frustrating doctors.

“ There’s no evidence that it is reducing elective abortions in Louisiana. There’s no evidence that it is helping anybody. There’s only evidence of harm,” said Dara Kass, an emergency physician and a professor at Brown University.

Since Louisiana’s law passed, similar legislation has been introduced in at least nine states, despite established abortion bans.

But so far, no other states have reclassified the medications. Pushback from the medical community and reproductive health advocates over implementation has surprisingly stifled any other attempts, said Alina Salganicoff, director of the women’s health policy program at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“This puts a risk  inside the healthcare system and potentially could delay really extremely time-sensitive lifesaving care,” Salganicoff said. “Especially where we have situations where we have really an unacceptably high maternal mortality situation in the United States.”

Instead of being a model for other states, Louisiana’s law has served as a cautionary tale. Freehill, the New Orleans OB-GYN, said her colleagues have also had patients struggle to fill their misoprostol prescriptions ahead of uterus examinations intended to help with their fertility.

“ So it’s having the complete opposite effect of what it’s been intended,” she said.

According to the New Orleans Health Department’s report, some pharmacists said they were too afraid to release the medication to the patient, confused about what’s required under the law. Others refused to fill prescriptions and stock the medication because they preferred to “stay away from any abortion pills.”

Tehmi Chassion, a pharmacist and a Democratic state representative in Lafayette, is pushing the state to study the law’s impact, given the loss of access to the medications.

Louisiana allows pharmacists to choose not to dispense medication if they are uncomfortable doing so, but Chassion said some pharmacists may be crossing a line by blocking access to medication based on their personal beliefs.

“ Those medications have helped save thousands of lives, and we just need to get to a safe space where prescribers and patients don’t have any worries,” Chassion said.

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The race is in Iowa, whose Medicaid program has been plagued with controversy since 2016, when the state hired national insurance companies to manage billions of dollars’ worth of benefits.

That shift was made by then-Gov. Terry Branstad, a Republican. With his executive order, Iowa joined most other states in privatizing the management of Medicaid, which covers healthcare for more than 67 million Americans with low incomes or disabilities.

The arguments have resurfaced this year during the competition to replace Republican Gov. Kim Reynolds, who was Branstad’s protégé and continued contracting with private companies to manage Medicaid benefits. Zach Lahn, the Republican candidate to succeed the retiring governor, supports the practice. Rob Sand, the Democratic candidate, wants to end it.

“It’s been a disaster,” said Sand, Iowa’s state auditor. “The number of complaints has been catastrophic.”

Pros and Cons

Supporters of privatization say the insurers, known as managed-care organizations, make Medicaid more effective and efficient. Critics contend the companies pad their profits by denying payment for crucial health services and by shortchanging agencies and professionals who provide care.

Iowa is among 41 states, plus the District of Columbia, that contract with outside companies to run at least part of their Medicaid programs. Overall, private insurers manage the benefits of more than three-quarters of Medicaid patients. Connecticut is the only state that has fully reversed course after privatizing its Medicaid system.

Sand has criticized privatized Medicaid for years. As state auditor, he alleging that the national insurers systematically deny or delay payment for services to which Medicaid participants are entitled.

He has vowed not to renew state contracts with the three insurers managing care for more than 600,000 Iowans on Medicaid, which is jointly financed by the state and federal governments. He would rather have state employees or nonprofit agencies review and pay bills from clinics, hospitals, and other healthcare providers.

Lahn told ºÚÁϳԹÏÍø News that Sand’s pledge to resume state administration of Medicaid “is the exact wrong idea.”

Lahn is a former activist for Americans for Prosperity, a national pro-business group affiliated with the Koch family. He contends that state governments and Medicaid participants benefit when insurers compete to serve them.

“There are very few things that government does more efficiently than the private sector,” he said.

Lahn, who is a businessman and farmer, emphasized that state officials should strictly enforce contract requirements, ensuring that the insurers treat Medicaid recipients fairly and make prompt payments to care providers. He also said he would bar insurers from using artificial intelligence systems to determine whether to pay for medical claims under Medicaid. “Iowans deserve to have a human looking at their case,” he said.

Sand said in a recent interview that he doesn’t want Iowa to fully return to a “fee-for-service” Medicaid system, in which hospitals, clinics, and other healthcare agencies would effectively be paid piecemeal for whatever services they provided. Instead, he said, state employees or nonprofit organizations could take over operation of a managed-care system, in which administrators review services to help ensure Medicaid participants receive what they need without wasting public money on ineffective services.

A few months ago, Republicans controlling the Iowa Legislature considered a bill to require the state to have a privately managed Medicaid system. That proposal would have blocked future governors from unilaterally shifting back to public management of the program. But the bill

Sand, a former assistant state attorney general, said he is confident he would have legal authority as governor to stop contracting with private Medicaid managers, although he cautioned that the transition would be complicated and could take time.

