But U.S. District Judge John D. Bates, in a , also agreed with the administration that it was unconstitutional for the government to use race or ethnicity as the basis to award money under a program created to expand internet skills and access.

“It was definitely disappointing,” said Angela Siefer, executive director of the National Digital Inclusion Alliance, a nonprofit that filed suit last year after not receiving a award meant to bolster digital and internet skills nationwide. “With this administration it’s really worrisome.”

Congress passed the $2.75 billion Digital Equity Act in 2021 as the skill development component of a multilayered “” initiative under President Joe Biden’s signature infrastructure law, which included a bigger pot of money for expanding internet infrastructure.

A few months into his second term, Trump directly attacked the Digital Equity Act on social media, pledging “” and calling the program “illegal.” The language echoed two Trump executive orders characterizing diversity, equity, and inclusion programs .

The National Telecommunications and Information Administration, which oversees implementation of the law, responded by Digital Equity Act grant programs, leaving states and organizations like the National Digital Inclusion Alliance in limbo.

In response to Bates’ decision, federal attorneys said the government would reinstate the NDIA-related competitive grant program without racial classification. The government aims to release a new grant application in December, according to a filed in the case.

The NDIA now must reapply for the grant award, which was slated to be disbursed among more than a dozen organizations and tribes, including the Cherokee Nation in Oklahoma, El Centro Hispano in Arkansas, Portland Community College in Oregon, and Community Service Programs of West Alabama. The grants are meant to go toward digital navigator programs, in which community workers teach technology and internet skills, according to the NDIA.

In western Ohio, Jamie Huber said her organization was a subrecipient of the NDIA grant funds. Huber, director of community services at the Northwestern Ohio Community Action Commission, said that without the funding, she is left searching for money to continue navigator programs such as one she runs for people who are unemployed, homeless, or both.

“How do you find a home? Well, you got to look online. And how do you find a job? You have to look online,” Huber said.

Huber’s digital navigators also teach internet skills at 10 senior centers in rural counties stretching along the corner of Ohio bordering Michigan and Indiana. They help active older adults learn how to go online to pay bills and get healthcare, so they “continue having agency over their own life,” Huber said.

Rural residents live sicker and die younger on average than people in the rest of the country when they live in counties lacking high-speed internet access and healthcare, an analysis by Ñî¹óåú´«Ã½Ò•îl Health News found.

At Computer Reach in western Pennsylvania, Executive Director Dave Sevick said his organization has cut staff and programs. He said the nonprofit, which started in 2001, has refurbished more than 24,000 computers, giving them away to families it finds through schools and churches.

“We’re aware that affordability is the biggest issue around, and this doesn’t make it any better for folks,” Sevick said. “We’re helping a little bit by getting a free computer out to people.”

The Digital Equity Act the money should benefit, including low-income households, older people, some incarcerated people, rural Americans, veterans, and members of racial or ethnic minority groups.

According to by the Pew Research Center, people in rural communities were less likely to have internet subscriptions compared with their urban and suburban counterparts.

The Pew Research polling that home broadband use among Black and Hispanic adults lagged that of white and Asian adults. While 81% of white adults surveyed said they subscribed to broadband at home, only 71% of Black adults and 68% of Hispanic adults said the same.

In court, lead federal attorney Patrick Butler argued that Congress failed to prove a compelling government interest when including the racial or ethnic criteria. Congress did not “identify anything close to” a specific instance of discrimination in the broadband industry, Butler said, .

Butler then surprised the court, if the racial or ethnic status could be severed from the law, “we would obviously apply the grant program without considering race.”

In his opinion severing the race factor, Bates that “the President lacks the power to cancel laws passed by Congress based on his bald disagreement with Congress’s policy determinations.”

Sen. Patty Murray (D-Wash.), a primary , said she will be “watching very carefully to ensure this administration does what Congress intended.”

“It is indisputable that these challenges are particularly pronounced in low income, rural, and Tribal communities — and there’s a reason Democrats and Republicans across the country support this program so strongly,” Murray said in a statement to Ñî¹óåú´«Ã½Ò•îl Health News. 

Sen. Ted Cruz (R-Texas) Biden’s infrastructure bill in 2021 and to the National Telecommunications and Information Administration in late 2024 asking the agency to pause the $1.25 billion competitive grants program, arguing the use of racial classifications “does not serve a compelling governmental interest.” Cruz did not respond to requests for comment.

Arielle Roth, administrator of the agency, previously worked as the telecommunications policy director for the Senate Commerce, Science, and Transportation Committee’s majority staff under Cruz. She was to lead the agency.

In June, during a House committee hearing, Roth had tense exchanges with Democrats who took issue with changes to the Biden-era infrastructure law’s internet deployment program, which now allows more satellite services rather than prioritizing fiber-optic cable lines.

Lawmakers also asked about the Digital Equity Act’s grant programs.

“Communities across the country deserve a clear answer and a path forward,” Rep. Nanette Barragán (D-Calif.) said during the hearing. While the National Digital Inclusion Alliance’s lawsuit does not include the state grants, Barragán asked how those grants would be rolled out, considering the federal judge’s decision on race.

California was awarded a $70 million state capacity grant. Early this year, the Justice Department to Congress asserting that the state grant and the competitive grant program both are illegally based on race, citing the Supreme Court’s decision invalidating affirmative action in higher education admissions. Roth declined to answer Barragán’s question, noting there is active litigation.

Barragán said she was “extremely” frustrated by “some of the responses or nonresponses.”

Stephen Yusko, a spokesperson with the National Telecommunications and Information Administration, declined to comment or respond to questions for this article.

The government and the National Digital Inclusion Alliance agreed to pause court proceedings to give the agency time to reinstate the competitive grant program. The NDIA has also proposed that the agency provide status reports every 30 days during the court pause “to ensure prompt attention to reinstatement,” according to the most recent .

“We need to make sure it’s all moving forward,” Siefer said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The decision by federal officials, citing authority granted under President Donald Trump’s signature tax-and-spending law, suggests the GOP-led state’s predicament could foretell other repercussions in how states are allowed to run the program under federal waivers.

