The drug is now marketed and sold across the state in roadside shops and small-town strip malls with little oversight from health authorities. Highway billboards advertise ivermectin as “Available Without a Prescription in Tennessee!” while dozens of pharmacies offer highly concentrated pills, sometimes at 10 or 20 times the potency of a standard tablet.

Ivermectin is a approved by the FDA for treating , which can generally be done with a single dose of three or four prescription-strength tablets. It is also used as a dewormer for horses and other livestock.

Its popularity surged during the pandemic as fringe doctors and anti-vaccine activists promoted it as a treatment for covid. have shown that ivermectin is against covid.

Nonetheless, it has since become a symbol of resistance against the medical establishment among conservatives and followers of the Make America Healthy Again movement, championed by Health and Human Services Secretary Robert F. Kennedy Jr.

Timothy Caulfield, a professor at the University of Alberta who studies health misinformation, said ivermectin became an “ideological flag” during the covid pandemic, opening the door for influencers to push the drug for other ailments to a “captured audience” even without proof it works for those conditions.

“This is really about profit. This is about political identity. This is about creating distrust in the existing biomedical community. This is about money,” Caulfield said in an interview with ABC News, which partnered with ºÚÁϳԹÏÍø News to report on ivermectin.

After a hantavirus outbreak on a cruise ship earlier this year, unproven claims that ivermectin is effective against the virus have been spread by some popular social media accounts and right-wing figures, including former congresswoman . The World Health Organization says it has seen that shows ivermectin is an effective hantavirus treatment.

Tennessee’s ivermectin bill was shepherded by a Republican supermajority in 2022. Its passage blindsided state medical officials and handed a victory to medical groups that spread covid misinformation.

Some pharmacy websites now offer the drug as a treatment for covid, “long haul vax symptoms,” diabetes, or cancer — despite no evidence of its effectiveness for those purposes — while the largely gives pharmacists immunity from lawsuits or professional sanctions related to ivermectin.

The law was also a harbinger of legislation to come: More than two dozen states have since considered look-alike bills that would make the politicized medication available without a requiring a doctor visit. 

John Mafi, a UCLA internal medicine physician who has studied the rise of ivermectin among cancer patients, worries it will lure people away from proven treatments. He co-authored a new study in prescribing rates for ivermectin and another antiparasitic drug, particularly in the South. The rise followed a January 2025 episode of the Joe Rogan Experience podcast in which actor Mel Gibson claimed ivermectin and other drugs cured three friends with stage 4 cancer.

“It’s going back to 19th-century quack science,” Mafi said about off-label use of ivermectin. “It is alarming that I’m seeing this really unproven therapy being touted to so many potentially vulnerable Americans.”

The FDA says ivermectin can be . Tennessee has seen a small but concerning rise in signs of overuse. The Tennessee Poison Center, which fields calls from people exposed to drugs or toxic substances, received more than 60 calls for possible ivermectin poisoning in 2025, the most since 2021. They included reports of vomiting, blurred vision, neurological problems, and difficulty walking.

“People are taking this because they just feel unwell. It’s almost like a panacea now,” said Rebecca Bruccoleri, the poison center’s medical director. “I’ve heard rumblings on the internet of using ivermectin for an alternative cancer treatment, and we’re seeing it definitely in here.”

Pharmacist Paul Hughey has dispensed ivermectin under the new law at two Tennessee pharmacies: Mt. Juliet Pharmacy and Compound Rx. He estimated that “up to 20 people in a week” are buying ivermectin but that peak demand was double or triple that amount.

For years, Hughey said in an interview, customers have relayed emotional “testimonies” about the drug healing the sick, “especially with the cancer patients.”

“I’ll get a doctor call in and they say: ‘Guess what. So-and-so is cured.’ And it’s just amazing to hear that. So anybody who doubts that,” Hughey said, “I don’t really know that they’re practicing medicine. I think they’re just following the narrative.”

‘I’ve Taken Bucketloads of This Stuff’

The linchpin of Tennessee’s ivermectin market is , a conservative doctor to the creation of the 2022 ivermectin law. She has with pharmacies across the state empowering them to sell the drug.

Tennessee’s law to dispense ivermectin without a specific prescription for each patient, through a “collaborative pharmacy practice agreement” with a doctor who provides what is functionally a pre-written, nonspecific prescription for all potential customers.

In podcast interviews, Sibley has said she has made as many as 40 of these agreements with Tennessee pharmacies, which she said forward her the paperwork on each ivermectin customer. Before selling the drug, pharmacies are required to ask customers questions about medical conditions and medications that could cause complications if taken with ivermectin. Afterward, the collaborating physician also is expected to receive a record for each person who purchases ivermectin.

“We literally have folks coming from all over the world to get our ivermectin,” Sibley said on in February 2025. “As the collaborator for these pharmacies, I get every person’s sheet.”

“They’re from every state,” she said. “They’re from Canada. They’re from Europe.”

Sibley did not respond to requests for comment.

ºÚÁϳԹÏÍø News has independently confirmed that Sibley signed agreements with at least 10 pharmacies. The agreements say pharmacists shall dispense ivermectin only in Tennessee, where Sibley is licensed, although one of those pharmacies said friends and family in Tennessee can “.”

Hughey, the Tennessee pharmacist, said Sibley had prescribing agreements ready to go when the law was enacted. He credited her with advancing ivermectin sales throughout the state.

“Had Dr. Sibley not stepped in and really pushed forward, there’s no telling how hard it would have been,” Hughey said. “It would have been a lot less widespread.”

Sibley also works with Children’s Health Defense, the Kennedy-founded group that has become one of the nation’s most influential anti-vaccine organizations. In podcasts, Sibley has referred to the covid vaccine as a “” and “ that’s ever been produced.”

Separately, before Tennessee legislators in 2024 about an alleged plot to change the weather and block sunlight. The New York Times then included her .

Sibley has said in podcast interviews that she was told by God to treat covid patients. She said she has advocated for ivermectin ever since.

“God agrees with what I’m doing,” Sibley said in 2023 on the podcast , which is recorded in Nashville. “I wake up every day and I say: ‘Yes, sir. I’m reporting to duty.’”

In legislative and government hearings throughout 2022, Sibley testified that she had treated around 4,400 people with ivermectin, including some Tennessee lawmakers, all without taking payment. Sibley described ivermectin as “a wonder drug” and said making it more available “.”

“I’ve taken bucketloads of this stuff myself,” Sibley said . “I feel like I’ve been a good test subject.”

Sibley has said she dispenses ivermectin using treatment guidelines developed by Paul Marik, who in 2020 co-founded the Independent Medical Alliance, a medical group that has promoted ivermectin as an effective treatment for , , , and .

Some Tennessee pharmacies now follow those protocols, too. The protocols recommend patients take 1.5 to five times as much ivermectin as is normally prescribed to treat parasites, with the dose taken for days or weeks instead of just once.

Marik and other ivermectin proponents sued the FDA in 2022 after it discouraged the use of the drug for covid by tweeting: “You are not a horse. You are not a cow. Seriously, y’all. Stop it.” The agency settled the lawsuit with no admission of wrongdoing and deleted the viral tweet in 2024.

The American Board of Internal Medicine has revoked Sibley’s and Marik’s board certifications but declined to explain why. Sibley still holds a Tennessee medical license; Marik is based in Virginia and is not licensed. Sibley and Marik the internal medicine board’s actions.

In response to questions from ºÚÁϳԹÏÍø News, Marik, through an Independent Medical Alliance spokesperson, said medical science benefits from “open discussion of ideas and treatments.”

“Many independent doctors have reported that treatments like Ivermectin, in conjunction with traditional treatments, are showing promise. These ideas should be explored,” alliance spokesperson Lynne Kristensen said in an emailed statement.

Marik testified in favor of Tennessee’s ivermectin legislation in 2022, telling lawmakers that it is necessary because people would otherwise buy animal-grade ivermectin in stronger dosages meant for livestock.

“They’re buying ivermectin from farm stores. We don’t know the quality,” Marik said at a March 2022 legislative hearing on the Tennessee bill. “So this would prevent that from happening.”

Tennessee Does Not Track Its Ivermectin Market

Arkansas, Idaho, Louisiana, and Texas enacted similar laws in 2025, and legislation that makes ivermectin available without the need for a doctor visit has been introduced or debated in at least 24 other states, according to a ºÚÁϳԹÏÍø News analysis. That means half the country could be following Tennessee down an unlit path, because no one knows the full scope of its ivermectin market.

Tennessee does not effectively track which pharmacies offer ivermectin this way, and the state government has been unable to produce some foundational documents that pharmacies are legally required to file before they sell the drug, according to a ºÚÁϳԹÏÍø News investigation.