A Toss-Up Race

National political observers say the Iowa governor’s race

This June, Lahn won an underdog primary campaign to beat a sitting congressman backed by President Donald Trump. Lahn gained Trump’s endorsement after winning the Republican primary. He is a vocal supporter of the Make America Healthy Again movement, led by Health and Human Services Secretary Robert F. Kennedy Jr., which aims to improve Americans’ diets and reduce environmental poisons.

Sand noted that Lahn’s past political activism included a failed 2014 attempt to defeat a proposal to cover more people under Montana’s Medicaid program.

Lahn said that at the time he worried the federal government would reduce how much money it would contribute to such Medicaid expansions, leaving states to foot much of the bill. He said he also didn’t want to see public programs such as Medicaid giving benefits to adults capable of providing for themselves. But he said those concerns have been allayed, partly by the Trump administration’s moves to require millions of Medicaid recipients to prove they are working, volunteering, or going to school.

If elected governor, he said, he would not try to reverse Iowa’s expansion of Medicaid, which happened in 2014 under Branstad.

Branstad also is the governor who decided in 2016 to hire private insurers to manage Medicaid.

Branstad, who declined to comment for this article, did not need the legislature to approve his momentous decision. He weathered controversy over the change, including allegations that the companies systematically denied payment for care that people with disabilities needed to remain in their homes.

Andy Schneider, a who studies health policy issues, said it’s understandable that many government leaders see an advantage in hiring private Medicaid management companies. Each state’s Medicaid program pays claims for hundreds of thousands or even millions of members, and administrators must scrutinize bills from thousands of hospitals, clinics, and other healthcare organizations. “That’s a heavy lift,” said Schneider, who worked in federal Medicaid administration when Barack Obama was president.

Schneider noted that Medicaid expenses are among the biggest parts of any state’s budget. The costs can vary dramatically year to year, he said, which is hard for legislators and governors to plan for. Management companies sign contracts for set amounts of money per enrollee, depending on people’s ages and health conditions. Managed-care companies say they can improve Medicaid members’ health and reduce expenses. But Schneider said have been unable to confirm or disprove those claims.

Federal law gives states flexibility in how they run their Medicaid programs, including whether they hire private insurers to manage the programs. “Unwinding those arrangements might take a little time, but there’s no question they can do it,” Schneider said.

Connecticut of private insurers to run Medicaid in 2012. to contract only with nonprofit insurers, starting in 2025, and that state’s governor doing away with private management altogether.

Gary Jessee, a former Texas Medicaid director who helped transition that state’s program into managed care, noted that most Americans’ health coverage is managed by some kind of insurance company, whether they obtain it on their own or get it through a government or employer plan.

Jessee now helps run a whose clients include Medicaid managed-care companies. He said states rarely talk about totally scrapping contracts with such companies. Instead, he said, states have options to change the contracts, including to increase oversight or limit profits.

Overall, Jessee said, managed-care companies help Medicaid enrollees obtain the services they need to stay healthy. But it’s hard to calculate how much money the companies save states, he said, because all healthcare costs have been rising, and new members of managed-care plans may at first use more services as the insurance companies encourage them to get regular checkups instead of waiting for emergencies.

Iowa’s Medicaid program is managed by three insurers: Molina Healthcare, Elevance Health subsidiary Wellpoint, and Centene subsidiary Iowa Total Care.

None responded to requests for comment for this article.

Catherine Gray of Des Moines helps run a Facebook page for families who use Iowa’s Medicaid system. Her adult son, John, is on Medicaid because of a disability. Gray said the managed-care companies have made it much harder for people to obtain services, including mental healthcare, dental care, and transportation to health appointments. Iowa’s shift to the private system was abrupt and chaotic, she said. “We know people have died,” she said.

Gray said she probably will vote for Sand for governor, even though she doesn’t agree with every nuance of his stance on Medicaid. She suspects many other Iowans who use the program will do the same. “They’ve really been put through the wringer for 10 years, and they’re exhausted.”

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Time is precious for him. Last year, doctors told the 76-year-old former truck driver that a combination of heart failure, lung disease, and liver damage had left him with only six months to live. “That was about 11 months ago,” Vantrease said in a May interview, smiling at having, for the moment, cheated death.

In June 2025, Vantrease began hospice, which focuses on quality of life for terminally ill patients, receiving regular visits from a nurse in his home in Novato, California. Medicare is covering those services for him. His hospice caregivers reminded him of the attention his unit received from medical staff in Vietnam.

“We used to call them guardian angels,” he said, “because they took such great care of you.”

But the Trump administration’s allegations of unchecked hospice fraud in California have tainted the industry’s reputation, prompting concerns that fewer patients will seek the care they need. Health policy researchers and hospice administrators worry that the negative attention on the industry and potential for overly punitive regulations could put California patients and taxpayers on the losing end.

“The fraud situation has done a lot of damage to the reputation of hospices overall and undone a lot of the progress that had been made in destigmatizing hospice,” said Lauren Hunt, an associate professor at the University of California-San Francisco’s Philip R. Lee Institute for Health Policy Studies who focuses on hospice care. “Policymakers should pursue targeted strategies that root out fraud and abuse without overburdening the many providers who are doing the right thing.”

Hospice care is facing sweeping restrictions. The Centers for Medicare & Medicaid Services in May announced a six-month national moratorium on hospice provider enrollment in Medicare and increased oversight in California and several other states with “elevated fraud risk”: Arizona, Georgia, Nevada, Ohio, and Texas.

In a statement, CMS spokesperson Timothy Foster said state inaction on hospice programs rife with fraud drove the need for federal intervention. Foster said CMS believes the crackdown won’t affect patients’ ability to obtain services, with roughly 7,000 hospices still approved nationwide, and that it will help ensure the hospices that remain provide the care “individuals near end of life deserve.”

“Ensuring patient safety and access to quality hospices and other certified healthcare services is paramount to CMS’ work,” Foster said.

Mehmet Oz, the CMS administrator, has said also protects taxpayer money. that even as for-profit hospices have expanded, the industry has saved Medicare money by offsetting other expensive care. A 2023 University of Chicago report commissioned by industry associations estimated that Medicare patients who used hospice over hospitals in 2019 .

California has already been cracking down on the problems, with Democratic Attorney General Rob Bonta deeming hospice fraud an “” last year and asserting that The state has had its own since 2021, with crimes over the years, and implemented to curb fraud this June.

Hunt said she’s heard from California healthcare providers who are reluctant to refer patients to hospice because they’re unsure the patients will receive high-quality care and from patients who don’t know which hospice providers they can trust. California hospice organizations of any state — as of 2022, according to the California state auditor’s office. That same year, CMS nationwide.

Hospice administrators in good standing have already found themselves in the crosshairs: A found that the federal government’s new anti-fraud task force has already suspended licenses for 43 legitimate hospices.

Still, Hunt and other policy researchers welcome the efforts to target unscrupulous operators.

“While most hospices are committed to providing high-quality care, there are serious concerns about a subset that exploit patients and the system for financial gain,” she said.

The hospice industry is uniquely vulnerable to fraud because of insufficient licensing regulations and inadequate oversight, according to industry researchers. And the percentage of the population aging into Medicare is rapidly rising, with spending expected to accelerate in the next 10 years.

Most of the rapid growth in operators has been among for-profit hospices, a state auditor’s report in 2022 noted. In California, about 94% of hospice providers are now for-profit, a shift from 20 years ago, when nonprofits in California and nationally. On average, for-profit operators per patient in pretax profit and $49 more per patient-day than nonprofit hospice operators, according to one study.

Skelly Wingard, CEO of By the Bay Health, a Northern California nonprofit that provides services to Vantrease, acknowledges that fraud is a big problem in the industry. “These organizations that have exploited patients were extremely savvy,” she said.

But Wingard warns against losing sight of the bigger picture.

“Hospice, when done well, is one of the most compassionate and meaningful benefits in healthcare,” she said. “We should be working to protect that, not inadvertently erode confidence in it.”

By the Bay Health has been in business for 50 years and serves around 750 hospice patients in the Bay Area. About 89% of them are covered by Medicare, 3% by California’s Medicaid program, Medi-Cal, and the rest by commercial health plans, Wingard said.

At home in Novato, Vantrease lifts his shirt to show where a catheter was surgically implanted to drain uncomfortable fluid buildup in his abdomen. The hospital trained his wife, Paula Vantrease, a retired career counselor, to connect a suctioning device to the catheter to siphon the excess fluid. A hospice nurse from By the Bay, Blake Knier, helped her master the technique the first few times she tried it at home.

“Paula is the rock in my foundation,” Mark Vantrease said.

Knier orders all of Vantrease’s medications and rejiggers them when necessary to manage his bouts of intense nausea and pain. Every week, Knier checks the surgical incision around the catheter for infection, listens to Vantrease’s lungs, checks his blood pressure, and cleans and dresses the open wounds that sometimes form from burst blisters on his legs, a complication of the fluid buildup and weakened skin.

Knier helps usher hospice patients and their families through critical turning points. He recalled guiding one patient’s daughter through her mother’s loss of appetite.

“It’s OK if your mother isn’t eating vegetables,” he told the patient’s daughter. “Let her eat ice cream, if that’s what she wants.”

California’s emergency regulations against fraud took effect in late June. In addition to tighter prescreening of license applicants, they call for minimum professional qualifications for management, higher nurse-to-patient ratios, stricter rules around physical office space, and other restrictions.

Hunt said the new regulations are a step in the right direction but urged caution.

“The broader impact on the industry should be closely monitored, particularly to ensure that well-intentioned, high-quality providers are not placed under undue strain or forced to close,” she said.

Late one night last year, when Knier wasn’t available, another hospice nurse from By the Bay Health came promptly to the Vantreases’ home in response to an urgent call from Paula.

“I felt like I was about to die,” Mark Vantrease said, explaining he’d just had a premonition that he wouldn’t wake up in the morning. His sons were called to his bedside. The family needed reassurance. So a nurse arrived, examined him, and checked their father’s vitals.

By midnight, he was sleeping.

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