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

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

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

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

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

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

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

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

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

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

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

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

Families Fight Back

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

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

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

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

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

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

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

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

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

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

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

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

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

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

States Struggle With High Spending

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

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

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

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

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

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

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

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

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

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

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

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

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

Patients Wait or Are Turned Away

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

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

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

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

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

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

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

‘It’s Heartbreaking’

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

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

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

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

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

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

High-Profile Incidents

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

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

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

37-Day Wait for a Bed

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

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

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

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

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

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

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

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

Yet backlogs at the Ohio hospitals mounted.

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

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

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

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

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

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

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

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

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

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

Sick System

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

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

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

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

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

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

Escapes and a Lockdown

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

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

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

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

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

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

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

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

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

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

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

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

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

A Disaster That Wasn’t Averted

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

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

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

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

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

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

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

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

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

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

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

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

‘He’s Not a Throwaway Child’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“No job has hired me.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What You Should Know

Changes to SNAP removed work-requirement exemptions for:

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

What SNAP Participants Should Do:

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

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

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

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

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

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

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

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

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

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

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

The Covid-19 Uninsured Group

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

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

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

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

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

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

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

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

Screening Students

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

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

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

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

How long that funding will last isn’t clear.

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

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

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

Local Free Testing

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

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

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

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

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

This story was produced by , which publishes , an editorially independent service of the .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

California Healthline correspondent Angela Hart contributed to this report.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

predict healthy tax collections over the next two years.

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

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

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

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

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

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

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

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

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

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

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Wilson, a retiree who worked as a public health department nurse supervisor in Duval County for 35 years, had just been diagnosed with COVID-19-induced pneumonia. She had a telemedicine appointment with her doctor.

Staring back from her screen was Dr. Rogers Cain, who runs a tidy little family medical clinic a couple of blocks from the Trout River in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was one of Cain’s patients who’d tested positive — he had seven other COVID patients that morning before noon. Three of her grown children had contracted the virus, too.

“It started as a drip, drip, drip in May,” said Cain, his voice muffled by his mask. “Now it’s more like a faucet running.”

Cain and Wilson are nervous. Over the past two decades, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks, including a small cluster of tuberculosis cases in 2012. And now they face the menace of COVID-19 in a city once slated to host this week’s Republican National Convention, in one of the states leading the latest U.S. surge.

Florida is both a microcosm and a cautionary tale for America. intended to protect communities against disease, staffing and funding fell faster and further in the Sunshine State, leaving it especially unprepared for the worst health crisis in a century.

Although Florida’s population grew by 2.4 million since 2010 to make it the nation’s third-most-populous state, a joint investigation by KHN and The Associated Press has found, the state slashed its local health departments’ staffing — from 12,422 full-time equivalent workers to 9,125 in 2019, the latest data available.

According to an analysis of state data, the state-run local health departments spent 41% less per resident in 2019 than in 2010, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much ― an average of 18%, according to data from the National Association of County and City Health Officials.

Even before the pandemic hit, that meant fewer investigators to track, trace and contain diseases such as hepatitis. It meant fewer public health nurses to teach people how to protect themselves from HIV/AIDS or the flu. When the wave of COVID-19 inundated Florida, the state was caught flat-footed when it mattered most, its main lines of defense eviscerated.

Now, confirmed cases have soared past 588,000 and deaths have risen to more than 10,000. Concerns over the virus prompted Republicans to cancel plans for an in-person convention in Jacksonville, opting for a pared-down version in North Carolina.

Health experts blame the funding cuts on the Great Recession and choices by a series of governors who wanted to move publicly funded state services to for-profit companies.

And when the pandemic took hold, they say, residents got mixed messages about prevention strategies like wearing masks from Republican Gov. Ron DeSantis and other political leaders. Voices within the health departments were muzzled.

“The reality, unfortunately, is people are going to die because of the irresponsibility of the decisions being made by the people crafting the budgets,” said , president of the , a nonprofit in Washington, D.C., offering tools and training. “Public health can’t help us get out of this situation without our elected officials giving us the resources.”

State officials neither answered specific, repeated questions from KHN and The Associated Press about changes in public health funding, nor made staffers available for deeper explanations.

Dr. , a former deputy secretary of Florida’s state health department, said failing to prepare for a foreseeable disaster “is governmental malpractice.” The nation’s pandemic response is only as good as the weakest link, he said. Since the virus respects no borders, other states feel the ripples of Florida’s failings.

Those failings are clear in Duval County, which had employed the equivalent of 852 full-time workers and spent $91 per person in 2008 but in 2019 had only 422 workers and spent just $34 per resident, according to the KHN-AP analysis of state data. That’s less than the of a single COVID test. Former county health director Dr. Jeff Goldhagen said the county’s team has been “dismantled to the extent that it could not really manage an outbreak.”

Yet it must.

Cain’s private north Jacksonville medical clinic alone has had about 60 confirmed COVID cases and eight deaths. “We are all on fire right now,” he said. “You have to have a fire department that is adequately equipped to put out the fire. ”

Dwindling Budgets

Florida faced similar shortcomings around the time of the last great pandemic, the 1918 flu. Back then, according to a , public health workers faced too many demands and their efforts were “to some extent scattered and transitory.” The state could have used at least three more district health officers, the report said: “It is a source of regret and a matter of grave concern to public health workers that the funds available are not sufficient.”

County-based health departments began in 1930, providing more robust services closer to home. About 50 years later, legislation created state-administered primary care programs in which county health departments provided low-income Floridians with the type of basic health care and treatment most people now get at private doctors’ offices.

The 1990s saw a move toward privatization, particularly as Medicaid managed care took hold, said a . Still, per-person spending on local public health rose until the late 1990s, when adjusted for inflation to 2019 dollars, peaking at $59.

Wilson, the retired public health nurse stricken with COVID-19, recalled how Duval County’s department started feeling the financial pain during former Republican Gov. Jeb Bush’s administration in the early 2000s and kept losing nurses and other staff until they were “very, very short.”

Beitsch, who worked for the state health department in the 1990s, said the downward trend continued under former Republican governors Charlie Crist and Rick Scott, fueled by a growing belief in shrinking government that flourished in many states. Florida’s leaders exerted more control over public health, Beitsch said, and “the amount of local autonomy has been diminishing with successive administrations.”

The recession that began in late 2007 sparked public health reductions across the nation that were especially harsh in Florida. By 2011, budget cuts and lack of money were the most frequently cited challenges in a Florida public health workforce survey, which pointed to growing needs. In the following years, the state had some of the nation’s highest rates of heart disease and diabetes.

Squeezed departments struggled and sometimes stumbled. A from the state health department’s inspector general for the 2018-19 fiscal year, for example, found a series of lost and inconsistent shipments of lab specimens from county health departments to the state lab — not long before the pandemic would make labs more important than ever.

As governor, Scott presided over the state from 2011 to 2019, when funding and staffing dropped most. Now a U.S. senator, he said through a spokesperson that he was unapologetic for health department cuts, which he characterized as a move toward “making government more efficient” without endangering public health.

“I’m sure that he had no problem with the cuts that were being made,” said , an associate professor in health administration at Florida Atlantic University. “To put it all on him is not fair because a bunch of little henchmen from the counties had to vote that way. … We keep voting in people who undervalue public health.”

Democratic state Sen. Janet Cruz, a legislator who has represented the Tampa region for a dozen years and sat on health care committees, said she watched lawmakers systematically cut money for health departments. When she questioned it, she said, some colleagues claimed the need wasn’t as great because the state was moving toward private family health care centers. “Public health in Florida has been wholly underfunded,” she said.

Some places have suffered more than others. Departments serving at least half a million residents spent $29 per person in 2019 on average, compared with $90 per person in departments serving 50,000 or fewer — a difference starker than the typical gap between larger and smaller departments nationally, according to an KHN-AP analysis. Experts can’t say exactly why the gap is wider in Florida, which has a state-run system, but point to politics and historical decisions about budgets.

Duval County’s health department spending was the equivalent of $34 per person, down 63% since 2008. Typically, about 22 workers, or 5% of the total staff, have been dedicated to preparing for and tracking disease outbreaks.

But when the pandemic hit, many there and elsewhere were diverted to fight the coronavirus, leaving little time for their typical duties such as mosquito abatement and tracking sexually transmitted infections such as syphilis.

“Current events demonstrate how bad a decision” the deep cuts to public health were, said , a professor of public health and family medicine at the University of South Florida. “It’s really come back to haunt us.”

Mixed and Muzzled Messages

The pandemic caught fire in Florida this summer as the state’s rapid reopening allowed people to flock to beaches, Disney World, movie theaters and bars.

The state has had more than half a million confirmed cases ― among them, players and workers for baseball’s Miami Marlins ― and 35,000 hospitalizations, yet DeSantis still hasn’t issued a mask mandate. Some local governments have. Jacksonville adopted one in late June, and about a week later Republican Mayor Lenny Curry announced he and his family were self-quarantining because he’d been exposed to someone who tested positive for the virus.

, director of infection prevention at the University of Florida-Jacksonville, lauded the mayor for the mask requirement, saying, “We know that masking works.” But he pointed out that other counties have different rules and that the inconsistent messaging breeds confusion.

St. Johns County began requiring masks in late July but only in county facilities. And DeSantis has appeared in public without a mask numerous times, including at

target=”_blank” rel=”noopener noreferrer”>an Aug. 13 coronavirus update

briefing during which some other speakers wore them.

“One voice is so critical during a pandemic,” said Dr. Jonathan Kantor, a Jacksonville epidemiologist and dermatologist. “We have to have one voice, and consistent leadership that is modeling behavior if we want to get people to change their behaviors.”

Instead, experts in Florida said, public health workers have been silenced or told by top state officials what to say. For example, that state leaders told school boards they needed health department approval to keep schools closed, then instructed health directors not to give it.

“All the communication is directed by the state, and localities are very limited in what they can do,” said Levine, the University of South Florida professor. “Anything to do with a mandate, there’s resistance to do at a state level. This includes the hot debate on masks. The locals have to extend the state messaging.” Local health officials “are being told bluntly: ‘Shut up,’” Bernet said. “They literally cannot speak.”

Beitsch, who now chairs the department of behavioral sciences and social medicine at Florida State University, said such limitations ― and similar mixed messages and silencing of medical experts at the national level ― fuels the politicization of public health and undermining of science.

“People think they should be listening to politicians and state legislative leaders about their health care. They’re not listening to health experts and the epidemiologists who say if you just wear a mask and if you just wash your hands, we can really, really reduce the spread of the virus,” said Cruz, the state senator. “People are confused, and they think this is a hoax and it’s nothing more than the flu.”

Meanwhile, the COVID caseload continues to rise, surpassing 25,000 in Duval County, with minorities stricken disproportionately, as elsewhere in the nation. In a county that’s 29% Black and 60% white, Black residents with COVID have been hospitalized at more than double the rate of white residents. Rates are also high for Floridians grouped together as “other,” including Native American, Asian and multiracial residents.

Duval County’s overall caseload is rising so fast that Goldhagen, the former health department director, said the agency has given up on contact tracing, which means trying to curb the virus by identifying and warning people who have been exposed.

“It’s impossible,” Goldhagen said. “Dismantling the system was a complete disregard for the health and well-being of the citizens of Florida.”

With an unequipped public health system, Wilson, the retired public health nurse, said it falls to everyone to lead Jacksonville, and Florida, out of the coronavirus crisis.

“My hope is that everybody begins to take this virus seriously, and wear their mask and stay social distancing. It can work if we do that,” said Wilson, whose condition has improved. “So, that’s my hope. Eventually there will be a vaccine that will curtail this virus. But until then, it’s up to us to help do that. And if we’re not serious about it, then we’re doomed.”

This story is a collaboration between KHN and The Associated Press.

Methodology

Spending and staffing data for Florida’s local health departments is from the Florida Department of Health. Florida Atlantic University professor Patrick Bernet provided additional state data on staffing by program area. KHN-AP adjusted spending data for inflation using the Bureau of Economic Analysis’ state and local government deflator.

COVID-19 data by race is from the Florida Department of Health. KHN-AP calculated rates per 10,000 people using data on race, regardless of ethnicity, from the U.S. Census Bureau’s 2018 American Community Survey. Statewide COVID-19 cases per day are from Johns Hopkins University.

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These cuts, which in Colorado include slashing $1 million from a program designed to keep people with mental illness out of the hospital and $5 million for addiction treatment programs in underserved communities, come amid the century’s largest health crisis when people may need those services most.

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

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

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

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

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

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

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

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

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

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

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

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

Families Fight Back

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

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

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

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

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

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

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

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

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

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

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

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

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

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

States Struggle With High Spending

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

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

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

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

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

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

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

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

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

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

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

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

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

Patients Wait or Are Turned Away

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

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

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

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

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

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

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

‘It’s Heartbreaking’

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

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

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

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

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

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

High-Profile Incidents

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

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

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

37-Day Wait for a Bed

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

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

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

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

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

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

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

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

Yet backlogs at the Ohio hospitals mounted.

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

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

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

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

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

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

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

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

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

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

Sick System

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

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

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

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

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

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

Escapes and a Lockdown

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

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

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

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

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

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

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

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

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

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

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

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

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

A Disaster That Wasn’t Averted

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

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

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

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

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

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

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

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

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

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

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

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

‘He’s Not a Throwaway Child’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“No job has hired me.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What You Should Know

Changes to SNAP removed work-requirement exemptions for:

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

What SNAP Participants Should Do:

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

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

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

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

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

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

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

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

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

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

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

The Covid-19 Uninsured Group

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

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

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

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

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

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

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

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

Screening Students

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

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

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

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

How long that funding will last isn’t clear.

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

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

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

Local Free Testing

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

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

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

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

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

This story was produced by , which publishes , an editorially independent service of the .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

California Healthline correspondent Angela Hart contributed to this report.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

predict healthy tax collections over the next two years.

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

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

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

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

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

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

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

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

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

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

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Wilson, a retiree who worked as a public health department nurse supervisor in Duval County for 35 years, had just been diagnosed with COVID-19-induced pneumonia. She had a telemedicine appointment with her doctor.

Staring back from her screen was Dr. Rogers Cain, who runs a tidy little family medical clinic a couple of blocks from the Trout River in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was one of Cain’s patients who’d tested positive — he had seven other COVID patients that morning before noon. Three of her grown children had contracted the virus, too.

“It started as a drip, drip, drip in May,” said Cain, his voice muffled by his mask. “Now it’s more like a faucet running.”

Cain and Wilson are nervous. Over the past two decades, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks, including a small cluster of tuberculosis cases in 2012. And now they face the menace of COVID-19 in a city once slated to host this week’s Republican National Convention, in one of the states leading the latest U.S. surge.

Florida is both a microcosm and a cautionary tale for America. intended to protect communities against disease, staffing and funding fell faster and further in the Sunshine State, leaving it especially unprepared for the worst health crisis in a century.

Although Florida’s population grew by 2.4 million since 2010 to make it the nation’s third-most-populous state, a joint investigation by KHN and The Associated Press has found, the state slashed its local health departments’ staffing — from 12,422 full-time equivalent workers to 9,125 in 2019, the latest data available.

According to an analysis of state data, the state-run local health departments spent 41% less per resident in 2019 than in 2010, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much ― an average of 18%, according to data from the National Association of County and City Health Officials.

Even before the pandemic hit, that meant fewer investigators to track, trace and contain diseases such as hepatitis. It meant fewer public health nurses to teach people how to protect themselves from HIV/AIDS or the flu. When the wave of COVID-19 inundated Florida, the state was caught flat-footed when it mattered most, its main lines of defense eviscerated.

Now, confirmed cases have soared past 588,000 and deaths have risen to more than 10,000. Concerns over the virus prompted Republicans to cancel plans for an in-person convention in Jacksonville, opting for a pared-down version in North Carolina.

Health experts blame the funding cuts on the Great Recession and choices by a series of governors who wanted to move publicly funded state services to for-profit companies.

And when the pandemic took hold, they say, residents got mixed messages about prevention strategies like wearing masks from Republican Gov. Ron DeSantis and other political leaders. Voices within the health departments were muzzled.

“The reality, unfortunately, is people are going to die because of the irresponsibility of the decisions being made by the people crafting the budgets,” said , president of the , a nonprofit in Washington, D.C., offering tools and training. “Public health can’t help us get out of this situation without our elected officials giving us the resources.”

State officials neither answered specific, repeated questions from KHN and The Associated Press about changes in public health funding, nor made staffers available for deeper explanations.

Dr. , a former deputy secretary of Florida’s state health department, said failing to prepare for a foreseeable disaster “is governmental malpractice.” The nation’s pandemic response is only as good as the weakest link, he said. Since the virus respects no borders, other states feel the ripples of Florida’s failings.

Those failings are clear in Duval County, which had employed the equivalent of 852 full-time workers and spent $91 per person in 2008 but in 2019 had only 422 workers and spent just $34 per resident, according to the KHN-AP analysis of state data. That’s less than the of a single COVID test. Former county health director Dr. Jeff Goldhagen said the county’s team has been “dismantled to the extent that it could not really manage an outbreak.”

Yet it must.

Cain’s private north Jacksonville medical clinic alone has had about 60 confirmed COVID cases and eight deaths. “We are all on fire right now,” he said. “You have to have a fire department that is adequately equipped to put out the fire. ”

Dwindling Budgets

Florida faced similar shortcomings around the time of the last great pandemic, the 1918 flu. Back then, according to a , public health workers faced too many demands and their efforts were “to some extent scattered and transitory.” The state could have used at least three more district health officers, the report said: “It is a source of regret and a matter of grave concern to public health workers that the funds available are not sufficient.”

County-based health departments began in 1930, providing more robust services closer to home. About 50 years later, legislation created state-administered primary care programs in which county health departments provided low-income Floridians with the type of basic health care and treatment most people now get at private doctors’ offices.

The 1990s saw a move toward privatization, particularly as Medicaid managed care took hold, said a . Still, per-person spending on local public health rose until the late 1990s, when adjusted for inflation to 2019 dollars, peaking at $59.

Wilson, the retired public health nurse stricken with COVID-19, recalled how Duval County’s department started feeling the financial pain during former Republican Gov. Jeb Bush’s administration in the early 2000s and kept losing nurses and other staff until they were “very, very short.”

Beitsch, who worked for the state health department in the 1990s, said the downward trend continued under former Republican governors Charlie Crist and Rick Scott, fueled by a growing belief in shrinking government that flourished in many states. Florida’s leaders exerted more control over public health, Beitsch said, and “the amount of local autonomy has been diminishing with successive administrations.”

The recession that began in late 2007 sparked public health reductions across the nation that were especially harsh in Florida. By 2011, budget cuts and lack of money were the most frequently cited challenges in a Florida public health workforce survey, which pointed to growing needs. In the following years, the state had some of the nation’s highest rates of heart disease and diabetes.

Squeezed departments struggled and sometimes stumbled. A from the state health department’s inspector general for the 2018-19 fiscal year, for example, found a series of lost and inconsistent shipments of lab specimens from county health departments to the state lab — not long before the pandemic would make labs more important than ever.

As governor, Scott presided over the state from 2011 to 2019, when funding and staffing dropped most. Now a U.S. senator, he said through a spokesperson that he was unapologetic for health department cuts, which he characterized as a move toward “making government more efficient” without endangering public health.

“I’m sure that he had no problem with the cuts that were being made,” said , an associate professor in health administration at Florida Atlantic University. “To put it all on him is not fair because a bunch of little henchmen from the counties had to vote that way. … We keep voting in people who undervalue public health.”

Democratic state Sen. Janet Cruz, a legislator who has represented the Tampa region for a dozen years and sat on health care committees, said she watched lawmakers systematically cut money for health departments. When she questioned it, she said, some colleagues claimed the need wasn’t as great because the state was moving toward private family health care centers. “Public health in Florida has been wholly underfunded,” she said.

Some places have suffered more than others. Departments serving at least half a million residents spent $29 per person in 2019 on average, compared with $90 per person in departments serving 50,000 or fewer — a difference starker than the typical gap between larger and smaller departments nationally, according to an KHN-AP analysis. Experts can’t say exactly why the gap is wider in Florida, which has a state-run system, but point to politics and historical decisions about budgets.

Duval County’s health department spending was the equivalent of $34 per person, down 63% since 2008. Typically, about 22 workers, or 5% of the total staff, have been dedicated to preparing for and tracking disease outbreaks.

But when the pandemic hit, many there and elsewhere were diverted to fight the coronavirus, leaving little time for their typical duties such as mosquito abatement and tracking sexually transmitted infections such as syphilis.

“Current events demonstrate how bad a decision” the deep cuts to public health were, said , a professor of public health and family medicine at the University of South Florida. “It’s really come back to haunt us.”

Mixed and Muzzled Messages

The pandemic caught fire in Florida this summer as the state’s rapid reopening allowed people to flock to beaches, Disney World, movie theaters and bars.

The state has had more than half a million confirmed cases ― among them, players and workers for baseball’s Miami Marlins ― and 35,000 hospitalizations, yet DeSantis still hasn’t issued a mask mandate. Some local governments have. Jacksonville adopted one in late June, and about a week later Republican Mayor Lenny Curry announced he and his family were self-quarantining because he’d been exposed to someone who tested positive for the virus.

, director of infection prevention at the University of Florida-Jacksonville, lauded the mayor for the mask requirement, saying, “We know that masking works.” But he pointed out that other counties have different rules and that the inconsistent messaging breeds confusion.

St. Johns County began requiring masks in late July but only in county facilities. And DeSantis has appeared in public without a mask numerous times, including at

target=”_blank” rel=”noopener noreferrer”>an Aug. 13 coronavirus update

briefing during which some other speakers wore them.

“One voice is so critical during a pandemic,” said Dr. Jonathan Kantor, a Jacksonville epidemiologist and dermatologist. “We have to have one voice, and consistent leadership that is modeling behavior if we want to get people to change their behaviors.”

Instead, experts in Florida said, public health workers have been silenced or told by top state officials what to say. For example, that state leaders told school boards they needed health department approval to keep schools closed, then instructed health directors not to give it.

“All the communication is directed by the state, and localities are very limited in what they can do,” said Levine, the University of South Florida professor. “Anything to do with a mandate, there’s resistance to do at a state level. This includes the hot debate on masks. The locals have to extend the state messaging.” Local health officials “are being told bluntly: ‘Shut up,’” Bernet said. “They literally cannot speak.”

Beitsch, who now chairs the department of behavioral sciences and social medicine at Florida State University, said such limitations ― and similar mixed messages and silencing of medical experts at the national level ― fuels the politicization of public health and undermining of science.

“People think they should be listening to politicians and state legislative leaders about their health care. They’re not listening to health experts and the epidemiologists who say if you just wear a mask and if you just wash your hands, we can really, really reduce the spread of the virus,” said Cruz, the state senator. “People are confused, and they think this is a hoax and it’s nothing more than the flu.”

Meanwhile, the COVID caseload continues to rise, surpassing 25,000 in Duval County, with minorities stricken disproportionately, as elsewhere in the nation. In a county that’s 29% Black and 60% white, Black residents with COVID have been hospitalized at more than double the rate of white residents. Rates are also high for Floridians grouped together as “other,” including Native American, Asian and multiracial residents.

Duval County’s overall caseload is rising so fast that Goldhagen, the former health department director, said the agency has given up on contact tracing, which means trying to curb the virus by identifying and warning people who have been exposed.

“It’s impossible,” Goldhagen said. “Dismantling the system was a complete disregard for the health and well-being of the citizens of Florida.”

With an unequipped public health system, Wilson, the retired public health nurse, said it falls to everyone to lead Jacksonville, and Florida, out of the coronavirus crisis.

“My hope is that everybody begins to take this virus seriously, and wear their mask and stay social distancing. It can work if we do that,” said Wilson, whose condition has improved. “So, that’s my hope. Eventually there will be a vaccine that will curtail this virus. But until then, it’s up to us to help do that. And if we’re not serious about it, then we’re doomed.”

This story is a collaboration between KHN and The Associated Press.

Methodology

Spending and staffing data for Florida’s local health departments is from the Florida Department of Health. Florida Atlantic University professor Patrick Bernet provided additional state data on staffing by program area. KHN-AP adjusted spending data for inflation using the Bureau of Economic Analysis’ state and local government deflator.

COVID-19 data by race is from the Florida Department of Health. KHN-AP calculated rates per 10,000 people using data on race, regardless of ethnicity, from the U.S. Census Bureau’s 2018 American Community Survey. Statewide COVID-19 cases per day are from Johns Hopkins University.

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These cuts, which in Colorado include slashing $1 million from a program designed to keep people with mental illness out of the hospital and $5 million for addiction treatment programs in underserved communities, come amid the century’s largest health crisis when people may need those services most.

You can .

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