Uninsured Archives - ��ϳԹ�� News

Listen: What To Do When Health Insurance Slips Out of Reach

Sam Whitehead — Thu, 05 Mar 2026 10:00:00 +0000

LISTEN: Can’t afford health insurance this year? Don’t be afraid to talk to your doctor about money and the cost of care. On WAMU’s “Health Hub” on March 4, ��ϳԹ�� News correspondent Sam Whitehead shared tips for people seeking affordable options without skipping care.

Health insurance could be out of reach for many Americans in 2026.

About a for Affordable Care Act marketplace coverage this year. The Congressional Budget Office told lawmakers that more could opt out in coming years after the GOP-led Congress let expire subsidies that helped many afford a plan. Meanwhile, plan premiums jumped, and new, stricter Medicaid eligibility rules kicked in.

If you lost health insurance this year, there may be ways to see the doctor without breaking the bank. On March 4, in conversation with WAMU host Esther Ciammachilli, ��ϳԹ�� News correspondent Sam Whitehead shared tips on .

Renuka Rayasam and Taylor Cook contributed reporting.

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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If You’re Pregnant and Uninsured, Medicaid Might Be Your Answer

Blake Farmer, Nashville Public Radio — Tue, 03 Feb 2026 10:00:00 +0000

LISTEN: If you’re newly pregnant and not able to afford health insurance, you may qualify for Medicaid. Reporters Cara Anthony and Blake Farmer — hosts of the new series “HealthQ” — explain that every state has a program to provide coverage for pregnant people.

When she noticed an unusual craving for hot dogs, Matte’a Brooks suspected her body was telling her something, so she decided to take a pregnancy test. She took two just to be sure. Both were positive.

“I was definitely scared,” said Brooks, 23, who was uninsured. “I was like, OK … I’m pregnant, so where do I go from here?”

Until then she hadn’t thought much about health care, but that changed when she found out that her daughter was on the way.

Brooks got that news last winter. The mix of joy, anxiety, and excitement she felt mirrors what many new parents feel at this time of year. Many Americans find out in January or February that they’re expecting, because in the U.S., August has consistently high birth rates.

A growing body of research shows that prenatal care can make a huge difference to the long-term health of both the parent and baby. This is part of why offers health coverage to pregnant women who meet income requirements and might otherwise go uninsured.

As a result, Medicaid pays for more than 40% of births in the U.S. and an even higher percentage in rural areas, according to KFF. But Medicaid also comes with limitations, and providers may restrict how many Medicaid patients they take, since the payments are than other insurers’.

Here are three things to know about signing up for Medicaid when pregnant.

1. Pregnancy Makes You a Priority

To sign up for government health care, you have to meet a number of requirements that vary widely by state. Most importantly, your income has to be below a certain threshold. In several states, most adults cannot qualify, regardless of income, if they’re not disabled or the parent of a child.

But the math is different for pregnancy. In Tennessee, for example, the eligibility cutoff in pregnancy is the income threshold for some other residents. So if you didn’t qualify for Medicaid previously and are now pregnant, it’s worth double-checking your state’s requirements.

2. Getting Covered Can Be Surprisingly Easy

To apply, you’ll likely proof of income, your Social Security number, and proof of residency. Brooks, an Illinois resident, told HealthQ that she found the sign-up process surprisingly easy. She learned about Medicaid from the provider at her initial prenatal visit.

“They asked if I had insurance. I didn’t know anything at the time,” she said. The nonprofit clinic gave her some phone numbers for the state Medicaid agency. She called and went to an in-person appointment to complete her application. She walked out of the office with coverage. In , pregnancy results in “presumptive eligibility,” which provides immediate coverage — even without confirmation of the pregnancy — while the application goes through the approval process.

3. Coverage Can Go Beyond Standard Medical Care

Medicaid provides all prenatal care at no out-of-pocket cost and usually a of postpartum care. That’s what happened to Brooks: Her appointments, medications, and delivery were free.

States cover dental, vision, and mental health care to varying degrees. Ashley Farrell, who lost her job when she was pregnant and applied to Medicaid in Georgia, said she received “rewards for going to your appointments,” including . Benefits vary by state.

People and Policy

Some maternal health advocates about how Medicaid cuts in the One Big Beautiful Bill Act will affect pregnancy coverage. Though it’s unclear when or how, states might scale back eligibility or offerings for expectant mothers.

Katherine Ruppelt at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer — approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and ��ϳԹ�� News.

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When Health Insurance Costs More Than the Mortgage

Renuka Rayasam — Mon, 02 Feb 2026 10:00:00 +0000

When Noah Hulsman, who owns a skate shop in Louisville, Kentucky, learned he no longer qualified for federal subsidies to help him pay for his “gold” Affordable Care Act health plan, the 37-year-old opted for skimpier coverage. But the deductible is about a quarter of his yearly income.

Loretta Forbes realized she would have to drop her plan after her monthly ACA marketplace premiums jumped tenfold in 2026. So the 56-year-old, who lives outside Nashville, Tennessee, started rationing her rheumatoid arthritis medications. Her husband, Jim, gave up on his fledgling handyman business and started looking for a job with insurance coverage.

And when Nicole Wipp learned the monthly premium for her family’s ACA plan would be more than their mortgage payment, she and her husband decided to drop their family plan and buy coverage only for their 15-year-old son.

After crunching the numbers, Wipp, 54, a self-employed lawyer in Aiken, South Carolina, said she and her family made the tough call.

“We decided that, ultimately, it would be better for us to gamble.”

Despite a contentious back-and-forth and the longest government shutdown in history last fall, the GOP-led Congress allowed enhanced ACA subsidies, which had helped millions of Americans cover all or part of their marketplace premiums since 2021, to expire on Dec. 31. With the loss of the subsidies and health care costs already surging, face tough decisions about their health coverage this year.

When Nicole Wipp learned the monthly premium for her family’s ACA plan would be more than their mortgage payment, she and her husband, Marcus Sutherland, decided to drop their family plan and buy coverage for only their son, Marek. (The Wipp family)

Hulsman, Forbes, and Wipp don’t qualify for Medicaid, the public insurance program for those with low incomes or disabilities. But like many others, they are being squeezed by the increasing costs of groceries, housing, and other necessities. Rising monthly health insurance premiums, along with copayments, high deductibles, and other out-of-pocket medical costs, can often push families like these to the brink.

More than 80% of Americans said their cost of living has increased in the past year, according to from that includes ��ϳԹ�� News. Health care costs ranked at the top of their concerns, with about two-thirds saying that they are somewhat or very worried about affording health care — more than said the same about other necessities, such as food and housing, the poll found.

“Premiums are getting quite unaffordable for a lot of people. The cost of both health care and other basic needs is rising,” said , director of private coverage at the health consumer group Families USA. “This is an especially critical time for Congress to do something.”

Most Republican lawmakers have refused to renew the enhanced subsidies. Most of the public says that inaction by Congress was the “wrong thing,” according to the KFF poll. Instead, GOP lawmakers have advocated for an expansion of and for more plans with lower premiums and steeper deductibles and copays that don’t reduce overall costs.

President Donald Trump released in January with few details about how to lower out-of-pocket costs for millions of Americans. The One Big Beautiful Bill Act, which he signed in July, is expected to leave millions uninsured over the next decade as it reduces federal health spending by nearly $1 trillion, mostly from Medicaid.

Already about 1.2 million fewer people have signed up for plans for this year under the ACA, also known as Obamacare, according to . Health policy analysts expect more people to stop making payments and drop coverage in the coming months. ACA marketplace insurers have said that they are charging 4 percentage points more in 2026 because they expect healthier people to drop plans as enhanced tax credits expire, leaving more sick and high-cost patients.

Rising costs and lack of congressional action are forcing many to make “untenable choices,” said , executive director and co-founder of the Center for Children and Families at Georgetown University.

“People are faced with absorbing this huge financial and health risk,” she said.

Forbes, the woman with rheumatoid arthritis near Nashville, had been on an ACA marketplace plan since 2018. But this year she and her husband, Jim, dropped their coverage after learning the monthly premium would jump from $250 to $2,500 because the enhanced subsidies expired. Jim, 59, gave up his handyman business and began searching for a job with health insurance.

“We were like: ‘OK, we can’t breathe. We’re gonna tap out,’” said Forbes, who was diagnosed with cervical cancer in 2021. Last year she lost her job at a retirement facility because she couldn’t work after she had a hysterectomy.

A day before their ACA coverage lapsed, her husband got a job offer at a property management company that provides health coverage. In January, they learned that Forbes was approved for Medicare because of her disability. The $155 monthly premium is automatically deducted from her disability check, she said.

Forbes’ Medicare plan starts in February, just in time for her next cancer screening.

“You cannot imagine what a relief it is to know I will have care,” Forbes said.

Even those who are insured face drastically higher out-of-pocket costs. This year, health insurers’ premiums for ACA marketplace plans , the result of higher hospital costs, the popularity of pricey GLP-1 drugs for obesity and diabetes, and the threat of tariffs, according to KFF. Nearly 4 in 10 adults said they were skipping or postponing necessary care because of costs, showed.

Hulsman, the Louisville shop owner, said he takes home about $33,000 a year from his business. Last year he paid about $105 a month for a gold plan on the marketplace, with a $750 deductible. This year, with the loss of the enhanced subsidy, Hulsman is paying the same monthly premium for a “bronze” plan, but with a deductible of $8,450, which he must pay out-of-pocket before his insurer starts paying for care. On average, deductibles for bronze plans are more than four times those of gold plans, according to .

Hulsman didn’t consider dropping health insurance, because Kentucky has limited . But he said he’ll try to get an estimate if he needs to go to a doctor. And he’s worried that a major accident could wipe out his skate shop. He won’t be able to buy inventory or pay shop bills if he has to meet his full deductible, he said.

“I’m just riding the line right now,” the skateboarder said. “One slip and it’s gonna be uncomfortable.”

Noah Hulsman, who owns a skate shop in Louisville, Kentucky, lost extra subsidies that helped him pay for a “gold” plan on the Affordable Care Act marketplace. (Luke Sharrett for ��ϳԹ�� News)

He got a “bronze” plan for this year, but the deductible is so high that one accident could make it hard for him to also pay his shop’s bills. (Luke Sharrett for ��ϳԹ�� News)

In South Carolina, Wipp dragged her family to get routine vaccinations on New Year’s Eve — the last day that she and her husband had health coverage.

This year’s monthly premium for a bare-bones bronze family plan would have cost them $1,400, up from $900 last year. They would still have faced high copays for doctor visits and need to meet a deductible of more than $10,000. Instead, they’re paying around $200 to cover just her son.

Wipp, who has a rare condition that causes cysts and other growths to form in the lungs, said she and her husband plan to pay out-of-pocket this year for any initial preventive care. Their second source of money, for larger medical expenses, is an old health savings account. But she said that account doesn’t have enough to cover a major accident or illness. And Wipp can’t add to the account while she is uninsured.

“The third source would be, I don’t know,” Wipp said. “The fourth is bankruptcy.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact ��ϳԹ�� News and share your story.

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It’s 2026 and You’re Uninsured. Now What?

Renuka Rayasam — Mon, 02 Feb 2026 10:00:00 +0000

(iStock/Getty Images)

Health policy changes in Washington will ripple through the country, resulting in millions of Americans losing their Medicaid or Affordable Care Act coverage. But there are still ways to find care.

Over the next decade, the GOP’s One Big Beautiful Bill Act is expected to slash nearly $1 trillion in spending from Medicaid, the state-federal program for people with low incomes and disabilities. The implementation of new work rules will cause some beneficiaries to lose their Medicaid coverage.

Millions of Americans are facing enormous increases in their out-of-pocket costs for ACA coverage. So far, 1.2 million fewer people have signed up for Obamacare plans compared with last year, and health policy analysts estimate more will lose coverage as they fail to pay their premiums.

Health costs are a top concern for Americans. Two-thirds of the public say they are somewhat or very worried about affording health care, more than express the same worries about utilities, food, housing, or gas, according to a , a health information nonprofit that includes ��ϳԹ�� News.

“All of this pain just doesn’t have to be there,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA.

Doctors and health policy researchers say health coverage, of any kind, is the best protection against major medical debt.

Caitlin Donovan, a senior director at the Patient Advocate Foundation, recommends exhausting every available option for health coverage before going uninsured.

Even a high-deductible plan can protect patients from medical bankruptcy “if the absolute worst-case scenario happens,” she said.

Here are five ways that the uninsured can find affordable care.

1. Don’t be afraid to talk with your doctor about money

Patients can be hesitant to tell their doctors they’re uninsured or be wary of expressing concern about being able to afford care.

But some hospitals, physicians, and other providers offer cheaper cash pay options, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF.

Often prices are negotiable. “Always ask,” she said.

Health care providers can make adjustments if they know patients are worried about money, said Ateev Mehrotra, a doctor and researcher at Brown University.

“If my patient tells me, ‘Doc, I’m gonna have to pay for this out-of-pocket,’ I’m gonna make a different risk calculus,” Mehrotra said.

That doesn’t mean a patient won’t get the care they need, he said. A doctor, for instance, might order an ultrasound instead of an MRI, which is more expensive.

2. Search for providers that specifically work with uninsured patients

If your usual provider won’t budge on prices, then search for providers that cater to patients without insurance.

Federally qualified health centers, or FQHCs, and other community clinics offer routine and non-emergency care, such as treatment for flu or infection, for low-income residents and the uninsured. Community health centers charge based on a sliding scale and see annually in some of the country’s most underserved areas, according to the National Association of Community Health Centers.

The Trump administration has made funding cuts that might lead some of the country’s approximately 1,500 FQHCs to close or cut services. But the administration still maintains .

Planned Parenthood also accepts uninsured patients. Its centers test for sexually transmitted diseases, provide birth control options, and offer postpartum and gender-affirming care .

And the National Association of Free & Charitable Clinics also offers to help people find free or low-cost care.

Most community clinics don’t offer specialty care, but they can usually refer patients who need more intensive services to providers willing to work with uninsured patients.

And academic medical centers tend to have more charity care programs that help uninsured patients lower their bills.

“If you’re uninsured or even underinsured, you might be able to qualify for a significant discount on the cost of your care,” Cox said.

Still, be wary of heading to the emergency room, which is the most expensive place to get care. While ERs are federally required to stabilize all patients regardless of their ability to pay, they can still leave you with a big bill — and often do.

3. Call your local health department

Health services vary widely from county to county, but many offer free vaccinations, family planning services, and testing for sexually transmitted infections, as well as for flu, covid, and tuberculosis.

Some county health departments also offer more advanced care, such as dental services and mental health or substance abuse programs. And some states have consumer assistance programs that can guide residents in finding care, Fish-Parcham said.

In addition, the Centers for Disease Control and Prevention’s makes free or low-cost breast and cervical cancer screenings available to low-income women in all states and territories. And some states cover screenings for other types of cancer as well.

4. It’s easier to shop around for drugs than doctors

Don’t just fill your prescription at the closest pharmacy. Instead, research generic drug options and look around for the best price on brand names.

A handful of sites such as and offer comparison shopping tools and information on other ways to get drug discounts.

And some retailers offer low-cost access to common prescription drugs — at prices cheaper than you would find if you had insurance. Walmart, for instance, sells 90-day prescriptions of of drugs for $10. As do , , and a new site called the .

Many drugmakers also offer patient assistance programs, coupons, and rebates on some medications. Check their websites for details on how to apply.

States also offer drug assistance programs. The steps to qualify and types of drugs vary, but has a list of programs and how they work.

Joining a clinical trial is another way to access treatment. The and its have lists, but patients must first meet the criteria. Clinical trials aren’t necessarily free, even with insurance, Donovan said, so be sure to ask about any associated costs.

5. Your diagnosis might lead you to specialized resources

Patients with a specific diagnosis might have additional options for specialty treatment.

For example, someone with breast cancer should check with the and the nonprofit , Cox said.

The Patient Advocate Foundation hosts that can help offset the cost of medical bills and provide other resources such as transportation and lodging, Donovan said. Just type in basic information such as age, location, and diagnosis to see what is available.

Disorder-specific foundations, such as those for lupus or irritable bowel syndrome, can also steer patients to free or low-cost resources or cover some costs of care, Donovan said.

“Everything is out there,” she said.

As you research affordable care options, don’t be tricked by plans that look like health insurance but don’t offer guaranteed protection against big bills.

Some short-term plans and health care sharing ministries might seem like good deals, but read the fine print. Some red flags to look for: too-good-to-be-true monthly payments; no coverage for preexisting conditions; morality clauses such as those prohibiting the use of alcohol or drugs; or a lack of coverage for benefits such as mental health counseling that are required in ACA plans.

��ϳԹ�� News correspondent Sam Whitehead contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ��ϳԹ�� News and share your story.

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Watch: A Strange Checkup Bill Revealed a Firefighter’s Kids Were Mistakenly Uninsured

Caresse Jackman, InvestigateTV — Tue, 27 Jan 2026 10:00:00 +0000

After Susannah Reed-McCullough’s husband died in 2018, she and their young daughters continued to receive health insurance through his job as a firefighter in Maryland.

Then, in 2024, she got an unexpected medical bill: $377 for a checkup for one of her children the previous fall. Reed-McCullough said she called the doctor’s billing department and learned the insurance company had dropped the children’s coverage.

The drop turned out to be a mistake. But Reed-McCullough said she was forced to act as the go-between for her late husband’s human resources department and their insurer — all while worried about her daughters’ being uninsured.

In this installment of InvestigateTV and ��ϳԹ�� News’ “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, explores how administrative errors can leave patients on the hook for medical bills they shouldn’t owe, sometimes with few options to correct a problem they didn’t create.

Jackman interviewed Elisabeth Rosenthal, senior contributing editor at ��ϳԹ�� News, who said accidental coverage drops are “a common problem” in need of attention from state regulators.

“People make mistakes, systems make mistakes, and they should be held responsible for them, not the patient,” Rosenthal said.

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Millions of Americans Are Expected To Drop Their Affordable Care Act Plans. They’re Looking for a Plan B.

Blake Farmer, Nashville Public Radio — Mon, 12 Jan 2026 10:00:00 +0000

Robert Sory feeds a treat to a blind, albino raccoon named Cricket. Russian foxes, African porcupines, emus, bobcats, and goats are also part of his menagerie. (Blake Farmer/WPLN)

It’s feeding time for the animals on this property outside Nashville, Tennessee. An albino raccoon named Cricket reaches through the wires of its cage to grab an animal cracker, an appetizer treat right before the evening meal.

“Cricket is blind,” said Robert Sory, who is trying to open a nonprofit animal sanctuary along with his wife, Emily. “A lot of our animals come to us with issues.”

The menagerie in Thompson’s Station includes Russian foxes, African porcupines, emus, bobcats, and some well-fed goats.

The Sorys are passionate about their pets and seem to put the animals’ needs before their own.

Both Robert and Emily started 2026 without health insurance.

Robert had been covered through a marketplace plan subsidized through the Affordable Care Act. His share of the monthly premiums was $0. When he looked up the rates for 2026, he saw that a barebones “bronze”-level plan would cost him at least $70 a month. He decided to forgo coverage altogether.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” he said. “It’s not affordable.”

Emily and Robert Sory are trying to open a nonprofit animal sanctuary at their home in Thompson’s Station, Tennessee. They have forgone health insurance this year and are looking for ways to pay for their care without coverage. (Blake Farmer/WPLN)

Dumping Coverage

Marketplace plans from the Affordable Care Act no longer feel very affordable to many people, because Congress did not extend a package of enhanced subsidies that expired at the end of 2025. Last week, the House did pass legislation to extend the expired subsidies, and negotiations have moved to the Senate. Without a deal, an estimated will go without coverage this year.

But even without a health plan, people will still need medical care. Many, like the Sorys, have been thinking through their plan B to maintain their health.

The Sorys both lost jobs in November, within days of each other. Robert worked as a farmhand. Emily worked at a staffing firm and lost her insurance along with her position.

“It’s a horrible, horrible market right now. Really tough,” she said.

The first time she had to pay out-of-pocket for her three monthly prescriptions, the cost was $184.

“To equate that to kind of how we think about it, you’re talking about 350 pounds of food for these animals,” Robert said. He pointed to his bobcats, who eat only meat.

A bobcat waits for a meaty meal served by Robert Sory. (Blake Farmer/WPLN)

Workarounds for the Newly Uninsured

To keep kibble in the food bowls, the Sorys are prepping for an uninsured future. They see the same psychiatrist and met with him to make a plan. He was willing to work with them by charging $125 per visit. They’ll have to go every three months to keep their prescriptions current.

And if other medical problems emerge? They’re hoping for the best.

“I’m not somebody who gets sick super often, thank God,” Robert said. “And if I do, generally I go to an emergency room where they’re going to bill me later.” Robert said he would arrange a repayment plan for bills like that.

Emily has costly health conditions and has already taken on substantial medical debt. “It’s just sitting there, and I’ve racked up money,” she said. “But I’ve had to go to the doctor.”

Donated Drugs and Sliding Scales

Hospitals and clinics are of newly uninsured patients. They’re also concerned that people won’t know about alternative ways to get medical care.

“We don’t have marketing dollars, so you’re not going to see big billboards or radio ads,” said , CEO of in Nashville. It’s one of the country’s 1,400 federally qualified health centers, also called FQHCs.

FQHCs are by the federal government. Although they do not usually offer free care, their fees tend to be lower or on a sliding scale.

Uninsured people who get care receive a bill, Beard said, “but the bill will be based on their ability to pay.”

FQHCs often have on-site pharmacies, and some offer prescription medications free of charge through a partnership with the , a Nashville-based nonprofit.

Many hospital pharmacies also partner with the nonprofit, which has donated by pharmaceutical companies to 277 sites in 38 states. must make the medicine available free of charge to people without insurance who have annual incomes below 300% of the federal poverty limit.

The organization primarily sources medications for chronic conditions such as high blood pressure, diabetes, and mental health. Demand is expected to outstrip supply in the new year, according to .

“We’re projecting and engaging with our manufacturers and asking them, ‘Are you willing to help support, for this future status that we are anticipating?’” he said. “By and large,” he said, pharmaceutical companies have said they’re willing to step up.

“It’s a continuous conversation that we’re having,” Cornwell said.

Emily Sory readies the foxes’ supper. (Blake Farmer/WPLN)

A Medicaid ‘Gap’ in 10 States

Hospitals will also have to find a way to care for more patients who cannot pay. Industry groups such as the have been vocal about the threat to hospitals’ financial health and have urged Congress to extend the enhanced subsidies, which take the form of tax credits.

The impact might be most acute in states like Tennessee that have not expanded Medicaid to cover people who work but do not have job-based insurance and cannot afford it on their own.

Ten states have chosen not to expand Medicaid to uninsured, low-income adults — an optional provision of the ACA that is mainly paid for by federal funds.

This Medicaid “gap” is , at the high end of the spectrum, by as much as 65% in Mississippi and by 50% in South Carolina, according to the Urban Institute.

As Emily Sory pets a Russian fox, she admits she is keenly aware that she will soon become part of this growing population. After all, her last job involved health care staffing. Her mother is a nurse.

“I understand the system. And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad,” she said. “But at the same time, I don’t have the money to pay it.”

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

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On the Hook for Uninsured Residents, Counties Now Wonder How They’ll Pay

Christine Mai-Duc — Tue, 06 Jan 2026 10:00:00 +0000

In 2013, before the Affordable Care Act helped millions get health insurance, California’s Placer County provided limited health care to some 3,400 uninsured residents who couldn’t afford to see a doctor.

For several years, that number has been zero in the predominantly white, largely rural county stretching from Sacramento’s eastern suburbs to the shores of Lake Tahoe.

The trend could be short-lived.

County health officials there and across the country are bracing for an newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Bill Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by over that period.

“This is the moment where a lot of hard decisions have to be made about who gets care and who doesn’t,” said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”

It’s an especially thorny challenge for states and New Mexico where counties are legally required to help their poorest residents through what are known as indigent care programs. Under Obamacare, both states were to include more low-income residents, alleviating counties of patient loads and redirecting much of their funding for the patchwork of local programs that provided bare-bones services.

Placer County, which estimates that 16,000 residents could lose health care coverage by 2028, quit operating its own clinics nearly a decade ago.

“Most of the infrastructure that we had to meet those needs is gone,” said Rob Oldham, Placer County’s director of health and human services. “This is a much bigger problem than it was a decade ago and much more costly.”

In December, county officials that provides care to mostly small, rural counties, citing an expected rise in the number of uninsured residents.

New Mexico’s second-most-populous county, Doña Ana, added dental care for seniors and behavioral health benefits after many of its poorest residents qualified for Medicaid. Now, federal cuts could force the county to reconsider, said Jamie Michael, Doña Ana’s health and human services director.

“At some point we’re going to have to look at either allocating more money or reducing the benefits,” Michael said.

Straining State Budgets

Some states, such as Idaho and Colorado, abandoned laws that required counties to be providers of last resort for their residents. In other states, uninsured patients often delay care or receive it at hospital emergency rooms or community clinics. Those clinics are often supported by a mix of federal, state, and local funds, according to the National Association of Community Health Centers.

Even in states like Texas, which opted not to expand its Medicaid program and continued to rely on counties to care for many of its uninsured, rising health care costs are straining local budgets.

“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” said Windy Johnson, program manager with the Texas Indigent Health Care Association. “It is a fiscal issue.”

California lawmakers face a nearly in the 2026-27 fiscal year, according to the latest estimates by the state’s nonpartisan Legislative Analyst’s Office. Gov. Gavin Newsom, who has acknowledged he is , has rebuffed to significantly raise taxes on the ultra-wealthy. Despite blasting the bill passed by Republicans in Congress as a that guts health care programs, in 2025 the Democrat rolled back state Medi-Cal benefits for seniors and for immigrants without legal status after rising costs forced the program to borrow $4.4 billion from the state’s general fund.

H.D. Palmer, a spokesperson for the state’s Department of Finance, said that the Newsom administration is still refining its fiscal projections and that it would be “premature” to discuss potential budget solutions.

Newsom will unveil his initial budget proposal in January. State officials have said California a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program’s entire budget.

“Local governments don’t really have much capacity to raise revenue,” said Scott Graves, a director at the independent California Budget & Policy Center with a focus on state budgets. “State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts.”

Reviving county-based programs in the near term would require “considerable fiscal restructuring” through the state budget, the Legislative Analyst’s Office said in .

No Easy Fixes

It’s not clear how many people are currently enrolled in California’s county indigent programs, because the state doesn’t track enrollment and utilization. But enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, at the time by Health Access California.

“We’re going to need state investment,” said Michelle Gibbons, executive director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”

In November, voters in affluent Santa Clara County approved a sales tax increase, in part to backfill the loss of federal funds. But even in the home of Silicon Valley, where the median household income is about 1.7 times the , that is expected to of the $1 billion a year the county stands to lose.

Health advocates fear that, absent major state investments, Californians could see a return to the previous , with local governments choosing whom and what they cover and for how long.

In many cases, indigent programs didn’t include specialty care, behavioral health, or regular access to primary care. Counties can also exclude people or income. Before the ACA, many uninsured people who needed care didn’t get it, which could lead to them winding up in ERs with untreated health conditions or even dying, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that “it created a very unequal, maldistributed program throughout the state.”

“Many of us,” she said. “including counties, are reeling trying to figure out: What are those downstream impacts?”

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Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000

Tony Leys — Tue, 25 Nov 2025 10:00:00 +0000

Elisabeth Yoder’s son, Darragh, was 15 months old in August when he developed what at first looked to his parents like hand, foot, and mouth disease. The common generally clears up in less than a week, but Darragh’s condition worsened over several days. His skin turned bright red. Blisters gave way to skin peeling off his face.

An online search of his symptoms suggested he had a serious bacterial infection. Yoder drove the toddler from their home in the small town of Mechanicsburg, Ohio, to the Mercy Health hospital in nearby Urbana.

Staff in the emergency room there quickly confirmed that Darragh had scalded skin syndrome and said he needed to be taken by a private company’s ambulance to Dayton Children’s, a hospital about 40 miles away.

“I asked them: ‘Can I take him? Can I drive him?’” Yoder said. “And they were like, ‘Oh, absolutely not.’”

So, Yoder and her son got into the ambulance, with Darragh strapped in his car seat. The ambulance driver didn’t turn on the siren or drive particularly fast, Yoder said. The trip took about 40 minutes, she said. “It was fairly straightforward transportation from Point A to Point B.”

Yoder had heard that ambulance rides can be pricey. But she didn’t know how much her son’s ride would cost.

Darragh was hospitalized for three days and recovered from the illness.

Then the bill came.

The Medical Procedure

During the ride, the ambulance crew monitored Darragh’s vitals and an intravenous line, inserted at the hospital, carrying fluids and antibiotics, but he received no other medical treatment, Yoder said.

The Final Bill

$9,250, which included a “base rate” charge of $6,600 for a “specialty care transport” and a mileage fee of $2,340, calculated at $60 for each of the ride’s 39 miles. It also included $250 for use of an intravenous infusion pump and $60 for monitoring Darragh’s blood oxygen.

The Problem: No Insurance, Few Protections

The children’s hospital charged only about $3,000 more for the toddler’s three-day stay than the ambulance company charged for the ride, Yoder said.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid, the public health program that covers low-income residents, or for the Ohio Children’s Health Insurance Program, which covers moderate-income kids.

The Yoders belong to a Christian health care sharing ministry, with members paying into a fund that helps reimburse them for medical bills.

Unlike health insurance, such arrangements do not offer members negotiated rates with ambulance companies or other medical providers. And there are no state or federal billing protections that would help an uninsured patient in Ohio with a ground ambulance bill.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid or for the Ohio Children’s Health Insurance Program. (Maddie McGarvey for ��ϳԹ�� News)

The federal No Surprises Act protects those with insurance from large bills for air ambulance transportation provided outside their insurers’ network agreements. But by the law — and even if they were, that wouldn’t have helped the Yoders, since they didn’t have insurance.

Patricia Kelmar, the senior director of health care campaigns , a national advocacy group, said ambulance charges vary widely. She said she’s seen per-mile charges ranging from less than $30 to more than $80, as well as base rates that differ dramatically.

Some patients, such as those with traumatic injuries, need ambulances with highly trained staff and advanced medical equipment, Kelmar said, so it makes sense that those rides would be more expensive. But patients rarely are told what the ride will cost until they receive a bill.

Jennifer Robinson, a spokesperson for Mercy Health, said she couldn’t comment on a specific patient’s case but said the staff follows established medical standards. “When a patient requires a higher level of treatment, ambulance transfer between facilities is best practice to ensure appropriate care,” she said in an email to ��ϳԹ�� News.

Kimberly Godden, a vice president for the ambulance company, Superior Ambulance Service, said a doctor at the first hospital requested a high-level transport for the patient, requiring specially trained staff.

“Our priority is always to ensure patients receive the highest-quality care when they need it most, and we respond to every call regardless of a patient’s ability to pay,” Godden said in an email. “Superior had the team and resources available to quickly and safely move the patient to the higher level of care they needed within the time frame set by the ordering physician.”

Godden said the company would offer a “charity care” rate to Yoder if the family qualified for it.

The Resolution

Yoder said she repeatedly discussed the bill with ambulance company representatives, including the option for charity care. They told Yoder the best deal they could offer was to reduce the total by about 40%, to $5,600, if the family paid it in a lump sum, she said.

After months of discussion, the family wound up agreeing to that deal, Yoder said. They put the charge on a new credit card, which gave them 17 months to pay it off with no interest.

They have agreed to payment plans with the two hospitals, which offered charity care discounts that dropped the bills to a total of about $6,800.

The Yoders expect the sharing ministry to reimburse them for about 75% of the payments they’re making to the hospitals and the ambulance service.

The Takeaway

Patients and their families should feel comfortable asking hospital staffers whether a recommended ambulance company is in their insurance network and how much the ride to another location will cost, said Kelmar, a national expert on such bills. “Shouldn’t the hospital know that?” she said. “I don’t think it’s that heavy of a lift.”

Kelmar said she doesn’t want to discourage people from taking an ambulance if a doctor says it’s necessary. Once consumers receive a bill for the service, she said, they often can negotiate the price down. It can help to look up what the ambulance service accepts as payment from government programs. Those rates are often much lower than the full-price charges patients see on a bill.

If the family had been covered by Ohio’s Medicaid program, the ambulance service would have been paid much less than it charged the Yoders. The public health program pays ambulance services for “specialty care transports,” plus $5.05 per mile. Those rates would have added up to $609.95 for the transportation part of Darragh’s ambulance ride.

Yoder said she wishes she had driven Darragh straight to the children’s hospital. If she had skipped the local ER, she said, they would have arrived at the bigger hospital sooner and she would have saved thousands of dollars.

But she didn’t feel as if she had a choice about putting her son in the ambulance, she said. The doctor told her it was necessary, and the hospital staff had already inserted an intravenous line. “I wasn’t going to pull out his IV line and just leave,” she said.

Yoder said she remains uninsured because she hasn’t seen any private insurance options that suit her family’s circumstances. No matter who pays the ambulance bill, she thinks the charges were much too high. She understands that patients can often negotiate discounts, she said, “but you shouldn’t have to work so hard for it.”

Yoder with her son, Darragh. (Maddie McGarvey for ��ϳԹ�� News)

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Projected Surge in Uninsured Will Strain Local Health Systems

Sam Whitehead — Wed, 17 Sep 2025 09:00:00 +0000

RIO GRANDE CITY, Texas — Jake Margo Jr. stood in the triage room at Starr County Memorial Hospital explaining why a person with persistent fever who could be treated with over-the-counter medication didn’t need to be admitted to the emergency room.

“We’re going to take care of the sickest patients first,” Margo, a family medicine physician, said.

It’s not like there was space on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of current patients, who filled the ER. An ambulance idled outside in the South Texas heat with a patient waiting for a bed to open up.

“Everybody shows up here,” Margo said. “When you’re overwhelmed and you’re overrun, there’s only so much you can do.”

Starr County, a largely rural, Hispanic community on the southern U.S. border, when it voted Republican in a presidential election for the first time in more than a century. Immigration and the economy in this community, where roughly a third of the population falls below the poverty line.

The Rio Grande Valley in South Texas has some of the highest uninsured rates in the U.S., which stresses its health systems. More communities could feel that strain as the number of uninsured residents is expected to swell over the next decade. (Sam Whitehead/��ϳԹ�� News)

Now, recent actions by the Trump administration and the GOP-controlled Congress have triggered a new concern: the inability of doctors, hospitals, and other health providers to continue to care for uninsured patients. It’s a fear not only in Starr County, which has one of the highest uninsured rates in the nation. Communities across the U.S. with similarly high proportions of uninsured people could struggle as additional residents lose health coverage.

About 14 million fewer Americans are expected to have health insurance in a decade due to President Donald Trump’s new tax-and-spending law, which Republicans dubbed the One Big Beautiful Bill Act, and the pending expiration of enhanced subsidies that slashed the price of Affordable Care Act plans for millions of people. The new law also that send billions of dollars to help those who care for uninsured people stay afloat.

“You can’t disinsure this many people and not have, in many communities, just a collapse of the health care system,” said Sara Rosenbaum, founding chair of the Department of Health Policy and Management at George Washington University’s Milken Institute School of Public Health.

“The future is South Texas,” she said.

��ϳԹ�� News is examining the impact of national health care policy changes on uninsured people and their communities. Though the Trump administration told ��ϳԹ�� News it is making “a historic investment in rural health care,” people who treat low-income patients, as well as researchers and consumer advocates, say recent policy decisions will make it harder for people to stay healthy. Doctors, hospitals, and clinics that make up the health care safety net could lose so much money they must close their doors, some of them warn.

“Because the patient’s bill is not going to get paid,” said Joseph Alpert, editor-in-chief of The American Journal of Medicine and a professor of medicine at the University of Arizona. “Uninsured patients stress the health care system.”

Starr County shows how this dynamic unfolds.

Primary care doctors in the county serve an average of each, nearly three times the U.S. average.

Margo, the family physician, said because so many people lack insurance and there are so few places to seek care, many residents treat the ER as their first stop when they’re sick.

In many cases, they have neglected their health, making them sicker and more expensive to treat. And requires ERs at hospitals in the Medicare program to stabilize or transfer patients, regardless of their ability to pay.

That leaves Margo and his team to practice what he described as “disaster medicine.”

“They come in with chest pain or they stop breathing. They collapse. They’ve never seen a doctor,” Margo said. “They’re literally dying.”

Health Systems in ‘Survival Mode’

When people are uninsured or on Medicaid, they tend to rely on a safety net of doctors, hospitals, clinics, and community health centers, which offer services free of charge or absorb getting reimbursed at lower rates than they do treating patients on commercial insurance.

Those providers’ financial situations can often be precarious, leading them to rely on myriad federal supports. The Trump administration’s cuts to health care and Medicaid in the name of eliminating “waste, fraud, and abuse” have many concerned they won’t weather the additional financial strain.

Trump’s new law funds his priorities, like extending tax cuts that mainly benefit wealthier Americans and expanding immigration enforcement. Those costs are covered in part by a nearly $1 trillion reduction in federal health spending for Medicaid within the next decade and changes to the ACA, such as requiring additional paperwork and shortening the time for people to sign up.

Many Republicans have argued Medicaid has gotten too large and strayed from the state-federal program’s core mission of covering those with low incomes and disabilities. And the GOP has fought to roll back the ACA since its passage.

Kush Desai, a spokesperson for the White House, said projections from the nonpartisan Congressional Budget Office about how many people could lose health insurance are an “overestimate.” He did not provide an estimate the administration sees as more accurate.

Supporters of the “One Big Beautiful Bill” say those who need health coverage can still get it if they meet new requirements such as working in exchange for Medicaid coverage.

And Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said even with the legislation, Medicaid spending will grow, just not as quickly.

The budget law won’t cause “the sky to fall,” Cannon said. “The inefficient providers should be shutting down.”

from AMGA, formerly the American Medical Group Association, which represents health systems across the country, found nearly half of rural facilities could close or restructure due to Medicaid cuts. Nearly three-quarters of respondents said they anticipated layoffs or furloughs, including of front-line clinicians.

Public health departments, which often fill gaps in care, also face federal funding cuts that have reduced their capacity. In South Texas’ Cameron County, the health department has eliminated nearly a dozen positions, said agency head Esmer Guajardo. In neighboring Hidalgo County, the health department has laid off more than 30 people, said Ivan Melendez, who helps oversee its operations.

In July, the Texas Department of State Health Services , a massive annual event that last year provided free health services to nearly 6,000 South Texas residents.

Gateway Community Health Center in Laredo, a border city north of the Rio Grande Valley, is in “survival mode,” with about a third of patients already lacking insurance and even more who will struggle to afford health care if the ACA subsides aren’t renewed, said David Vasquez, its director of communications and public affairs. The center is looking for other forms of funding to avoid layoffs or cuts to services, and its expansion and hiring plans are on hold, Vasquez said.

That downsizing is happening as more people lose health insurance and need free or reduced-cost care.

Esther Rodriguez, 39, of McAllen has been out of work for two years and her husband makes $600 a week working in construction. Neither of them has health insurance.

Medicaid covered the bills for the births of her five children. Now, she depends on a mobile health clinic run by a local medical school, where she can pay out-of-pocket for routine checkups and drugs to control her Type 2 diabetes. If she needed more care, Rodriguez said, she would go to the ER.

“You have to adapt,” she said in Spanish.

‘Death by a Thousand Cuts’

People’s inability to pay results in uncompensated care, or services that hospitals, doctors, and clinics don’t get paid for, which, under an earlier version of the megabill, was projected to increase by $204 billion over the next decade, , a nonprofit think tank.

But the Trump administration is also cutting other support that helped offset the cost of care for people who can’t pay. The new law caps federal programs that many health providers for low-income people have come to depend on, especially in rural areas, to shore up their budgets. These include taxes on hospitals, health plans, and other providers that states use to help fund their Medicaid programs. Such provider taxes are a “financial gimmick,” Desai said.

While the law creates a temporary $50 billion fund to support rural doctors and hospitals, that’s a little over a third of estimated Medicaid funding losses in rural areas, , a health information nonprofit that includes ��ϳԹ�� News. Desai called the analysis “flawed.”

Any loss in revenue could spell financial ruin, especially for small rural hospitals, said Quang Ngo, president of the Texas Organization of Rural & Community Hospitals Foundation.

“It’s kind of like death by a thousand cuts,” he said. “Some will probably not make it.”

And the hits could keep coming. The Trump administration’s budget request for the coming fiscal year calls for cuts to multiple rural health programs operated through the Health Resources and Services Administration. Desai said the spending law’s investment in rural health “dwarfs” the cuts.

In February, the Trump administration announced funding cuts of 90% to the ACA navigator program, which helps people find health insurance. That program has been “historically inefficient,” Desai said.

In December 2023, nearly 3 million of Texas’ uninsured were eligible for ACA subsidies, Medicaid, or the Children’s Health Insurance Program, , a public policy think tank.

Maria Salgado, a community health worker in South Texas’ Rio Grande Valley, says many of her clients need help navigating the often complicated process of enrolling in — and keeping — health coverage. “Health insurance is not a luxury; it’s a necessity,” she says. (Sam Whitehead/��ϳԹ�� News)

Maria Salgado spends her workdays tabling at community events, dropping off flyers at doctors’ offices, and holding one-on-one meetings with clients of MHP Salud, a nonprofit that connects residents to Medicaid and ACA coverage.

She worried funding cuts would really set the organization’s efforts back: “A lot of community members here, they’re going to be left behind,” said Salgado, a community health worker, or promotora.

Chris Casso, a primary care physician who grew up in McAllen and now practices there, held back tears as she described treating patients who have put off seeing a doctor because of an inability to pay, only to have their preventable conditions deteriorate.

She worries about the future of her community as , potentially leaving few providers to treat uninsured people.

“It’s heartbreaking,” she said, sitting in a small back room in her office in a suburban strip mall, wedged between a Kohl’s and a Shoe Carnival. “These are hardworking people,” she said. “They try their best to take care of themselves.”

Casso said her own sister, who worked as a medical biller in a physician’s office, couldn’t afford health insurance. She delayed care and died at age 45 of complications from diabetes and heart disease. Casso worries the future will find more people in similar situations.

“Our population is going to suffer,” she said. “It’s going to be devastating.”

Casso grew up in McAllen, Texas, and now practices family medicine there. Her sister died at age 45 because she couldn’t afford health insurance to treat her heart disease and diabetes. Casso worries more in her community could face a similar fate. (Sam Whitehead/��ϳԹ�� News)

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Researchers Shift Tactics To Tackle Extremism as Public Health Threat

Taylor Sisk — Mon, 08 Sep 2025 09:00:00 +0000

Rebecca Kasen has seen and heard things in recent years in and around Michigan’s capital city that she never would have expected.

“It’s a very weird time in our lives,” said Kasen, executive director of the .

Last November, a group of people were captured on surveillance video early one morning mocking a “Black Lives Matter” sign in the front window of the center, with one of them vandalizing its free pantry. That same fall, Women’s Center staff reported being harassed.

A couple of blocks down East Michigan Avenue, Strange Matter Coffee, which supports progressive causes in the community, has been confronted by “” outside its storefront. Some toted guns or cameras, sometimes chanting slogans supporting President Donald Trump, generally unnerving customers and staff, Kasen said.

In many cases, throughout the U.S. over the past few years have been driven by the deepening and disinformation-driven rebellion against responses to the covid-19 pandemic. More recently, backlash against immigration and diversity, equity, and inclusion initiatives has heightened tensions.

Last year, the documented nationwide sowing unrest through a wide range of tactics, sometimes violent. Over the last several years, the group writes, the political right has increasingly shifted toward “an authoritarian, patriarchal dedicated to eroding the value of inclusive democracy and public institutions.”

Researchers at American University’s , or PERIL, say that in online spaces, “hate is intersectional.” (For example, Pasha Dashtgard, PERIL’s director of research, explains, platforms dedicated to male supremacy are often also decidedly antisemitic.) Seemingly innocuous discussions erupt into vitriol: The release of “A Minecraft Movie” prompted tirades against an alleged trend toward casting Black women and nonbinary people.

The continued escalations drove staffers at PERIL and the Southern Poverty Law Center to approach the problem from a different angle: Treat extremism as a public health problem. are now operating in Lansing, Michigan, and Athens, Georgia, offering training, support, referrals, and resources to communities affected by hate, discrimination, and supremacist ideologies and to people susceptible to radicalization, with a focus on young people.

The team defines extremism as the belief that one’s group is in direct and bitter conflict with another of a different identity — ideology, race, gender identity or expression — fomenting an us-versus-them mentality mired in the conviction that resolution can come only through separation, domination, or extermination.

Researchers who study extremism say that, as the federal government terminates grants for violence prevention, state governments and local communities are recognizing they’re on their own. (CARE receives no federal funding.)

Aaron Flanagan, the Southern Poverty Law Center’s deputy director of prevention and partnerships, said his organization and PERIL came together about five years ago to examine a shared research question: What would it take to create a nationally scalable model to prevent youth radicalization, one that’s rooted in communities and provides solutions residents trust?

They looked to a decades-old German counterextremism model called mobile advisory centers. The objective is to equip “all levels of civil society with the skills and knowledge to recognize extremism” and to engage in conversations about addressing it, Dashtgard said.

“We’re not about, ‘How do you respond to a group of Patriot Front people marching through your town?’” Pete Kurtz-Glovas, who until June served as PERIL’s deputy director of regional partnerships, explained during a training in January. “Rather, ‘How do you respond when your son or a member of your congregation expresses some of these extremist ideas?’”

Michigan has long been considered . Timothy McVeigh and Terry Nichols, convicted of the bombing of a federal building in Oklahoma City in 1995, were associated with a militia group in the state. Some of the men charged in 2020 in the plot to had ties to a militia group calling itself the Wolverine Watchmen.

The state’s capital city and adjacent East Lansing, where Michigan State University is, are relatively progressive but have seen conflict.

Will Verchereau has a vivid recollection from the early days of the pandemic: a pickup truck speeding down the street in their Lansing neighborhood, a Confederate flag flying from it, music blasting, later joining a rolling protest that clogged streets around the Capitol to protest Whitmer’s covid lockdown directives.

Members of the far-right “Boogaloo” movement stand on the steps of the Michigan Capitol during a rally on Oct. 17, 2020. (Seth Herald/Getty Images)

Incrementally, the community has responded to these expressions of extremism. After the confrontations at Strange Matter Coffee, Verchereau, a board member of the , which advocates for and supports the LGBTQ+ community, said people banded together to talk about “how to be safe in those moments; how to de-escalate when and where possible.”

The CARE initiative reinforces such efforts. The centers offer tool kits catered to specific audiences. Among them are a to online radicalization, a , and “.”

Flanagan said the team views this public health model as separate from but complementary to law enforcement interventions. The goal is to have law enforcement as minimally engaged as possible — to detect nascent warning signs and address them before police get involved.

The resources help identify conditions that can make people more susceptible to manipulation by extremists, such as unaddressed behavioral health issues and vulnerabilities, including having experienced trauma or the loss of a loved one.

Lansing resident Erin Buitendorp witnessed protesters, some of them armed, flood the state Capitol building during the pandemic over lockdown and masking orders. She’s a proponent of the public health approach. It’s “providing people with agency and a strategy to move forward,” she said. It’s a way to channel energy “and feel like you can actually create change with community.”

Lansing and Athens were chosen for a number of reasons, including their proximity to universities that could serve as partners — and to rural communities.

In the small town of Howell, 40 miles southeast of Lansing, outside a production of the play “The Diary of Anne Frank” at an American Legion post.

In nearby DeWitt, the local school district proposed a mini lesson on pronouns for a first grade class that involved reading the picture book “They She He Me: Free to Be!” Threats against school staff followed and officials canceled the lesson. Since then, the CARE team has helped provide support to teachers there in holding conversations on contentious topics in classrooms and in dealing with skeptical parents.

“It’s really important that rural communities not be left behind,” Flanagan said. “They persistently are in America, and then they’re often simultaneously demonized for some of the most extreme, or extremist, political problems and challenges.”

The CARE team hopes to expand its program nationwide. Similar public health initiatives have been launched elsewhere, including Boston Children’s Hospital’s and the , run by New York City’s Citizens Crime Commission.

And in June a new tool, the , went live, offering guidance to help prevent violent extremism.

Pete Simi, a professor of sociology at Chapman University and a leading expert on extremism, sees a daunting task ahead, with extremism’s having become more mainstream over the past 25 years. “It’s just devastating,” he said. “It’s really startling.”

Simi said that while there was previously talk of shifts in the Overton window, the range of ideas considered politically acceptable to mainstream society, “I would say now it has been completely shattered.” Violent extremists now feel “unshackled, supported by a new administration that has their back.”

“We are in a more dangerous time now than any other in my lifetime,” Simi said.

The Rev. Pippin Whitaker ministers the Unitarian Universalist Fellowship of Athens in Georgia, which last year received a package of ammunition in the mail with no note included. She embraces framing extremism, and people’s lack of awareness of it, as a public health issue.

“If you have a germ out there,” Whitaker said, “and people aren’t aware that if you wash your hands you can protect yourself, and that it’s an actual problem, you won’t enact basic protective behavior.”

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