Doctors and pharmacies are the Tennessee Department of Health when they sign agreements that allow ivermectin to be dispensed without patient-specific prescriptions, although it is not clear whether this consistently occurs.

In response to a ºÚÁϳԹÏÍø News public records request for those ivermectin notifications filed by pharmacies, the agency over three months produced records from only 12 pharmacies, half of which have agreements with Sibley. The agency said it did not locate records related to at least 13 others that ºÚÁϳԹÏÍø News has identified as selling ivermectin without requiring individual prescriptions.

Department of Health spokesperson Dean Flener said the agency would not answer questions about whether or how it regulates ivermectin or the pharmacies that distribute it.

Tennessee has said it does not track how much of the drug is sold in the state, and the amount is not well captured by federal or insurance data sources. That’s because the drug is often sold at compounding pharmacies, which make customized medications that are not FDA-approved and rarely covered by insurance. Drugmakers and wholesalers did not respond to questions about how much ivermectin they supply to pharmacies in the state.

Even the Independent Medical Alliance, one of ivermectin’s , says it doesn’t know how much is flowing through Tennessee.

States are getting pressure from clinicians ”who have had success with the use of ivermectin,” said IMA President Joseph Varon, a physician based in Houston. “That’s what happened in Texas, and that’s what happened in Tennessee.”

‘An Unproven, Potentially Unsafe Drug’

Once signed by Tennessee Gov. Bill Lee, the state’s ivermectin law took effect immediately — even before the state’s physician and pharmacy licensing boards created rules to guide the process, which Tennessee law also requires. 

Some board members were shocked.

“We’re talking about an unproven, potentially unsafe drug,” Shant Garabedian, a doctor on the state’s Board of Osteopathic Examination, said of off-label ivermectin use during a . “It’s already law. Somehow it passes without our sort of input.”

In meetings that followed, at least five members of Tennessee’s medical boards voiced concerns about the law beyond safety and efficacy. Some said pharmacists could overcharge for a drug that normally costs pennies per pill. Some worried that a loosely regulated, cash-based ivermectin market might attract shady characters, especially because the law also shields prescribers from ivermectin-related civil lawsuits.

“This involves no clinical engagement,” Melanie Blake, then-president of the Board of Medical Examiners, said during a . “If they’re exempt from liability as well, I hate to think of things that individuals could do just to make money, but this would be one.” 

The boards eventually enacted regulations affirming that ivermectin could be dispensed without any diagnosis. Board members said the law left them no choice.

“This is more of a situation where, legally, the legislature has decided for us,” John McGraw, another board member, said in a . “This has sort of tied our hands in a lot of ways.”

The first known sale under the new law occurred in Sibley’s home of Johnson City, a city of about 74,000 people in northeastern Tennessee. According to a , Sibley entered into a collaborative agreement with pharmacist Josh Harrison at The Compounding Lab, which dispenses drugs for people and animals. 

The first customer was Bernadette Pajer, an anti-vaccine activist who has worked with Children’s Health Defense. In a of the Nashville podcast Rebunked With Scott Armstrong, Pajer said Sibley was a medical adviser for the group and described the first ivermectin sale.

“On that day, she was the doctor, he was the pharmacist making the sale, and I was the first customer,” Pajer said. “So that was pretty cool.”

Ivermectin pharmacies have spread across the state. In the suburbs of Nashville, Roman Pharmacy advertises ivermectin on at least four billboards along Interstate 65, and is mostly focused on the drug. Outside Knoxville, allows customers to order ivermectin for multiple sclerosis and Parkinson’s disease, or “to use it to detoxify.”

Roman Pharmacy did not respond to interview requests. Fresh Pharmacy declined an interview.

In Chattanooga, the Medicine Counter pharmacy says on its website that ivermectin should be taken “only as prescribed by your healthcare provider.” And yet the pharmacy sells some of Tennessee’s available without a prescription from a doctor — up to 21 times as strong as a standard tablet, for nearly $19 per pill — according to the ºÚÁϳԹÏÍø News analysis.

Himanshu Patel, Medicine Counter’s head pharmacist, declined to be interviewed. He said in an email that the pharmacy operates in a “very competitive market” and that its strongest pills were below the maximum dose for humans evaluated by the FDA for safety purposes.

And then there is Compound Rx, which, in addition to selling ivermectin in its store, has built a website in preparation to ship nationwide. The site, which is in “test mode,” cannot currently make any sales. It also asks customers how they heard about the pharmacy, with a dropdown menu of answers that features right-wing figures such as Donald Trump Jr., Steve Bannon, Laura Ingraham, and Kevin Sorbo.

Who is not listed as an option? Your doctor.

Hughey, the Compound Rx pharmacist, said he wasn’t involved with the website, which he said may never launch.

The highly concentrated pills are a concern for Tennessee state Sen. Richard Briggs, who worries lawmakers have created a “dangerous” ivermectin market rife with “misleading advertising” about what the drug can actually do.

Briggs, who is a surgeon and the only Republican who voted against the ivermectin bill in 2022, said he planned to introduce legislation to rein in the sale of ivermectin when lawmakers reconvene in 2027.

“But it may be a hard sell, because with the anti-vaxxers and some of these other folks,” Briggs said. “We don’t base a lot of things that we do on science, data, or facts. To a lot of folks in the legislature, the facts are just an inconvenience.”

‘Enough Trouble With Ivermectin’

Lawmakers in at least seven states have considered ivermectin legislation this year, including Alabama, Florida, Oklahoma, and South Carolina. If enacted, these bills would allow people to obtain ivermectin without an individual prescription, like in Tennessee, or make it available over the counter.

Kennedy praised such legislation at an event in Texas last August.

“I think it’s a really good bill,” he said of Texas’ ivermectin legislation, according to . “I think Americans should have the choice.”

But proponents have hit roadblocks. A Utah bill failed to advance out of the state House this year. In Oklahoma, some lawmakers have put up a fight.

“I’m a scientific person. I need to see some research and some data that shows what we’re treating,” Oklahoma state Rep. Cynthia Roe, a Republican and nurse practitioner who opposes the state’s ivermectin bill, said in an interview. “And God forbid somebody start giving it to their kid.”

Back in Tennessee, one of the medical boards that was alarmed when the law was enacted in 2022 started to distance itself from ivermectin altogether.

In January, the Board of Medical Examiners grappled with how to punish Ricky Lee Jackson, a doctor who was licensed in Tennessee and had been sanctioned and fined by Washington state’s medical commission. The Tennessee board normally mirrors punishments from other states without hesitation. But the Washington case centered on Jackson prescribing ivermectin for covid, which in Tennessee no longer required a patient to see a doctor.

After a debate, the board voted to reprimand Jackson — but told its staff to ensure the public record made .

“This board has been in enough trouble with ivermectin,” member Keith Anderson said, according to a . “Maybe we ought to just leave that out.”

journalist Blake Farmer and reporter Adam Friedman contributed to this report.

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7B Care Clinic has been operating in Sandpoint since 2001 and was previously called Life Choices Pregnancy Center and Sandpoint Crisis Pregnancy Center. It is of a nationwide network of Christian evangelical centers called Care Net. 7B, one of about 1,200 pregnancy centers affiliated with Care Net, offers pregnancy tests, limited ultrasounds, parenting and life skills classes, community support groups, and other free resources, such as children’s clothing. Donations from people, businesses, and more than 40 churches keep 7B’s operations running, Executive Director Janine Shepard said.

Such centers are known as crisis pregnancy centers or pregnancy resource centers. They offer limited resources and medical services to pregnant women and aim to dissuade them from having abortions. Healthcare groups including the have said many crisis pregnancy centers use unethical and deceptive practices to bring women into their organizations.

Traffic at 7B has picked up since the local hospital and its OB-GYNs moved out of state three years ago. The closure left a hole in reproductive health services in this town of more than 10,000 on the shores of Lake Pend Oreille and surrounding rural areas.

“We are seeing a lot more people,” Shepard said.

By December 2024, more than two years after the U.S. Supreme Court overturned nationwide abortion rights in its Dobbs decision, Idaho had of its OB-GYNs. 7B is expanding, with the goal of bringing obstetric care back to Sandpoint. The organization plans to add to its current building once it’s paid off, Shepard said, and it’s in talks with a hospital about 30 miles away in Washington state to bring in an OB-GYN once a week to provide prenatal care.

If obstetric care existed now in Sandpoint, Shepard said, “we wouldn’t even be considering” the expanded services. “But there’s such a need. And our community suffers because of it.”