Nearly every state has at least one waiver to run its Medicaid program differently than required by federal law, such as allowing the use of private managed-care plans or expanding eligibility for mental health or long-term care services. Some Medicaid waivers have stretched decades, renewed by presidential administrations of both parties, effectively making the demonstration programs they created permanent.

Arkansas is one of a dozen states with a waiver expiring Dec. 31 that face the additional restrictions the Trump administration has placed on new or renewed waivers.

Though it has yet to finalize its decision, the federal Centers for Medicare & Medicaid Services said Arkansas’ 13-year-old waiver does not comply with new “budget neutrality” rules that take effect in January, said Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services. The rules tighten a policy forbidding Medicaid waivers from increasing federal spending on the program beyond what it would have increased without the waiver.

The state is now seeking a two-year extension after hearing from CMS that its request for a five-year renewal would not be granted. If its Medicaid expansion waiver is not renewed, Arkansas officials have said they will continue offering expanded eligibility through existing Medicaid law, a change that could leave enrollees with access to fewer doctors and other health providers.

Rather than place more people in its traditional Medicaid program serving largely children, pregnant women, and disabled people, Arkansas obtained a waiver to buy Affordable Care Act marketplace policies from private insurers for adults covered by the Medicaid expansion. This “private option” gave enrollees greater choice of doctors and other health providers, because some doctors are more willing to see patients with private coverage, which generally pays more than regular Medicaid.

The move helped cut the state’s uninsured rate by nearly half, but it also ended up costing more than if beneficiaries were covered under Medicaid’s traditional, fee-for-service program.

Critics characterize the new waiver rules as part of a Trump administration effort to dramatically shrink Medicaid, the government program for those who are low-income or disabled, which grew rapidly under Presidents Barack Obama and Joe Biden.

“What we have here is a sneaky way to cut Medicaid expansion and the Medicaid program,” said Nicole Huberfeld, a professor of health law at Boston University.

Medicaid enrollees won’t know whom to blame if they lose coverage because the administration is using arcane regulatory processes to make the changes, Huberfeld said.

At issue are waivers granted by the government that allow states flexibility from existing Medicaid law in how they cover low-income residents, as long as the changes will not increase what Medicaid costs the federal government.

Pivoting from the long-standing practice of checking only retroactively whether states were keeping their budget promises, the Trump administration that it would not renew or approve any waivers unless CMS first certified that they would not increase costs to the federal government.

In its , the agency said the new waiver rules are expected to reduce federal spending.

“Characterizing enforcement of a statutory budget neutrality requirement as a cut misrepresents both the law and this guidance,” CMS spokesperson Timothy Foster said in an email to Ñî¹óåú´«Ã½Ò•îl Health News. The federal waivers are intended “to test innovative approaches to delivering care, not provide an open-ended mechanism for increasing federal spending.”

Other states with waivers expiring at the end of December include Georgia, which has added about 18,000 low-income people to Medicaid under its waiver, and California, which has used its waiver to expand coverage of social services including food and housing.

California and Georgia Medicaid officials told Ñî¹óåú´«Ã½Ò•îl Health News that they are still working with CMS in hopes of renewing their waivers. The loss of federal waiver approval could cause states to curtail benefits or eligibility expansions.

In Arkansas, it would mean redesigning the state’s Medicaid expansion program.

Arkansas’ initial waiver was granted in 2013, when its Democratic governor at the time worked with a Republican-controlled legislature to adopt a pioneering style of Medicaid expansion under the Affordable Care Act.

It was one of the first Southern states to expand Medicaid, granting coverage to many low-income residents. Forty states and Washington, D.C., have also fully expanded Medicaid to cover more low-income adults under the law also known as Obamacare.

The state’s Medicaid expansion enrollees were already facing a confusing time. Starting in January, they will need to prove they work or meet an exemption to be eligible for coverage under Trump’s law, the One Big Beautiful Bill Act. And one of the state program’s two private health insurers — Centene — announced in July that it was pulling out at the end of the year.

Sam Dubke, a spokesperson for Republican Arkansas Gov. Sarah Huckabee Sanders, told Ñî¹óåú´«Ã½Ò•îl Health News that the Sanders administration is trying to negotiate a temporary extension of its waiver “to ensure impacted Arkansans maintain access to quality, affordable healthcare during this transition period.”

“Looking ahead to the next legislative session, CMS has provided the state with an opportunity for bold, conservative healthcare reform, and the governor will work with her partners in the legislature to build a sustainable model that maintains the same high quality of care and saves taxpayer dollars,” Dubke said.

The Trump administration’s new restrictions on waivers, implemented under the same law that imposes work requirements as a condition of eligibility and reduces Medicaid spending by about $900 billion over a decade, could affect millions of enrollees and billions in spending. About a third of the almost $600 billion in federal spending on Medicaid and the Children’s Health Insurance Program in 2024 supported programs created by waivers, according to CMS.

In a , the Government Accountability Office found that the three-year spending limit the federal government approved for Arkansas’ Medicaid waiver was nearly $800 million more than what the state would have spent through its traditional Medicaid program.

Arkansas is one of several states that expanded Medicaid under the ACA using a waiver, with others including Indiana, Michigan, New Hampshire, and Iowa.

States will have to clear several more bureaucratic hurdles to retain waivers under the new CMS guidance, said Alice Lam, a managing director with consulting and legal firm Manatt. That could lead to fewer benefits or reduce the number of people eligible for Medicaid, she said.

Robert Nelb, director of policy at America’s Essential Hospitals, which represents safety net hospitals, said he and most experts believed when it passed that the One Big Beautiful Bill Act was merely codifying CMS policy on budget neutrality.

But the Trump administration has interpreted the law to restrict states’ use of waivers, he said.

Nelb said many long-standing waivers that have been renewed multiple times are now at risk and that the loss of state waivers could threaten money hospitals rely on to cover uninsured patients and improve care in their communities.

“There is a real concern that this will put added burdens on states up front and slow down new innovations in Medicaid,” Nelb said.

