California lawmakers an expired law that would require the state to identify companies that employ 100 or more people and have employees enrolled in Medi-Cal, the state’s Medicaid program. Nevada has had a similar law in place since 2017, though a proposal for one in Oregon stalled when its legislative session ended in March.

The California bill author, Democratic state Sen. Lola Smallwood-Cuevas, said she is deeply troubled by what is going to happen when work requirements kick in. According to the state, out of more than on Medi-Cal will be subject to the rule.

“We think this is a bill that’s about fairness,” Smallwood-Cuevas said. “It’s a basic principle that taxpayers deserve transparency about which large employers are shifting their healthcare costs onto the public.”

Large employers that regularly top Nevada’s list, such as Walmart and Amazon, have said that the state included part-time and seasonal workers in their counts and that their full-time hourly employees to qualify for Medicaid.

Walmart spokesperson Katrina Proffitt said that the company offers affordable medical coverage to most employees, including eligible part-time workers, and that most of its plans include no-cost virtual care options.

“Healthcare affordability and access to quality care remain real barriers for many Americans, and Walmart continues to be committed to being part of the solution,” Proffitt said.

The push to name and shame companies reflects dueling narratives about the biggest abusers of the joint state-federal Medicaid program, which reached nearly in government spending in 2024. The Trump administration, led by Centers for Medicare & Medicaid Services Administrator Mehmet Oz, has called out blue states for not doing enough to fight insurer fraud and abuse. State Democratic leaders, meanwhile, are pushing back by calling attention to big employers that don’t offer affordable health benefits, which leaves taxpayers subsidizing healthcare costs for the low-wage workforce.

Some states have considered financial penalties. Democratic New Jersey Gov. Mikie Sherrill signed a bill in June that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in this year.

In Sacramento, California, Democrats want to figure out a way to make large businesses pay for their employees’ health coverage. State lawmakers struck a deal with Democratic Gov. Gavin Newsom, who is contemplating a presidential bid as he wraps up his final year in the governor’s office, to explore tax options. Any tax hike would be up to the new governor.

States face of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through that requires nondisabled Medicaid enrollees ages 19 to 64 in most states to prove they are working, volunteering, or going to school at least 80 hours a month to keep their coverage.

Yet federal work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the . Nebraska and Montana have begun enforcing the rule.

One health policy researcher said employer Medicaid reports highlight the lack of affordable healthcare options available to low-wage workers. More than half of adults enrolled in Medicaid who don’t have dependent children already meet the 80-hour-a-month requirement or face challenges that would likely qualify them for an exemption, .

“There’s a whole set of people who are working — they may not satisfy the work requirement provisions, they may not get the exemption that they’re qualified for, and they don’t have access to that employer-sponsored insurance either,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Employers Push Back

While employer lists haven’t succeeded in bringing down Medicaid costs, supporters say measuring the burden can be the first step and help lawmakers make the case for further action.

In Nevada, Amazon has employed more Medicaid enrollees than any other company since 2020, according to the state’s report . For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers that the reports are misleading because they have included part-time and seasonal employees. The state’s includes only full-time employees, plus those who could not be confirmed as either full- or part-time employees.

That came to 4,914 Amazon employees and 3,503 Walmart workers in Nevada on Medicaid in 2025.

There are no penalties for companies on the list.

Amazon said it pays its workers more than double the $7.25-an-hour federal minimum wage and noted that Medicaid eligibility is based on household income and size rather than an individual’s wage. That means two employees who earn the same pay may have different eligibility depending on whether they have children or live with parents.

“Pointing fingers at Amazon over Medicaid is a red herring,” said spokesperson Alisa Carroll. “What really needs to happen is a significant and large increase in the federal minimum wage — that would be a big boost for American families.”

Nevada Medicaid spent nearly $950 million on healthcare for more than 133,000 full-time employees and more than 140,000 of their dependents. While the total amount spent dipped in fiscal year 2025, the average cost per member per year increased by nearly 17%.

Yvanna Cancela, a former Nevada lawmaker who sponsored the legislation on Medicaid work reports, said the annual reports force an important conversation “about whether or not this is the kind of economy we want and whether or not it is right or just that people who work full-time don’t make enough to have health insurance.”

A Fraying Safety Net

Health researchers say that uninsured people delay or skip and that their children may end up losing coverage, too.

One analysis found that more than were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. is pending in the legislature.

She compared Medi-Cal to a trampoline that has become a “very tattered kind of fishnet” overwhelmed by people falling into it. President Donald Trump’s spending-and-tax law pulls and rips at the safety net, she said.

When people lose food assistance and health benefits, they must choose between paying for medicine and paying for rent, Smallwood-Cuevas said.

“We’re going to see more people in their cars, more people on the street, and a lot more people in the emergency room,” she said. “That is dangerous for all of California.”

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When Gov. Gavin Newsom, using his , refused to extradite a physician accused of prescribing and mailing abortion pills to a Louisiana woman, he said California would “not ever” allow “extremist politicians” to punish its doctors.

Newsom, who is considering a run for president, has long championed reproductive rights, but state lawmakers in the Democratically controlled California legislature know future governors might not have the same political beliefs.

Republican gubernatorial candidate Steve Hilton, a former Fox News host endorsed by President Donald Trump, has vowed to honor these types of extradition requests from other states if he’s elected, Louisiana “is trying to uphold what its people voted for, and California is undermining it.” His opponent, Democrat Xavier Becerra, has said he would deny the requests.

Legislation advancing in Sacramento is the latest chapter in a tit for tat that’s been happening between conservative and liberal states since 2022, when the U.S. Supreme Court overturned Roe v. Wade, ending federal legal protections for abortion.

by state Assembly member Rebecca Bauer-Kahan, which is being heard in committee, would take some decisions out of the governor’s hands, requiring governors to deny extradition requests for healthcare providers who prescribe abortion medication or administer gender-affirming care. It would also shield anyone in California who helped patients travel to California or another state to receive legal care. While opponents cast “shield laws” as an incursion on other states’ authority, supporters of the bill view it as insurance — even with Becerra leading Hilton 52% to 31%, according to by the University of California-Berkeley Institute of Government Studies.

Newsom spokesperson Marissa Saldivar said the governor doesn’t comment on pending legislation. Hilton and Becerra didn’t return calls for comment.