As rural communities face the and , crisis pregnancy centers are growing in influence. Some states have approved legislation granting the organizations greater protections from oversight and regulation, and clinics have seen a massive and in recent years.

In a town with limited maternity care, 7B has been providing important resources to struggling low-income women. But critics say the religious nonprofit, which is not medically licensed and isn’t required to meet regulatory standards for medical facilities, has an agenda that makes it an inappropriate place for pregnant patients to seek medical care.

Jen Jackson Quintano, a Sandpoint resident and the founder of the Pro-Voice Project, a nonprofit that advocates for abortion rights in Idaho, said crisis pregnancy centers mislead patients by drawing them in with the offer of free pregnancy-related services before delivering their anti-abortion pitch.

“We all need clarity on what those services are: ministry-first, rather than comprehensive medicine,” Quintano said.

Shepard said there are misconceptions about the organization, and she invites people to take a tour of 7B to learn what it does. She said her staff talk to pregnant women about abortion, adoption, and parenting as options and hope they feel supported enough to make a “life-affirming” decision.

7B reflects a trend of crisis pregnancy centers seeking to expand their operations in maternal care deserts and regions with gaps in women’s healthcare, said Andrea Swartzendruber, an associate professor of epidemiology and biostatistics at the University of Georgia College of Public Health. Swartzendruber has studied crisis pregnancy centers in the U.S. since 2018.

“Crisis pregnancy centers have, for years and years, capitalized on gaps in access to healthcare,” she said. “In no way, shape, or form do crisis pregnancy centers have the infrastructure or ability or training to bridge those gaps.”

According to Swartzendruber’s research, more than 2,600 crisis pregnancy centers operated in the U.S. as of 2024, more than three times the number of . Many centers have been found to engage in with clients, including putting misleading information on their websites making them appear to be legitimate medical clinics with the goal of attracting women who are seeking abortions.

The organizations are also seeing support from the Trump administration. On May 10 — Mother’s Day — the Department of Health and Human Services sharing resources and information for new and expectant mothers. It includes a map to find pregnancy centers and cites services the centers provide, such as pregnancy tests, ultrasounds, and medical referrals.

‘The Perfect Place for This’

Sandpoint is a small mountain town in a deeply conservative and Christian part of a state with a strict abortion law put into place after the Supreme Court overturned Roe v. Wade.

Amelia Huntsberger, one of the OB-GYNs who left Sandpoint three years ago, said the town is “the perfect place for this,” referring to the expansion of the 7B Care Clinic.

In underresourced areas, the benefits that crisis pregnancy centers may bring are welcome.

Lori Sabin, a licensed midwife in Bonners Ferry, about 30 miles north of Sandpoint, said that 7B is a helpful resource to the community, especially for people who struggle to get healthcare because of a lack of health insurance or who face challenges in traveling for care.

“The nicest thing about 7B is all their services are free,” Sabin said, adding that the classes and free baby items are particularly helpful for young first-time mothers. “They can point them in the right direction. They tell them where the midwives are; they tell them where the OBs are.”

Huntsberger, who practiced in Sandpoint for more than a decade and now lives in Oregon, also acknowledged the benefits she saw 7B bring for patients, including the parenting classes and support groups. But she has concerns about its resemblance to a medical facility that provides healthcare.

Lisa Battisfore, founder of Reproductive Transparency Now, a Chicago-based organization that provides education and outreach about crisis pregnancy centers, acknowledged that the limited services they provide can be helpful but said the bad outweighs the good.

“If someone needs diapers or someone needs formula and a crisis pregnancy center is willing to give that to them, it’s difficult to say that that in isolation is a bad thing, but you have to look at the bigger picture,” Battisfore said.

Crisis pregnancy centers are largely unregulated and are protected by First Amendment rights to free speech and religious exercise. The Supreme Court crisis pregnancy centers to go to court to block a state attorney general’s subpoena for donor funding information. Critics say lack of oversight allows centers to spread misinformation about abortion and abortion pill “reversal,” a procedure the American College of Obstetricians and Gynecologists has called “.”

Crisis pregnancy centers have against states trying to increase regulation and oversight. Those protections have allowed some of the organizations to blur the line between anti-abortion activism and medical care.

“They seem to be really good at walking on both sides of that line when it suits them best, and that does not suit pregnant people best,” Battisfore said.

She referenced a recent case in Texas in which a woman was hospitalized for an ectopic pregnancy days after she received an ultrasound and a clean bill of health from a crisis pregnancy center. An OB-GYN who works with the Abundant Life Pregnancy Resource Center “there is nothing to fix” when asked about the error. There have been at crisis pregnancy centers.

What’s Next for Sandpoint

angered a lot of locals when it closed its labor and delivery unit three years ago. Residents lamented that women needed to travel farther to give birth and mourned the loss of the OB-GYNs. Since then, the hospital has been working to rebuild trust with the community.

This year, the hospital created a women’s health committee that includes hospital board members, staff, and others. Hospital CEO John Hennessy and Chief Medical Officer Stacey Good, a physician, said their priority is to hear from the community and increase awareness about the women’s healthcare that’s still available.

Women can still receive a range of services, including prenatal care from a nurse practitioner who travels to Bonner General from Coeur d’Alene once a week and other clinicians who can provide more basic gynecological care. A position for a gynecologist at the hospital has been open since May 2023, and Hennessy said filling it remains a priority.

Sandpoint resident Makayla Sundquist, a licensed counselor, grew up in town. She got married last year and has been thinking about starting a family with her husband. She wondered if she would feel safe knowing she’d need to travel at least an hour to the nearest hospital with labor and delivery services.

But she also has doubts about 7B as a potential option for local care. She was skeptical that an anti-abortion, faith-based organization would provide accurate information on the options available to her.

“It is something that I do think about and do have fear about,” Sundquist said. “I wish that wasn’t my reality.”

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The certified professional midwife pressed the button on a handheld Doppler ultrasound machine she placed on Collins’ belly. “That’s her heartbeat,” she said to Collins’ 3-year-old daughter, who sat beside her mom as a whooshing sound filled the room. “I think Mommy’s baby’s right here.”

The midwife is not licensed as a nurse. In Georgia, that makes what she’s doing illegal. ºÚÁϳԹÏÍø News agreed not to identify her by name.

Georgia is one of seven states where delivering babies can earn non-nurse midwives, at minimum, a cease-and-desist letter requiring them to end their careers. In North Carolina, it’s a . In New York, .

Meanwhile, demand for their services is increasing. Intended home births rose by 42% nationally from 2020 to 2024, according to the National Center for Health Statistics, and those births are often overseen by certified professional midwives. In Georgia, they rose by 72%. Midwives who assist with home births typically see clients from prenatal appointments through after childbirth, providing more postpartum checkups than most new mothers receive.

Home births make up nationwide. In the eight states where they were most common in 2024 — Hawai‘i, Idaho, Montana, Pennsylvania, Utah, Vermont, Wisconsin, and Wyoming— they made up 3-5% of births.

As that number rises, midwifery advocates said, regulating the practice with licenses would allow home births to be safer. Free birth — without the help of a skilled professional before or after labor — can be .

“People are going to keep having their babies at home, and they deserve a trained provider,” said Missi Burgess, president of the Georgia chapter of the National Association of Certified Professional Midwives.

For decades, professional midwives have been advocating for laws to legalize and regulate their profession. More lawmakers have supported those efforts in the past 15 years, with 36 states and Washington, D.C., allowing them to get licensed to deliver babies. Last year, a wave of state lawmakers — in Georgia, Mississippi, Nebraska, New York, North Carolina, Ohio, and West Virginia — tried to add their states to the list, although none of their bills has become law.

Certified professional midwives deliver babies in homes or birth centers. Rather than attend nursing school — which many can’t afford — they earn a nationally recognized certificate by attending at least 55 births and demonstrating their knowledge. Nurse-midwives more often deliver babies in hospitals or clinics than in patients’ homes.

Some hospitals and doctors oppose midwife licensing proposals without certain guardrails. The American College of Obstetricians and Gynecologists showing that infants are twice as likely to die during planned births at home or in birth centers as in hospitals, while acknowledging that the data remains limited. It doesn’t account for several factors, including who assisted in the birth.

Still, prominent stories of home births with midwives gone wrong contribute to the skepticism around licensing laws. In 2023, The Washington Post of a licensed midwife who pleaded guilty to felonies in Virginia after an infant death and assisted with home births in Maryland in which two more babies died.

In Mississippi, a bill that would have regulated and licensed professional midwives died after a state senator blocked a vote in the committee he chaired. Democratic Sen. Hob Bryan he didn’t “wish to encourage that activity.”

