Now she worries the cost of those drugs could rise — not because of price increases, but because of a tax system revamp put on the ballot by the state’s Republican-dominated legislature and backed by the Republican governor.

Prescription drugs and doctor visits are currently exempt from taxes in the state. But in August, Missouri voters will weigh in on a proposed constitutional amendment to give the legislature the power to replace the state’s income tax with expanded sales taxes, including on goods and services currently exempt.

“Politicians want Missourians to trust them when they say not to worry about our medications and healthcare being up for grabs,” Ortbals said at a June press event organized by Progress MO, a progressive advocacy group.

“I have spent enough time in Jefferson City to know better,” said Ortbals, who works for a Democratic state legislator but was speaking in her personal capacity. “I have watched them speak about protecting life while making lifesaving healthcare less accessible.”

Taxes on healthcare are unusual in the United States but not unprecedented. Most states over-the-counter drugs. Illinois, Missouri’s neighbor, prescription drugs. Delaware, Hawai‘i, New Mexico, and Washington all on services by physicians, dentists, out-of-hospital nursing providers, and medical laboratories.

Critics of the amendment to eliminate income tax in Missouri say it’d be difficult to make up the lost revenue without also imposing taxes on healthcare. Nearly two-thirds of the state’s general revenue budget comes from income taxes, about $8.7 billion in 2026. Failing to make up that revenue could lead to steep cuts in state services.

The proposed tax cut comes at an already precarious time for the state budget. Missouri Gov. Mike Kehoe in spending in this year’s budget over concerns of lagging revenues. The state legislature has passed a since 2022, including . Federal covid aid has propped up the budget in recent years, but the that the surplus is dwindling. And the state is projected to in federal Medicaid funding over 10 years due to cuts from President Donald Trump’s signature One Big Beautiful Bill Act.

Proponents of the Missouri income tax proposal, such as of the Show-Me Institute, a conservative think tank, say the cut would in the state, both of which have been flat in recent years. He doubts healthcare would be among the things subject to sales tax. But even if it were, he said, it could be done in ways that wouldn’t target lower-income residents. New Jersey, for example, (excluding reconstructive surgeries), which tend to be performed on wealthier people.

In a statement to ºÚÁϳԹÏÍø News, Kehoe spokesperson Gabby Picard said the governor “will never support extending sales taxes on agriculture, healthcare, or real estate,” noting that the legislature would have to decide what to exempt if the ballot measure passes.

Federal law already prohibits states from imposing taxes on many healthcare services covered by government programs such as Medicare, the federal health insurance program for seniors, and Medicaid, the joint state-federal health insurance program for people with low incomes or disabilities, Picard wrote. More than were insured through those two programs in 2024.

But Jay Hardenbrook, advocacy director for AARP Missouri, argued that raising taxes on healthcare, real estate, and agriculture is the for the amendment, considering the legislature doesn’t need special permission to cut income taxes. He cautioned that because the amendment opens the door to new taxes on anything, it could unleash a “weird feeding frenzy” with special-interest groups lobbying for exemptions.

“Let’s say we do protect prescription drugs from a tax increase; does that mean that the cost of food goes up?” Hardenbrook said.

And if the Missouri measure passes and the legislature exempts healthcare and real estate from new taxes, Hardenbrook worries about cuts to state-funded services like home and community-based care.

“When I talk about taxes going up, and the price of every good and services going up, that’s the best-case scenario,” Hardenbrook said. “The worst-case scenario is that the income tax just goes away, and we just don’t have the money to do the things that we need to do.”

have no income tax, and Washington taxes only capital gains, but of the Institute on Taxation and Economic Policy, a progressive think tank, said the way Missouri is going about its elimination is nearly unprecedented. Only Alaska has repealed a broad-based personal income tax that had previously accounted for a significant portion of the state budget, Davis said.

“The situation in Alaska was they struck oil, and they had this gusher of economic activity and tax revenue that resulted from that,” Davis said. “Missouri has not struck oil.”

A 2012 tax cut in Kansas that reduced income taxes for individuals and eliminated them for some types of businesses created a large budget hole, prompting lawmakers there to the cuts five years later.

Tsapelas of the Show-Me Institute said Missouri’s income tax elimination wouldn’t happen overnight but would instead be more akin to in the state: phased in and tied to revenue targets that would shield the state from massive budget gaps.

“It’s not as doom and gloom as some people are worried about,” Tsapelas said.

But Ortbals, the healthcare advocate, said too many Missourians are already delaying medical care because of costs.

“I want a Missouri where young people can afford to stay, where families can afford to grow, where chronic illness does not become financial ruin,” Ortbals said.

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

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.”

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

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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.”

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

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Eight days before my 33rd birthday in April, a social worker at a crisis clinic near Denver determined I was an imminent danger to myself. She placed me on an involuntary 72-hour mental health hold.

What came next wasn’t treatment, but a search for a bed. Clinic staffers called area hospitals with inpatient psychiatric units, asking if they had available beds. They didn’t. So, I was told I had to spend the night at the clinic, which is open 24/7. I settled into a recliner, trying to make myself comfortable as my mind drifted in a blank, disassociated haze. Sleep came in brief bursts.

Since the 1950s, the United States has seen a nationwide due in part to deinstitutionalization and the rise of antipsychotics. But that has created a critical shortage for those needing help. From 2011 to 2023, the number of hospitals with inpatient psychiatric units , according to a 2025 study. Another study from that year found that this country has 28.4 inpatient psychiatric beds per 100,000 people — not even half the 60-bed ratio researchers frequently refer to as the .

The shortage has created what the American Psychiatric Association : emergency rooms overwhelmed with people suffering from severe mental health illnesses, inpatient stays prematurely shortened to speed up bed turnover, and acutely ill individuals left without critical care.

“Where are these people going?” said , an assistant health policy professor at Rutgers University, who co-authored those 2025 studies. “For people who don’t receive this care, they don’t just go away. How is it affecting them? Society? Their families?”

Meanwhile, the White House shut down the part of the national suicide hotline catering to LGBTQ+ youth, President Donald Trump’s 2027 budget proposal calls for cuts to agencies , and Health and Human Services Secretary Robert F. Kennedy Jr. recently announced a plan to .”

A Fractured System

I was already intimately familiar with the country’s fractured mental healthcare system before I was involuntarily committed. What I had yet to experience myself, I saw through my wife: waitlists, outpatient programs stretched beyond capacity, and inpatient psychiatric care so scarce that access often depends on surviving a crisis severe enough to justify it.

She died by suicide after we had separated.

As the years passed, grief and anxiety pushed me from observer to patient.

At the crisis clinic, I woke up the following morning disoriented and groggy. In the bathroom — its door deliberately unable to latch, swinging both ways so staffers could enter in case of an emergency — I stood at the sink and watched the faucet run, trying to piece together how I had ended up here.

America’s history of treating mental illness is long and complicated.

The 19th and 20th centuries saw the removal of people with severe mental disorders from jails and — squalid facilities designed to house the poor — to state asylums that (though they ultimately became ). From the 1860s to the 1930s, the number of psychiatric hospitals increased dramatically, according to the American Psychiatric Association, and by 1955, the number of psychiatric beds in the U.S. peaked at more than half a million.

However, owing to the development of antipsychotics, the belief that psychiatric institutions were inhumane, and President John F. Kennedy’s 1963 to free thousands of Americans from a life in institutions, many state hospitals shut down. An estimated for adults and kids are left in a country where more than 14 million experience severe mental illness each year.

Two years after JFK’s legislation passed, a new policy prohibited federal Medicaid funds from covering inpatient psychiatric care in facilities . The goal was to encourage states to move patients out of large, often substandard psychiatric institutions into community-based care settings.

The consequences of these changes, however, have been far-ranging. People with severe mental illnesses are often forced to as they wait for a bed to open. The length of stay in state psychiatric hospitals , according to research by the Treatment Advocacy Center, a national organization focused on eliminating barriers to the treatment of severe mental illness. And some people with mental illness .

From 1986 to 2014, as the behavioral health crisis intensified, mental health expenditures in the U.S. rose from $32 billion to $186 billion — though the proportion of that spending allocated to inpatient care .

This period also recorded major policy shifts affecting inpatient hospitalization rates, notably the 1999 U.S. Supreme Court decision in Olmstead v. L.C. The ruling shifted care away from psychiatric facilities by mandating states to people with developmental and mental disabilities.

“The road to hell is paved with good intentions,” said Leslie Carpenter, legislative advocacy manager at the Treatment Advocacy Center. “A lot of these bills, including the Community Mental Health Act, were really well intended and ended up with adverse consequences.”

For me, that next day at the clinic passed both painfully slowly and in a blur. A staff member I hadn’t met before told me they were still reaching out to hospitals across the region. The search for a bed continued.

‘No One Wants To Pay for Any of This Care’

Last year, members of Congress introduced two bills to change the 16-bed Medicaid funding cap at inpatient psychiatric facilities, the and the , which would increase the cap to 36 beds. Both have stalled in the House.

According to the Congressional Budget Office, a federal agency that analyzes budgetary and economic issues, eliminating the 16-bed limit would increase Medicaid expenditures from 2024 to 2033.

“No one wants to pay for any of this care that people need,” said Colorado state Sen. , a Democrat who has witnessed limitations to Colorado’s mental healthcare system firsthand because her son has schizoaffective disorder.

In lieu of federal action, states are stepping up to bridge the gaps.

Colorado, 15 other states, and Washington, D.C., now operate under waivers allowing Medicaid to fund inpatient facilities for mental health treatment, according to KFF data. Seven additional states have waivers pending. One 2025 study found that these waivers may be tied to fewer hospitalizations, emergency department visits, and incarcerations .

Yet even local efforts to improve mental healthcare face resistance. In California, Colorado, Iowa, Missouri, Nebraska, and New York, locals have pushed back against proposed psychiatric facilities for minors, claiming such facilities will worsen safety and lower property values. Behavioral health advocates have disputed these claims and argued they are rooted in stigma.

That psychiatric facility in Colorado was . The state has nearly 20 inpatient beds per 100,000 people, , according to 2022 data across all 50 states plus Washington, D.C., collected by the Treatment Advocacy Center. Wyoming ranked first with 47.3 beds per 100,000 residents, although, as the least populous state, it has only 275 total inpatient beds compared with California’s 5,703. Minnesota ranked last, with only 4.3 inpatient beds per 100,000 residents.

While increasing the number of inpatient psychiatric beds is vital, mental health advocates are also calling for , such as peer support specialists and clubhouses, where people with serious mental illnesses can learn life skills and find community.

When it came time for me to use our mental health safety net, I was among the fortunate ones: At noon the day after my hold began, a bed opened at a hospital in Denver — a rare stroke of luck in a system in which many people wait days or weeks for the care they need. An ambulance transferred me to the hospital at 3 p.m., marking 21 hours into my 72-hour hold.

Two days later, on my last day at the psychiatric hospital, I stood outside the nurse’s station awaiting discharge papers.

A man I had not seen before looked at me and asked, “Are you leaving?”

“Yes,” I said. “Are you being admitted?”

“Yeah,” he responded. “This is my third time being hospitalized in a year.”

I shook his hand. “Good luck,” I said, and I walked out the door.

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

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

QUINCY, Calif. — When Taletha Washburn and the staff at Plumas Charter School first heard that California wanted to help schools treat more kids struggling with mental health, it felt like a well-timed remedy for a rural community where families struggle to find care.

Getting the program funding up and running, however, has proved difficult.

Employees spent two years “spinning our wheels,” attending state-led webinars, filling out countless forms, and researching electronic health record systems to prepare, said Washburn, the school’s executive director. When they reached out for assistance, she said, they waited months for a state response.

The school received its first reimbursement check in April. Washburn said the school has been reimbursed $8,000 and has at least $12,000 in outstanding claims. For a program Washburn had thought could be a game changer in her small rural town, it’s been a disappointing bust.

Plumas Charter is among roughly 1,000 public schools, community colleges, and universities that participate in Gov. Gavin Newsom’s first-in-the-nation initiative requiring that health insurance companies reimburse them for on-campus behavioral healthcare. California schools have been adding counselors, therapists, and psychiatrists to provide services where young people spend most of their time, making mental health treatment more accessible to kids whose families might have spent months waiting to see private therapists.

Five years after the program’s launch, Washburn and other California school officials say they have encountered a rollout fraught with inadequate guidance from the state, an incomplete billing infrastructure, a lack of standardized forms, and persistent delays signing up and getting paid. More than half of California’s school systems and colleges don’t participate in the billing program. Of those that do, fewer than one-fifth as of June 1, according to the latest state data.

The program hasn’t come close to bringing in the half-billion dollars in promised revenue to cover the salaries of thousands of counselors, therapists, and wellness coaches, many of whom school districts hired with a deluge of federal covid pandemic funding. As a result, schools across California have issued amid local budget cuts.

“One of the things that makes people hate government is when we make a promise and then we struggle to keep that promise because we can’t get the administrative part of it up and running,” said state lawmaker Dawn Addis, a former special education teacher and Democrat who has criticized the program’s slow implementation.

Newsom’s office declined to make the governor available for an interview for this article. At a May press conference to release his final state budget proposal, the Democratic governor pointed to the “unprecedented” initiative, saying “no other state in the nation has done more.”

“We have a lot more work to do to deal with the crisis of our time,” Newsom said. “Making investments in wellness, not just physical health, but mental health for our kids, is a good investment.”

He did not answer when asked whether he considered the program a success.

Tom Insel, the former head of the National Institute of Mental Health, who has advised Newsom, said the rocky rollout, in many ways, reflects the groundbreaking nature of what California is trying to do. Still, given the level of investment so far, he too had expected clearer evidence of dramatic improvement.

“What we struggle with in California is: We spend the money, but we don’t always see the outcomes. It’s sobering to realize, especially as an advocate, that you could actually get the programs, get the money, get everything that you want from the policy side, but the execution just isn’t there.”

A First-in-the-Nation Plan?

In 2021, 1 in 10 high school students nationwide said they’d attempted suicide, by then the second-leading cause of death for young people ages 10 to 24.

In response, Newsom announced a “Master Plan for Kids’ Mental Health,” promising an overhaul of California’s behavioral health system that he said would be transformative. National mental health experts said Newsom’s initiative was the most ambitious attempt of any state to tackle a youth mental health crisis that had metastasized during the pandemic.

The state funneled $730 million in one-time funding into workforce efforts, such as campaigns to recruit mental health workers and programs to repay student loans. An additional $220 million has gone to facilitate partnerships between local governments and school officials, and $381 million was distributed in grants to schools and community groups for facilities or services, according to an analysis of program funding by ºÚÁϳԹÏÍø News.

The state has spent roughly $532 million to date on digital apps designed to connect families with counseling and provide a consultation service for primary care physicians handling behavioral health issues outside their expertise, while an additional $232 million has gone toward state operations and program evaluations.

And the state has added 1,855 school counselors since 2021, according to statistics from the American School Counselor Association, which in recent years has integrated mental health into professional standards. That’s well below the 10,000 Newsom had pledged by the end of this year as part of his initiative.

The of Newsom’s Children and Youth Behavioral Health Initiative focused on schools and was designed to increase behavioral health services on campus — at no cost to families. Schools would be able to bill health insurers, who would be required to reimburse them.

Some $1.3 billion — nearly a third of the total investment — has gone toward setting up campus wellness centers, new billing infrastructure, and beefing up school-based mental health support in other ways.

Filing claims became an administrative nightmare for schools unfamiliar with the complex world of medical billing.

In February 2025, when the Fresno County Office of Education launched its medical billing, it felt “like building the plane while flying it,” Trina Frazier, assistant superintendent of student services, told lawmakers in a public hearing a couple of months later. The delays were so acute that lawmakers last year authorized $20 million in grants to Fresno and 170 other school systems so they wouldn’t have to lay off newly hired mental health staffers while waiting for reimbursements.

Anaheim Elementary School District in Orange County, which state officials called a “champion” of the program, has recouped more than $1.1 million since its 23 campuses began billing student insurance in February 2025, said program specialist Shirley Diaz.

Still, that accounts for less than 30% of the behavioral health services the district has provided to students over that time. It’s not just the complexity of medical billing that has hampered the claims process. Parents have also been reluctant to provide health insurance information in the largely Latino district, where residents have been fearful of immigration raids carried out by the Trump administration.

To help administer claims across California, the state signed a $65 million contract with Carelon Behavioral Health, a service , one of the nation’s largest health insurers. But schools have struggled to get claims cleared, and many have spent hundreds of thousands of dollars to troubleshoot and bill claims.

As of June 1, the Boston-based administrator has approved about 232,100 claims totaling more than $11.3 million to 186 school districts and educational agencies, according to the Department of Health Care Services.

That’s a small fraction of the thousands of entities the state had hoped would participate and far from the $500 million a year state officials told schools the program could eventually provide for school-based mental health services.

“We probably were given the impression that this was going to happen more quickly and now there’s this reality of a kind of slow growth,” said Amy Blackshaw, behavioral health project director for the California School-Based Health Alliance.

Carelon contract manager Christina Kim declined to comment to ºÚÁϳԹÏÍø News and referred questions to the state. Autumn Boylan, deputy director of the Office of Strategic Partnerships at DHCS, said staff members incorporated early feedback from school districts and extended claim deadlines, loosened onboarding requirements, and hosted webinars and office hours. But changes of this magnitude, she said, take time.

“We’re trying to help the school districts increase their scale,” Boylan told lawmakers at a May 4 hearing. “It’s not a problem of claims being submitted and not paid. It’s a problem of claims not yet being submitted for payment.”

Boylan noted the volume of reimbursements has increased exponentially since the first claims were filed in November 2024.

Meanwhile, children and youths continue to struggle and have trouble accessing care. In 2024, nearly ages 12-17, for example, reported delaying or skipping mental healthcare because they couldn’t get an appointment, while 1 in 4 teens said they did so because of cost, up from roughly 6.5% the previous year, according to data from the California Health Interview Survey.

The share of young adults 18-24 who reported ever seriously considering suicide has stabilized but remains higher than pre-pandemic, according to the annual survey, conducted by the UCLA Center for Health Policy Research.

And while the suicide rate among Californians ages 12-25 has dropped from its high in 2021, this mirrors national trends, and state rates for female and Black youths increased from 2023 to 2024. “We have to have high expectations that when we invest in the magnitude of billions as this program did, we would have results to show,” said Assembly member David Alvarez, a Democrat in San Diego.

Other states have taken note of California’s implementation difficulties, some adopting a few strategies rather than the dozens California chose to roll out at once, said Sharon Hoover, formerly the co-director of the National Center for School Mental Health at the University of Maryland. Illinois, for instance, has focused on universal mental health screenings for schoolchildren while Colorado has expanded coverage of some behavioral health services for youths who lack a formal diagnosis.

“It’s always hard to be first, and someone has to be brave enough and hopeful enough to take that leap,” Hoover said.

Launching its reimbursement program before billing infrastructure was in place, Hoover said, created momentum but also posed challenges to school districts and providers. Still, she added, Newsom’s focus on prevention and early intervention became one of the biggest national policy shifts in years.

“We’re going to look back on this thinking it was one of the most progressive actions in the history of public systems,” said Alex Briscoe, a principal at the nonprofit Public Works Alliance who has pushed for system reform in kids’ mental health. “We spent a significant amount of money preparing for it. I just don’t think we did that very well or strategically.”

Rural Schools Struggle Most

Students at Plumas Charter School had endured a relentless wave of trauma by fall 2021. Wildfires, covid shutdowns, and, weeks into the school year, a car accident that killed a classmate and left two others severely injured. Teachers saw signs of depression, anxiety, and frequent outbursts among their K-12 students. Nine kids that year reported considering suicide, an all-time high.

So, the school hired a full-time therapist and wellness coach with temporary federal funds.

Senior Will Coelho wasn’t there for any of it, but by the time he arrived in the remote California logging town of Quincy a year later, he’d been through plenty of his own loss.

Days before the pandemic lockdowns, a friend had died in a . Isolated at home, Coelho struggled to process his grief, he said. That year, his stepfather became increasingly violent and, after a bitter, years-long custody fight, Coelho left the Central Valley to move in with his dad in the remote town in Northern California, just weeks before starting high school.

One day, he found himself chatting with a faculty adviser, the new kid half-joking about therapy. At her suggestion, Coelho started seeing the school therapist weekly, on campus and free of charge.

“It has had a large impact on the way I process emotions and my outlook on life,” he said.

Behind the scenes, school officials struggled with how they would continue to cover the therapist’s salary.

Twice, the state rejected the school’s application to the state’s landmark billing program, telling school officials they hadn’t met all the requirements, such as having sufficient systems to bill private insurers and collect student insurance information.

When school staffers flagged difficulties filing claims online, Washburn added, state officials suggested they submit paper claims instead.

The experience has soured Washburn and her staff on the program, which she said doesn’t work for small rural districts like hers where the human resources director is also the office business manager, and the faculty member who manages discipline also teaches PE.

DHCS spokesperson Tony Cava said that many charter schools are small and wouldn’t be expected to participate. While charter schools make up about half of eligible entities, Cava said, they serve only 12% of California’s students.

Lawmakers who represent small, rural districts have argued the program should be able to serve all kids. Early this year, Addis proposed legislation that would give intensive technical help to school officials who need it.

Even if it passes, it may be too late to help Plumas Charter. Washburn is unsure her school will reap enough revenue to pay for their therapist. “In theory, this should be a good program,” Washburn said. “We’re too small, and our funds are too limited to just keep waiting.”

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Since the summer of 2025, Florida leaders have aimed to make the state the first to drop some of those vaccine mandates. The anti-vaccine rhetoric has often been positioned as a push for “medical freedom.” Related efforts to revise laws and regulations rumbled along at the state health department and in the legislature for months.

But by the end of April, the fight seemed to have stalled out.

In the opening minutes of a special session on April 28, the Republican speaker of the Florida House, Daniel Perez, refused to bring the vaccine issue to the floor.

“There is some concern here, on my behalf, about children being in school without measles, mumps, polio, and chickenpox vaccines that have been working for decades,” Perez told reporters afterward.

For now, at least, the push to end childhood vaccine mandates has failed in Florida, and that outcome could offer insights into such efforts’ chances in other states. An Associated Press analysis found that at least 350 anti-vaccine bills in state legislatures last year. Many focused on relaxing requirements for vaccines in schools.

Ladapo: Mandates Are Bodily ‘Slavery’

Last September, Gov. Ron DeSantis and Florida Surgeon General Joseph Ladapo set the stage for the anti-vaccine campaign. They held a news conference at a private Christian school east of Tampa, where the state would work to end all vaccine mandates in Florida law.

“Every last one of them is wrong and drips with disdain and slavery,” he said.

“Who am I, as a government or anyone else,” Ladapo said, “or who am I as a man standing here now, to tell you what you should put in your body?”

Political analysts say that the prospects for efforts to cut back on vaccine mandates are closely tied to the political prospects of Republicans trying to maintain their majorities at the state and federal levels. DeSantis is term-limited, and his governorship ends in January. And the congressional midterms are in November.

“For Republicans, they’re a little bit leery,” said , an associate professor of political science at the University of Central Florida. “They know we’re in an election cycle. They know political history. And it’s pretty clear that the president’s party tends to lose seats in the midterm election.”

Although hundreds of anti-vaccine bills have been introduced in state legislatures, the noisy rhetoric and splashy headlines don’t guarantee passage, said , an associate professor of health policy at Georgetown University.

In many states, including Florida, “there’s a disconnect between what we hear a lot from a potentially vocal minority about how they feel about vaccines compared to where the majority of people really are,” Whitener said.

“For most people,” she said, ”they still support the idea of near-universal vaccination, still understand the importance of vaccinating children to protect people who can’t be vaccinated.”

A last year by KFF and The Washington Post showed 81% of parents supported school vaccine requirements.

“They support these vaccines,” said , a senior vice president at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. “They support protecting their kids through these mandates. And that includes Florida parents.”

Unwinding Mandates by Law, and by Regulation

To undo some of the vaccine mandates, Florida’s legislature would have to pass new bills. Others could be changed by a rulemaking process at the state Department of Health, including for chickenpox, hepatitis B, pneumococcal conjugate, and Haemophilus influenzae type B.

At a Dec. 12 forum in Panama City hosted by the health department, public comment went on for hours, with those who wanted to keep the mandates slightly outnumbering those who opposed them.

“This is about freedom,” said one speaker, Larry Downs Jr. “The default setting should be freedom, not these corporate chemical vaccine injections.”

Florida schoolteacher Marion Fesmire has worked overseas. She defended vaccine requirements in part because of some of the suffering she has seen.

“I’ve seen kids with polio. I’ve seen blind kids. I’ve seen kids die before they’re even 10 years old. It’s heartbreaking,” Fesmire said.

The health department hasn’t held any more public forums on vaccines since then.

Nor has the department filed the paperwork needed to change the vaccination rules, including a statement of regulatory costs. In that, the department must estimate whether changing the rules could affect personal income, the number of visitors to the state, or the size of the Florida workforce.

In an April 13 email, the health department said that it is “currently in the rulemaking process” and that any updates would be posted in the Florida Administrative Registrar.

Pushing for a New Exemption

During the winter legislative session, a , didn’t include removing mandates but did feature a new kind of exemption. In addition to a religious or medical exemption, a parent could exempt a child for reasons of personal conscience. This type of exemption is .

Democrats, the minority in the Florida Legislature, came out against it.

“It’s currently very easy to opt out for religious reasons from school immunizations,” state Sen. (D) said while speaking from the chamber floor. “Why is this bill necessary? Given that context, is your bill just about giving people more options to ignore school immunizations, or is it intended to solve a public health problem?”

A few Republicans also opposed the bill. State Sen. (R) brought up the measles outbreak. Florida is the state with the number of measles cases this year, with 155 as of June 6.

“I truly believe that this is a dangerous bill, and I cannot vote for it,” Harrell said.

The bill also included a permanent ban on mandates for any mRNA-based vaccines and would have allowed nonprescription sales of ivermectin. That anti-parasite medication rose to popularity as an alternative treatment for covid, although the Food and Drug Administration determined that the available clinical trial data does not demonstrate effectiveness against covid in humans.

Florida’s previous surgeon general, Scott Rivkees, , calling it “the equivalent of walking into a pharmacy and requesting amoxicillin for a self-diagnosed infection.”

In the end, when the failed to make it to committee.

Yet, people on both sides say the Florida fight is far from over, especially given the lingering mistrust of the medical establishment after the covid pandemic.

“There are many more people now who have skepticism about the wisdom of public health policy and law,” said Barbara Loe Fisher, an anti-vaccine activist who has been working to end mandates since the early 1980s.

“I don’t think that that’s going to disappear,” she said. “I think it’s going to grow.”

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

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Even the bill’s backers say securing passage this year is a long shot. But the effort is one more opportunity for Democrats to highlight voters’ frustration about healthcare costs leading into the November election.

Polls show Americans are very concerned about affordability, with finding fewer than half of Americans say they can consistently afford healthcare.

Wyden’s bill would focus on what many consider a critical pocketbook issue in traditional Medicare: There’s no limit on what a beneficiary could pay in cost sharing.

“Everyone else in the health insurance neighborhood has one — employer coverage, the Affordable Care Act, all of them have a cap,” the Oregon Democrat told ºÚÁϳԹÏÍø News. “There’s no good, common-sense reason why the flagship health program doesn’t have the same protection.”

Critics of a cap, meanwhile, are likely to pounce on the cost to the federal budget, which could be significant.

Wyden, already making the battle lines clear, added, “I suspect it will come up on the floor of the Senate that Democrats want to give a fair shake to people on traditional Medicare and Republicans want to help billionaires.”

Policy, Political Dynamics at Work

The underlying issue is the 20% share of have to pay for medical services after they’ve met any deductibles. Without a ceiling or upper limit, an expensive condition such as cancer or a long hospital stay could result in beneficiaries paying thousands of dollars in costs.

That concern leads enrolled in traditional Medicare to purchase separate insurance, often called Medigap. (Others get such coverage through job-based retiree plans.)

Medigap insurance plans have seen rapid premium increases and can cost thousands of dollars a year, especially for couples. That price tag can be unaffordable for some beneficiaries, who may instead turn to private-sector Medicare Advantage plans offered by commercial insurers, or go without.

The Wyden proposal would set a $5,000 cap in traditional Medicare. Any amounts paid by a Medigap plan or a retiree health plan toward beneficiaries’ care would count toward that cap. It also includes other provisions to help older people with lower incomes, including eliminating an asset test to qualify for special programs that help reduce costs.

Medicare would pick up any amounts over that $5,000 limit, which is lower than the one Congress set for the rival Advantage plans — , although insurers can set smaller amounts.

Setting a cap in the traditional program, proponents argue, would help level the playing field between traditional Medicare and Advantage plans, which often cost consumers far less than traditional Medicare with a Medigap supplement. Premiums for these policies would probably be lower, they say, because the insurers’ financial exposure would be limited.

The Medicare Advantage program has historically had strong support from Republicans, who like its private-sector aspect and note that it can potentially do more to control costs, such as by using specific networks of doctors and hospitals, or requiring preapproval for some services, which the traditional program cannot do.

The plans also offer enrollees additional benefits, such as eyeglasses, hearing aids, and prescription drug coverage, and have now attracted more than .

Along with that growth, however, has also come increased scrutiny over concerns about denials of patient services and the to the traditional program. Recently, some health systems have , citing concerns about tardy payments or prior authorization requirements, while insurers where they offer Advantage coverage.

The bill has not yet been analyzed by the Congressional Budget Office, so there is no official estimate of increased costs to taxpayers for Medicare. Still, it would raise those costs — at a time when other health programs are being cut, the Medicare trust fund is scheduled to of funding in 2033, and the .

That is likely to draw sharp rebukes from fiscal hawks and other conservatives who question whether billions in tax dollars should be used to pick up costs that would otherwise be paid by enrollees or by the supplemental insurance plans many purchase to do so. They are likely to note that beneficiaries could also choose to join private sector Advantage plans, which eliminate the need for supplementary insurance coverage such as Medigap.

Key Questions: Who Benefits? Who Pays?

A cap’s cost to taxpayers, while not officially scored yet, is likely to be significant, although adding one could also save individual consumers money. A recent study from Brown University gives some clues.

A $5,000 cap could save enrollees , the study says, both in direct savings and reductions in their Medigap supplemental premiums. Just over 11% of traditional Medicare beneficiaries, about 3.2 million, would directly benefit from such a cap if it was implemented in 2028, said the study, which did not receive outside funding.

Over the next 10 years, it estimates, just over 52% of all traditional beneficiaries would exceed the $5,000 cap at least once.

Still, lead author Andrew Ryan, a professor at Brown’s School of Public Health, said analysts estimated such a cap “could cost over $50 billion annually, which is a lot of money” to add to the federal balance sheet.

Critics are likely to focus on the cap’s expense and the number of people who might benefit.

“How many people are hitting a level of cost they can’t afford on Medicare? “asked Jackson Hammond, a senior policy analyst with the Paragon Health Institute, a conservative think tank influential with the GOP.

Any cap “is generally going to increase expenses for the program without adding a lot of benefits to enrollees,” said Hammond, who spoke with ºÚÁϳԹÏÍø News before the legislation was introduced.

Supporters, though, have a different view.

Certainly, with “any policy that’s going to cost money, there will be an argument over where the money is coming from,” said Brian Keyser, a research associate at the liberal Center for American Progress who also spoke with ºÚÁϳԹÏÍø News before the Wyden measure was introduced.

Keyser co-authored that suggested lawmakers could pay for changes in traditional Medicare, such as an out-of-pocket cap, if they reduced the amount the government pays Medicare Advantage insurers, pointing to government estimates that Advantage would cost the government $76 billion more this year than if the same number of people were in the traditional program.

Finding a way to add a cap “is right and fair because without it, people who become seriously ill can spend their life savings on cost-sharing Medicare,” Keyser said.

Such an idea, however, on and off for years. Knowing that, the bill’s backers acknowledge that passage is unlikely — but they say they’re playing the long game for now.

“We’re going to push for it in the next Congress, when we believe we will be in the majority,” Wyden said.

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, with approximately 120,000 members, has put forward two ballot initiatives to cap the pay of medical executives and require community clinics to spend the vast bulk of their revenues on patient care.

The California Hospital Association has responded with its own ballot proposal that would make it tougher for unions to spend money on political initiatives in the future. It would require approval by a union’s rank-and-file membership for any spending of $1 million or more on statewide measures, or $100,000 or more on local ones.

The competing measures, which have drawn enough verified signatures to qualify for the November ballot, come at a time when the rising cost of healthcare is emerging as a .

The Service Employees International Union affiliate has seized upon affordability angst to resurrect a proposal for a cap on healthcare executive compensation, which it has failed to achieve multiple times before. The proposed measure garnered more than 1 million petition signatures.

“This initiative reflects the serious crisis we face and that affordability is a real thing,” said Vikas Saini, president of the Lown Institute, a Massachusetts-based healthcare think tank. “I think it also reflects grassroots anger and a desire to do something.”

Mikey Vaughn, a certified nursing assistant at Cedars-Sinai Medical Center, said that the Los Angeles hospital, despite its reputation as the go-to place for the rich and famous, often lacks supplies and staffing levels that he and his colleagues need to do their jobs effectively and without undue stress.

“The executive pay initiative would, I hope, be used to hire staff and to actually provide better resources for our patients,” said Vaughn, a member of SEIU-UHW’s executive board and political committee.

Thomas Priselac, then-president and CEO of Cedars-Sinai Medical Center, in fiscal year 2024, according to the organization’s most recent available federal tax filing. Kaiser Permanente’s CEO, Gregory Adams, made . Warner Thomas, head of Sutter Health, made .

Cedars-Sinai spokesperson Duke Helfand said if the measure passed, the hospital would be unable to recruit and retain physicians, nurses, and specialists, dramatically impairing its ability to provide healthcare.

“Such a scenario would be disastrous not only for Cedars-Sinai but for hospitals across Los Angeles and California,” Helfand said.

The union wants to cap compensation at $450,000 a year for senior hospital and medical group executives, as well as other administrative and managerial staff. However, the initiative does not stipulate how dollars diverted from payroll must be spent.

The union has dubbed the latest proposal the “Health Care Executive Compensation Act of 2026.” A heavyweights opposing it — hospitals, physicians, and clinics, among others — has rebranded it the “Health Care Endangerment Act.”

Carmela Coyle, CEO of the hospital association, called the measure a cynical political ploy. “It’s bad policy and it’s going to have bad consequences across California,” she said.

Glenn Melnick, a healthcare economist at the University of Southern California, said that even if the initiative were fully implemented and pay cuts enacted, he doubts it would reduce the cost of healthcare for patients.

SEIU-UHW does not have an estimate of the total amount the initiative would claw back from pay packages that exceed the limit.

Opponents of the initiative note that it doesn’t target only executive pay but would affect medical practitioners who are also managers. That could include chief medical officers and chief nursing officers, as well as heads of surgery, emergency rooms, oncology, obstetrics, cardiology, and other specialties, they say.

It would be up to each hospital, health system, and physician group to report which staff members exceed the cap and by how much.

Ultimately, who is subject to the pay cap “probably will have to be battled out in court,” said the hospital association’s Coyle. “That’s why we are throwing everything we can at it.”

The second SEIU-UHW ballot initiative, on community clinics, is already in court. , which represents clinics, filed a federal lawsuit in April seeking to invalidate it before it reaches the November ballot.

The proposed measure would require to spend at least 90% of their revenues on activities directly related to their mission of providing care for low-income populations. If it were to pass, over 90% of those clinic organizations would be on the hook for penalties totaling $1.7 billion in the first year alone and “would face similarly crippling penalties every year,” commissioned by the primary care association and conducted by the Berkeley Research Group, an international consulting company.

Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said many pivotal services the clinics provide — translation and transportation, for example — would likely not be counted toward the spending requirement.

“They are targeting a group of what they see as employers and we see as the safety net,” she said.

The lawsuit cites the harm to clinics and claims the proposed spending requirement would interfere with federal authority.

Renée Saldaña, a spokesperson for SEIU-UHW, characterized the lawsuit against the initiative as “a really desperate attempt by the clinic industry to try and avoid accountability.”

SEIU-UHW, , is also behind a controversial proposal that would impose a one-time 5% levy on California residents with fortunes over $1 billion to backfill the funding gap created by federal cuts coming down the pike under Republicans’ One Big Beautiful Bill Act. The law, passed last July and signed by President Donald Trump, is projected to squeeze over $900 billion from the Medicaid health coverage program for low-income people by 2034, including as much as in California.

The hospital association, the community clinic group, and the California Medical Association, which represents physicians, oppose the wealth tax proposal. But Saldaña said all three of the union’s ballot proposals tie into an overarching strategy to counter the widening healthcare disparities caused by the federal law. Referring to the proposed pay cap, she said, “We believe the primary concern of healthcare providers, including executives, should be to serve the community, heal patients, and not be in healthcare just to enrich themselves.”

Over the years, the union has submitted dozens of local and statewide ballot initiatives, including ones to cap the pay of hospital executives, regulate dialysis clinics, and raise the minimum wage of healthcare workers.

The hospital association calculates that SEIU-UHW has spent nearly $125 million on local and statewide initiatives since 2012. But healthcare industry groups have spent far more opposing them. The hospital association data shows that the union spent nearly $36 million on three ballot proposals to regulate the dialysis industry, but dialysis companies poured in $302 million to defeat them, according to state campaign finance records.

The union’s ongoing political efforts “threaten patient access to quality health care,” according to the hospital association’s ballot initiative, which could limit how much unions spend on future ballot measures.

Saldaña hinted at a possible lawsuit should that measure pass, saying that “we don’t see the legal viability” of it. The proposal, she said, is an attempt “to silence the front-line healthcare workers.”

Ultimately, a ballot initiative won’t cure the ills that plague healthcare in the United States, said the Lown Institute’s Saini. What’s needed, he said, is “an evaluation and reimagination of healthcare.”

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One Minnesota lawmaker wants to steer money from an existing healthcare tax back to hospitals so they can expand their charity care programs for patients who can’t afford their bills.

The proposal follows a Minnesota Star Tribune-ºÚÁϳԹÏÍø News investigation that found hospitals across the state spend far less on charity care than hospitals in many other states, and use widely different standards to decide who qualifies for free or discounted care.

State Rep. Steve Elkins said helping hospitals with their own tax contributions makes sense as more Minnesotans are losing health insurance.

“Hospitals are providing a fair amount of charity care, but they kind of have an obligation to do something more than they are doing,” said Elkins, who May 13, in the final days of the legislative session.

Elkins noted recent reports by the and Minnesota’s indicating some hospitals are gaining more in nonprofit tax benefits than they are spending on community benefits, including charity care.

Simply demanding more from hospitals isn’t necessarily the answer, though, Elkins said. Newly released financial data shows 31 Minnesota hospitals meet the state’s definition of financial distress because they lost money on operations in four of the last eight years.

Hennepin County Medical Center in Minneapolis appears poised for a this year to prevent the urban trauma center from closing.

HCMC provided the most charity care of any Minnesota hospital in 2024, an estimated $88 million, which consumed more than 3% of its operating budget. Elkins said he suspects some charity care patients from other hospitals are being diverted to HCMC, which has a process for automatically screening patients for financial needs upon admission.

Incentivizing hospitals to be more generous could take pressure off HCMC, Elkins said. The state gains about $250 million per year from a 1.56% tax on hospital patient revenue, which roughly equates to the $241 million that hospitals spent on charity care in 2024, according to estimates by the Minnesota Department of Health.

“You could pretty much make every Minnesota hospital whole with all of the charity care they’re providing,” he said.

A lack of state standards allows some hospitals to limit free care to people making less than $15,000, while others offer care to people living alone who make as much as $47,000. Being stingy with charity care can be self-defeating for hospitals, which end up wasting money in debt collection efforts from patients who couldn’t afford their bills in the first place, said Eli Rushbanks, director of policy advocacy for Dollar For, a nonprofit that helps U.S. patients apply for charity care.

“It’s not really a question of whether they are doing better than other states. It’s a question of whether they are doing enough” for Minnesota’s patient population, he said. “Minnesota has charity care-eligible patients who are not receiving charity care.”

Some state-by-state disparities in charity care are beyond the control of hospitals, and even signal positive trends. Lower rates of chronic disease mean Minnesotans need less healthcare in the first place. Higher levels of insurance coverage mean they don’t need charity care as much to afford their healthcare.

Elkins’ idea of taking money from hospitals and giving it back with strings seemed unnecessary to leaders of the Minnesota Hospital Association, which would prefer to see the tax disappear.

Joe Schindler, the association’s vice president for finance policy, said one alternative would be moving the money into the Medicaid health insurance program for people with low incomes or disabilities. He said that would unlock more federal matching dollars to benefit patients and help close the reimbursement gap in that program.

Hospital systems have discretion to decide the income and financial thresholds by which patients qualify for financial assistance in the form of free care or partial discounts. Elkins’ proposal wouldn’t change that, but other state leaders and advocates have proposed models that standardize how charity care is offered.

Dollar For recommends policies that at least provide discounts to households with incomes around 400% of the federal poverty level, because there are fewer bad debt cases and lawsuits involving patients with incomes above that level, Rushbanks said. The Star Tribune-ºÚÁϳԹÏÍø News analysis of 123 Minnesota nonprofit or government-run general hospitals showed 52 provide discounts to patients with household incomes at 350% or higher, but the rest fall below that level.

After investigating irregularities in charity care at Mayo Clinic last year, Minnesota Attorney General Keith Ellison recommended that the state set a minimum floor for charity care eligibility across all hospitals. He also recommended all hospitals adopt presumptive eligibility systems that assume patients need financial help until proven otherwise.

This week’s article “makes it clear there is more work in front of us, and I will continue to use the power of my office to help Minnesotans get the medical care they need, no matter what’s in their bank accounts,” Ellison said in a statement.

Charity care is only one category of community benefits reported by hospitals for which they don’t receive direct payment. Other examples include providing medical education services for training doctors and nurses, and maintaining money-losing services such as obstetrics or emergency care in rural and underserved communities.

Whether hospitals gain more in nonprofit tax savings than they spend on community benefits depends on what’s included in the state auditor’s analysis. Hospitals are chronically underpaid for the cost of medical care by Medicaid, and the state hospital association reports that as a community benefit.

The legislative audit found that only 28 Minnesota hospitals spent less on community benefits than they saved in taxes in 2023, when that underpayment was part of the total. When excluded along with other research and education expenses, 62 hospitals spent less on the remaining community benefits than they gained in tax benefits as nonprofits.

Elkins said his idea to redistribute tax revenue could motivate hospitals to spend more on charity care or other community benefits. The state also could recruit more doctors, he said, if Minnesota hospitals increased residency slots for required on-the-job training after medical school.

The idea is an easier sell right now, given Minnesota’s budget surplus, he acknowledged, but could create challenges in future years when lawmakers would have to find ways to replace the lost revenue for other state needs. The lawmaker said he intends to bring it up next year if it doesn’t make it into the state’s health budget this session.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hospitals Want Guardrails

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Becoming Part of the System

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

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

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

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

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

“Something has to change,” Haynes said.

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

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

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