“Protecting providers from prosecution should not rely on shifting political winds or a single person’s decision,” said Alyssa Sherer, a nurse practitioner who spoke in support of the bill at a Senate committee hearing in June. Sherer is also the medical director at Hey Jane, a telehealth medication abortion provider. 

Thirteen states have banned abortion outright, and 28 other states ban abortion somewhere between six weeks and viability. At the same time, other states that allow abortion have enacted shield laws to protect doctors and nurses from liability when they prescribe across state lines.

People living in states with total abortion bans are increasingly getting abortion pills prescribed via telehealth, from 74,000 abortions in 2024 to 92,000 abortions in 2025, according to the Guttmacher Institute, citing numbers from its Monthly Abortion Provision Study.

Critics of shield laws say that states have a legitimate interest in enforcing their own statutes and that such laws represent an attempt by some states, like California, to nullify the legal decisions of others.

“If California says, ‘We’re not going to honor any other state’s laws. We’re going to ship abortion pills into your states. You can’t have a law that says abortion is illegal,’ I don’t know — that doesn’t seem like a workable situation,” said Greg Burt, who is vice president of the California Family Council and has spoken in opposition to shield laws at the State Capitol.

Twenty-one other states and Washington, D.C., have similar shield laws, but Arizona, California, Michigan, North Carolina, and Pennsylvania’s rely on an executive order, which could be reversed by a successor, according to the Guttmacher Institute.

Amanda Barrow, a senior staff attorney at the Center on Reproductive Health, Law, and Policy at UCLA Law, said passing extradition protections would put California on firmer footing, because an executive order “could be revoked by a governor who is anti-abortion or anti-gender-affirming-care.”

Hilton has said he would do just that if elected.

“Just as I wouldn’t want to see Louisiana coming in and undermining something that we voted for here in California,” the GOP candidate told KQED in January. 

During a , Becerra said he was strident about protecting reproductive rights as the state’s attorney general. “Absolutely no,” Becerra said of allowing California physicians to be extradited. 

This year, Hawai‘i to its existing shield laws. And Oregon , including banning law enforcement from cooperating with out-of-state or federal investigations into care that’s legal in the state.

But Republican legislators in conservative states have cast telehealth visits as an end run around their laws. And some have moved to restrict abortion pill access.

The governors of , , and have signed bills this year that criminalize the sale, purchase, or distribution of medication that induces an abortion. Those states make it a felony to provide medication abortion drugs to people who are seeking to end a pregnancy. The laws impose up to 10 years in prison with potentially tens of thousands of dollars in fines.

Mississippi amended the state’s controlled substances code to add abortion pills as a criminal category. Although the state already prohibits abortion broadly, the measure specifically addresses distribution, which could subject out-of-state providers to prosecution.

In January, Louisiana a California doctor, Remy Coeytaux, mailing abortion pills to a patient. Newsom denied the request. Likewise, New York Gov. Kathy Hochul denied Louisiana’s February 2025 extradition request for a .

Texas has taken a slightly different legal tact. Attorney General Ken Paxton, a Republican running for the U.S. Senate, obtained a default judgment of more than $100,000 against the New York doctor targeted by Louisiana, but a , citing New York’s shield law. Neither Paxton nor Louisiana Attorney General Liz Murrill responded to requests for comment. 

Fear of being charged with a crime for providing quality medical care is contributing to physicians leaving medicine, said Sacramento emergency room doctor Kamara Graham, who is vice president of the California chapter of the American College of Emergency Physicians, which is supporting the bill.

“It’s really conflicting and hard for us to weigh that concern of: Will I get extradited and charged and potentially be taken away from my family? Or do I do the right thing for my patient?” Graham said.

The availability of medication used in most abortions could soon change nationwide. Under the leadership of Health and Human Services Secretary Robert F. Kennedy Jr., the Food and Drug Administration it is conducting a safety review of mifepristone, one of two medications in pill form that is used in most U.S. abortions. The FDA maintains the drug is safe and effective.

If the FDA were to decide that mifepristone is not safe, such a ruling would supersede state laws, even in states where abortion is legal. If mifepristone is restricted, many telehealth groups have said they would switch to using only the other medication, misoprostol.

“The elephant in the room is whether the Trump administration, particularly after the midterms, makes some kind of move to put national limits on access to abortions,” said Mary Ziegler, a law professor at UC-Davis who has written several books on reproductive health law.

“Not everything is something that the legislature can solve for,” Ziegler said, “because there’s some uncertainty about how the federal courts are going to react to all of this.”

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The Republican blasted California during back-to-back political attacks in May, saying the heavily Democratic state is committing “outrageous fraud” and “stealing” by spending state and federal Medicaid money meant for basic medical treatment on unconventional services such as housing and nutrition assistance, gym memberships, and even tribal prayers and, he claimed, exorcisms.

“The California Medicaid program will pay for herbal medicines, meal deliveries. They’ll pay for housing,” Kennedy said. “I don’t know what housing has to do with healthcare.”

“California, they’re just setting all kind of records,” he added. “They’re wild people.”

Despite criticism from congressional Republicans and growing scrutiny from the Trump administration, Gov. Gavin Newsom, a Democrat considering a presidential run, said he’s proud of California’s spending on social services in Medi-Cal, the state’s Medicaid program. It’s a multibillion-dollar experiment to help medically frail patients meet their housing, food, and other social needs that Newsom says is not only legal but also a more cost-effective and evidence-backed approach to providing healthcare for Californians with complex health conditions. He counters that investing in services outside clinical settings can help people avoid emergency rooms and hospital admissions, improve their long-term health, and ultimately save taxpayers money.

“It’s about whole-person care,” Newsom said, adding that he hopes President Donald Trump’s administration sees California’s leadership and agrees with the “reforms we’re advancing as national best practices.”

Now one of the governor’s marquee health initiatives is at the center of an intensifying partisan battle with Republicans in Washington, D.C., who have moved to rein in billions in healthcare spending on low-income and disabled people across red and blue states. It’s a philosophical divide: Conservatives say social services are a financial strain on Medicaid and shouldn’t be considered healthcare, while liberals argue that investing in prevention ultimately saves money. While experiments proliferated across the country under President Joe Biden, the Trump administration federal policy encouraging state Medicaid programs to address health-related social needs.

The Medicaid fight is putting patients in limbo.