But midwives said they have a sympathetic ear now in the Trump administration, with its Make America Healthy Again movement. Cassaundra Jah, executive director of the , said she has been on calls with midwifery groups pushing for the Department of Health and Human Services to provide legal protections for them, and some midwives have been in contact with the agency.

HHS spokesperson Emily Hilliard declined to comment on policy proposals but told ºÚÁϳԹÏÍø News that the administration “regularly meets with a wide range of stakeholders to hear input from the American public.”

Hospitals Want Guardrails

Advocates for the license say allowing certified professional midwives to provide care would help address a shortage of maternity care providers.

“Some midwives are leaving our state,” Rep. , a chiropractor who sponsored the Georgia bill, said during a hearing on the measure last year. “They’re being forced to quit. And now we have a shortage of these providers to take care of our pregnant moms.”

A by the March of Dimes found that 35% of counties in the U.S. have no birthing facility or obstetric provider. Georgia has the 13th-highest maternal mortality rate in the nation, according to the .

After the U.S. Supreme Court’s reversal of Roe v. Wade in 2022 eliminated federal protection for abortion, six-week abortion bans prompted more providers to leave states such as Georgia and Texas. Idaho lost by December 2024, two years after its abortion ban took effect. Doctors who left states with such laws cited fear of prosecution and an inability to provide the standard of care.

Of the 13 states with the fewest maternity care providers per capita, nine had a full or six-week abortion ban as of 2024, .

Licensing midwives won’t solve the larger maternity care shortage, but it’s a first step, said , a professor of midwifery and the principal investigator at the Birth Place Lab at the University of British Columbia. Certified professional midwives currently attend only about 1.4% of births in the U.S., according to federal data.

The would have granted certified professional midwives licenses through a state board, allowed them to administer lifesaving medications, and required their services to be covered by private insurance and Medicaid. They would not have needed a physician to supervise them. Without that mandate, giving birth outside of a hospital could be an option for more people.

But the Georgia Department of Public Health and the Georgia Hospital Association opposed the licensing bill, primarily because they wanted more regulations than the midwives were willing to accept — including physician supervision.

Anna Adams, a spokesperson for the hospital association, suggested establishing transfer agreements that required all women planning to have a home birth to register at the hospital first. When a laboring woman is transferred to a hospital, which happens in about , “we have no prior knowledge of this patient,” Adams said. “It’s a tricky situation to inherit when you’re trying to save the mother and the baby without any background.”

Georgia midwives said they planned to bring the licensing proposal back next year.

In early April, three midwives for restricting their ability to practice, arguing that the rules violate the state constitution.

“Every pregnant person should be able to choose where they give birth and with whom,” said Jamarah Amani, a plaintiff in the lawsuit and co-founder of the .

Black women are three times as likely to die during or after childbirth as white pregnant patients. In January, a prominent Black nurse-midwife in South Carolina died after unexpected complications from childbirth.

Today, midwives and their clients are predominantly white, but the home birth rate among Black women rose 42% nationally from 2019 to 2024, according to the Centers for Disease Control and Prevention.

“Ultimately the system has failed us as a people,” said Tina Braimah, a Black nurse-midwife who attended home births for a decade. She then opened a in North Carolina, allowing her to see more clients from a variety of backgrounds. “When the system consistently fails you, you look for other options.”

Becoming Part of the System

Many maternal health researchers say mothers fare better when midwives are a key part of the health system. In 2018, researchers at the Birth Place Lab published a study of all 50 states showing that integrating midwives was associated with better outcomes for moms and babies, including lower rates of infant deaths. Integration involves collaboration among all kinds of midwives and doctors so that patients can easily transfer to or from a hospital. It also involves giving all midwives the authority to practice the full range of their skills, including prescribing lifesaving medication.

A by the National Academies of Sciences, Engineering, and Medicine states that data from other countries suggests home births can be as safe as hospital births for low-risk women who are part of an integrated, regulated system.

Washington state has one of the highest rates of in the U.S., according to the . Its home birth rate is consistently higher than the national rate, while its remains lower than the national average.

One in 5 women report being mistreated during maternity care, according to a . Pregnant patients tend to be more satisfied when midwives lead their care, whether at a hospital, a birth center, or home.

Hannah Haynes gave birth to her first three children in a hospital near her home in Jefferson, Georgia. During the third labor, which was induced, she received a catheter that led to a urinary tract infection and then sepsis, a life-threatening condition. She was separated from her newborn for four days while receiving treatment.

“Something has to change,” Haynes said.

Haynes regrets electing to get induced when it wasn’t medically necessary. She gave birth to her fourth child at home, with the help of a certified professional midwife she trusted. She’s pregnant with her fifth and plans to use the same midwife. She said she won’t deliver at a hospital again.

“I was a little nervous,” Haynes said, because she had heard rumors that midwives didn’t know what they were doing. But after meeting the midwife, “I just felt so confident in her.”

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But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.

Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.

Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.

As in Indiana, Republican Idaho lawmakers approved a three-month requirement, and the state’s governor signed the bill into law on April 10.

The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.

“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.

The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.

Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.

Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.

When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.

Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.

“I think very few,” Roob replied. “It’ll never be none.”

After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.

Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.

Republicans have said imposing these limits protects the Medicaid program’s longevity.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”

Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.

Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.

Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.

“If the point is to get people engaged, the one month would do it,” Mueller said.

Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”

An analysis by the Center on Budget and Policy Priorities predicted that work rules will and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”

Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.

In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”

Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.

Chappell, a Republican, said his initiative would encourage a “working mindset.”

Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”

Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.

She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.

“I work very hard,” Meyer said.

In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.

of adults ages 19 to 64 on Medicaid already work, according to KFF. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, KFF has found.

Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.

For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.

Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.

But this short-term hardship exemption would be off the table in Missouri.

Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.

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“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

ºÚÁϳԹÏÍø News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

Long Wait Times for Help

Republicans argue the Medicaid changes, which will take effect Jan. 1, 2027, in most states, will encourage enrollees to find jobs. Research on other Medicaid work requirement programs has found little evidence they increase employment.

The Congressional Budget Office would cause more people to lose health coverage by 2034 than any other part of the GOP budget law. It said last year more than 5 million people could be affected.

Many states don’t have the staff to process Medicaid applications or renewals quickly, said consumer advocates and researchers.

The Centers for Medicare & Medicaid Services tracks whether states can handle the most common type of benefit application within a 45-day window.

In December, about 30% of all Medicaid and Children’s Health Insurance Program, or CHIP, applications in Washington, D.C., and Georgia to process. More than a quarter took that long in Wyoming. In Maine, 1 in 5 applications missed that deadline.

CMS began publicly sharing state Medicaid call center data in 2023, revealing a taxed system, researchers and consumer advocates said.

In Hawaii, people waited on the phone for more than three hours in December. They waited for nearly an hour in Oklahoma, and more than an hour in Nevada.

In 2023, state Medicaid agencies began making sure enrollees who were protected from being dropped from the program during the covid pandemic still qualified for coverage. That Medicaid unwinding process didn’t go well in many states, and lost their benefits.

Health policy researchers and consumer advocates say rolling out the new Medicaid rules will be a bigger challenge. The Medicaid work rules will require extensive IT system changes and training for workers verifying eligibility on a tight timeline.

“It is a much larger scale of administrative complexity,” said Sophia Tripoli, senior director of policy at Families USA, a health care consumer advocacy organization.

After months of trying to get someone on the phone, Crouch said, she finally got answers to questions about her Medicaid benefits after writing to the office of U.S. Rep. Sarah McBride (D-Del.). McBride’s office contacted the state’s Medicaid agency, which eventually called with an update, Crouch said.

Crouch didn’t qualify for Medicaid after all. She said that had never come up in two years of interactions with the state.

“It makes absolutely no sense” that the state never realized she shouldn’t have been on the program, Crouch said.

Delaware’s Medicaid agency didn’t respond to requests for comment on Crouch’s situation.

States Short-Staffed for Medicaid

Some states told ºÚÁϳԹÏÍø News in late March that they’ll need more staff to roll out the work rules effectively.

Idaho said it has 40 eligibility worker vacancies. New York estimated it will need 80 new employees to handle the additional administrative work, at a cost of $6.2 million. Pennsylvania said it has nearly 400 open positions in county human services offices in the state. Indiana’s Medicaid agency has 94 open positions. Maine wants to hire 90 additional staffers, and Massachusetts wants to hire 70 more.

As of early March, Montana had filled 39 of 59 positions state officials projected it would need. The state still plans to roll out the rules early, starting July 1, despite its long struggle with system backlogs that applicants said have delayed benefits.

Missouri’s social services agency has been cutting staff and has 1,000 fewer front-line workers than it did roughly a decade ago — with more than double the number of enrollees in Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, according to comments Jessica Bax, the agency director, made in November.

“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”

States could have a hard time finding people interested in taking those jobs, which require months-long training, can be emotionally challenging, and generally offer low pay, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“They get yelled at a lot,” said Brooks, who formerly ran New Hampshire’s Medicaid and CHIP customer service program. “People are frustrated. They’re crying. They’re concerned. They’re losing access to health care, and so sometimes it’s not an easy job to take if it’s hard to help someone.”

States are paying government contractors millions of dollars to help them comply with the new federal law.

Maximus, a government services contractor, provides eligibility support, such as running call centers, in 17 states that expanded Medicaid and interacts with nearly 3 in 5 people enrolled in the program nationally, according to the company.

During a February earnings call, company leadership said Maximus can charge based on the number of transactions it completes for enrollees, independent of how many people are enrolled in a state’s Medicaid program.

Maximus has “no one-size-fits-all approach” to the services it offers or the way it charges for those services, spokesperson Marci Goldstein told ºÚÁϳԹÏÍø News.

The company, which reported bringing in $1.76 billion in 2025 from the part of its business that includes Medicaid work, expects that revenue to continue to grow, even as people fall off the Medicaid rolls, “because of the additional transactions that will need to take place,” David Mutryn, Maximus’ chief financial officer and treasurer, said during the earnings call.

Losing Medicaid health coverage isn’t just an inconvenience, since many people enrolled in the program probably don’t make enough money to pay for health care on their own and may not qualify for financial help for Affordable Care Act coverage, said Elizabeth Edwards, a senior attorney with the National Health Law Program.

People could be unable to afford medications or get essential care, which could lead to “devastating” health impacts, she said.

“The human stakes of this are people’s lives,” she said.

ºÚÁϳԹÏÍø News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

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A mom of seven, Pipe is a doula on the reservation who supports new and expectant parents. She does that work free, around her day job. That’s because in this town of about 2,000 people, the closest hospital that delivers babies is 100 miles away.

“Women need this help,” Pipe said.

Doulas ready parents for childbirth, support their deliveries, and can be a steady presence in a baby’s first months. their work with lower rates of costly birth and postpartum complications — especially in hard-to-reach places like Lame Deer.

But that help can be scarce. As Pipe put it: “Doula doesn’t pay the bills around here.”

Things were supposed to change this year. Montana was set to join that reimburse doulas through their Medicaid programs to ease gaps in care. Montana lawmakers approved the payments last year, authorizing up to $1,600 per pregnancy. Pipe hoped that money would give her the chance to leave her post office job one day to help more parents.

But the state Department of Public Health and Human Services postponed adding doula services to its Medicaid program in late March, citing a budget shortfall driven in part by higher-than-expected Medicaid costs.

“DPHHS will not be moving forward with the implementation of doula services in the Montana Medicaid benefit package at this time,” department spokesperson Holly Matkin told ºÚÁϳԹÏÍø News.

The news caught Pipe by surprise — she hadn’t heard any updates in a while, but the state had finalized its licensing rules for doulas in January. Last year, she supported three people through their deliveries. She doesn’t have time for much more. That weighs on her. the people on the Northern Cheyenne Indian Reservation , and the people she helps usually can’t afford to pay a doula.

“I was looking forward to serving more people,” Pipe said. “Now that’s not going to happen anytime soon.”

Charlie Brereton, who heads the health department, told state lawmakers in March that the agency projected a $146.3 million shortfall in federal Medicaid funds for this year. Health officials predict another deficit next year as states feel the effects of Republicans’ massive tax-and-spending law, the One Big Beautiful Bill Act. Signed last year, that law is projected to reduce federal Medicaid spending by nearly $1 trillion over 10 years.

Matkin said it’s “unclear” whether the agency can authorize doula coverage this year. The deficit will lead the department to seek supplemental funding from state lawmakers. When an agency makes that kind of request for the first year of the state’s two-year budget cycle, requires it to create a plan to reduce its spending.

Around the country, optional Medicaid services — such as doula support, home health care, and dental work — are at risk of losing funding as states brace for federal Medicaid cuts to hit their bottom lines. Already, lawmakers in Idaho are considering their own reductions to Medicaid to balance the state’s budget. cutting tens of millions of dollars in services for people with disabilities.

In Montana, doula services are unlikely to be the only Medicaid cutbacks announced. “All options are on the table,” Brereton told lawmakers in March.

Stephanie Morton, executive director of Healthy Mothers, Healthy Babies-The Montana Coalition, said more than half of Montana’s counties are designated as maternity care deserts.

“Budget cuts will continue to diminish the limited services families rely upon in these counties,” said Morton, whose nonprofit had advocated for doula Medicaid reimbursement. “This decision feels like the first of many rollbacks and cuts Montanans will face.”

Laboring Alone

At the check-in just outside town, Pipe handed a waking newborn to his mother and unwrapped a new swaddle for the child. This would have to be a quick visit — she was already late for work.

The mother, Britney WolfVoice, held her newborn son as her three young daughters stood close by. Pipe has been with WolfVoice and her husband for the birth of their newborn son and youngest daughter.

She helped them create delivery plans. For the birth of WolfVoice’s youngest daughter a few years ago, Pipe brought cedar oil, a sacred plant used for prayer, and calmed WolfVoice through her contractions. For the recent birth of her son, when hospital backlogs delayed WolfVoice’s induction, Pipe encouraged her to advocate for an earlier appointment by routinely calling the hospital. Doctors had recommended the procedure to avoid complications.

“Misty is one person who I can count on to be my voice,” WolfVoice said.

If someone needs a ride to a doctor’s appointment, Pipe takes time off work to drive them. If a client goes into labor when Pipe’s at the post office, she texts two other free doulas she knows of on the reservation to see if they have time to help until her shift ends. But they also have day jobs.

Pipe herself has ridden that 100-mile stretch between home and the hospital in labor and in the back of an ambulance. Twice, she gave birth in emergency rooms along the way. In one of her pregnancies, she miscarried at home and couldn’t get a doctor appointment for days.

The long distance to receive care often meant her husband had to stay behind to tend to their other children at home.

“I labored alone so many times,” Pipe said. “I just want to make sure no one’s alone.”

Rural maternity care deserts are a , especially as labor and delivery units continue to shutter. In many tribal communities, a lack of care coincides with long-standing inequities caused by centuries of .

Predominantly Indigenous communities face the longest distances to obstetric facilities compared with all other racial and ethnic groups, according to a 2024 report from the March of Dimes. That’s part of the reason Indigenous women are far more likely to get sick from pregnancy and as white women.

Indigenous patients are supposed to be guaranteed access to health care through the federal Indian Health Service. But the chronically underfunded agency has severe gaps. A small fraction of its hospitals and clinics offer labor and delivery. As of 2024, only seven states had either an IHS or tribal birth facility, . To help fill in those shortfalls, Medicaid is the for many Native Americans, according to KFF.

Even where care exists, Native women can experience a distrust of health systems, according to Pipe and other health workers. The U.S. government has a long history of removing children from tribal homes and forcing Native American women to undergo sterilization.

of the Pacific Institute for Research and Evaluation’s Southwest center has studied premature deaths among Native Americans. A member of the Fort Sill-Chiricahua-Warm Springs-Apache Tribe, Haozous said data on maternal health disparities in pregnancy and postpartum often misses a key point.

“It’s not that women are just not taking care of themselves,” Haozous said. “The system is set up for them to not have access to care.”

On top of funding cuts, the One Big Beautiful Bill Act will add more frequent eligibility checks and work requirements to access Medicaid. Those changes, when they take effect later this year and next, will lead an estimated 5.3 million people to lose their coverage by 2034.

Native Americans are exempt from some of the law’s new rules, such as the work requirements. Even so, tribal patients can get tangled in administrative hurdles. That includes struggling to enroll in the first place or to prove their tribal status. A full-time college student, WolfVoice said that when she got pregnant, it took about six months to enroll in the state’s Medicaid program.

Despite Montana’s long struggle with a backlogged Medicaid system, state officials aim to implement work requirements this summer, well before the federal deadline.

‘Moccasins on the Ground’

As Pipe pulled into her driveway one day after a full shift at the post office, her kids ran to her. She was also greeted by Felicia Blindman, a 63-year-old public health nurse who used to work for the tribe. The two sat in lawn chairs into the night and brainstormed ways to connect more women to services — such as free prenatal classes.

Pipe’s four youngest children played around them. Her 14-year-old daughter is already certified as an Indigenous doula. Her 8-year-old daughter has begun helping Pipe pick up prescriptions for moms without a car who live out of town. Pipe hopes one day they could do that work full-time, if they want to.

Because of the lost Medicaid payment, Pipe said, she will continue to balance her job with her birth work, even if it means persuading more people to become doulas, such as family and respected community members, to cover more ground.

“It’s not going to stop me from training more birth workers, more young people, more aunties,” Pipe said. “For now, I guess it’s more about grassroots, moccasins on the ground, helping each other.”

She said that means telling pregnant people who walk into the post office she’s there to help if they need support. At least, as long as she’s not at her day job.

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Sam Walker, 35, has severe autism and other disabilities. He is deaf and cannot speak. Sometimes when he’s frustrated, he hits himself or others.

Medicaid provides about $8,500 a month for health workers who visit his apartment in the basement of his parents’ home. The staffers help him with everyday tasks, including dressing, bathing, and eating. They also take Walker on outings, such as dining at restaurants, volunteering at Goodwill, and exercising at a recreation center or on park trails. They stick to a strict routine, which soothes him.

His parents say that without the in-home services, their son would need to move to a specialized residential facility in another state. Sending him away would break their hearts and cost taxpayers much more money. They strive to keep him home because they know change makes him anxious.

“The last thing I want is to put him into some kind of care facility, where he’ll just get kicked out,” said his mother, Leisa. The Iowa Department of Health and Human Services did not respond to ºÚÁϳԹÏÍø News’ questions about the Walkers’ case.

Federal Cuts Raise Pressure

Patient advocates say state administrators in Iowa appear to be reining in Medicaid spending by cutting what are known as home and community-based services for people with disabilities, and they’ve heard of multiple families facing battles like the Walkers’.

Disability rights advocates expect the pressure to intensify as states respond to reductions in federal Medicaid funding called for under the Trump administration’s signature tax and spending law, which passed last year.

June Klein-Bacon, CEO of the Brain Injury Association of Iowa, said the cuts and proposed rule changes appear to be part of a quiet attempt to save money in response to the state’s budget deficit and expected reductions in federal Medicaid funding.

Medicaid, jointly financed by the federal and state governments, covers people with low incomes or disabilities. Walker is one of served by “Medicaid waiver” programs, which pay for care that allows people with disabilities or who are at least 65 to live at home.

Unlike most parts of Medicaid, waiver programs are optional for states. Idaho’s governor noted that fact in January, when he suggested legislators consider cutting them. Disability rights groups fear other states will do the same. Leaders in , , and have considered such cuts this year.

Leisa Walker has heard Trump administration officials claim the national Medicaid cuts are intended to reduce waste, fraud, and abuse. That’s not how it will play out, she said. “These are real people, real families, and this causes real suffering when you do this to people,” she said. “It’s a very scary time.”

a private insurance company that manages Sam Walker’s Medicaid benefits, intends to cut his in-home care coverage by about $3,200 per month, his mother said. Company leaders told a judge they are following state officials’ direction, but they did not dispute Leisa Walker’s math.

Walker has been on the waiver program for three decades. It covers assistance from workers known as “direct service providers” — one of whom has been with him for 25 years. His parents receive no pay for the hours they spend caring for him when the aides aren’t working.

On a February morning, Leisa and Kent Walker drove an hour and a half to Des Moines for an appeal hearing. An administrative law judge sat behind a wooden desk in a conference room as the Walkers and their lawyer faced off against three representatives from Iowa Total Care, a subsidiary of the national insurer Centene Corp.

Leisa testified that her son is 6 feet tall and weighs 230 pounds. Although he knows some sign language, he has trouble communicating, she said. When he becomes frustrated or his routine is interrupted, he sometimes wails and hits himself or other people. “It’s devastating to watch,” she testified.

He’s not a bad person, she said. “He doesn’t understand how strong he is.”

She said her family would try to keep his main caregiver employed under the planned Medicaid reduction but would have to drop others who cover nights and weekends. She said no residential facility near their southern Iowa home could address her son’s complicated needs. She said a case manager told her that a Florida facility might be the closest one that could safely handle him.

Leisa Walker testified that the state’s Medicaid program would pay about $22,000 per month to put him in an institution, more than double what the program spends on his home care.

Sam Walker’s longtime psychiatrist, Christopher Okiishi, testified that Walker’s family and their support staff spent years developing a “fragile” but stable existence for him.

Lori Palm, a senior manager for Iowa Total Care, testified that Sam Walker gets about 16 hours of daily assistance financed by Medicaid. Palm said much of that time amounts to “supervision.” She said state officials recently advised her company that the program should pay mainly for “skill-building” time, not supervision.

The Walkers showed the judge a 2018 document in which a previous Iowa Medicaid director stipulated that supervision of people with disabilities is an allowable service for workers paid under the program.

Judge Rachel Morgan asked the Iowa Total Care representatives if the recent policy change was made in writing by the state Department of Health and Human Services. They said it was not and that they couldn’t specify who at the department had given them the new guidance.

The judge suggested during the hearing that for someone like Sam Walker, learning to regulate emotions could be an important form of skill-building. Three days later, the judge ruled in the Walkers’ favor, writing that the insurer’s attempt to cut care hours was improper. The insurer appealed the decision to the director of the Iowa Department of Health Human Services, who could overrule it. The dispute could eventually wind up in district court.

Iowa Total Care and the state Department of Health and Human Services did not respond to questions about the reports that many other Iowans with disabilities face reductions in care hours covered by Medicaid. Department spokesperson Danielle Sample said in an email that the agency supports home and community-based services, which, she noted, help “states save money by avoiding expensive long-term facility care.”

Spokespeople for the federal Department of Health and Human Services, which oversees Medicaid nationally, did not respond to a request for comment on the issue.

Medicaid waiver programs started in the 1980s, after President Ronald Reagan heard about an Iowa girl with a disability who was forced to live in a hospital for months because Medicaid wouldn’t pay for home care. The Republican president thought it was outrageous that the girl, had to live that way, even though home care would have been cheaper.

Members of Congress approved allowing states to use their Medicaid programs to pay for in-home care. But they made the change optional, to offer states flexibility and encourage innovation.

Designating such spending as optional “waiver programs” also made the change more politically palatable, said Kim Musheno, senior director of Medicaid policy for , which represents people with intellectual and developmental disabilities.

Prospects were much different for babies born with serious disabilities before the change, Musheno said. “Doctors instructed families to forget they existed, and to put them in an institution.”

Waivers Have Been Cut Before

All states have Medicaid waiver programs, but benefits and the number of people covered vary significantly. Applicants often wait months or years to get into the programs because of limited funding. More than 600,000 Americans were on waiting lists or “interest lists” for waiver services in 2025, , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Disability rights advocates and care providers have fought for decades to maintain funding for the programs, but a national leader said the threat feels especially severe now.

“When Medicaid is cut, people with disabilities are at the center of the impact,” said Barbara Merrill, CEO of the American Network of Community Outcomes and Resources, which represents agencies that care for people with intellectual disabilities or autism.

That’s what happened after Congress reduced Medicaid funding in 2011, according to a recent paper published by .

States could again rein in waiver programs by limiting enrollment, reducing covered services, or cutting pay for caregivers, who already are in short supply.

However, states that try to cut the in-home care programs could face legal challenges, Musheno said. The U.S. Supreme Court declared in 1999 that people with disabilities have a right to live outside of institutions if possible. The decision, in the case of , has been cited in lawsuits against states that fail to provide care options apart from nursing homes and similar facilities.

Several Iowans who belong to a Facebook group for Medicaid participants have posted in recent weeks that their families were notified of impending cuts in coverage of home care services for people with disabilities.

Sam Walker’s main caregiver, Andy Koettel, has worked with him since Walker was in fourth grade. Koettel, who works full-time, knows how to keep Walker calm in most situations and soothe him during a blowup. Their relationship took years to build, and it is a key reason Walker can continue to live at home with his parents, Koettel said.

“If I was not there, it would be incredibly difficult for all of them,” he said.

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Services at risk include the 24/7 care that allows a 39-year-old with cerebral palsy to live independently; the in-home caregiving that lets a 26-year-old with brain damage from a hemorrhage at birth stay in his family home; and private duty nursing for a 19-year-old with cerebral palsy who has qualified for hospice care for complications including pulmonary decline from a spinal cord injury.

Concerns for such care arose when Idaho Gov. Brad Little, a Republican, proposed cutting $22 million from Medicaid — the joint state-federal health insurance program for people with low incomes or disabilities — to balance the state budget. Home- and community-based services such as caregiving, nursing, and residential rehabilitation are optional under Medicaid, and Little for the cuts.

Across the country, people with disabilities and their families are confronting similar plans to cut Medicaid as states grapple with budget challenges compounded by congressional Republicans’ One Big Beautiful Bill Act, which is expected to reduce federal spending on Medicaid by nearly $1 trillion over the next decade.

A four-hour town hall on the proposal in Idaho drew to the state capitol. Colorado lawmakers heard from concerned residents before pausing a pay cut for family caregivers. In Missouri, families raised alarms about a to services for people with disabilities.

“We saw this coming. We’ve tried to educate members of Congress,” said Kim Musheno, the senior director of Medicaid policy at The Arc, a national disability rights organization.

“Whenever there’s pressure on state budgets like those that are caused by the One Big Beautiful Bill Act, they go after Medicaid, and then they go after optional services,” Musheno said.

Many cuts included in the GOP bill, which President Donald Trump signed into law in July, haven’t yet taken effect, but the law is already impacting state budgets, particularly in states that align their tax rules with federal regulations.

Conforming to the federal law is expected to cost Idaho this year. Colorado lawmakers were called into a special session last year to address a created by the law. Those shortfalls — combined with national trends of increased Medicaid costs, , and further tax cuts passed by some state legislatures — are putting pressure on Medicaid programs.

Still, Musheno said she was surprised by how quickly Idaho targeted services for people with disabilities. “I couldn’t believe it.”

Little had already ordered Medicaid cuts last year as part of an effort to address a budget shortfall after years of and increasing program costs. That led to a in September for medical providers’ work with Medicaid patients. Little’s new proposed would be on top of those previous rate cuts.

“We were told by the legislature that they want to save some money in Medicaid, and so what we put together was a list of seven different options that were there,” Little said at a Feb. 17 press event. “There’s only so many levers we can pull in the Medicaid area that doesn’t jeopardize our funding.”

‘We Just Hold Our Breath’

Amber Grant said any further cuts for the nursing agency that provides care for her 19-year-old son, Matty, could be catastrophic.

He was born with brain damage and cerebral palsy before suffering a spinal cord injury when he was 10. In 2024, he briefly received hospice care before the family decided to work with a palliative care team to help him live out his life.

Through Medicaid, Matty qualifies for 120 hours of in-home private duty nursing care per week. But because of a nursing shortage, he typically receives only about half of that care, and Grant said it would get worse if the nursing agency is subjected to any more reductions.

“The reality is that any of us at any point in time could become disabled,” Grant said. “What kind of quality of care would we want?”

The potential cuts run even deeper for Grant’s family. Through another optional in-home Medicaid program, she and her husband, Jason, are both eligible to be paid for caring for their older son, Luke. The 24-year-old has autism, epilepsy, and an autoimmune condition and requires supervision 24 hours a day.

Jason primarily works as a self-employed remodeler, but Grant’s only income is the $21 an hour she gets to care for Luke. But she can be compensated only for the time she has him one-on-one, meaning when someone else is taking care of Matty, such as Jason or his nurses.

Grant said keeping up with the family’s house payments will be nearly impossible if they lose that income, and she said it seems like only a matter of time before some or all of her sons’ in-home care is disrupted. Idaho is in federal Medicaid funding over the next decade as a result of the One Big Beautiful Bill Act, according to KFF, a national health information nonprofit that includes ºÚÁϳԹÏÍø News.

“We just hold our breath every legislative session,” Grant said. “I feel like I’m always trying to prove their worth, to prove their value, and it’s exhausting.”

State Rep. Josh Tanner, a Republican who co-chairs the legislature’s powerful budget committee, said he opposed cutting home- and community-based services, but it was up to a separate committee and workgroup to finalize cuts to the Medicaid program.

Medicaid covers . , the federal government picked up 80% of the state program’s $3.6 billion tab in 2023. Tanner said tapping the state’s $1.3 billion in reserves to fill the $22 million gap was a nonstarter.

“We don’t really have an overall revenue problem in the state right now,” Tanner said, “but we do have a spending problem, and part of that has been Medicaid in general.”

Senate Minority Leader Melissa Wintrow, a Democrat on the budget committee, disagreed, pointing instead to five years of tax cuts passed by the Republican supermajority that have in lost revenue, including last year.

“What we need to do is restore the revenue that we cut and put it back and admit the mistake and stop harming people and the very services that Idahoans depend on,” Wintrow said.

‘It Keeps Me Awake at Night’

It’s also unclear whether cuts to community-based care would save Idaho money, something Tanner acknowledged. For optional Medicaid programs to be approved by the federal government, states must demonstrate that they are cheaper than existing alternatives, such as being cared for in a nursing home. Cutting community-based care would probably push many people with disabilities into more costly institutional care.

That’s what Toni Belknap-Brinegar fears for her son Antahn Brinegar.

A brain hemorrhage at birth left Antahn, now 26, with severe brain damage, physical and developmental issues, and a seizure disorder. Belknap-Brinegar is his primary caregiver, but she realized when Antahn was 8 or 9 that she wasn’t physically capable of caring for her growing son. Now 200 pounds, he has two paid in-home caregivers, Belknap-Brinegar said, both single mothers whose own livelihoods may be in the balance amid talks of cuts.

Nursing homes aren’t equipped to properly care for Antahn, Belknap-Brinegar said. He needs to be constantly monitored for seizures. He can’t communicate his needs well, for example when he has to go to the bathroom.

“Without the services that he has and the care that he gets now, he would end up in a care center, and frankly, he would die,” Belknap-Brinegar said.

While home and community-based services are technically optional parts of Medicaid, a required states to provide them to people with disabilities when appropriate. A Justice Department investigation in the waning days of the Biden administration found that Idaho was into nursing homes, in violation of that ruling. The Trump administration is attempting to slash access to the lawyers who help ensure those rules are followed.

Documents also show the state agency that oversees Medicaid does not think the state has enough space in its residential facilities to care for all the people whose home- and community-based services could be cut under the governor’s plan.

That’s Ned Fowkes’ worry for his 39-year-old daughter, Eva.

A brain bleed when she was an infant left Eva with severe cerebral palsy and significant developmental disabilities. Although Eva is unable to speak, she has a “wonderful awareness,” Fowkes said, and is able to communicate through her expressions and convey her preferences.

After being cared for by her parents for 21 years, Eva was eager for the chance to move into a supported living home, where she could get round-the-clock care while living with another person with disabilities.

“Like most 21-year-olds, she probably wanted to hit the road and not be under the roof of her parents anymore,” Fowkes recalled. “She’s always been courageous in that sense.”

Fowkes and his wife visit at least three times a week, but at 79 and 76, they are no longer able to provide their daughter’s direct care.

The staff at Eva’s home already barely make a living wage, Fowkes said. Cuts to the program that pays for her care would trigger more turnover — or, worse, shutter the agency that staffs the home.

“I don’t know what we would do,” Fowkes said. “Eventually we’d lose our home. We would be bankrupt. Where would Eva go? Where would her roommate go? Who would care for them?”

“It keeps me awake at night,” he said. “Believe me.”

ºÚÁϳԹÏÍø News’ Hayat Norimine contributed to this report.

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It’s all part of a drama that roiled the ACA’s 2026 open enrollment period. Congressional debate over whether to extend more generous subsidies made available under the Biden administration led to and focused public attention on rising health care costs and the affordability issue.

The enhanced subsidies, which expanded eligibility both by lowering the percentage of household income people had to pay toward their care and removing an income cap, expired at the end of last year. As a result, just about everyone buying ACA coverage saw their costs increase. For some, what they paid toward premiums doubled or more, even though less generous subsidies remain in place.

Many experts expected ACA enrollment, which hit a record 24 million in 2025, to fall this time around.

“If you raise the price of something a whole lot, economics tell us that a lot of people will buy less of it or not buy at all,” said Katherine Hempstead, a senior policy officer with the Robert Wood Johnson Foundation.

Here are things to watch now:

Initial Numbers Aren’t Final

The in December 2024 that not extending the enhanced subsidies would cause 2.2 million people to lose insurance in 2026, with further increases in following years. Analysts with the Wakely Consulting Group would opt out of insurance for this year.

Data released Jan. 28 by federal officials showed a year-over-year enrollments across the federal healthcare.gov marketplace and those run by states. Overall, there were 23 million enrollees, including 3.4 million new to ACA coverage.

At about the same time last year, there were , with 3.9 million new to the marketplaces.

But there’s more to it than those initial numbers.

For one thing, both years’ data was pegged to Jan. 15 for the federal marketplace, which closed its open enrollment period that day. But, the data for the states that run their own marketplaces included sign-ups in most cases only through Jan. 10 or 11, even though some held open enrollment until the . Thus, the numbers don’t reflect what might have happened in those last days. Was there a surge in state sign-ups? Or, conversely, did the marketplaces see more enrollees cancel their coverage?

Additionally, those initial numbers are a mix of newly minted ACA enrollees and existing customers, many of whom were auto-reenrolled for 2026 — which raises other issues.

For existing, reenrolled policyholders, the real figures won’t be known for weeks or months, when it becomes clear how many actually pay their premiums. Some consumers may not have focused on their reenrollment costs or may have hoped Congress would extend the subsidies.

That’s an important factor to keep in mind because the CBO and Wakely estimates of millions losing insurance were based on projections for full-year coverage, not initial sign-ups.

In the coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters.

Sharp Differences in State Enrollment Patterns

Changes are also afoot in the 19 other states (and the District of Columbia) that , some of which have issued more detailed data about enrollment than the federal marketplace.

Most states saw lower enrollment for 2026 than the prior year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows.

In a few states — including New Mexico, Texas, California, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased.

The jump was largest in New Mexico, with its initial number of people selecting plans up by nearly 14%. Increases were in the single digits in the other states and Washington, D.C.

New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. , including California, Colorado, Maryland, and Washington, used state money to help some enrollees.

The , a collective of 22 state marketplaces supported by the National Academy for State Health Policy, said initial enrollment figures . Compared with the same time last year, outright plan cancellations are up 83% in Colorado, disenrollments are four times what they were in Idaho, and Virginia has seen cancellations double.

New enrollments are from the same period last year, according to data from the state. In Pennsylvania, people ages 55 to 64, the group with the highest premiums, and young people 26 to 34 in higher numbers than other age groups, state data shows.

“We have drastically higher rates of people dropping their coverage,” said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority. “We had 70,000 drop in the last two months, from early retirees to small-business owners to farmers not knowing how to make ends meet.”

On Feb. 9, Pennsylvania released , showing enrollment dropped by about 2% from last year, although that figure masks some of the effects. The state says nearly 18% of enrollees dropped coverage altogether, with older and rural residents being the most likely to fall out.

Some Republicans credited Trump-administration-backed anti-fraud measures, which included a range of , for tightening the system. Although some of those actions were paused by a federal court and have not taken effect, those ACA critics, some of whom have produced that millions may have been improperly enrolled, say that’s behind the decline. They have previously for unauthorized enrollments or ACA plan-switching by commission-seeking brokers.

States that run their own ACA marketplaces, however, reported little or no such unauthorized switching. Relative to the federal marketplace, the state-based ACA platforms employ additional safeguards to prevent brokers from accessing consumers’ coverage without authorization.

Among consumers not returning to the marketplace, the main reason is cost, said Mila Kofman, executive director of the DC Health Benefit Exchange Authority, which runs the district’s ACA marketplace.

“When we looked at who these folks are, half are small-business owners,” Kofman said. “They are not folks committing fraud.”

Lower Premiums, Higher Deductibles

Rather than sticking with automatic reenrollment, existing customers in many states shifted sharply into lower-priced “bronze” plans that come with higher deductibles than silver, gold, and platinum plans.

California saw 73% of renewing members who switched plans move to a bronze plan, up from 27% at the same time last year, the State Marketplace Network reported. In Maine, bronze enrollment now represents almost 60% of all plans purchased.

People are “looking at what works in their monthly budget, looking for that lower premium,” said Stacey Pogue, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “Some might be crossing their fingers that they won’t need to meet their deductible.”

On average, bronze plans have an . All ACA plans are required to cover certain preventive services — such as some vaccinations, cancer screenings, and other tests — without a copayment or deductible, but most everything else is covered only after an annual deductible is met.

High deductibles can lead some patients to avoid seeking medical care, Hempstead said.

“People are terrified to use their care,” she said. “They may delay something until it’s more serious.”

She added that medical providers, including hospitals and doctors, are bracing for an increase in the number of insured patients who can’t afford to pay their deductibles.

“Everyone is anticipating that hospitals will have to give out more charity care, which will hurt their bottom lines and might lead them to have to lay off people or close or reduce services,” she said.

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“We saw a turnaround in his behavior, and our other children,” said Burkhammer, who has adopted or fostered 10 kids with his wife. “There are real impacts on real kids.”

The Republican turned his experience into legislation, sponsoring a bill to from food sold in the state. It became law in March, making West Virginia the first state to institute such a ban from all food products.

The bill was among a slew of state efforts to regulate synthetic dyes. In 2025, roughly 75 bills aimed at food dyes were introduced in 37 states, according to .

Chemical dyes and nutrition are just part of the broader “Make America Healthy Again” agenda. Promoted by Health and Human Services Secretary Robert F. Kennedy Jr., MAHA ideas have made their deepest inroads at the state level, with strong support from Republicans — and in some places, from Democrats. The $50 billion — created last year as part of the GOP’s One Big Beautiful Bill Act to expand health care access in rural areas — offers incentives to states that implement MAHA policies.

Federal and state officials are seeking a broad swath of health policy changes, including rolling back routine vaccinations and expanding the use of drugs such as ivermectin for treatments beyond their approved use. State lawmakers have introduced dozens of bills targeting vaccines, fluoridated water, and PFAS, a group of compounds known as “forever chemicals” that have been linked to cancer and other health problems.

In addition to West Virginia, six other states have targeted food dyes with new laws or executive orders, requiring warning labels on food with certain dyes or banning the sale of such products in schools. California has had a law regulating food dyes since 2023.

Most synthetic dyes used to color food have been . Some clinical studies have found a link between their use and . And in early 2025, in the last days of President Joe Biden’s term, the Food and Drug Administration known as Red No. 3.

Major food companies including have gotten on board, pledging to eliminate at least some color additives from food products over the next year or two.

“We anticipate that the momentum we saw in 2025 will continue into 2026, with a particular focus on ingredient safety and transparency,” said John Hewitt, the senior vice president of state affairs for the Consumer Brands Association, a trade group for food manufacturers.

This past summer, the group called on its members to from their products by the end of 2027.

“The state laws are really what’s motivating companies to get rid of dyes,” said , regulatory counsel for the Center for Science in the Public Interest, a nonprofit health advocacy group.

, the senior director of state health policy for the Association of State and Territorial Health Officials, said the bipartisan support for bills targeting food dyes and ultraprocessed food struck him as unusual. Several red states have proposed legislation modeled on California’s 2023 law, which bans four food additives.

“It’s not very often you see states like California and West Virginia at the forefront of an issue together,” Baker-White said.

Although Democrats have joined Republicans in some of these efforts, Kennedy continues to drive the agenda. He appeared with Texas officials when the state enacted a package of food-related laws, including one that bars individuals who participate in the Supplemental Nutrition Assistance Program — SNAP, or food stamps — from using their benefits to buy candy or sugary drinks. In December, the U.S. Department of Agriculture approved similar . Eighteen states will block SNAP purchases of those items in 2026.

There are bound to be more. The Rural Health Transformation Program also offers incentives to states that implemented restrictions on SNAP.

“There are real and concrete effects where the rural health money gives points for changes in SNAP eligibility or the SNAP definitions,” Baker-White said.

In October, California Gov. Gavin Newsom signed a bill that sets a and will phase them out of schools. It’s a move that may be copied in other states in 2026, while also providing fodder for legal battles. In December, San Francisco City Attorney David Chiu , accusing them of selling “harmful and addictive” products. names specific brands — including cereals, pizzas, sodas, and potato chips — linking them to serious health problems.

Kennedy has also for chronic diseases. But even proponents of the efforts to tackle nutrition concerns don’t agree on which foods to target. MAHA adherents on the right haven’t focused on sugar and sodium as much as policymakers on the left. The parties have also butted heads over some Republicans’ championing of , which can spread harmful germs, and the consumption of , which contributes to .

Policymakers expect other flash points. Moves by and the that are making vaccine access more difficult have led blue states to find ways to set their own standards apart from federal recommendations, with 15 Democratic governors announcing a in October. Meanwhile, more red states may eliminate vaccine mandates for employees; . And Florida Gov. Ron DeSantis is pushing to .

Even as Kennedy advocates eliminating artificial dyes, the Environmental Protection Agency has on chemicals and pesticides, leading MAHA activists to calling on President Donald Trump to fire EPA Administrator Lee Zeldin.

Congress has yet to act on most MAHA proposals. But state lawmakers are poised to tackle many of them.

“If we’re honest, the American people have lost faith in some of our federal institutions, whether FDA or CDC,” said Burkhammer, the West Virginia lawmaker. “We’re going to step up as states and do the right thing.”

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