In 2025, the Trump administration told states it would no longer renew Medicaid waivers to help enrollees with job training or to allow continuous eligibility for adults and children for specific time periods without verifying their income eligibility.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The wristbands are part of a growing initiative first launched by North Carolina-based ECU Health as Congress sought to address the nation’s growing maternal mortality crisis during the covid pandemic. , and the state’s health department have begun distributing the wristbands, to give mothers and care providers a visual reminder of the life-threatening health risks after birth.

The Connecticut state health department; large health systems in Arkansas, Georgia, and Mississippi; and hospitals in at least 24 other states have also embraced the program. The wristbands are intended to make emergency workers aware of postpartum risks, ensure better treatment, and help lower maternal mortality rates in the U.S., where happen after the day of delivery — and nearly 40% happen after the six-week mark.

This year, North Carolina plans to expand the initiative with part of the through the Rural Health Transformation Program, a provision of President Donald Trump’s signature One Big Beautiful Bill Act, also known as HR 1.

Tamika Auguste, a physician and the board chair at the American College of Obstetricians & Gynecologists Foundation, praised the wristbands as a useful tool “to increase awareness and education around postpartum health.” But she and others who focus on maternal health said efforts like the wristband campaigns are only part of what’s needed to combat the broader maternal mortality crisis in the U.S.

And they noted the wristbands’ popularity is emerging as Trump’s 2025 law is expected to reduce Medicaid spending by over 10 years, according to a Congressional Budget Office analysis. Medicaid, the federal-state program that covers healthcare for low-income families, pays for .

Elisabeth Wright Burak, a policy researcher at Georgetown University’s Center for Children and Families, said Trump’s tax-and-spending law is stifling the momentum states had been gaining with maternal care since 2022. That’s when Congress allowed states to extend postpartum Medicaid coverage , which nearly every state did.

Now, those extensions could end up on the chopping block, Burak said, as states seek ways to manage Medicaid losses.

“There is no question that HR 1 risks setting the clock back for maternal health,” Burak said.

warned that postpartum patients have more to worry about with the new law than simply cuts to Medicaid. States are also setting up systems that may not adequately track pregnant and postpartum enrollees who should be exempt from the law’s new work requirements, erroneously dropping them from coverage, Burak’s report said.

Maternal Mortality

U.S. maternal mortality rates have risen and fallen over the past seven years, with 649 maternal deaths in 2024, according to the most recent . Tennessee had the worst maternal mortality rate in the nation from 2020 to 2024, around 42 deaths per 100,000 births, according an analysis of CDC data by the . North Carolina’s rate was about 29 in 100,000, with a national average of 23.

In its , North Carolina said the initiative creating the “I Gave Birth” wristbands reduced postpartum readmissions by nearly a third at ECU Health Medical Center in Greenville, without elaborating. In online promotions, some hospitals the can , though many have recently launched and their impact has yet to be studied.

“Additional research is needed to conclusively confirm the outcomes of such initiatives,” said Hannah Jones, a spokesperson for the North Carolina health department.

Hospitals to patients who have given birth and instruct them to wear it for weeks or months, hoping they’ll be reminded to check in with a physician if they feel chest pain, have headaches, or start bleeding. The accessory resembles the yellow , part of a cancer awareness campaign launched by cyclist Lance Armstrong’s foundation. A nurse also talks through postpartum risks with the patients, and they’re sent home with pamphlets and guidebooks on how to care for their new child and themselves.

“The bracelet itself is simply a reminder of, ‘Hey, I got education,’” said Jessica Noble, a nurse with East Carolina University-connected ECU Health who pioneered the initiative.

It’s also intended to alert first responders and other healthcare providers that a woman has recently given birth and to check for postpartum complications, such as low blood pressure, bleeding, or infections. and sometimes don’t have adequate training to recognize postpartum complications, research shows, which can be dangerous when those patients end up in an emergency room.

Postpartum wristbands gained traction across the country through health awareness campaigns fueled by social media posts and evening news segments. New mothers appeared in promotional photos and videos wearing the wristband and raving about the accessory, saying it celebrated childbirth.

Some postpartum patients who faced traumatic births or mental health struggles saw it differently.

‘So Many Risks’

Alexandra Mellon gave birth last year. Her daughter was stillborn. Devastated, she sought out a therapist, donated her breast milk, and tried to find meaning in her circumstances. She spent a year feeling isolated, she said, often because people don’t know what to say.

Mellon said wearing one of the wristbands would have been a painful reminder of her loss.

Now she works as a doula in Asheville, North Carolina. Mellon said what she thinks new moms need most is community and emotional support. The wristband could help encourage that for some patients, she said, but isn’t for everyone.

“There are so many risks, and it’s just like you almost become invisible,” she said.

More than 80% of pregnancy-related deaths , according to the CDC. The Centers for Medicare & Medicaid Services in March , developed during the Biden administration, that urged hospitals to create better emergency department protocols to catch postpartum complications and to measure their work against state and national maternal health data.

But those efforts faced a major threat last year when the Trump administration CDC funding for state-level maternal mortality data in its proposed 2026 budget. While Congress rejected that move, the administration did tracking postpartum patients’ health.

The Trump administration $113.5 million in CDC maternal health research in its proposed 2027 budget. Congress has instead proposed increasing funding to .

Without more research, it’s unclear how effective the wristbands are in encouraging postpartum patients to seek care when they need it. A of mass media campaigns to improve health outcomes, such as preventing risky substance use or encouraging exercise, found that the campaigns didn’t change behaviors. found that the U.S. “Back to Sleep” campaign, which educates parents on safe sleeping practices with babies, dramatically reduced rates of sudden infant death syndrome for several years after it launched in 1994, though rates .

In 2020, the CDC tried , “Hear Her,” aimed at helping women speak up when something felt wrong after delivery.

The CDC released years later that said it “had the unintended consequence of appearing to put the burden on the people who are pregnant or postpartum to speak up.”

ECU Health Medical Center created the wristband initiative in 2021 and . In it the authors noted the pregnancy-related readmission rate at the Greenville hospital fell 0.77%. It attributed the change to the “education provided to patients, family members, and medical personnel” in the initiative, without elaborating.