Lucy Rodriguez teaches Mexican folk dancing in the town of Hollister, in California’s Central Coast region. She said her life turned around this year once an intensive case manager with Titanium Healthcare, which contracts with health insurers to provide services, began helping her manage her chronic diseases and stay on top of her medical appointments and prescriptions, even picking up free food boxes for her. The 73-year-old is on Medicare and Medi-Cal, which offers more extensive benefits. The low-income health program has helped pay her utility bills, and she was recently approved for home-delivered meals.

“This has been a godsend,” said Rodriguez, who has diabetes, high blood pressure, and kidney disease. “I was getting so stressed out and depressed. It’s really hard when you’re on a fixed income. Groceries are so expensive, and with summer, electricity gets even more expensive. But this is really improving my life.”

She worries the Trump administration will cut benefits to low-income older people.

Last year, the Centers for Medicare & Medicaid Services warned states that federal funding for social services would be determined on a . CMS spokesperson Christopher Krepich said the agency is not ending current agreements, known as waivers, that grant states temporary permission to provide social services, which are paid for with state and federal dollars. But future applications, for new services or to extend existing initiatives, could be at risk if they veer too far from traditional healthcare.

“Moving forward, CMS will work with states on innovative waivers that address core healthcare needs, as consistent with evidence-based approaches tied to clinical diagnoses and services, to the goal of ultimately improving health outcomes in the Medicaid population,” Krepich said in a statement.

In a further escalation, the Justice Department put out a allowing states to institutionalize people with disabilities and severe mental illness instead of providing community-based care. Republicans have also targeted states, mostly blue ones, for what they say is a failure to go after waste, fraud, and abuse in Medicaid. In May, CMS Administrator Mehmet Oz stood alongside JD Vance as the vice president announced the deferral of in Medicaid money to California over suspicions of fraud.

California Attorney General Rob Bonta said Republicans are simply trying to score political points while ignoring the healthcare needs of poor people. “The federal government wants to politicize fraud,” Bonta said, “and use it, unfortunately, as a bludgeon and a cajole to beat up on blue states.”

Social Healthcare

Health policy researchers say roughly are linked to socioeconomic, environmental, and behavioral factors, such as housing instability, homelessness, food insecurity, and exposure to violence, whereas 20% is associated with medical care delivered in hospitals and clinics. That evidence to tackle social services.

At least 24 states use their own money while drawing federal Medicaid funds for . Colorado, Massachusetts, New York, North Carolina, Oregon, and Pennsylvania are among those that provide housing and nutrition assistance.

As the Trump administration pulls back on social services, states are rethinking how to fund benefits that have improved preventive care for low-income people. Some have launched new benefits under what’s known as a state plan amendment, a mechanism states use to modify their Medicaid programs that doesn’t need federal waiver approval. and , for example, use this to add recuperative care for homeless patients after hospitalization. These short-term care facilities offer people the opportunity to recover, bridging the gap between hospital discharge and independent living.

This approach “has the advantage of establishing a permanent, statewide benefit that does not require ongoing federal renewals, offering greater stability and predictability,” said Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services.

Other states, meanwhile, rely on federal waivers, which require renewal to provide social services. Arizona officials said the state intends to submit a request by the end of September to continue to provide housing and other services to homeless patients, or those at risk of homelessness, with a serious mental illness and a chronic health condition or recent incarceration.

“When members have access to stable housing and supportive services, they are more likely to engage in ongoing care and less likely to experience avoidable emergency department visits and inpatient admissions,” said Roberta Harrison, interim director of the Arizona Health Care Cost Containment System.

California, which has been the most aggressive state in adopting social services, has taken a two-pronged approach to keep its vast offerings funded past this year. The state is using its authority to make most of its existing social services and benefits permanent in Medi-Cal managed-care coverage. That regulatory maneuver bypasses federal waiver approval — a move that could attract further Republican scrutiny.

But not everything the state offers can be funded without permission from the federal government. As some services are made permanent, the Newsom administration is seeking new waivers to continue other social services, while also adding more.

It’s an ambitious approach that would expand California’s social healthcare experiment. Newsom said he’s worried that the federal government will decline the . “How could you not be with this administration?” he said. “I’m always concerned.”

New Front in Healthcare

California offers most of its health-related social services under within Medi-Cal, which has a proposed budget of . Although there are more than 14 million residents on Medi-Cal, the state has been selective about who gets help from in its program, called California Advancing and Innovating Medi-Cal, or . Patients with complex needs can also receive help navigating their health and social needs from specialized social workers under a benefit known as .

Since 2022, California has been offering social services, spending nearly $12 billion in joint state and federal money, long-term Medi-Cal spending by keeping enrollees out of costly institutions including emergency rooms, jails, nursing homes, and mental health crisis centers.

CalAIM had provided social services to more than patients as of September 2025, the most recent state data available. And nearly low-income Californians have received intensive . Some patients receive both services.

Among the services California is making permanent: Homeless patients can get help finding an apartment, with Medi-Cal paying rental and six months of rent. Patients with chronic conditions such as diabetes and heart disease are eligible for home-delivered meals. Asthmatic patients can get mold removed from their homes to control flare-ups. Low-income seniors with disabilities can get a wheelchair ramp installed free of charge. And inmates leaving jail or prison can be connected immediately with primary care, mental health, and substance use treatment.

The social services — especially housing, food assistance, and home modifications — are success in stabilizing the health of the most complex patients, while achieving savings for Medi-Cal through reductions in emergency room visits and hospitalizations and less reliance on institutional care such as nursing homes, the state Department of Health Care Services.

In the Central Valley, for instance, Health Plan of San Joaquin CEO Lizeth Granados said CalAIM has helped place homeless patients who were routinely hospitalized into housing. And patients with uncontrolled diabetes saw their blood sugar drop after receiving nutrition counseling and home-delivered meals.

Overall, Granados said, the health plan has seen major improvements in chronic disease management and reductions in hospital stays, dropping to 44 inpatient hospitalizations per 1,000 members since it launched in 2022, down from 61 per 1,000 before CalAIM.

In Orange County, officials with CalOptima Health credited CalAIM housing services for contributing to a nearly . “We’ve been able to expand our street medicine programs, too,” said Yunkyung Kim, the insurer’s chief operating officer.

Around the state, Medi-Cal health insurers said they’re optimistic that CalAIM will continue to save money and improve patient health. Yet, the fate of some services will be decided by the Trump administration.

California has asked CMS to continue enrolling jail and prison inmates in Medi-Cal 90 days before their release to maintain consistent treatment for substance use, mental disorders, or physical conditions, a .

The state has also proposed a new job assistance benefit that counties could opt into to help patients find and retain work in response to upcoming federal work requirements imposed by congressional Republicans’ One Big Beautiful Bill Act, signed by Trump last summer.

And the state wants to continue its array of traditional healers and natural helpers for Californians with tribal affiliations, including music therapy, dancing, drumming, and referrals to sweat lodges for mental health treatment and substance use recovery. While it covers spiritual services, such as ceremonies, rituals, and herbal remedies, state officials said Medi-Cal does not cover exorcisms.

Already, the Trump administration’s positioning has forced the state to eliminate room-and-board benefits, which is threatening local efforts to provide recovery beds.

The state is cutting short-term post-hospitalization housing, which was meant to prevent hospitals from or those at risk of homelessness onto the streets. The CalAIM service providing up to six months of temporary housing and ongoing care is ending at the close of this year. And the state is cutting recuperative care benefits, no longer paying for beds for patients to recover from illness or injury, instead offering only wraparound services.

In San Francisco, these beds have been crucial in reducing overdose deaths, helping transition homeless people off the streets and into housing, and reducing hospital bed usage, said Neal Sheran, a medical director with the city’s Department of Public Health. The city’s health plan operates a sobering center, and recuperative care facilities where patients can recover from hospitalizations.

“We’re concerned,” Sheran said. “Funding for the overnight piece of these programs is really crucial to their success.”

Cuts on the Horizon

Even without federal threats, state budget pressures have strained CalAIM financing. Newsom has proposed for social services by $68.3 million this fiscal year. The cut will deepen next year and remain at $150.2 million per year beginning in 2028.

Providers worry that Medi-Cal patients will lose access. And services, such as home-delivered meals and housing assistance, will be further restricted.

“It’s moving us back to the old days where our healthcare system is more expensive and reactive, instead of investing in prevention,” said Anwar Zoueihid, a vice president and the chief strategy officer at the Los Angeles-based Partners in Care Foundation, a CalAIM provider. “It’s contradictory to Make America Healthy Again.”

To save money, the state is tightening eligibility to limit services and . For instance, Medi-Cal patients with food insecurity would no longer be eligible for home-delivered healthy meals without a qualifying condition like diabetes. And a homeless patient would get capped at six months for help finding an apartment.

Some of the biggest providers of CalAIM say services should be continuously evaluated and curtailed if health plans were too permissive. In some cases, food and housing services were given to low-income patients who didn’t necessarily qualify as the highest-need.

“It’s important everybody takes a look with a very sober view at whether we’re truly benefiting people so we’re spending money in the right places,” said Charlie Robinson, the chief health equity officer at L.A. Care, one of the state’s largest Medi-Cal health insurers.

Dorothy Seleski, the Medi-Cal president for Health Net, said the health insurer isn’t deterred by state and federal cuts.

“Regardless of what happens at the federal level, we are committed,” she said. “This is a significant transformation of the healthcare system, and we are already seeing major reductions in avoidable emergency room trips, avoidable hospital admissions, and we’ve closed gaps in preventive care.”

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She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill — first introduced in New York in 2016 — could become law.

‘A Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years — Oregon’s law, the first in the country, was enacted in 1997 — the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, ‘We have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

‘You Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say ‘You need A, B, and C,’ and Columbia-Presbyterian can say, ‘We also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state — usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS — the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease — rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, ‘People should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

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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 patient lived alone, and “really struggles with social isolation,” Guzman said. After a serious fall and subsequent surgery, the woman was using a wheelchair. She confided that she would like to attend services at a church down the road but had no way to get there and did not want to seem “a bother.”

“We called the pastor to see if there was someone who could pick her up” on Sundays, Guzman said. And there was.

The next day, Guzman visited a woman with heart failure who required constant oxygen. She lives in “less than ideal housing,” with no kitchen and only a plug-in heater for warmth.

“We were trying to figure out if she qualifies for HUD housing or assisted living,” Guzman said, referring to the federal Department of Housing and Urban Development. “We spent a lot of time talking about the options and came up with a game plan.”

Wednesday’s schedule included a 20-mile drive to Hood River to see an 81-year-old woman whose partner of nearly 40 years was contending with a serious cancer. Guzman, who speaks to her in Spanish, found her distraught at the possibility of losing him.

Guzman had arranged for the woman to begin seeing a therapist to help her through the crisis — no minor achievement. But on this visit, “I just handed her tissues and tried to give words of comfort,” she said. “Honestly, sometimes just sitting and listening” is the best response.

A community healthcare worker, the , is a “trusted member” of a local community or someone who has “an unusually close understanding” of it, enabling the worker to serve as intermediary between patients and the healthcare system.

These workers have been on the job since the 1960s, particularly in rural and low-income areas. Today, their numbers are growing. The Bureau of Labor Statistics , which the National Association of Community Health Workers says is probably an underestimate.

That partly reflects the difficulty of counting workers who go by a variety of names — community health educators, outreach specialists, promotores de salud — and operate under different state regulations, sometimes with no licensure or certification required.

What they have in common is that “they talk like the people they work with,” said Sam Cotton, who directs the curriculum for several such programs at the University of Louisville in Kentucky.

With shortages of healthcare professionals and an aging population, “there’s a lot of momentum for this,” she said.

In Oregon, for example, five rural clinics employ community health workers, who become state-certified after completing 90 hours of online training, through a program called Connected Care for Older Adults. A sixth clinic employing a community health worker operates in neighboring Washington.

Their frail patients are struggling. “They can’t drive, so they can’t get to a grocery store and shop,” said Elizabeth Eckstrom, chief of geriatrics at Oregon Health & Science University, who helped oversee the program’s start in 2022. “They’re not taking their medications, either for cognitive reasons or because they can’t get to a pharmacy.”

Few have completed an advance directive, specifying the care they want — or don’t want — if they suffer a health crisis.

Connected Care’s community health workers tackle many of those not-exactly-medical problems — from installing wheelchair ramps to helping patients apply for food and housing benefits. They are allotted 90 days to work with each patient, usually during home visits.

They help coordinate follow-up appointments. They administer cognitive and mental health screenings and watch for the use of too many medications, entering their observations into the patients’ electronic health records.

“It’s like being the eyes and ears for the doctors, to see what’s happening outside the 20 minutes they get to spend with patients,” said Guzman, whose work has ranged from ordering a bath mat to reporting suspected financial abuse.

In a  (average age: 77), a subsample found substantial decreases in emergency department visits and hospitalizations among those served by community health workers.

More extensive research, not yet published, supports that finding, Eckstrom said.

“ED visits cost thousands, and hospitalizations are tens of thousands,” she pointed out. The cost per patient for the 90-day program is $1,500. Its workers earn $25 an hour, a fairly typical wage, and receive full employee benefits.

Manali Patel, an oncologist at Stanford University, found for older patients with advanced cancer in a clinical trial at the Department of Veterans Affairs’ Palo Alto Health Care System.

“Lots of people were passing away” in the intensive care unit, she recalled. “If we’d asked, they probably would have wanted to be at home.” Oncologists, she added, are “notoriously bad at engaging in and documenting those conversations.”

But when a lay health worker made regular phone calls to help patients understand their options, discuss their preferences with their care team, and file advance directives, the results — published in JAMA Oncology in 2018 — were “very dramatic,” Patel said.

More than 90% of the participating veterans had their goals documented in their records compared with fewer than 20% of the control group. The lay worker’s patients had significantly fewer emergency room visits and hospitalizations and were more likely to enroll in hospice care.

Patel and her co-authors have gone on to document the benefits of lay health workers, the term they used, in undertaking other tasks in other settings.

In oncology clinics in Arizona and California, for instance, two bilingual lay health workers to cancer patients over age 75 to assess symptoms like pain, nausea, breathlessness, and depression.

Alerting healthcare teams to these patients’ problems substantially reduced their emergency department use and hospitalizations, and the cost savings averaged $12,000 a patient.

“This low-tech, human-administered intervention reaped huge dividends,” said an  in JAMA.

“Community health workers should be part of every healthcare team,” Eckstrom said. “They support the patient in ways the medical system just can’t, no matter how hard we try.”

One obstacle to expanding their use, however, is unstable funding.

In 2024, Medicare began covering some community health worker services, but not all. (The costs of driving 30 miles to remote homes, for example, are not reimbursed.) Medicaid coverage is piecemeal, reimbursing for some services in some states and not others.

“A lot of community health worker roles rely on short-term grants,” said Neena Schultz, a director of the National Association of Community Health Workers. “Sustainability is something we talk about every day.”

The organization and other supporters are pressing for more state and federal funding. The new federal , which is distributing $10 billion a year, will include funding for community health worker programs, but cuts to state Medicaid budgets could more than offset those gains.

The grants funding Connected Care for Older Adults continue, though. Guzman, employed by the nonprofit clinic One Community Health, keeps making her rounds.

One recent victory: A newly widowed patient in his 60s, struggling financially without his wife’s income, lost his housing and was sleeping in his truck. Through another patient, Guzman learned of an unused recreational vehicle whose owner was willing to donate it.

The widower now lives comfortably in a mobile home park.

When you’re in a patient’s home, “there’s a sense of ease,” Guzman said. “They feel safer talking about things. They don’t feel rushed. You develop a relationship, and they feel they have someone to advocate for them.”

The New Old Age is produced through a partnership with .

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The federal government doesn’t track how many children have entered foster care because of immigration enforcement actions, leaving it unclear how often it happens. In Oregon, as of February two children had been placed in foster care after being separated from their parents in immigration detention cases, according to Jake Sunderland, a spokesperson for the Oregon Department of Human Services.

“Before fall 2025, this simply had never happened before,” Sunderland said.

As of mid-February, nearly by Immigration and Customs Enforcement. The record 73,000 people in detention in January represented an compared with one year before. According to , parents of 11,000 children who are U.S. citizens were detained from the beginning of Trump’s term through August.

The news outlet NOTUS that at least 32 children of detained or deported parents had been placed in foster care in seven states.

Sandy Santana, executive director of Children’s Rights, a legal advocacy organization, said he thinks the actual number is much higher.

“That, to us, seems really, really low,” he said.

Separation from a parent is deeply traumatic for children and can lead to , including post-traumatic stress disorder. Prolonged, intense stress can lead to more-frequent infections in children and developmental issues. That “toxic stress” is also associated with responsible for learning and memory, according to KFF.

, and amended existing laws during Trump’s first term to allow guardians to be granted temporary parental rights for immigration enforcement reasons. Now the enforcement surge that began after Trump returned to office last year has prompted a new wave of state responses.

In New Jersey, lawmakers are considering to amend a state law that allows parents to nominate standby, or temporary, guardians in the cases of death, incapacity, or debilitation. The bill would add separation due to federal immigration enforcement as another allowable reason.

Nevada and California passed laws last year to protect families separated by immigration enforcement actions. California’s law, called the , allows parents to nominate guardians and share custodial rights, instead of having them suspended, while they’re detained. They regain their full parental rights if they are released and are able to reunite with their children.

There are significant legal barriers to reunification once a child is placed in state custody, said Juan Guzman, director of children’s court and guardianship at the Alliance for Children’s Rights, a legal advocacy organization in Los Angeles.

If a parent’s child is placed in foster care and the parent cannot participate in required court proceedings because they are in detention or have been deported, it’s less likely they will be able to reunite with their child, Guzman said.

are U.S. citizens who live with a parent or family member who does not have legal immigration status, according to research from the Brookings Institution, a Washington, D.C.-based think tank. Within that group, 2.6 million children have two parents lacking legal status.

Santana said he expects the number of family separation cases to grow as the Trump administration continues its immigration enforcement campaign, putting more children at risk of being placed in foster care.

the agency to make efforts to facilitate detained parents’ participation in family court, child welfare, or guardianship proceedings, but Santana said it’s uncertain whether ICE is complying with those rules.

ICE officials did not respond to requests for comment for this report.

Before the change in California’s law, the only way a parent could share custodial rights with another guardian was if the parent was terminally ill, Guzman said.

If parents create a preparedness plan and identify an individual to assume guardianship of their children, the state child welfare agency can begin the process of placing the children with that individual without opening a formal foster care case, he added.

While Nevada lawmakers expanded an existing guardianship law last year to include immigration enforcement, the measure requires the parents to take the additional step of filing notarized paperwork with the secretary of state’s office, said Cristian Gonzalez-Perez, an attorney at Make the Road Nevada, a nonprofit that provides resources to immigrant communities.

Gonzalez-Perez said some immigrants are still hesitant to fill out government forms, out of fear that ICE might access their information and target them. He reassures community members that the state forms are secure and can be accessed only by hospitals and courts.

The Trump administration has taken through the Centers for Medicare & Medicaid Services, the IRS, the Supplemental Nutrition Assistance Program, the Department of Housing and Urban Development, and other entities.

Gonzalez-Perez and Guzman said that not enough immigrant parents know their rights. Nominating a temporary guardian and creating a plan for their families is one way they can prevent feelings of helplessness, Gonzalez-Perez said.

“Folks don’t want to talk about it, right?” Guzman said. “The parent having to speak to a child about the possibility of separation, it’s scary. It’s not something anybody wants to do.”

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Raven’s case reveals a little-known gap in the U.S. donation system: There is no clear, nationally binding way to opt out — or to ensure a later “no” overrides an earlier “yes” in a different state.

This gap, along with a range of other issues related to the organ procurement system, has become a point of bipartisan congressional concern. Late last year, the House Ways and Means subcommittee on oversight examining what members described as shortcomings, including alleged consent failures.

The panel’s scrutiny of organ procurement organizations, or OPOs, and their consent practices is a first step toward a more meaningful accountability plan that could help maintain trust across the system, according to some committee staff members.

The trust in our organ procurement and transplant system “has been eroded,” said Rep. Terri Sewell of Alabama, the panel’s senior Democrat, calling for stronger transparency and oversight to rebuild public confidence.

“Respect for autonomy — our ability to make our own decisions (self-determination) — allows for both ‘yes’ and ‘no’ decisions and for changing one’s mind,” Margaret McLean, a bioethicist at Santa Clara University, said in an email.

“Medical decision-making is not well served in a context of ambiguity,” she said.

And if a donor revokes consent, she added, “revocation by that person should carry the same ethical and procedural weight as the initial authorization, perhaps more.”

Raven Kinser Changed Her Mind

Raven was 25 when she died. Her parents, Jeff and Jaime Kinser, were at home in Michigan when they received the phone call that shattered their world. They drove through the night to the Newport News hospital, where they learned Raven’s disposition had been referred to LifeNet Health, the region’s federally designated OPO. LifeNet a failing OPO by the Centers for Medicare & Medicaid Services, meaning it doesn’t meet the government’s standards for how well it finds donors and recovers usable organs for transplant compared with other organizations.

Under federal law, hospitals are required to refer deaths and imminent deaths to OPOs, which take responsibility for donation-related decisions and discussions.

OPOs occupy a hybrid position in the health care system, as private nonprofit entities that hold exclusive, federally authorized contracts to recover organs within defined regions. They are regulated by CMS and overseen by the Health Resources and Services Administration, but that oversight occurs primarily through certification standards, performance metrics, and periodic audits rather than routine public disclosure requirements. With donor registries largely managed at the state level and no unified federal reporting requirement for removals, comprehensive national data on revocations is elusive.

OPOs are meant to separate bedside care from organ procurement decisions — to help prevent conflicts of interest and preserve the trust that decisions about life-sustaining treatment are made solely in the dying patient’s interest. But the , leaving families unsure who is in control if and when conflicts arise.

The Kinsers, for instance, felt their daughter would not have wanted to go through the donation process, but, at the time, had no evidence. Jaime remembers telling her husband that Raven would have been mad at them for letting it happen. In an effort to stop it, Jaime inquired about whether she would be asked to sign a consent form. But a LifeNet staff member told her that wasn’t an option because donation was Raven’s “living will,” Jaime said. Meanwhile, Raven’s parents said, her personal effects, including her Virginia driver’s license, which bore no donor designation, had not yet been turned over to the family, leaving them no meaningful way to challenge LifeNet’s determination in real time.

Jaime struggled with this outcome, even mentioning in Raven’s obituary that she was an organ donor. “How would you try to make peace with something that you felt was so wrong but had no proof?” Jaime said.

Two months passed before the Kinsers gained possession of the license, which, as they had expected, showed that Raven had not opted to be an organ donor.

According to the Kinsers, LifeNet staff told them that Raven’s status as a registered donor was established by her designation on her older Michigan license.

An emailed statement attributed to Douglas Wilson, LifeNet executive vice president, said the OPO follows federal law on organ donation, the , and queries applicable state donor registries, relying on time stamps and governing law to determine the , legally valid expression of intent. Under that framework, a prior donor authorization remains enforceable unless a valid revocation is recorded in the regional OPO’s donor registry.

Because of privacy laws, Wilson said, LifeNet could not comment on the specifics of any individual case.

Raven Kinser’s choice not to be a donor when she applied for a Virginia license in July 2024 was not reflected in the registry LifeNet consulted, according to her parents, who said that is what the organization told them. According to Lara Malbon, executive director of Donate Life Virginia, which manages the state’s organ donor registry, if someone changes their donor status while completing a Virginia driver’s license or ID transaction, “that information is sent to our registry, and the registry is updated daily to reflect those changes.” Malbon also said Virginia’s registry includes only people who have “affirmatively said ‘yes’ to becoming an organ, eye, and tissue donor, and it retains records solely for those who have made that decision.”

The Kinsers said they were never told why Raven’s Virginia DMV record was insufficient, or how an older yes from Michigan could outweigh a newer no in Virginia.

In December, the Kinsers filed a complaint with the Health Resources and Services Administration, urging federal regulators to investigate LifeNet’s actions and require OPOs to provide families with documented proof of the donor’s current status at the time of referral. They also called for OPOs, which operate as federally designated regional monopolies but are structured as private nonprofits, to be made subject to public records laws.

When Opting Out Doesn’t Stick

Such confusion is not unique to the Kinser family. It is a consequence of the organ donation consent process in the United States.

“I have also wondered that: why there’s not just one” registry for organ donation, Jaime said. If you go to get a firearm, you have one federal registry, she said.

Here’s how the system works: Americans typically register their organ donation intentions when they apply for driver’s licenses through state DMVs, and that decision remains governed largely by state law. That has led to 50 different sets of rules and very little federal regulation of what has become an in the U.S.

In some states, a donor checkbox is a binding legal document. In other states, the same choice may have different rules about when it takes effect, what it covers, and how it can be revoked.

Those differences can be big. State rules determine whether a person’s “gift” is limited to transplantation or also includes research and education. They determine whether the donation authorization includes tissue. And they can determine what counts as a valid revocation and when it is legally recognized.

Because of the system’s fragmentation, though, signals can cross when someone changes their mind, like Raven; it’s not always reflected from one state system to another.

Under state versions of the Uniform Anatomical Gift Act, a donor’s most recent legally valid expression of intent is meant to control.

“Personal autonomy is paramount to everything,” said Adam Schiavi, a neurointensivist who studies end-of-life decision-making. “If I say I want to be a donor, or if I say I don’t want to be a donor, that has to take precedence over everything else.”

But states differ in how revocation must be recorded and which registry is considered authoritative if someone has lived in more than one state. Those inconsistencies can create uncertainty when records conflict across jurisdictions.

“It has to be the most recent expression, not the most recent yes,” Schiavi said.

In Michigan, a change to someone’s donor status is reflected immediately in the secretary of state’s system, but only affirmative “yes” registrations appear in the registry. Removal information remains in internal motor vehicle records. In Virginia, the state registry includes only those who have affirmatively said “yes,” retaining records solely of donors, creating potential gaps if someone believes a DMV change alone is sufficient.

Elsewhere, processes and volumes differ sharply. New Mexico updates driver records in real time but does not transmit status changes to its donor registry. Instead, donor services receive restricted search access. The state logged nearly 15,000 removals in late 2021 and almost 30,000 in 2022. Florida, which maintains formal removal records through weekly DMV data files, reported 356,161 removals in 2020, more than 1.5 million in 2023, and over 1.2 million in 2025. Kentucky processed 847,371 donor registrations from 2020 to 2025, but only 16,043 icon removals, with registry withdrawal handled separately. In 2025, more than 570,000 Texans opted into the registry, while over 31,000 individuals requested removal.

According to a federal official who asked not to be identified for fear of professional repercussions, OPOs have been highly effective at lobbying states to broaden the definition of consent and authorization — shaping how those terms are applied, whether those statuses must be renewed, and how easy or difficult it is for someone to opt out.

In subsequent correspondence with federal officials, the Kinsers have urged reforms to prevent OPOs from relying on older registry entries when a more recent state DMV record exists, and they have called for criminal penalties in cases in which consent is knowingly misrepresented. Federal regulators have not indicated whether such proposals are under consideration.

Congress Takes a Closer Look

Ethicists have long cautioned that consent must be more than a checkbox and must remain grounded in respect for the donor-patient. In an October on organ transplantation, the American College of Physicians emphasized that clinicians’ primary duty is to the patient in their care, and that maintaining trust requires transparency and safeguards to prevent conflicts of interest from blurring that “bright line.”

Advocates say those steps leave unresolved the core problem raised by the Kinser family: the lack of a clear, legally binding way for people to say “no” and for that decision to follow them across state lines.

The said it “supports strengthening donor registries and enhancing registry interoperability to ensure that an individual’s documented donation decision is honored.” But OPOs have also argued that current policies protect donation as a legally enforceable gift and prevent families from overriding a loved one’s “yes” in the midst of grief. They argue that stronger, more durable consent helps reduce missed donations and saves lives.

Congress and federal regulators are considering changes to the nation’s organ donation system, including how consent is recorded and what should happen when a donor changes their mind.

Sen. Ron Wyden (D-Ore.) last year to create new federal standards for patient safety, transparency, and oversight of organ transplants, including a formal authorization for hospital or OPO staff to pause harvesting if there is any “clinical sign of life.”

HHS press secretary Emily Hilliard said the agency is “committed to holding organ procurement organizations accountable” and to “restoring integrity and transparency” to organ donation policy, calling reforms essential to informed consent and protecting donor rights. CMS issued related March 11, but it does not address the problems highlighted by the Kinsers’ case.

Critics of the organ transplant system say it is difficult for families to obtain documentation or independently verify how consent determinations were made in disputed cases.

HRSA has launched a sweeping modernization of the Organ Procurement and Transplantation Network, the national system that oversees organ allocation and transplant policy. Federal officials have described the overhaul as the most significant restructuring of the transplant system in decades, aimed at breaking up a long-standing contractor monopoly, strengthening patient safety oversight, and replacing aging technology infrastructure.

Central to that effort is modernizing the OPTN’s data systems: improving interoperability, audit trails, and transparency in how decisions are documented and reviewed. A more modern federal data architecture could make it easier to trace which registry was queried, what time stamp controlled, and how a consent determination was reached in disputed donations that span multiple states. But the modernization effort would not change the underlying state-by-state legal framework for donor authorization and what counts as a valid “no.”

Meanwhile, Donate Life America, a national nonprofit that supports state donor registries, also runs the , a central database that allows people to sign up as organ donors directly. Unlike many DMV systems, the national registry lets people log in at any time to view, update, or remove their registration and print proof of their decision. The group is also starting a project to let participating states send registrations directly into the national system, creating one place to track donor sign-ups and removals across state lines.

Each of the proposals comes with trade-offs, and both advocates and OPOs have raised concerns about how they would work in practice.

“Just doing a dump truck dump of information is not going to do much unless you really apply it through checking and auditing,” said Arthur Caplan, a professor of bioethics at New York University’s Grossman School of Medicine. “It could be like the IRS. They don’t have to audit everybody. Just do a spot audit once in a while.”

The Kinsers aren’t opposed to organ donation itself. They celebrated Raven’s donation in her obituary, and in their complaint to federal regulators, they wrote, “We are NOT anti-organ donation, and we will never take away the gift of life our oldest daughter gave to others. However, that was not LifeNet’s choice to make.”

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

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

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

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

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

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

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

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

Public Health Guided by Science

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

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

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

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

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

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

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

Funding Cuts Hurt All

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

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

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

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

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

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

Robust Vaccine Schedule

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

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

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

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

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

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

Influencing Red States

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

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

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

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

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The city’s mobile crisis team had just gotten a call about a man walking around outside without shoes. The man’s family told the team he was having a mental health crisis and wouldn’t come inside.

As they drove down the highway toward the city’s outskirts, team member Evan Thiessen spoke with the relative who had reached out.

“You’re doing the right thing, and we’re going to make sure he gets help today, OK?” he said.

They pulled up the man’s police record on a laptop and saw that he did have a record of some previous encounters with police, including some that had turned violent.

, a licensed therapist, had that in mind as they pulled into a neighborhood of single-family homes. He stepped out of the Ford Bronco and headed toward the front door.

A Funding Problem

Many communities around the country send out teams like this one to help people in psychiatric crisis, rather than dispatching regular police.

A found there were at least 1,800 mobile teams nationwide in 2023. But financial support for them is often inadequate and inconsistent, leaving many communities struggling to keep the teams operating.

Two programs — one in Great Falls, in central Montana, and one in Billings, in south-central Montana — recently shut down. Six units remain in Montana.

The strategy in Eugene, Oregon, but gained momentum nationally over the past 10 years.

Recent about police killing people who are experiencing a psychiatric crisis have sparked conversations about how to safely and effectively respond. Most police officers are not trained to deal with people experiencing delusions or hallucinations, nor to de-escalate situations involving threatening behaviors to themselves or others.

An across 27 states found that about a third of the victims showed signs of being in crisis. Another study found that people with a serious mental illness were at least to experience use of force by police as those without.

By contrast, crisis response teams have been trained to de-escalate such situations and provide appropriate therapeutic care.

When the team arrived at the house in Bozeman, the man had already gone back inside. The team then talked with the man’s family for about half an hour and helped them devise a plan to keep him at home — and safe. Before they left, team members determined the man wasn’t a threat to himself or others.

Also, they planned to follow up within a few days to connect him with ongoing mental health care. After an encounter with the team, some clients might need follow-up therapy, assistance with psychiatric medications, or help finding treatment for substance abuse.

The Bozeman team is available 12 hours a day, seven days a week, and costs roughly $1 million a year to run.

Police departments are generally funded by local taxpayers. Mobile crisis teams don’t have a single, reliable source of funding.

Some, despite successful operations and , are or have closed entirely. One that shuttered was Oregon’s .

Most crisis calls end with people staying where they are, avoiding a trip to the emergency room or going to jail, according to , which runs the mobile crisis program in Bozeman.

Beyond police and firefighters, members of the public can call the team directly.

“I’ve been out on calls where individuals have barricaded themselves in residences or in their vehicles with a firearm. So, helping to assist not only law enforcement, the negotiators, but consulting on the behavioral health side of that,” said Ryan Mattson, who leads the Bozeman crisis team.

The program has reduced the time that Bozeman police officers must spend on mental health calls by nearly 80%, according to Mattson, and prevented unnecessary ER visits.

Residents and political leaders see that value, he said, but finding a way to pay for the service has been difficult.

“I’m confident we’ll be here through next fiscal year. That’s about as confident as I am at this point,” Mattson said.

Mobile crisis programs in Montana, which began operating about five years ago, have cost more than the state originally projected.

Health insurance is sometimes a revenue source for mobile crisis teams. That’s because a crisis call is a type of mental health service, provided by trained professionals such as therapists or crisis intervention specialists. Still, many private insurance companies don’t reimburse for mobile crisis services.

What Medicaid Pays For — And Doesn’t

Medicaid, the government-funded insurance program for low-income and disabled Americans, is another funding source. Two-thirds of states allow Medicaid reimbursement for such calls, but rates vary.

In Montana, Medicaid reimburses the team only for the time they spend responding to a call in the field. Additional time spent on a case — documenting the encounters, or waiting for the next call — isn’t reimbursed.

“You need to pay for the capacity to be at the ready, just like we do with fire or police, regardless of whether somebody is going to be called out,” said of Inseparable, a nonprofit that advocates for mental health policy reform.

It’s not feasible for mobile crisis teams to rely solely on reimbursement from insurance companies, she said.

To deal with the shortfalls, many mobile teams rely on a patchwork of grants and other funding, according to , who studies Medicaid policy at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Some state governments have stepped in to help.

Eight states, including New Jersey, California, and Washington, mandate that private insurers cover the cost of mobile crisis calls for people on their plans, according to Kimball. At least 10 states have implemented fees on cellphone bills to help pay for service.

Montana hasn’t followed suit.

The state provides about $2 million annually in supplemental funds to help the mobile teams pay for service calls that aren’t reimbursed through Medicaid, according to an emailed statement from Jon Ebelt, a state health department spokesperson.

But program managers counter that the paperwork to access that funding is complicated and often isn’t worth the staff time.

Will Montana Step In?

Despite this state support, mobile teams are still struggling to stay afloat, Ebelt acknowledged. He said Montana officials are considering boosting what Medicaid reimburses for each service call.

In Missoula, the mobile crisis team turned to local taxpayers for additional help. Their annual expenditure is $1.4 million, but Medicaid reimbursements were covering only about 20% of the cost, according to program manager John LaRocque. Even with local tax dollars, the program faces a $250,000 shortfall, so LaRocque is looking for grants.

Mobile crisis is still a relatively new concept, and growing pains are to be expected, said Sierra Riesberg, director of the .

Still, abrupt closures create instability and lead some patients to the ER, placing financial pressure on another distressed part of the local health system.

“A much-needed service is available and then not available, available and then not available. These things need to be taken into consideration when developing programs in communities,” she said.

If more mobile crisis teams shut down, that might interfere with Montana’s recent efforts to overhaul an outdated and underfunded mental health system. The state’s only psychiatric hospital hasn’t kept up with the to the facility.

Later this year, Montana hopes to join a federal pilot program to open a new type of clinic: , or CCBHCs. Those clinics will receive boosted levels of federal funding, but they are required to offer round-the-clock mobile crisis services as well as other crisis care.

That could be a tall order for rural communities, said , an executive at in Great Falls.

Alluvion used to operate the mobile crisis team in Great Falls before it shuttered the service. One major reason it closed was that the expected Medicaid payments covered less than anticipated. Before Alluvion would consider getting involved again, the state would need to “completely revamp” the way the service is funded, Schreiner said.

“Is it a priority for our state or not?” he asked.

This article is from a partnership with and .

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .