Dressed in blue with a big ribbon in her blond curls, the 3-year-old sat in her mother’s lap carefully enunciating a classmate’s first name after hearing the words “best friend.” Just months ago, Gaile Osborne didn’t expect her adoptive daughter would make friends at school.

Diagnosed with autism at 14 months, Aubreigh Osborne started this year struggling to control outbursts and sometimes hurting herself. Her trouble with social interactions made her family reluctant to go out in public.

But this summer, they started applied behavior analysis therapy, commonly called ABA, which often is used to help people diagnosed with autism improve social interactions and communication. A tech comes to the family’s home five days a week to work with Aubreigh.

Since then, she has started preschool, begun eating more consistently, succeeded at toilet training, had a quiet, in-and-out grocery run with her mom, and made a best friend. All firsts.

“That’s what ABA is giving us: moments of normalcy,” Gaile Osborne said.

But in October, Aubreigh’s weekly therapy hours were abruptly halved from 30 to 15, a byproduct of her state’s effort to cut Medicaid spending.

Other families around the country have also recently had their access to the therapy challenged as state officials make deep cuts to Medicaid — the public health insurance that covers people with low incomes and disabilities. North Carolina attempted to cut payments to ABA providers by 10%. Nebraska cut payments by nearly 50% for some ABA providers. Payment reductions also are on the table in Colorado and Indiana, among other states.

Efforts to scale back come as state Medicaid programs have seen spending on the autism therapy balloon in recent years. Payments for the therapy in North Carolina, which were $122 million in fiscal year 2022, are in fiscal 2026, a 423% increase. Nebraska saw a 1,700% jump in spending in recent years. Indiana saw a 2,800% rise.

Heightened awareness and diagnosis of autism means more families are seeking treatment for their children, which can range from 10 to 40 hours of services a week, according to Mariel Fernandez, vice president of government affairs at the . The treatment is intensive: Comprehensive therapy can include 30-40 hours of direct treatment a week, while more focused therapy may still consist of 10-25 hours a week, released by the council.

It’s also a relatively recent coverage area for Medicaid. The federal government autism treatments in 2014, but not all covered ABA, which Fernandez called the “gold standard,” until 2022.

State budget shortfalls and the nearly $1 trillion in looming Medicaid spending reductions from President Donald Trump’s One Big Beautiful Bill Act have prompted state budget managers to trim the autism therapy and other growing line items in their Medicaid spending.

So, too, have a series of state and federal audits that raised questions about payments to some ABA providers. A of Indiana’s Medicaid program estimated at least $56 million in improper payments in 2019 and 2020, noting some providers had billed for excessive hours, including during nap time. A similar audit in Wisconsin estimated at least $18.5 million in improper payments in 2021 and 2022. In Minnesota, state officials had into autism providers as of this summer, after the late last year as part of an investigation into Medicaid fraud.

Families Fight Back

But efforts to rein in spending on the therapy have also triggered backlash from families who depend on it.

In North Carolina, families of 21 children with autism filed a lawsuit challenging the 10% provider payment cut. In Colorado, a group of providers and parents is over its move to require prior authorization and reduce reimbursement rates for the therapy.

And in Nebraska, families and advocates say cuts of the magnitude the state implemented — from 28% to 79%, depending on the service — could jeopardize their access to the treatment.

“They’re scared that they’ve had this access, their children have made great progress, and now the rug is being yanked out from under them,” said Cathy Martinez, president of the , a nonprofit in Lincoln, Nebraska, that supports autistic people and their families.

Martinez spent years advocating for Nebraska to mandate coverage of ABA therapy after her family went bankrupt paying out-of-pocket for the treatment for her son Jake. He was diagnosed with autism as a 2-year-old in 2005 and began ABA therapy in 2006, which Martinez credited with helping him learn to read, write, use an assistive communication device, and use the bathroom.

To pay for the $60,000-a-year treatment, Martinez said, her family borrowed money from a relative and took out a second mortgage before ultimately filing for bankruptcy.

“I was very angry that my family had to file bankruptcy in order to provide our son with something that every doctor that he saw recommended,” Martinez said. “No family should have to choose between bankruptcy and helping their child.”

Nebraska mandated insurance coverage for autism services in 2014. Now, Martinez worries the state’s rate cuts could prompt providers to pull out, limiting the access she fought hard to win.

Her fears appeared substantiated in late September when Above and Beyond Therapy, one of the largest ABA service providers in Nebraska, notified families it planned to terminate its participation in Nebraska’s Medicaid program, citing the provider rate cuts.

Above and Beyond’s website advertises services in at least eight states. The company was paid more than $28.5 million by Nebraska’s Medicaid managed-care program in 2024, according to a . That was about a third of the program’s total spending on the therapy that year and four times as much as the next largest provider. CEO Matt Rokowsky did not respond to multiple interview requests.

A week after announcing it would stop participating in Nebraska Medicaid, the company reversed course, citing a “tremendous outpouring of calls, emails, and heartfelt messages” in a letter to families.

Danielle Westman, whose 15-year-old son, Caleb, receives 10 hours of at-home ABA services a week from Above and Beyond, was relieved by the announcement. Caleb is semiverbal and has a history of wandering away from caregivers.

“I won’t go to any other company,” Westman said. “A lot of other ABA companies want us to go to a center during normal business hours. My son has a lot of anxiety, high anxiety, so being at home in his safe area has been amazing.”

Nebraska officials the state previously had the highest Medicaid reimbursement rates for ABA in the nation and that the new rates still compare favorably to neighboring states’ the services are “available and sustainable going forward.”

States Struggle With High Spending

State Medicaid Director said his agency is closely tracking fallout. Deputy Director said that while no ABA providers have left the state following the cuts, one provider stopped taking Medicaid payments for the therapy. New providers have also entered Nebraska since officials announced the cuts.

One Nebraska ABA provider has even applauded the rate cuts. Corey Cohrs, CEO of , which has seven locations in the Omaha area, has been critical of what he sees as an overemphasis by some ABA providers on providing a blanket 40 hours of services per child per week. He likened it to prescribing chemotherapy to every cancer patient, regardless of severity, because it’s the most expensive.

“You can then, as a result, make more money per patient and you’re not using clinical decision-making to determine what’s the right path,” Cohrs said.

Nebraska put a on the services without additional review, and the new rates are workable for providers, Cohrs said, unless their business model is overly predicated on high Medicaid rates.

In North Carolina, Aubreigh Osborne’s ABA services were restored largely due to her mother’s persistence in calling person after person in the state’s Medicaid system to make the case for her daughter’s care.

And for the time being, Gaile Osborne won’t have to worry about the legislative squabbles affecting her daughter’s care. In early December, North Carolina Gov. Josh Stein canceled all the Medicaid cuts enacted in October, citing lawsuits like the one brought by families of children with autism.

“DHHS can read the writing on the wall,” , announcing the state health department’s reversal. “That’s what’s changed. Here’s what has not changed. Medicaid still does not have enough money to get through the rest of the budget year.”

Osborne is executive director of Foster Family Alliance, a prominent foster care advocacy organization in the state, and taught special education for nearly 20 years. Despite her experience, she didn’t know how to help Aubreigh improve socially. Initially skeptical about ABA, she now sees it as a bridge to her daughter’s well-being.

“It’s not perfect,” Osborne said. “But the growth in under a year is just unreal.”

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“That’s what I’m trying to avoid,” said Ferguson, who still calls Quincy Jackson III her baby. She remembers a boy who dressed himself in three-piece suits, donated his allowance, and graduated high school at 16 with an academic scholarship and plans to join the military or start a business.

Instead, Ferguson watched as her once bright-eyed, handsome son sank into disheveled psychosis, bouncing between family members’ homes, homeless shelters, jails, clinics, emergency rooms, and Ohio’s regional psychiatric hospitals.

Over the past year, The Marshall Project – Cleveland and ºÚÁϳԹÏÍø News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

State psychiatric hospitals nationwide have largely lost the ability to treat patients before their mental health deteriorates and they are charged with crimes. Driving the problem is a meteoric rise in the share of patients with criminal cases who stay significantly longer, generally by court order.

Patients Wait or Are Turned Away

Across the nation, psychiatric hospitals are short-staffed and consistently turn away patients or leave them waiting with few or no treatment options. Those who do receive beds are often sent there by court order after serious criminal offenses.

In Ohio, the share of state hospital patients with criminal charges jumped from about half in 2002 to .

The surge has coincided with a steep decline in total state psychiatric hospital patients served, down 50% in Ohio in the past decade, from 6,809 to 3,421, according to the . During that time, total patients served nationwide dropped about 17%, from 139,434 to 116,320, with state approaches varying widely, from adding community services and building more beds to closing hospitals.

Ohio Department of Behavioral Health officials declined multiple interview requests for this article.

The decline in capacity at state facilities unfurled as a spate of local hospitals across the country shuttered their psychiatric units, which disproportionately serve patients with Medicaid or who are uninsured. And the financial stability of is likely to deteriorate further after Congress passed President Donald Trump’s One Big Beautiful Bill Act, which slashes nearly $1 trillion from the federal Medicaid budget over the next decade.

The constricted flow of new patients through state hospitals is “absolutely” a crisis and “a huge deal in Ohio and everywhere,” said retired Ohio Supreme Court Justice Evelyn Lundberg Stratton. As co-chair of the state attorney general’s , Lundberg Stratton has spent decades searching for solutions.

“It hurts everybody who has someone who needs to get a hospital bed that’s not in the criminal justice system,” she said.

‘It’s Heartbreaking’

Quincy Jackson III’s white socks stuck out of the end of a hospital bed as police officers stood watch.

At 5 feet, 7 inches tall, Jackson has a stocky build and robotic stare. Staff at Blanchard Valley Hospital in Findlay, Ohio, had called for help, alleging Jackson had assaulted a security guard.

“I’m sick; I take medication,” Jackson said to the officers, according to law enforcement body camera footage. His hands were cuffed behind his back as he lay on the bed, a loose hospital gown covering him.

Ferguson called it one of his “episodes” and said her son experienced severe psychosis frequently. In one incident, she said, Jackson “went for a knife” at her home.

From December 2023 through this July, Jackson was arrested or cited in police reports on at least 17 occasions. He was jailed at least five times and treated more than 10 times at hospitals, including three state-run psychiatric facilities. A recent psychiatric evaluation noted that Jackson has been in and out of community and state facilities since 2015.

Jackson is among a glut of people nationwide with severe mental illness who overwhelm community hospitals, courtrooms, and jails, eventually leading to backlogs at state hospitals.

High-Profile Incidents

That dearth of care is often cited by families, law enforcement authorities, and mental health advocates after people struggling with severe mental illness harm others. In the past six months, at least four incidents made national headlines.

In August, a homeless reportedly diagnosed with schizophrenia fatally stabbed a woman on a train. Also in August, police said a with a history of mental health issues killed three people, including a child, at a Target store. In July, a homeless who family members said had needed treatment for decades attacked 11 people at a Walmart store with a knife. In June, police shot and killed a reportedly diagnosed with schizophrenia after authorities said he attacked law enforcement.

Mark Mihok, a longtime municipal judge near Cleveland, told a spring that he had never seen so many people with serious mental illnesses living on the streets and “now punted into the criminal justice system.”

37-Day Wait for a Bed

At Blanchard Valley Hospital, sheriff’s deputies had taken Jackson from jail for a mental health check. But Jackson’s actions raised concerns.

In the body camera video, a nurse said Jackson was “going to be here all weekend. And we’re going to be calling you guys every 10 minutes.”

The officer responded: “Yeah, well, if he keeps acting like that, he’s going to go right back” to the county jail.

Within minutes, Jackson was taken back to jail, yelling at the officers: “Kill me, motherf—–. Yeah, shoot them, shoot them. Pop!”

Statewide, Ohio has about 1,100 beds in its six regional psychiatric hospitals. In May, the median wait time to get a state bed was 37 days.

That’s “a long time to be waiting in jail for a bed without meaningful access to mental health treatment,” said Shanti Silver, a senior research adviser at the national nonprofit Treatment Advocacy Center.

Long waits, often leaving people who need care lingering in jails, have drawn lawsuits in several states, including , , and , where a large 2014 class action case forced systemic changes such as expansion of crisis intervention training and residential treatment beds.

Ohio officials noticed bed shortages as early as 2018. State leaders assembled task forces and . They launched community programs, crisis units, and a statewide emergency hotline.

Yet backlogs at the Ohio hospitals mounted.

Ohio Department of Behavioral Health Director LeeAnne Cornyn, who left the agency in October, wrote in a May emailed statement that the agency “works diligently to ensure a therapeutic environment for our patients, while also protecting patient, staff, and public safety.”

Eric Wandersleben, director of media relations and outreach for the department, declined to respond to detailed questions submitted before publication and, instead, noted that responses could be publicly found in a governor’s working group report .

Elizabeth Tady, a hospital liaison who also spoke to judges and lawyers at the May gathering, said 45 patients were waiting for beds at Northcoast Behavioral Healthcare, the state psychiatric hospital serving the Cleveland region.

“It’s heartbreaking for me and for all of us to know that there are things that need to be done to help the criminal justice system, to help our communities, but we’re stuck,” she said.

Ohio officials added 30 state psychiatric beds by in Columbus and are planning in southwestern Ohio.

Still, Ohio Director of Forensic Services Lisa Gordish told the gathering in Cleveland that adding capacity alone won’t work.

“If you build beds — and what we’ve seen in other states is that’s what they’ve done — those beds get filled up, and we continue to have a waitlist,” she said.

This year, Jackson waited 100 days in the and Montgomery County jail for a bed at a state hospital, according to jail records.

Ferguson said she was afraid to leave him there but could not bail him out, in part, she said, because her son cannot survive on his own.

“There’s no place for my son to experience symptoms in the state of Ohio safely,” Ferguson said.

Sick System

Patrick Heltzel got the extended treatment Ferguson has long sought for her son, but he stabbed a 71-year-old man to death before getting it.

The 32-year-old is one of more than receiving treatment in Ohio’s psychiatric hospitals.

“People need long-term care,” Heltzel said in October, calling from inside Heartland Behavioral Healthcare, near Canton, where he has lived for more than a decade after being found not guilty by reason of insanity of aggravated murder. Inpatient care, he said, helps patients figure out what medication regimen will work and deliver the therapy needed “to develop insight.”

As he spoke, the sound of an open room and patients chatting filled the background.

“You have to know, ‘OK, I have this chronic condition, and this is what I have to do to treat it,’” Heltzel said.

As the ranks of criminally charged patients in Ohio’s hospitals have increased over the past decade, the shift has had an impact on patient care: The hospitals have endangered patients, have become more restrictive, and are understaffed, according to interviews with Heltzel, other patients, and former staff members, as well as documents obtained through public records requests.

Escapes and a Lockdown

Katie Jenkins, executive director of the National Alliance on Mental Illness Greater Cleveland, said the shift from mostly civil patients, who haven’t been charged with a crime, to criminally charged patients has changed the hospitals.

“It’s hard in our state hospitals right now,” she said. Unfortunately, she said, patients who have been in jail bring that culture to the hospitals.

In the first 10 months of 2024, at least nine patients escaped from Ohio’s regional psychiatric hospitals — compared with three total in the previous four years, according to .

, two female patients at Summit Behavioral Healthcare near Cincinnati escaped after one lunged at a staff member. In another, a man broke a window and climbed out.

Most of the escapes, though, were not violent. Days after a patient at Northcoast during a trip to the dentist in a Cleveland suburb, state officials stopped allowing patients to leave any of the six regional hospitals.

to leaders at the hospitals said officials had seen “similarities across multiple facilities,” raising significant concern about “ensuring patient and public safety.”

For Heltzel, the inability to go on outings or to his mother’s house on the weekends was a setback for his treatment. In 2024, when the lockdown began, he had more freedom than most patients at the psychiatric hospitals, regularly leaving to go to the local gym and attend off-site group therapy.

His mother signed him out each Friday to go home for the weekend, where he drove a car and played with his 2-year-old German shepherd, Violet. On Sundays, Heltzel was part of the “dream team” at church, volunteering to operate the audio and slides.

Federal records reveal that, at Ohio’s larger state-run psychiatric hospitals, including Summit and Northcoast, patients and staff have faced imminent danger.

In 2019 and 2020, federal investigators responded to patient deaths, including two suicides in six months at Northcoast. One hospital employee told federal inspectors, “The facility has been understaffed for a while and it’s getting worse,” according to . “It is very dangerous out here.”

Disability Rights Ohio, which has a federal mandate to monitor the facilities, in October against the department. The advocacy group, alleging abuse and neglect, asked for records of staff’s response to a Northcoast patient who suffocated from a plastic bag over their head. At the end of October, the court docket showed the parties had settled the case.

Retired sheriff’s deputy Louella Reynolds worked as a police officer at Northcoast for about five years before leaving in 2022. She said the increase in criminally charged patients meant the hospitals “absolutely” became less safe. Her hip still hurts from a patient who threw her against a cement wall.

Reynolds said officers should be able to carry weapons, which they don’t, and that more staff are needed to handle the patients. Mandatory overtime was common, she said, and often staff would report to work and not “know when we would get off.”

A Disaster That Wasn’t Averted

Back at Heartland, Heltzel requested conditional release. The judge denied the release request.

Heltzel said it was devastating. He grew up Catholic and said, “I was kind of looking for absolution.”

Now, Heltzel said he is practicing acceptance. “Acceptance is all the more important to practice when you don’t agree with something,” Heltzel said, adding, “I’m a ward of the state.”

He still hopes to be released: “I just do what I can to move forward.”

Heltzel, like Jackson, had been hospitalized before and released.

In early 2013, Heltzel said, he asked his dad to kill him. “And he refused and I did smack him,” he said. Heltzel was sent to Heartland for a short stay — about 10 days, according to his mother, Jan Dyer. She recalled “begging” the hospital staff to keep him.

Heltzel said he remembers not being ready to leave: “I was still sick, and I was still delusional.” Back at home, he said, he had a “sense of existential dread, like that all this horrible stuff was going to happen.” He stopped taking his medication.

Within weeks, Heltzel killed 71-year-old Milton A. Grumbling III at his home, placing him in a chokehold and stabbing him repeatedly, according to . He beat him with a remote control and then left, taking a Bible from the home, as well as a ring. Delusional with schizophrenia, Heltzel believed that Grumbling had sexually abused him in another life, according to the records.

A family member of the man he killed told the judge in 2023 that Heltzel should “stay in prison,” according to .

In denying his conditional release, judges cited Heltzel’s failure to take medication before killing Grumbling.

Jenkins, who said she worked at a state hospital for nine years before becoming the lead advocate for NAMI Greater Cleveland, said psychiatric medications can take as long as six weeks to become fully effective.

“So clients aren’t even getting stabilized when they’re being hospitalized,” Jenkins said.

‘He’s Not a Throwaway Child’

In a July interview, Jackson said inconsistent care or unmedicated time in jail “worsens my symptoms.” Jackson was on the phone during a stay at a state psychiatric hospital.

Without medicine, “my head hurts, to be honest,” Jackson said, before asking to get off the phone because he was hungry. It was lunchtime. “Can you get the information from my mom?” Jackson said. “She has the records.”

After Jackson hung up the phone, Ferguson explained that “he says the food is excellent, so he does not want to miss it.” And, she added, the hospital staff had not yet seen the explosive side of her son.

In early September, after 45 days at Summit — his longest stay yet at a state psychiatric hospital — Jackson returned to the Montgomery County jail facing misdemeanor charges because of with staff at a Dayton behavioral health hospital. In court, Ferguson said, her son struggled to explain to the judge why he was there. On a video call from the jail days later, she saw him playing with his hair and ears.

“That tells me he’s not OK,” Ferguson said.

Before Jackson’s diagnosis more than a decade ago, Ferguson said, her son wasn’t a troublemaker. He had goals and dreams. And he’s still “loved and liked by a lot of people.”

“He’s not a throwaway child,” she said.

 is a nonprofit news team covering Ohio’s criminal justice systems.

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

ºÚÁϳԹÏÍø News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

ºÚÁϳԹÏÍø News South Dakota correspondent Arielle Zionts contributed to this report.

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El residente de Austin, de 20 años, calificó el año pasado para recibir beneficios federales de alimentos porque salió del sistema de cuidado temporal (foster care, en inglés) de Texas, al que ingresó cuando era bebé.

El Programa de Asistencia Nutricional Suplementaria —conocido como SNAP, por sus siglas en inglés, o cupones de alimentos— ayuda a alimentar a 42 millones de personas con bajos ingresos en el país. Ahora, debido a cambios incluidos en la ley que los republicanos llaman One Big Beautiful Bill Act, Santillan-Garcia pronto podría tener que demostrar a las autoridades que está trabajando para conservar este beneficio.

Contó que perdió su último empleo por faltar al trabajo para ir al doctor para tratarse infecciones estomacales recurrentes. No tiene auto y ha solicitado empleo en supermercados, Walmart, Dollar General, “en cualquier lugar que se te ocurra” al que pueda llegar caminando o en bicicleta.

“Ningún trabajo me ha contratado”.

Según la nueva ley federal de presupuesto, más personas deben demostrar que están trabajando, haciendo voluntariado o estudiando para ser elegibles para SNAP.

Quienes no entreguen la documentación a tiempo corren el riesgo de perder la ayuda alimentaria por hasta tres años.

Al principio, se instruyó a los estados que comenzaran a contar “faltas” de los participantes a partir del 1 de noviembre, el mismo día en que millones de personas vieron suspenderse sus beneficios de SNAP por la negativa de la administración de Donald Trump a financiar el programa durante el cierre del gobierno.

Sin embargo, autoridades federales dieron marcha atrás a mitad de ese mes y dieron a los estados hasta diciembre para aplicar las nuevas reglas.

La ley también limita aún más cuándo los estados y condados con alto desempleo pueden eximir a los beneficiarios de estos requisitos. Pero una batalla legal sobre esa disposición ha generado que los plazos para cumplir con las nuevas normas varíen según el lugar donde vive la persona, incluso dentro del mismo estado en algunos casos.

El Departamento de Agricultura de Estados Unidos (USDA, por sus siglas en inglés) no respondió a una lista detallada de preguntas sobre cómo se implementarán las nuevas reglas de SNAP, y la Casa Blanca tampoco respondió a un pedido de comentarios sobre si estas reglas podrían dejar fuera del programa a personas que dependen de él.

La ley sí extendió exenciones para muchos integrantes de pueblos nativos americanos.

Aun así, los estados deben cumplir con las nuevas reglas o enfrentar sanciones que podrían obligarlos a cubrir una parte mayor del costo del programa, que el año pasado fue de aproximadamente $100.000 millones.

El presidente Trump firmó esta enorme ley presupuestaria, junto con los nuevos requisitos de SNAP, el 4 de julio. Según Chloe Green, subdirectora de la Asociación Estadounidense de Servicios Humanos Públicos (American Public Human Services Association), que asesora a los estados en programas federales, los estados inicialmente estimaron que necesitarían al menos 12 meses para aplicar cambios de tal magnitud.

Según la ley, las personas “capaces de trabajar” que están sujetas a requisitos laborales pueden perder el acceso a los beneficios por tres años si pasan tres meses sin presentar documentación que demuestra sus horas trabajadas.

Dependiendo de cuándo los estados apliquen las reglas, muchas personas podrían comenzar a ser excluidas del programa a principios del próximo año, dijo Lauren Bauer, investigadora en estudios económicos del centro de análisis Brookings Institution. Se espera que los cambios dejen al menos a 2,4 millones de personas fuera de SNAP durante la próxima década, según la .

“Es muy difícil trabajar si tienes hambre”, sentenció Bauer.

Muchos adultos beneficiarios de SNAP menores de 55 años ya tenían que cumplir con requisitos de trabajo antes de que se promulgara la ley presupuestaria.

Ahora, por primera vez, los que tengan entre 55 y 64 años, y los padres cuyos hijos tengan 14 años o más deben documentar al menos 80 horas mensuales de trabajo o de otras actividades válidas.

La nueva ley también elimina exenciones que desde 2023 se aplicaban a veteranos, personas sin vivienda y jóvenes que salieron del sistema de cuidado temporal, como Santillan-Garcia.

Políticos republicanos han dicho que estas nuevas reglas forman parte de un esfuerzo más amplio para eliminar el despilfarro, el fraude y el abuso en los programas de asistencia pública.

La secretaria de Agricultura, Brooke Rollins, dijo en noviembre que, además de aplicar la ley, requerirá que millones de personas vuelvan a solicitar los beneficios para reducir el fraude, aunque no dio más detalles. En , Rollins afirmó que quiere asegurarse de que los beneficios de SNAP lleguen solo a quienes son “vulnerables” y “no pueden sobrevivir sin ellos”.

Green explicó que los estados están obligados a notificar a las personas que estarán sujetas a cambios en sus beneficios antes de que se los corten. Algunos estados han anunciado los cambios en sus sitios web o por correo, pero muchos no están dando suficiente tiempo para que los beneficiarios se pongan al día.

Defensores contra el hambre temen que los cambios, y la confusión que generan, aumenten el número de personas que enfrentan inseguridad alimentaria. Este año, los bancos de alimentos han reportado cifras récord de personas en busca de ayuda.

Incluso cuando cumplen con los requisitos laborales, muchas personas enfrentan dificultades para subir documentos y hacer que los estados procesen sus beneficios a través de sistemas saturados.

En , alrededor de 1 de cada 8 adultos dijo haber perdido los beneficios alimentarios por problemas al entregar la documentación. Algunos fueron dados de baja por errores del estado o por falta de personal.

Pat Scott, trabajadora comunitaria del Centro de Asistencia de Recursos Beaverhead, en la zona rural de Dillon, en Montana, es la única persona en al menos una hora de distancia conduciendo que ayuda a la población a acceder a asistencia pública, incluidos adultos mayores sin transporte confiable. Pero el centro solo abre una vez por semana, y Scott afirma que ha visto a personas perder la cobertura por problemas con el portal estatal en internet.

Jon Ebelt, vocero del Departamento de Salud de Montana, dijo que el estado trabaja continuamente para mejorar sus programas. Agregó que, si bien algunas reglas han cambiado, ya existe un sistema para reportar el cumplimiento de los requisitos laborales.

En Missoula, Montana, Jill Bonny, directora del albergue Poverello Center, explicó que sus clientes sin techo ya enfrentan grandes desafíos para solicitar ayuda: con frecuencia pierden sus documentos en medio del reto diario de cargar con todas sus pertenencias.

Bonny dijo que también le preocupa que los cambios federales puedan llevar a más personas mayores a quedarse sin hogar si pierden los beneficios de SNAP y tienen que elegir entre pagar la renta o comprar comida.

En Estados Unidos, las personas de 50 años o más son dentro de la población sin vivienda, según datos federales.

Sharon Cornu, directora ejecutiva del St. Mary’s Center, una organización que apoya a adultos mayores sin hogar en Oakland, California, afirmó que las nuevas reglas están generando desconfianza. “Esto no es normal. No estamos jugando con las reglas de siempre”, dijo Cornu sobre los cambios federales. “Es una medida punitiva y malintencionada”.

A principios de noviembre, un juez federal en Rhode Island ordenó al gobierno de Trump entregar los pagos completos de SNAP durante el cierre del gobierno, que terminó el 12 de noviembre.

Ese mismo juez intentó frenar algunos de los nuevos requisitos laborales. Ordenó al gobierno respetar los acuerdos existentes que eximen del requisito de trabajo a ciertas personas en algunos estados y condados hasta que finalicen dichos acuerdos. En total, 28 estados y el Distrito de Columbia tenían estas exenciones, con fechas de finalización distintas.

Para complicar aún más la situación, algunos estados, como Nuevo México, tienen exenciones que hacen que personas en diferentes condados deban cumplir las reglas en distintos momentos.

Green explicó que si los estados no documentan adecuadamente el estatus laboral de los beneficiarios de SNAP, se les forzará a pagar después. Según la nueva ley, por primera vez los estados deben cubrir una parte del costo de los alimentos, y el monto dependerá de qué tan bien calculen los beneficios.

Durante el cierredel gobierno, cuando nadie recibió beneficios de SNAP, Santillan-Garcia y su novia dependieron de tarjetas de regalo de supermercados que les dio una organización sin fines de lucro para alimentar al bebé de su novia. Para comer ellos, recurrieron a un banco de alimentos, aunque muchos productos, como los lácteos, le hacen daño a Santillan-Garcia.

Le preocupa que en febrero vuelva a estar en la misma situación cuando tenga que renovar sus beneficios —ya sin la exención para jóvenes que salieron del sistema de cuidado temporal—. Las autoridades de Texas aún no le informan qué deberá hacer para seguir recibiendo SNAP.

Santillan-Garcia dijo que reza para que, si no logra encontrar trabajo, pueda encontrar otra forma de seguir cumpliendo los requisitos y mantener sus beneficios.

“Probablemente me los van a quitar”, dijo.

Lo que debes saber

Los cambios en SNAP eliminaron las exenciones a los requisitos laborales para:

• Personas de entre 55 y 64 años
• Cuidadores de menores de 14 años en adelante
• Veteranos
• Personas sin vivienda
• Jóvenes de hasta 24 años que salieron del sistema de cuidado temporal

Qué deben hacer los beneficiarios de SNAP

• Consultar con organizaciones de asistencia pública para saber cuándo entran en vigencia las nuevas reglas en su región. Es posible que las revisen al momento de recertificar, pero podrían pedirle cumplir con los requisitos laborales mensuales mucho antes.
• Informar a su estado si está a cargo de un menor de 14 años que vive en su hogar; está embarazada; estudia al menos medio tiempo; asiste a un programa de tratamiento de alcohol o drogas; tiene una condición física o mental que le impide trabajar; es una persona indígena; o cuida a un miembro del hogar incapacitado. Si cumple con alguno de estos criterios, podría seguir estando exento.

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The Supplemental Nutrition Assistance Program — commonly referred to as food stamps, or SNAP — helps feed 42 million low-income people in the United States. Now, because of changes included in the One Big Beautiful Bill Act, to keep his food benefits Santillan-Garcia might soon have to prove to officials that he’s working.

He said he lost his last job for taking time off to go to the doctor for recurrent stomach infections. He doesn’t have a car and said he has applied to a grocery store, Walmart, Dollar General, “any place you can think of” that he could walk or ride his bike to.

“No job has hired me.”

Under the new federal budget law, to be eligible for SNAP benefits, more people are required to show that they are working, volunteering, or studying. Those who don’t file paperwork in time risk losing food aid for up to three years. States were initially instructed to start counting strikes against participants on Nov. 1, the same day that millions of people saw their SNAP benefits dry up because of the Trump administration’s refusal to fund the program during the government shutdown. But federal officials backtracked partway through the month, instead giving states until December to enforce the new rules.

The new law further limits when states and counties with high unemployment can waive recipients from requirements. But a legal battle over that provision means that the deadline for people to comply with the new rules varies depending on where recipients live, even within a state in some cases.

The U.S. Department of Agriculture did not respond to a detailed list of questions about how the new rules around SNAP will be implemented, and the White House did not respond to a request for comment about whether the rules could kick off people who rely on the program. The law did extend exemptions to many Native Americans.

Still, states must comply with new rules or accrue penalties that could force them to pay a bigger share of the program’s cost, which was about $100 billion last year.

President Donald Trump signed the massive budget bill, along with the new SNAP rules, into law on July 4. States initially predicted they would need at least 12 months to implement such significant changes, said Chloe Green, an assistant director at the American Public Human Services Association who advises states on federal programs.

Under the law, “able-bodied” people subject to work requirements can lose access to benefits for three years if they go three months without documenting working hours.

Depending on when states implement the rules, many people could start being dropped from SNAP early next year, said Lauren Bauer, a fellow in economic studies at the Brookings Institution, a policy think tank. The changes are expected to knock at least 2.4 million people off SNAP within the next decade, according .

“It’s really hard to work if you are hungry,” Bauer said.

Many adult SNAP recipients under 55 already needed to meet work requirements before the One Big Beautiful Bill Act became law. Now, for the first time, adults ages 55 to 64 and parents whose children are all 14 or older must document 80 hours of work or other qualifying activities per month. The new law also removes exemptions for veterans, homeless people, and former foster care youths, like Santillan-Garcia, that had been in place since 2023.

Republican policymakers said the new rules are part of a broader effort to eliminate waste, fraud, and abuse in public assistance programs.

Agriculture Secretary Brooke Rollins said in November that in addition to the law, she will require millions to reapply for benefits to curb fraud, though she did not provide more details. Rollins she wants to ensure that SNAP benefits are going only to those who “are vulnerable” and “can’t survive without it.”

States are required to notify people that they are subject to changes to their SNAP benefits before they’re cut off, Green said. Some states have announced the changes on websites or by mailing recipients, but many aren’t giving enrollees much time to comply.

Anti-hunger advocates fear the changes, and confusion about them, will increase the number of people in the U.S. experiencing hunger. Food pantries have reported record numbers of people seeking help this year.

Even when adhering to the work rules, people often report challenges uploading documents and getting their benefits processed by overwhelmed state systems. In a survey of SNAP participants, about 1 in 8 adults reported having lost food benefits because they had problems filing their paperwork, according to . Some enrollees have been dropped from aid as a result of state errors and staffing shortfalls.

Pat Scott, a community health worker for the Beaverhead Resource Assistance Center in rural Dillon, Montana, is the only person within at least an hour’s drive who is helping people access public assistance, including seniors without reliable transportation. But the center is open only once a week, and Scott says she has seen people lose coverage because of problems with the state’s online portal.

Jon Ebelt, a spokesperson with the Montana health department, said the state is always working to improve its programs. He added that while some of the rules have changed, a system is already in place for reporting work requirements.

In Missoula, Montana, Jill Bonny, head of the Poverello Center, said the homeless shelter’s clients already struggle to apply for aid, because they often lose documentation amid the daily challenge of carrying everything they own. She said she’s also worried the federal changes could push more older people into homelessness if they lose SNAP benefits and are forced to pick between paying rent or buying food.

In the U.S., are the fastest-growing group experiencing homelessness, according to federal data.

Sharon Cornu is the executive director at St. Mary’s Center, which helps support homeless seniors in Oakland, California. She said the rule changes are sowing distrust. “This is not normal. We are not playing by the regular rules,” Cornu said, referring to the federal changes. “This is punitive and mean-spirited.”

In early November, a federal judge in Rhode Island ordered the Trump administration to deliver full SNAP payments during the government shutdown, which ended Nov. 12. That same judge sought to buffer some of the incoming work requirements. He ordered the government to respect existing agreements that waive work requirements in some states and counties until each agreement is set to end. In total, and the District of Columbia had such exemptions, with different end dates.

Adding to the confusion, some states, including New Mexico, have waivers that mean people in different counties will be subject to the rules at different times.

If states don’t accurately document SNAP enrollees’ work status, they will be forced to pay later on, Green said. Under the new law, states must cover a portion of the food costs for the first time — and the amount depends on how accurately they calculate benefits.

During the government shutdown, when no one received SNAP benefits, Santillan-Garcia and his girlfriend relied on grocery gift cards they received from a nonprofit to prioritize feeding his girlfriend’s baby. They went to a food pantry for themselves, even though many foods, including dairy, make Santillan-Garcia sick.

He’s worried that he’ll be in that position again in February when he must renew his benefits — without the exemption for former foster care youths. Texas officials have yet to inform him about what he will need to do to stay on SNAP.

Santillan-Garcia said he’s praying that, if he is unable to find a job, he can figure out another way to ensure he qualifies for SNAP long-term.

“They’ll probably take it away from me,” he said.

What You Should Know

Changes to SNAP removed work-requirement exemptions for:

• People ages 55 to 64.
• Caretakers of dependent children 14 or older
• Veterans
• People without housing
• People 24 or younger who aged out of foster care

What SNAP Participants Should Do:

• Check with public assistance organizations to find out when the new rules go into effect in your region. Your benefits may be checked at recertification, but you may be required to meet the monthly work reporting rules long before that.
• Let your state know if you’re responsible for a dependent child younger than 14 who lives in your home; pregnant; a student at least half the time; attending a drug or alcohol treatment program; physically or mentally unable to work; a Native American; or a caretaker of an incapacitated household member. If so, you may still be exempt.

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While Congress debates whether to put more money into free testing, California is leaning on programs it already had in place: special state-based coverage for uninsured Californians, school testing, and free tests offered by clinics, counties, and other groups. Absent free options, people without health insurance could pay as much as depending on where they get tested.

At the same time, demand for community testing — from residents with and without insurance — has dropped precipitously.

On a recent Thursday, only three people could be found getting tested at seven testing sites in Sacramento County. Staffers at these locations — from the formerly bustling mass-testing site at the state fairgrounds to a tiny kiosk in a church parking lot — said hardly anyone shows up anymore even though testing is still important for monitoring and reducing the spread of covid-19. They mostly see regulars who come in for routine testing required by their employer or school.

Dr. Olivia Kasirye, the public health officer for Sacramento County, said the county sends specimens to a state lab at no cost to the county, which has helped keep free testing services up and running. California is quietly , but the state says it will shift testing to a network of commercial labs. State officials told KHN there will be no changes for patients.

“I think we can maintain services” for now, but the future is uncertain, Kasirye said.

Since the beginning of the pandemic, the federal government had reimbursed providers for testing, treating, and vaccinating uninsured people for covid-19. But the stopped accepting reimbursement claims for tests and treatments March 22, and for vaccinations April 5, saying the money had run out. The government had been reimbursing providers per test.

Since then, states and counties have been watching their case rates and coffers to see whether they can keep testing uninsured residents.

In Alabama, Dr. Scott Harris, the state health officer, said offering free testing to people five days a week through county health departments is “probably not something we’re going to be able to sustain much longer,” especially in pockets of the state with large uninsured populations.

“We’re going to have zero services for those people,” Harris said. “And no ability to incentivize providers to see them.”

Congress returns from recess in late April but may not renew the program. Lawmakers previously considered extending it but chose not to include money for it in a that’s been pending since early April.

The Covid-19 Uninsured Group

Health care advocates say California has been able to continue free testing for the uninsured, including for residents without legal documentation, because of how it used a separate pot of federal funding. Although also leveraged pandemic support, advocates believe California expanded benefits the most.

In August 2020, California created an insurance program with pandemic relief money to cover covid-related treatments, testing, and vaccines for uninsured people or those whose insurance plans don’t cover those services. The Covid-19 Uninsured Group essentially acts as Medicaid for covid, but with no income requirements. That’s different from traditional Medi-Cal, California’s Medicaid program, which is for low-income people.

Coverage will end when the federal public health emergency does. On April 13, the U.S. Department of Health and Human Services renewed the emergency declaration for 90 days, extending it to .

The state program is a clever way to use federal dollars, said David Kane, a senior attorney at the Western Center on Law & Poverty. But he noted there are drawbacks. People must be enrolled before they can obtain services, and they can’t enroll themselves. Only certain health care providers, mostly hospitals and clinics, can sign people up.

“The program was never designed to exist in isolation,” Kane said, “but now it does.”

About 291,000 people were enrolled in the program as of April 4, according to Anthony Cava, a spokesperson for the state Department of Health Care Services, which administers Medi-Cal. An estimated Californians, or around 9.5% of people younger than 65, are uninsured.

Kane suggested that people find a qualified provider by the Department of Health Care Services or by calling the and get enrolled as soon as possible, especially if they are used to walking up to a testing site and paying nothing.

The challenge is getting people to sign up before they get sick or need a test, Kane said, and keeping the program going with the added patient load.

Screening Students

Another major source of free testing in California is public schools.

California distributed more than to schools before students left for spring break. The schools in turn handed out the rapid tests to families so they can screen students before sending them back to campus. The state had a similar program for the winter holidays.

The winter testing was “incredibly effective,” according to Primary Health, the company running the program for the state. About voluntarily reported their results back to a sampling of schools, according to the company.

In addition, the state is paying Primary Health to operate more than 7,000 free testing sites — most of which are in schools — by using leftover federal covid relief money disbursed to states at the beginning of the pandemic.

How long that funding will last isn’t clear.

“It seems like the federal government is stepping back and saying this portion of health care is going back to health care as we know it,” said Abigail Stoddard, Primary Health’s general manager of government and public programs.

Stoddard’s conversations with schools outside California are changing. Instead of conducting surveillance testing to determine whether the virus is circulating on campus, as California is doing, many are moving toward testing only kids with symptoms, she said.

For example, Primary Health operates , where schools are applying for grants to fund testing and will decide whether tests will be for sick students, healthy ones, or just staffers.

Local Free Testing

Free testing is still available in California through some hospitals, community clinics, local health departments, and private companies working with the state, although how long those options will remain is unclear.

In Sacramento County, the loss of federal funding for testing uninsured people has gone mostly unnoticed so far. “Our hope is that we have enough services and resources in the community that the additional coverage going away will not have a huge impact,” Kasirye said.

The county health department still offers free community testing to uninsured people .

But they may get harder to find. The testing company Curative used to offer free lab-run PCR and rapid antigen tests around the state, but now that the federal funding has run out, it offers only PCR tests to the uninsured for free. The company has also reduced the number of its sites, from 283 on April 14 to 135 on April 19.

In some states, Curative has either stopped testing uninsured people — or is charging them $99 to $135 per test.

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Newsom, a self-described feminist and the father of four young children, has long advocated family-friendly health and economic policies. Flush with a projected budget surplus of $75.7 billion, state politicians have come up with myriad legislative and budget proposals to make poorer families healthier and wealthier.

They include ending sales taxes on ; adding benefits such as doulas and early childhood trauma screenings to Medi-Cal, the state’s Medicaid program; allowing pregnant women to retain Medi-Cal coverage for a year after giving birth; and a pilot program to provide a universal basic income to low-income new parents.

“COVID-19 laid inequity bare for all to see,” Assembly member Wendy Carrillo (D-Los Angeles) said in a written statement. She is the co-author of Senate Bill 65, led by Sen. Nancy Skinner (D-Berkeley), which would pour hundreds of millions of dollars into family and health care programs annually, focusing on minority groups that Carrillo said were “pushed out of the social safety net by the prior White House.”

Newsom and the Democratic-controlled legislature are unified on major health care and social safety-net expansions, which would direct billions in health benefits and cash assistance to the state’s most vulnerable residents and low-income parents. Legislative Democrats for years have pushed a progressive agenda to help struggling parents and families, featuring proposals like those to permanently end taxes on menstrual products and diapers — .

“We don’t need to balance the budget on half of the population that has a uterus,” said Assembly member Cristina Garcia (D-Bell Gardens), who has to the “pink tax” on diapers and menstrual products.

Skinner, chair of the Senate budget committee, is among the powerful lawmakers who’ve put forward legislation to make childbirth safer and parenthood more affordable. Her bill, which cleared the Senate and was up for consideration this week in the state Assembly, has several features that would dramatically expand maternal health care (transgender men also get pregnant and give birth).

Before the pandemic, Medi-Cal covered mothers only up to 60 days after their pregnancies ended unless their income fell below a certain line or they had a mental health diagnosis. Skinner’s bill, part of a to improve birth outcomes, would expand full Medi-Cal coverage to 12 months after the end of a pregnancy. Other would intensify state reporting and reviews of fetal and pregnancy-related deaths and severe maternal morbidity, expand housing benefits for families that have a pregnant member, and increase training programs for midwives.

Newsom’s $268 billion budget blueprint includes about $200 million a year to fully implement the expansion of Medi-Cal coverage for new mothers, with matching dollars from the federal government until those funds expire in 2027. If the expansion were not renewed, the state would revert to previous Medi-Cal qualifications.

in California in 2017, the last year for which data could be found.

“Not all postpartum issues end at 60 days, and when patients lose insurance, we can’t address them in the usual way,” said Dr. Yen Truong, an OB-GYN who works with the American College of Obstetricians and Gynecologists on legislative issues in California.

About half of pregnancy-related deaths occur during the pregnancy or on the day of delivery, but about 12% take place after giving birth, according to the Centers for Disease Control and Prevention.

The U.S. had 17.4 early maternal deaths per 100,000 live births in 2018, according to the most recent CDC data with state figures. California’s rate, , was among the lowest in the nation, but the state collects data on maternal deaths in a way that could result in underestimates.

California’s overall numbers also obscure stark racial disparities. Statewide, Black infants averaged , compared with an average of three deaths among white babies. Data from 2013 from showed Black women had pregnancy-related deaths at rates more than four times as high as the overall rate in the state’s largest county.

“Given our state’s wealth and medical advancements, this is unacceptable,” Skinner, vice chair of the Legislative Women’s Caucus, said in a news release.

Democrats also appear unified on another aspect of Skinner’s bill: a pilot program to test a universal basic income program for struggling families. The bill would give $1,000 a month to low-income expectant and new parents with kids under 2 years old in counties that decide to participate. Newsom has also proposed for pilot programs for universal basic income.

These issues could play well, especially among women, and improve Newsom’s standing going into a recall election later this year, said Rose Kapolczynski, a longtime campaign consultant to former U.S. Sen. Barbara Boxer who has worked on reproductive health care issues in Sacramento.

Indefinitely rescinding sales taxes on diapers and menstrual products — the taxes have been — is a particular no-brainer because of its bipartisan appeal, she said.

“It’s hard for Republicans to attack something that is a tax cut, and sales taxes are regressive, so progressives would like it,” Kapolczynski said.

As for Medi-Cal expansions, Kapolczynski said that even though it wouldn’t affect most Californians, the pandemic has made health care even more important to voters. “The budget surplus is allowing many things that were called impossible to be possible, and that includes health care bills,” she said.

Investing in California’s young families could help close the racial gap in maternal and infant mortality, said Nourbese Flint, executive director of the Black Women for Wellness Action Project, which endorsed Skinner’s bill.

Flint is especially excited about the possibility of covering doulas through Medi-Cal. Doulas, trained as emotional and physical supports for women in pregnancy and postpartum, have been linked to and . If doulas saved Medi-Cal money by reducing cesarean births, that could enable the state to renegotiate payments for labor and delivery, according to an . Under Newsom’s proposed budget, Medi-Cal coverage of doulas would cost about .

California’s would become the first Medicaid program to include “full spectrum” doula coverage, meaning it would include care for women who have abortions, miscarriages and stillbirths, said Amy Chen, a senior attorney at the National Health Law Program.

“California has always led the country and been a little bit in front of where our federal government is when it comes to covering folks,” Flint said.

California Healthline correspondent Angela Hart contributed to this report.

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With Republicans now controlling both chambers of the Montana legislature and the governor’s office, a lawmaker is reviving an effort to both broaden and increase the frequency of eligibility checks to search for welfare fraud, waste and abuse. Proponents say it’s about what’s fair — weeding out people who don’t qualify, protecting safety nets for those who do, and saving the state millions. But advocates for low-income people who rely on such services and some policy analysts say such changes would unfairly drop eligible people who need the aid.

“We’re not looking to do anything mean. We’re taking the emotion out of it,” state Sen. , a Republican, said during a on his bill, the Provide for the Welfare Fraud Prevention Act. “If you don’t qualify, then you shouldn’t be participating in that program.”

The , and measures underway in and , are similar to earlier efforts undertaken to cut costs in states such as Illinois and Michigan. But this year’s bills come even as Congress states more Medicaid dollars if they ensure people have continuous coverage through the pandemic because of its economic shock waves.

The Montana would create a system potentially run by third-party vendors that would mine a large swath of data to see if someone, for example, has assets like a boat, has won the lottery or has filed for benefits in another state. The vendor could earn a bonus for flagging more cases than the state projected. State employees would have the final say in cutting someone from Medicaid, the Children’s Health Insurance Program, food stamps or other aid programs.

The state estimates the measure could save Montana’s treasury between $1.4 million and $2.3 million each year over the next four years by dropping more than 1,500 people on Medicaid and 277 children covered by CHIP.

This isn’t Smith’s first effort to create such a law. He sponsored a similar in 2015 that was vetoed by the state’s then-governor, Democrat Steve Bullock. In the , Bullock said the measure duplicated steps the state already took and unfairly stigmatized Montanans who are poor. Opponents of Smith’s latest proposal have repeated those concerns. Smith didn’t respond to several requests for an interview.

But this time, the potential legislation has a clearer path. The state has a new governor, Greg Gianforte, a Republican who called for heightened Medicaid eligibility checks throughout his 2020 campaign.

During Montana’s first hearing for the renewed effort, of Opportunities Solutions Project was the sole person to testify in support of the bill.

“I’ve seen this play out in state after state,” Centorino said. “Turns out, the less you look for welfare, fraud and waste, the less you find.”

Opportunity Solutions Project, the lobbying wing of the Foundation for Government Accountability, a right-leaning think tank, has backed that followed FGA model legislation. The organizations have also been in trying to link food assistance to work requirements and block states from expanding Medicaid.

Opportunity Solutions Project’s attempts to influence laws at the federal level, too, appear to be growing. The nonprofit spent $25,500 lobbying the federal government in 2017 and $420,000 last year, the Center for Responsive Politics.

Opponents of the Montana bill have said the focus on welfare recipients is misplaced. Nationally, most Medicaid payments deemed improper last year were tied to states not collecting information that federal standards already call for, not necessarily for covering ineligible enrollees, according to a U.S. Department of Health and Human Services .

, a University of Baltimore law professor, said the potential bonus Montana would pay a company finding more savings than expected is especially concerning.

“The goal should not be to create some bounty hunter system to find alleged cheats that don’t exist,” Gilman said. “This is built on an unfounded mistrust of poor people and undermines public support for social programs.”

If states do move to undertake broad data searches, she said, they need to start with a pilot program to test for errors in its design. Gilman called Michigan the ultimate cautionary tale. The state, which had used a new computer program to spot cheaters, ended up mired in lawsuits after it thousands with unemployment fraud between 2013 and 2015.

The Trump administration and federal agencies encouraged states to increase eligibility checks. According to a KFF analysis, as of January 2019 were conducting checks more often than during annual renewals, with some doing so quarterly. (KHN is an editorially independent program of KFF.)

, co-director of KFF’s Program on Medicaid and the Uninsured, said Medicaid and CHIP across the nation from late 2017 through 2019. Rudowitz said it’s hard to untangle all the reasons the enrollment declines occurred, but increased verification efforts that add to administrative hurdles create barriers to coverage.

, with the left-leaning Center on Budget and Policy Priorities, said people may not realize they’re still eligible when notified that their benefits are in question or may not even receive the notice. She said a search for benefits filed in a separate state may flag aid that can cross states, such as food stamps, and such searches can pull up property someone no longer owns. Frequent wage checks may not take into account inconsistent jobs. The onus would fall to the aid recipient to prove they are still eligible in each scenario, she said.

One state that Opportunity Solutions Project points to as a success is Illinois, which in 2012 hired a company to identify Medicaid recipients who might not be eligible. Wagner, who was an associate director with the Illinois Department of Human Services at the time of the change, said Illinois is unique because the state knew it had a backlog of status checks. Within a year, Illinois had canceled benefits for nearly 150,000 people. But the that more than 75% of cancellations were due to clients’ failure to respond to a state letter asking for more information. Wagner said similar issues have occurred in other states.

“In many cases, those individuals remain eligible, but they have a gap in coverage and they have to reapply and do what they can to get back on the program,” said Wagner. “There’s a large cohort of people who never get that done.”

Of all the people Illinois dropped, nearly 20% had reenrolled by the end of the year. That issue — people getting knocked off when they’re eligible — already happens in annual renewals. But Wagner said more checks means more people losing benefits, and more work for states to bring those people back onboard.

Centorino, with Opportunity Solutions Project, said systems that remove qualified people aren’t being implemented properly, but added it’s not too heavy of a lift to respond to an eligibility question.

“The alternative is not is not resolving the discrepancy at all and just assuming that there is no discrepancy and continuing to fund benefits for somebody who may be ineligible,” he said.

In Montana, even with the bill’s clearer shot at becoming law, some elements that opponents criticized were rolled back after the state estimated it would need to hire 42 employees to run the new system. Smith reduced how many programs would fall under its scrutiny and pulled back eligibility checks to twice a year instead of quarterly. He removed a rule that the system pay for itself, and he cut a section that would have disenrolled people who don’t respond to eligibility questions or notices within 10 business days.

Nonetheless, if a new system flags issues in people’s enrollment, the state will have to go out searching for why. The bill is under consideration in the Senate and must also pass the House before it goes to Gianforte for signing.

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Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county’s Mental Health Local Advisory Council.

“I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away,” Buckley-Patton said. “They’re lonely, they’re isolated, they’re depressed, but they’re not going to call a suicide hotline.”

States across the U.S. are still stinging after businesses closed and millions of people lost jobs due to covid-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, (KHN is an editorially independent program of KFF.)

The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven’t anticipated.

“It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization,” said , president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. “We are not likely to see the results of that either in terms of people seeking care — or suicide rates going up — until we’re on the other side of the pandemic.”

Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money and tapped into rainy day funds to make ends meet. Health programs, often among the most expensive part of a state’s budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.

This year, the outlook doesn’t seem quite so bleak due in part to relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states’ tax revenues even as millions of lower-income workers were laid off.

“It has turned out to be not as bad as it might have been in terms of state budgets,” said Mike Leachman, vice president for state fiscal policy for the nonpartisan .

But many states still face cash shortfalls that will be made worse if additional federal aid doesn’t come, Leachman said. to push through Congress a $1.9 trillion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.

New York Gov. Andrew Cuomo, a Democrat, with spending cuts and tax increases if a fresh round of aid doesn’t materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they’re going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska, Wyoming continue to face grim economic outlooks with oil, gas and coal prices down and tourists cutting back on travel, Leachman said.

Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.

“Everybody right now is just trying to protect and make sure we don’t have additional cuts,” said Doyle Forrestal, CEO of the .

That’s also what Buckley-Patton wants for Montana’s Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.

She led the county’s effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.

Through persuasive grant writing and donations coaxed from elected officials, Buckley-Patton and her team secured office space, equipment and a part-time employee for a resource center that’s open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.

But now Buckley-Patton worries even those modest gains will be threatened in this year’s budget. Montana is one of the few states with a budget on a two-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.

predict healthy tax collections over the next two years.

In January, at the start of the legislative session, the panel in charge of building the state health department’s budget proposed starting with nearly $1 billion in cuts. The panel’s chairperson, Republican Rep. , pledged to add back programs and services on their merits during the months-long budget process.

It’s a strategy Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.

“I have grave concerns about this legislative session,” she said. “We’re not digging out of the hole; we’re only going deeper.”

Republicans, who are in control of the Montana House, Senate and governor’s office for the first time in 16 years, are considering reducing the income tax level for the state’s top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.

“Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?” asked Heather O’Loughlin, co-director of the .

Mary Windecker, executive director of the , said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.

But one bright spot, she said, is a proposal by new Gov. Greg Gianforte, a Republican, to create that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.

Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.

“In the public’s mind, there’s drug addicts and there’s the mentally ill,” she said. “Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.”

[Correction: This article was updated at 4:45 p.m. ET on Feb. 6 to correct the value of President Joe Biden’s proposed relief package.]

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Wilson, de 81 años, jubilada que trabajó como supervisora de enfermería del departamento de salud pública en el condado de Duval durante 35 años, acababa de ser diagnosticada con neumonía inducida por COVID-19.

Era su cita de telemedicina y al otro lado de la pantalla estaba el doctor Rogers Cain, quien dirige una pequeña clínica familiar en el norte de Jacksonville, un área predominantemente de raza negra donde el coronavirus está impactando fuerte. Cain ya había atendido virtualmente a siete pacientes con COVID durante la mañana.

Cain y Wilson están nerviosos. Durante años, ambos fueron testigos de como el departamento de salud del condado se quedaba sin dinero y personal, lo que fue dificultando la capacidad de Duval para responder a brotes.

Y ahora enfrentan a COVID-19 en uno de los estados que lidera el alza de casos en los Estados Unidos.

Florida es tanto un microcosmos como una advertencia para el país. A medida que la nación , la dotación de personal y los fondos cayeron más rápidamente en este estado, dejándolo especialmente desprotegido para la peor crisis de salud en un siglo.

Aunque la población de Florida creció en 2,4 millones desde 2010, el estado redujo drásticamente la dotación de personal de sus departamentos de salud locales, de 12,422 trabajadores de tiempo completo a 9,125 en 2019, según observó una investigación conjunta de KHN y The Associated Press.

Los departamentos de salud locales, administrados por el estado, gastaron un 41% menos por residente en 2019 comparado con 2010, según un análisis de datos estatales, cayendo de $57 a $34. Los departamentos de todo el país también han recortado gasto, pero menos de la mitad, según datos de la Asociación Nacional de Funcionarios de Salud del Condado y la Ciudad.

Incluso antes que iniciara la pandemia, ya había menos investigadores disponibles para rastrear y contener enfermedades como la hepatitis. Cuando la ola de COVID-19 inundó Florida, sus principales líneas de defensa ya habían sido diezmadas.

Ahora, los casos confirmados han superado los 588.000 y las muertes superaron las 10.000. La preocupación por el virus hizo que los republicanos cancelaran los planes para la convención nacional en persona en Jacksonville, esta semana.

Expertos en salud culpan por los recortes de fondos a la Gran Recesión y a una serie de gobernadores que quisieron transferir los servicios estatales financiados con fondos públicos a empresas con fines de lucro.

Y, dicen que, cuando la pandemia recrudeció, el gobernador republicano Ron DeSantis y otros líderes políticos enviaron mensajes contradictorios sobre estrategias de prevención como el uso de máscaras. Las voces dentro de los departamentos de salud estaban amordazadas.

“Lamentablemente, la realidad es que la gente va a morir por la irresponsabilidad de las decisiones que toman las personas que elaboran los presupuestos”, dijo , presidente de la , una organización sin fines de lucro en Washington, DC, que ofrece recursos y formación para mejorar la salud pública.

Los funcionarios estatales no respondieron a preguntas específicas de The Associated Press y KHN sobre cambios en la financiación de la salud pública, ni pusieron a disposición personal para explicaciones más profundas.

El , ex subsecretario del departamento de salud del estado de Florida, dijo que no prepararse para un desastre previsible “es negligencia gubernamental”.

Dado que el virus no respeta fronteras, otros estados sienten los efectos de las fallas de Florida.

A pesar de un movimiento hacia la privatización en la década de 1990, el gasto por persona en salud pública local fue aumentando, alcanzando un máximo de $59 cifra ajustada por la inflación al dólar de 2019.

Beitsch dijo que la tendencia a disminuir continuó bajo los ex gobernadores republicanos Charlie Crist y Rick Scott, impulsada por una creciente creencia en la contracción del gobierno. Scott, ahora senador nacional, dijo a través de un vocero que no se disculpaba por los recortes del departamento de salud, a los que caracterizó como acciones para “que el gobierno fuera más eficiente”.

La capacidad de manejar los brotes de enfermedades se ha visto obstaculizada en algunas comunidades de Florida más que en otras debido a esta reducción.

Los departamentos que atienden al menos a medio millón de residentes gastaron solo $29 en salud pública por persona en promedio en 2019, en comparación con $90 por persona en aquellos que atienden a 50,000 o menos, una diferencia más marcada que la brecha típica entre departamentos más grandes y más pequeños a nivel nacional, según el análisis de KHN-AP.

El gasto del departamento de salud del condado de Duval fue el equivalente a $34 por persona, un 63% menos que en 2008. Por lo general, alrededor de 22 trabajadores, o el 5% del personal total, se han dedicado a prepararse y rastrear brotes de enfermedades.

“Los acontecimientos actuales demuestran qué malas fueron las decisiones de realizar profundos recortes a la salud pública”, dijo la doctora Marissa Levine, profesora de salud pública y medicina familiar en la Universidad del Sur de Florida. “Realmente han regresado para vengarse”.

Florida tiene ahora más de medio millón de casos de COVID y 35,000 hospitalizaciones. Aunque DeSantis todavía no ha emitido un mandato de usar máscaras faciales, algunos gobiernos locales, como el de Jacksonville, sí lo han hecho.

Chad Neilsen, director de prevención de infecciones en la Universidad de Florida-Jacksonville, elogió al alcalde de la ciudad por el requisito de usar cubrebocas, pero señaló que otros condados tienen reglas diferentes y que el mensaje inconsistente genera confusión.

“Tenemos que tener una sola voz y un liderazgo constante si queremos que la gente cambie su comportamiento”, dijo el doctor Jonathan Kantor, epidemiólogo y dermatólogo de Jacksonville.

En cambio, expertos en Florida dijeron que los trabajadores de salud pública han sido silenciados o los altos funcionarios estatales les han indicado qué decir. A los funcionarios de salud locales “se les dice sin rodeos: ‘Cállate'”, dijo Patrick Bernet, profesor asociado de administración de salud en la Florida Atlantic University. “Literalmente, no pueden hablar”.

Beitsch, quien ahora preside el departamento de ciencias del comportamiento y medicina social en la Universidad Estatal de Florida, dijo que esto, y una dinámica similar a nivel nacional, alimenta la politización de la salud pública y el debilitamiento de la ciencia.

Mientras tanto, el número de casos de COVID aumenta.

Con un sistema de salud pública que no está equipado, Wilson, la enfermera de salud pública jubilada, dijo que es responsabilidad de todos sacar a Jacksonville, y a Florida, de la crisis.

“Mi esperanza es que todos comiencen a tomarse este virus en serio, usen su máscara y mantengan el distanciamiento social”, dijo Wilson, cuya condición ha mejorado. “Eventualmente habrá una vacuna. Pero hasta entonces, depende de nosotros ayudar. Y si no lo tomamos en serio, estamos condenados”.

Dearen es reportero de The Associated Press, y Ungar y Recht son reporteras de KHN.

Esta historia es una colaboración entre The Associated Press y KHN, un servicio de noticias sin fines de lucro que cubre temas de salud. Es un programa editorialmente independiente de la Kaiser Family Foundation que no está afiliado a Kaiser Permanente.

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