Campaigns like the “I Gave Birth” initiative are far from a final solution to maternal mortality, said Noble, the campaign’s architect and lead author on the ECU Health study. If she “had a magic wand,” she said, North Carolina would not just have better postpartum care but would also address the root causes of pregnancy complications. “But I don’t have one, and I can’t make system-level change immediately.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

“They called me a ‘liability to the job site,’” Pugh said, recalling the words of his manager when a seizure cost him his last job at a fast-food restaurant in this western Montana city.

When the 46-year-old lost work in the past, his wife of 10 years covered their rent and he tended to their home until he found another job. But his wife died last year. Soon after, Pugh became homeless. His problem with alcohol became worse, which made managing his seizures more difficult.

“When she died, my whole base was depleted,” Pugh said.

Medicaid pays for the prescriptions that keep Pugh’s seizures at bay. The government-subsidized health coverage would also pay for an addiction treatment program that Pugh said he has tried to get into, but he was told there’s a waitlist.

Pugh’s goal has been to get healthy enough to work again. But he’s worried about being able to keep the Medicaid coverage he needs to get to that point.

Early Embrace of New Rules

In the spring, the federal government finalized regulations requiring millions of people who receive Medicaid benefits to prove they’re working, volunteering, or going to school to keep their coverage. States have until January to begin those checks. Montana, Arkansas, and Nebraska have already started implementing them.

The Trump administration’s federal work requirements exempt certain groups of people: those with disabilities, those older than 64, pregnant people and Native Americans, among others. To receive an exemption, anyone without a clear-cut qualification — such as through their age or disability status — will have to prove they’re too sick to work.

But the administration decided that being homeless isn’t a medical condition and can’t count as an automatic out from having to meet the new requirements. Many conservative policymakers support work requirements, and some states have attempted to implement such rules for years. At least four states — Montana, Arizona, Kentucky, and Utah — previously proposed policies that included homelessness as an exemption.

But federal officials have said that’s not allowed. In an email to Ñî¹óåú´«Ã½Ò•îl Health News, the Centers for Medicare & Medicaid Services declined to provide a comment on the record. But the agency confirmed that states must stick to the federal government’s list of exemptions. Homelessness in the U.S. increased by 27% from 2013 to 2025, from the Department of Housing and Urban Development. Last year, about 746,000 people .

Many, like Pugh, qualified for Medicaid, though the number of enrollees who are homeless is difficult to measure. In 2023, who received medical or behavioral health services through one of the nation’s roughly 300 programs were enrolled in Medicaid.

Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the federal regulations are a lot stricter than many states had expected, even those on board with work requirements. (KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

“It took everyone by surprise,” Tolbert said.

Mehmet Oz, who leads CMS, touted the regulations as a “path to prosperity” during a press conference in June.

“We need to get people to try to work,” Oz said. In June, 25 mostly Democratic-led states over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess. The work requirements are projected to increase the number of uninsured people nationwide by by 2034, according to the Congressional Budget Office.

Most states will begin to implement the Medicaid work requirements in January. 

Montana plans to begin booting Medicaid enrollees from coverage this October if they can’t prove they’re in compliance with the work requirement.

“My Medicaid is still active, but when are they gonna cut that off from me?” Pugh said. “I can’t get employed. How am I supposed to survive?”

The differences between the states’ and federal government’s exemption lists don’t end with people who are homeless. In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members — two other groups left off the federal exemption list.

“These are simply parties that, due to a number of conditions, cannot meet those requirements,” Republican state Rep. Ed Buttrey said in 2019 when the Montana Legislature passed its first Medicaid work requirement bill. Buttrey did not comment for this article.

Federal officials have said many people who are homeless could fall under another exemption, such as being too sick to work. But, like many states, Montana’s system to automatically conduct those checks through existing medical records isn’t ready, though health department spokesperson Jon Ebelt said it should be in place by October. Anyone not automatically exempted by the state would have 30 days to prove their case.

A Possible Exemption for Health

Pugh might qualify for a pass due to his seizures. But getting to doctor appointments the past year has been hard for him.

The anniversary of his wife’s death just passed. Typically, Pugh has to find a new place to sleep outside each night. One night while camping, Pugh lost his wallet and important documents. And with the addiction treatment centers that accept Medicaid patients overbooked, Pugh has had to rely on willpower to avoid drinking.

“I’m taking it one day at a time,” he said.

A little over two hours north, in Kalispell, Dustin Goss, a case manager at a homeless shelter called Samaritan House, said Pugh’s experience reflects why he’s worried that people who qualify for an exemption will get tangled in bureaucratic tape.

“You can’t really worry about getting paperwork done when you don’t know where you’re eating today,” Goss said.

Cassidy Kipp, who heads Samaritan House, said once people find shelter and start to stabilize, they typically find work. But even then, meeting the new requirements can be challenging. Clients often start with temporary and informal jobs — such as cleaning out a storage unit — that don’t come with a pay stub, Kipp said. 

Kaitlyn Bosshardt, a social worker at Partnership Health Center, a health clinic in Missoula, has seen more people priced out of longtime rentals as housing costs outpace people’s paychecks. Meanwhile, affordable housing and rental aid are limited.

Partnership Health is one of roughly 1,400 health centers nationwide that receive federal funding to serve patients based on what they can afford — meaning even those who lose Medicaid can receive care. But organizations representing health centers have said if too many patients lose the coverage, some clinics won’t be able to fill the financial hole.

The other problem is that these clinics generally don’t provide specialty care.

One day in June, as temperatures hovered around 90,  Pugh visited Watershed Navigation Center, a refuge run by Partnership for people without steady housing to have a meal or see a doctor. His doctor, Atarah Sidey, told Pugh that the neurology clinic that managed his seizures had dismissed him from their care after he missed three appointments.

She referred Pugh to the other neurologist in town and talked about trying to find treatment for his addiction.

“It’s just that if I don’t make the effort at changing, it ain’t gonna happen and I’m gonna end up found on the side of the road somewhere,” Pugh told Sidey.

“You got this, though, Tywon,” she responded as Pugh nodded his head. “You can do this.”

Pugh has connected with a social worker for help keeping his Medicaid. By late July, he was waiting for space to open at a Missoula addiction treatment center and waiting on responses from two job applications.

In the hard moments, Pugh imagines his wife telling him to stay calm, that things will get better.

“I just don’t wanna lose hope in the meantime,” he said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Source: <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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Ñî¹óåú´«Ã½Ò•îl Health News will update this database as more states respond to emails and public records requests for their documents.

Note: Data collected as of Sept. 11, 2026. Ñî¹óåú´«Ã½Ò•îl Health News reporters searched state websites, requested documents, and filed public records requests. Ñî¹óåú´«Ã½Ò•îl Health News continues to collect documents.

Sources: Documents publicly posted online or released in response to Ñî¹óåú´«Ã½Ò•îl Health News requests; <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Researchers this spring discovered in water in several coastal locations across New York’s Long Island, and town officials in the Hamptons vacation destination about the findings. in Florida have been infected this year, and in June urged people to take precautions.

About 1 in 5 people infected by the bacteria die, sometimes within a day or two of becoming ill, according to a Centers for Disease Control and Prevention . The bacteria, Vibrio vulnificus, can enter open wounds and cause tissue death and systemic sepsis.

“Many people with Vibrio vulnificus infection can get seriously ill and need intensive care or limb amputation,” the CDC says.

The risk of such public threats is mounting because climate change is expanding the territory of certain pathogens, but researchers say there’s another concern. The Trump administration has cut investments in programs and agencies that prevent, track, and respond to health hazards the federal government is now confronting.

Consider the , which can infest and kill livestock, in the U.S. in June. The U.S. Department of Agriculture lost in the first six months of 2025, according to a report from the USDA’s Office of Inspector General, and the agency’s winnowed-down inspection service is helping lead the response to the parasite.

Or malaria. A freeze on foreign aid disrupted international malaria prevention efforts, and warned that the U.S. is vulnerable to the reintroduction of the infectious disease.

And when it comes to Vibrio, the Trump administration began removing hundreds of deep-sea instruments that and yield data that helps that can allow the bacteria to flourish. the data to study Vibrio, which can when water temperatures and .

“It is important to track coastal temperatures, and that will relate to the distributions of Vibrio,” said Christopher Gobler, a professor in the School of Marine and Atmospheric Sciences at New York’s Stony Brook University, though he added that there are also other sources of data for researchers.

The Trump administration to dismantle the ocean monitoring system following bipartisan opposition to the effort in Congress.

But it’s still curtailing Vibrio surveillance. The life-threatening species that’s found in water can also sicken or kill people who eat contaminated seafood, such as infected with the bacteria. And infections from Vibrio vulnificus linked to consuming raw or undercooked shellfish as the presence of other pathogens in food decrease.

Since 1995, 10 states have participated in a federal program called the Foodborne Disease Active Disease Surveillance Network, or FoodNet. The program, with the CDC, monitors and track cases of foodborne illness caused by eight specific pathogens, including Vibrio. But last year the Trump administration to report on all but two pathogens, which means states no longer must report cases to the CDC.

Federal officials deny the moves are putting Americans at risk, saying the CDC continues to monitor these pathogens through other national surveillance systems to ensure ongoing visibility into disease trends and outbreaks.

Meanwhile, some former health leaders say the ramifications of sweeping cuts to health agencies and global prevention programs are becoming more apparent, undermining U.S. response efforts and initiatives that aim to safeguard the country from diseases.

“We are letting down defenses that were necessary to protect against microbial threats,” said Tom Frieden, a former CDC director who is now president and chief executive of Resolve to Save Lives, which works to stop preventable disease. “Instead of protecting, we’re doing the opposite.”

Do Limited Resources Mean Higher Risks?

The administration defends its actions, including massive layoffs at government health agencies, as necessary to eliminate wasteful spending.

The Department of Health and Human Services “is advancing the most significant public health reforms in a generation focused on prevention, accountability, scientific transparency, and better health outcomes,” agency spokesperson Emily Hilliard said in an email. “The Department is putting American families at the center of public health decision-making.”

Evidence suggests health risks are rising even as the Trump administration pulls back on resources for research, detection, and response.

Early in his administration, President Donald Trump opted to freeze and review work on global health programs. Trump’s cost-reduction effort, led by billionaire Elon Musk, also dismantled the U.S. Agency for International Development.

As a result, work was disrupted on the President’s Malaria Initiative, a George W. Bush-era program aimed at combating malaria in hard-hit countries that is credited with saving more than . USAID had in the program since 2005.

In addition, for global malaria programs were targeted for termination, , an independent research group that includes Ñî¹óåú´«Ã½Ò•îl Health News. The report didn’t include data on the total value of those specific malaria grants.

And the spending freeze halted research for more effective . The administration dissolved the CDC’s , shuffling staffers to other divisions and on the disease. HHS didn’t respond to an email asking how many staff members had been moved.

The life-threatening infectious disease spread by mosquitos was in 1951. But the CDC’s updated guidance on investigating domestic cases that “the country remains susceptible to malaria reintroduction.”

resulted in 10 people in Arkansas, Florida, Maryland, and Texas becoming infected locally, and mosquitoes capable of transmitting malaria are found throughout most of the country.

“The majority of U.S. residents lack protective immunity against malaria, rendering persons susceptible to severe illness and death if infected,” the CDC said in the May report.

HHS declined to comment on any of the specific cuts but said the CDC works with domestic and international partners to reduce the burden of malaria and prevent its reestablishment in the U.S.

It’s not just cuts to funding that are raising health risks, say researchers and former health officials. Significant staffing cuts mean there are fewer people working on preventing or tracking diseases, they say.

“Yes, the programs have been cut in terms of reduction in staff, but I would say, equally important, you have reductions in expertise,” said Jeanne Marrazzo, CEO of the Infectious Diseases Society of America. “It’s irreplaceable.”

Screwworm is a species of parasitic blowfly producing larvae that can enter open wounds and devour tissue, infecting people and animals. Like malaria, it has long been eliminated in the U.S., and disease monitoring efforts have been key to keeping it out.

The cuts at USAID stripped from the United Nations’ , which focuses on global food security and the such as screwworm.

In the wake of the administration’s cost-cutting initiatives, more than 20,000 employees are gone from the USDA, which develops and implements agriculture policy and provides resources to producers of livestock vulnerable to the parasite.

On June 3, the first new case of screwworm in the U.S. was confirmed, and there have now been infected with parasite. An expanding outbreak could devastate the cattle industry.

Agriculture Secretary Brooke Rollins during the Trump administration have led to screwworm’s return. Instead, she has , saying it didn’t do enough to prevent reintroduction into the U.S. Rollins said on X that “” under the previous Biden administration was partly to blame, providing no evidence.

The USDA did not respond to an email seeking comment.

Ashish Jha, a doctor who served as the White House covid response coordinator during the Biden administration, said there’s no truth to the claim that immigrants lacking legal status have brought screwworm into the U.S.

Investments in tracking and combating diseases have suffered, he said, because HHS Secretary Robert F. Kennedy Jr. is prioritizing the prevention of chronic disease at the expense of efforts to curtail infectious disease.

“Who doesn’t want a healthier country? It sounds great, but it’s kind of a bait and switch,” Jha said. “They’re doing the opposite. They’re letting down our defenses that are necessary to protect us against microbial threats.”

HHS’ Hilliard disagreed, saying Kennedy’s actions are making the agency more effective.

“Secretary Kennedy is delivering that reform by streamlining operations, reducing redundancies, and returning HHS to pre-pandemic staffing levels,” she said. “At the same time, he is dismantling policies and incentives that contributed to a nationwide chronic disease epidemic.”

Surveillance Gaps

Jha pointed to Trump’s decision to withdraw the U.S. from the World Health Organization, which coordinates global responses to public health issues and crises, and to the dismantling of USAID.

The pullback has had implications for the Ebola outbreak in the Democratic Republic of Congo, aid workers say.

Without the same amount of funding from USAID, the International Rescue Committee, which partners to deliver front-line health, surveillance, and outbreak preparedness activities in Congo, .

“Funding cuts have left the region dangerously exposed,” Heather Reoch Kerr, IRC’s country director for Congo, said .

The outbreak is roughly 7,000 miles away, but its spread has the , with stepped-up surveillance and entry restrictions on airline travelers. Federal officials have said that the dismantling of USAID hasn’t hampered detection or response.

“The U.S. government continues to move aggressively to contain the Ebola outbreak at its source in order to protect the American people and prevent further international spread,” the State Department said .

Trump’s decision to disengage with the WHO was criticized by following a hantavirus outbreak this spring on a cruise ship that had set sail from Argentina. the , and they questioned why the president suggested creating a costly new rather than sticking with the WHO — especially, they say, when the U.S. is cutting back on the surveillance programs it already has.

The federal government has tracked Vibrio cases as part of the FoodNet program, which aims in part to identify and curtail outbreaks. Reporting on cases of Vibrio is now optional.

Close to half of the cases of foodborne illness caused by Vibrio vulnificus have , and some within 24 hours after consumption of tainted shellfish such as raw oysters. The bacteria can multiply rapidly, leading to septic shock and blistering skin lesions. The pathogen is becoming to antibiotics.

The CDC estimates that of Vibrio infection occur annually, with infections from the most severe species, Vibrio vulnificus, steadily rising. , that species has led to 429 cases due to infections of open wounds and 135 cases from contaminated food.

“The more surveillance you get, you can connect the dots,” said Bill Marler, a Seattle-area food safety lawyer. “If a tree falls in the woods and you don’t hear it, did the tree fall? It’s easier not to report diseases. Then they can say, ‘Look at how safe our food supply is.’”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

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

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

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

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

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

“This is really about profit. This is about political identity. This is about creating distrust in the existing biomedical community. This is about money,” Caulfield said in an interview with ABC News, which partnered with Ñî¹óåú´«Ã½Ò•îl Health News to report on ivermectin.

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

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

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

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

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

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

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

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

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

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

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

‘I’ve Taken Bucketloads of This Stuff’

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

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

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

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

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

Sibley did not respond to requests for comment.

Ñî¹óåú´«Ã½Ò•îl Health News has independently confirmed that Sibley signed agreements with at least 10 pharmacies. The agreements say pharmacists shall dispense ivermectin only in Tennessee, where Sibley is licensed, although one of those pharmacies said friends and family in Tennessee can “.”

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

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

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

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

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

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

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

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

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

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

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

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

In response to questions from Ñî¹óåú´«Ã½Ò•îl Health News, Marik, through an Independent Medical Alliance spokesperson, said medical science benefits from “open discussion of ideas and treatments.”

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

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

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

Tennessee Does Not Track Its Ivermectin Market

Arkansas, Idaho, Louisiana, and Texas enacted similar laws in 2025, and legislation that makes ivermectin available without the need for a doctor visit has been introduced or debated in at least 24 other states, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis. That means half the country could be following Tennessee down an unlit path, because no one knows the full scope of its ivermectin market.

Tennessee does not effectively track which pharmacies offer ivermectin this way, and the state government has been unable to produce some foundational documents that pharmacies are legally required to file before they sell the drug, according to a Ñî¹óåú´«Ã½Ò•îl Health News investigation.

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

In response to a Ñî¹óåú´«Ã½Ò•îl Health News public records request for those ivermectin notifications filed by pharmacies, the agency over three months produced records from only 12 pharmacies, half of which have agreements with Sibley. The agency said it did not locate records related to at least 13 others that Ñî¹óåú´«Ã½Ò•îl Health News has identified as selling ivermectin without requiring individual prescriptions.

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

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

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

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

‘An Unproven, Potentially Unsafe Drug’

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

Some board members were shocked.

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

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

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

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

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

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

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

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

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

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

In Chattanooga, the Medicine Counter pharmacy says on its website that ivermectin should be taken “only as prescribed by your healthcare provider.” And yet the pharmacy sells some of Tennessee’s available without a prescription from a doctor — up to 21 times as strong as a standard tablet, for nearly $19 per pill — according to the Ñî¹óåú´«Ã½Ò•îl Health News analysis.

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

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

Who is not listed as an option? Your doctor.

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

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

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

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

‘Enough Trouble With Ivermectin’

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

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

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

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

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

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

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

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

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

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

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

That’s not stopping Florida lawmakers from trying to adopt Medicaid work requirements anyway. It’s the only legislative body in a nonexpansion state to even consider it so far.

“You need to go to work if you want your friends and neighbors to pay for your health care,” said , the Republican sponsor of a Medicaid work requirement proposal making its way through the legislature.

The move baffles health care advocates and Medicaid experts. Some doubt it’s even legal under President Donald Trump’s signature domestic policy law.

“You cannot change the terms of the work requirement,” said , an attorney and a professor at Georgetown University’s McCourt School of Public Policy, issued by the Centers for Medicare & Medicaid Services. For Cuello, the answer is clear: “It’s a pretty easy no.”

Medicaid work requirements affect Washington, D.C., and the 40 states that have expanded Medicaid eligibility to all nondisabled adults ages 19 through 64 with incomes up to 138% of the federal poverty level, as prescribed under the Affordable Care Act. That’s an income of $22,025 a year for a single person.

Starting next January, those states must require people in their expansion groups to report at least 80 hours a month of work, education, or community service to qualify for and maintain Medicaid coverage.

About 4 million people are enrolled in Florida’s program, and Gaetz estimates that about 147,000 of them are adults who “could work and should work.”

They “are able-bodied and they don’t have small children at home, and they aren’t taking care of an elderly person or a disabled person,” he said. “Yet they receive Medicaid benefits.”

People affected by would primarily be parents of children 14 and older, and some 19- and 20-year-olds, he said. A in the Florida House would apply Medicaid work requirements to parents of children ages 6 and older.

To qualify for Medicaid in Florida, a working-age adult without a disability must generally be caring for a child or an older or disabled family member and cannot earn more than 26% of the federal poverty level, or about $592 a month for a family of three.

Most adults who are not disabled and receive Medicaid already work, and many people in low-paying jobs do not receive health insurance through an employer, , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. Among single adults ages 19 to 64 in Florida who made under $15,000 a year in 2024, through work.

Critics say Florida’s proposal would likely force some people to become uninsured, even if they meet the work requirement. That’s because the state’s Medicaid income limit is so low that working the mandated 80 hours a month would likely cause those individuals to exceed the income eligibility limit but also leave them earning too little to qualify for subsidized coverage on the Affordable Care Act marketplace.

Michelle Mastrototaro said she lost her Medicaid coverage in November after taking a part-time job as a teaching assistant at a Tampa elementary school last year. Mastrototaro, 47, cares for a disabled teenage son and likely would not need to meet Florida’s proposed work requirement.

But she said her biweekly wages from working about 17 hours a week pushed her past the Medicaid income limit. She has struggled to afford her prescription medications since.

“What I’m making is nothing,” Mastrototaro said. “I am scavenging just to make ends meet.”

The Gaetz-led proposal ignores “the hard realities of what it takes to be qualifying for Medicaid in Florida,” said , executive director of Florida Voices for Health, a nonprofit that advocates for Medicaid expansion. “On its face,” he said, “it doesn’t make sense.”

Medicaid experts say the holds that nonexpansion states cannot adopt work requirements.

A state that hasn’t added more low-income adults to its Medicaid program can’t impose work requirements on those who are already covered, Cuello said. States must cover specific categories of low-income people — such as children, pregnant women, some parents, older adults, and people with disabilities — to receive federal funding for their programs.

States that have expanded Medicaid eligibility to a limited group of low-income adults, namely Georgia and Wisconsin, will be required to impose work requirements on those enrollees.

, launched in July 2023, already includes a requirement that newly eligible adults report at least 80 hours of work or community engagement. Federal approval for the program expires at the end of December, and the state . will have to implement a work requirement by Jan. 1.

South Carolina applied in June for federal approval to to nondisabled parents and caregivers ages 19 to 64 who earn 67-100% of the federal poverty level. That’s about $18,300 to $27,300 a year for a family of three. The state’s application is pending with CMS, and if approved would implement work requirements for those newly eligible adults.

Gaetz said if the Florida legislation were approved, the state would develop a “business plan” for implementing work requirements and seek CMS approval.

It is unclear how much it would cost, but experience in states with Medicaid work requirements suggests that implementation would be expensive. States must upgrade their eligibility and enrollment systems, hire additional staff, and inform the public of the new mandate.

For its program, Georgia spent about $54.2 million on administrative changes out of $80.3 million in total spending for the program from October 2020 to March 2025, according to from the U.S. Government Accountability Office. Most of the administrative spending — about $47.4 million, or 88% — came from the federal government.

Georgia’s experience echoes others’, according to a 2019 of states that received approval to implement Medicaid work requirements during the first Trump administration. That report focused on five states — Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin — and estimated costs would total $408 million. They ranged from $6 million in New Hampshire to more than $270 million in Kentucky, though those figures did not reflect all the state costs.

Florida’s computer infrastructure for collecting and verifying information and determining eligibility is more than 30 years old and is being replaced. That is anticipated to be completed in 2028 and cost more than $180 million.

A legislative analysis of Gaetz’s bill estimated that if 1 in 4 people affected by the proposed work requirement were to lose Medicaid coverage, the state could save about $80 million a year.

Darius, with Florida Voices for Health, said those potential savings hardly seem worth the effort.

“It requires the state to build this giant regulatory-like framework and to rebuild systems, and to employ a whole set of people to chase down the very small number of folks who would ultimately be touched by this,” he said.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Most States Will Have To Implement Medicaid Work Rules

The federal budget reconciliation law passed in July will require Medicaid enrollees in 42 states and the District of Columbia to show they’re working, volunteering, or attending school for 80 hours a month starting Jan. 1, 2027, to keep their coverage. The eight states that did not expand their Medicaid programs to cover additional low-income adults won’t have to implement the work rules.

*Georgia currently has an active work requirement program.

Source: <a href=”; target=”_blank”>KFF</a>

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told Ñî¹óåú´«Ã½Ò•îl Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you’re going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Scattered visits to free clinics notwithstanding, Guevara hadn’t had a full medical checkup in years. She required dental work. She wanted to start looking for a job. And she was overwhelmed by the maze of paperwork needed simply to get her off the street, much less to make any of the other things happen.

But Guevara had help. The Jamboree Housing Corp., an affordable-housing nonprofit that renovated the former Stanton, California, hotel Guevara now calls home, didn’t just move her in — it also provided her a fleet of wraparound services. Jamboree counselors helped Guevara navigate the health care system to see a doctor and a dentist, buy a few things for her apartment, and get training to become a caregiver.

“I was years on the street before I got the kind of help I needed so I could help myself,” said Guevara, 68.

Amid the Trump administration’s apparent opposition to using Medicaid funding for such social services, staffers at Jamboree and similar affordable housing providers in California have been worried about losing federal money, particularly as the experimental waivers that provide the primary funding for the program they rely on expire at the end of 2026. But as it turns out, the state had the foresight several years ago to designate certain nonhousing social services, such as mental health care, drug counseling, and job training, as a form of Medicaid spending that will continue to be reimbursed.

Catherine Howden, a spokesperson for the federal Centers for Medicare & Medicaid Services, confirmed that California’s use of the “in lieu of services” classification for these wraparound programs is allowed under federal regulations.

“It is starting to sound positive that we will, at the very least, be able to continue billing for these services after the waiver period,” said Natalie Reider, a senior vice president at Jamboree Housing.

During President Donald Trump’s first term, states were permitted to use Medicaid money for social support services not typically covered by health insurance. But the second Trump administration is reeling that policy back in, saying that the intervening Biden administration took the supportive services process too far. Howden said in a statement that the policy “distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans.”

Through CalAIM, a five-year experimental build-out of the Medicaid system, programs like Jamboree were able to leverage federal funding to offer the kinds of nonhousing social services that experts contend are essential to keeping people permanently housed.

However, these wraparound services are only one component of the CalAIM initiative, which is attempting to take Medicaid, known as Medi-Cal in California, in a more holistic direction across all areas of care. And when CalAIM launched, California officials gave the programs the Medicaid “in lieu of services” designation, known as ILOS, effectively putting them outside the waiver process and ensuring that even when CalAIM sunsets, money for those social initiatives will continue to flow.

“California has tried to future-proof many of the policy changes it has made in Medi-Cal by including them in mechanisms like ILOS that do not require federal waiver approval,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. “That allows these policy changes to continue, even with a politically hostile federal administration.”

The designation allows these social services to be funded through Medicaid managed-care plans under existing federal laws because they are cost-effective substitutes for a Medicaid service or reduce the likelihood of patients needing other Medicaid-covered health care services, said Glenn Tsang, policy adviser for homelessness and housing at the state’s Department of Health Care Services. The state could not provide an estimate of the annual funding for these wraparound services because they are not distinguished from other payments made to Medicaid managed-care plans.

“We are full steam ahead with these services,” Tsang said, “and they are authorized.”

Although California was the first state to incorporate the designation for such housing and other health-related social support, Tsang said, several other states — including Arizona, Arkansas, Florida, New York, and North Carolina — are now using the mechanism in a similar fashion.

Early results suggest such support saves on health care spending. When Jamboree, in Northern California, in the Central Valley, and other permanent supportive housing providers employ a holistic approach that includes social services, they have reported higher rates of formerly homeless people remaining in housing, less frequent use of costly emergency health services, and more residents landing jobs that help them pay rent and stay housed.

At the nonprofit MidPen Housing, which serves 12 counties in and around the San Francisco Bay Area, roughly 40% of the units in the program’s pipeline are earmarked for “extremely low-income” people, a group that includes the homeless, said Danielle McCluskey, senior director of resident services.

CalAIM reimbursements help fund the part of MidPen that focuses on supportive services across a wide range of experiences, from chronic homelessness to mental health issues to those leaving the foster care system. McCluskey described it as one leg of a three-legged stool, the others being real estate development and property management.

“If any of those legs are not getting what they need, if they’re not funded or not staffed or resourced, then that stool is kind of wobbly — off-kilter,” the director said.

A recent found that people who used at least one of the housing support services — including navigation into new housing, health care assistance, and a deposit to secure an apartment — saw a 13% reduction in emergency department visits and a 24% reduction in inpatient admissions in the six months that followed.

Documenting those outcomes is critical because the department needs to show federal officials that the services lessen the need for other, often costlier Medicaid-covered care — the essence of the classification.

Advocates for the inclusion of supportive services argue that the American system ultimately saves money on those investments. As California’s homeless population to more than 187,000 on a given night — nearly a quarter of the U.S. total — Jamboree has been allocating more of its resources to permanent supportive housing.

Founded in 1990 in Orange County, Jamboree builds various types of affordable housing using federal, state, and private funding. Reider said about a fifth of the organization’s portfolio is dedicated to permanent supportive housing.

“They’re not going back out to the streets. They’re not going to jail. They’re not going to the hospitals,” Reider said. “Keeping people housed is the No. 1 outcome, and it is the cost-saver, right? We’re using Medicaid dollars, but we’re saving the system money in the long run.”

Guevara, who wound up on the streets after a falling-out with family in 2015, spent years living out of her truck before a shelter worker connected her with Jamboree. There, she was paired with a specialist to help her figure out how to get and see a doctor, and to keep up with scheduling the battery of medical tests she needed after years spent living in temporary shelters.

“I also got a job developer, who helped me get this job with the county so I can pay my rent,” Guevara said of her position as a part-time in-home caregiver. “Now I take care of people kind of the same way people have been taking care of me.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .