Dowse wore a full-body protective suit with a plastic face mask. As a pediatrician in southern Utah, he couldn’t risk getting even a mild infection, because many of his patients are babies too young for measles vaccines or children whose parents choose not to protect them with immunizations. “I went in looking like a scientist in E.T.,” he said.

Measles can cause brain damage, deafness, or death in newborns. If the baby entered the world with a measles rash and fever, Dowse was prepared to give the infant a spinal tap to assess the risk of neurological damage.

Luckily, flushed and crying, the baby looked healthy. To keep it that way, Dowse wanted to inject the baby with concentrated antibodies against the measles virus. To his surprise, the parents objected, promising to give their child “all kinds of vitamin A,” Dowse said. He begged them not to, saying, “You can’t see it on the surface, but the baby’s body is fighting the measles.” They were afraid of vaccines, so Dowse explained that antibodies were different and that they would stop measles from replicating in the infant.

“That shot is going to basically give the baby ammo to fight,” Dowse said.

The parents relented. A couple of days later, they left the hospital with a child who had narrowly skirted an infection that killed many thousands of babies a century ago. Nonetheless, Dowse said he doubted they would be returning for childhood vaccinations to protect their baby against a bevy of illnesses. Like more than a dozen Utah doctors and health officials who spoke with Ñî¹óåú´«Ã½Ò•îl Health News, Dowse has adjusted his expectations.

He is part of a reluctant cohort of medical professionals now on the front line of America’s regressive next chapter in health history, one in which dangerous and preventable diseases return.

“I wish that people could see what I see,” said Nathan Money, a hospital pediatrician in Utah whose eyes welled up with tears as he described children he’s treated for measles struggling to breathe. “This train is going in the wrong direction, and it can feel like a helpless situation, because we’re just not seeing the public messaging and leadership that’s needed to turn this around.”

Since measles was deemed eliminated in the U.S. a quarter century ago, public health workers have extinguished sporadic outbreaks in close-knit, undervaccinated communities with targeted methods: Isolate people with measles and quarantine their contacts to contain the virus. But as vaccination rates , the virus is moving beyond insulated communities, overwhelming public health departments constrained by shoestring budgets. Larger outbreaks, the kind not seen for a generation, have forced health officials into a new paradigm: They have stopped racing to “contain” infections and shifted gears into what they call “mitigation.”

Utah made that transition early this year, once the outbreak hit “a point where you no longer have control over it,” said state epidemiologist Leisha Nolen. By March, measles had been detected in every health jurisdiction in the state and in northern Arizona. More than 950 people have tested positive in the two states since the outbreak began in August, but many people with measles haven’t been tested. A of measles viruses suggested that the true number of cases last year could have been 6.5 times what was known.

Last year under President Donald Trump, U.S. measles cases exceeded 2,000 for the first time since 1992. Six months into 2026, the U.S. has already surpassed that threshold. Prolonged outbreaks exact a toll on children, who have spent days in hospitals for severe infections and missed weeks of school for mild ones. Adults with measles miss work. Parents delay daycare to keep their babies safe. Doctors in Utah have enacted labor-intensive protocols to keep measles from spreading in clinics. Newborns and people with weakened immune systems who have been exposed to the virus receive infusions of concentrated antibodies costing $500 to $1,000. Medical visits for measles . Health departments spend millions trying to curb infections.

“This is like a snowball that gathers speed as it rolls downhill,” said Emilie Morris, a hospital pediatrician in Salt Lake County and Utah County. A full-throttle campaign to educate communities on the safety of vaccines and the diseases they prevent could turn the situation around, doctors and health officials said. It would require an effort similar to what the anti-vaccine movement has long done in videos, blogs, and podcasts. For example, the anti-vaccine organization that Robert F. Kennedy Jr. founded before taking the helm at the Department of Health and Human Services, Children’s Health Defense, visits , , and has bought that downplay the threat of viruses while wildly exaggerating the risk of vaccine side effects. Kennedy’s and as health secretary are adding to parents’ doubt.

After the development of vaccines and antibiotics in the mid-1900s, virologist and Nobel laureate Frank Macfarlane Burnet wrote, “One can think of the middle of the twentieth century as the end of one of the most important social revolutions in history, the virtual elimination of the infectious diseases as a significant factor in social life.”

He couldn’t have imagined what was coming.

‘Year of Sickness’

In communities nestled among the red sandstone cliffs and riparian forests of southern Utah, measles took hold last summer. At the main school in Hildale, a town along the Arizona border, just 30% of kindergartners are considered adequately immunized by Utah’s health department, meaning they’ve gotten recommended vaccines against measles, tetanus, polio, and more. Exemptions from childhood vaccine requirements are easily acquired in the state: Parents need only claim personal, religious, or medical reasons.

Many people in Hildale and the surrounding towns are connected to the Fundamentalist Church of Jesus Christ of Latter-Day Saints, a sect that has been leery of the government since a police raid in 1953 separated polygamous parents from their children. Shirlee Draper, a southern Utah resident who grew up in the faith, said they became ever more isolated in the early 2000s under the leadership of Warren Jeffs. Before he was sentenced to life in prison for sexual assault against minors, Jeffs instructed his followers to withdraw from public schools and mainstream medicine.

“Growing up, we all got our vaccines,” said Draper, who left the group during Jeffs’ reign. “It wasn’t until Warren Jeffs came along that there started to be more and more resistance.”

After Jeffs went to prison, many people left the faith but remained concerned about vaccines because of online misinformation, such as claims that the shots are toxic. Today a small shop in Hildale sells mouth sprays and oral drops professing to detoxify vaccines. Water, glycerin, and “whole grain alcohol” are listed as ingredients in one called Vxx-Dtx.

A mother who Ñî¹óåú´«Ã½Ò•îl Health News agreed not to name, because she fears stigmatization, said she considered getting her kids vaccinated when schools in southwest Utah started seeing measles cases last summer. She had split from the fundamentalist group but still worried about vaccines giving her children autism or other complications. in top-tier scientific journals have refuted a link between vaccines and autism, but the anti-vaccine movement has kept the notion alive.

Then the woman’s son told her that his classmate had a rash and spit on him, she said. A few days later, he fell ill with a fever, followed by vomiting, diarrhea, and a head-to-toe rash.

“He felt downright sick for 10 to 14 days,” the woman said. “It was hard to see the end of the tunnel.”

Then her daughters came down with measles. She had a fleeting case, too, even though she had been vaccinated as a child. Breakthrough infections and are relatively rare. Only 4% of reported this year and last have been among people who’ve had two doses of the measles, mumps, and rubella vaccine.

By the time the family recovered, the son had missed nearly three weeks of school, the daughters a month, and the mother had postponed an important family gathering because she didn’t want to spread infections. “I just got my youngest’s missed-school report and it’s super high,” she said. “This is the year of sickness.”

The woman said she regretted not getting her kids vaccinated when the outbreak started. She said she knows about 30 people who have fallen sick with the measles. Except for a few who needed medical care, they haven’t been tested. “I bet there’s been thousands of cases,” she said.

Measles doesn’t have a cure. She and others have tried to ease symptoms with cod liver oil, vitamin C, zinc, and “essential oils,” plant extracts long used in folk medicine that have become a lucrative industry in Utah. People in southwest Utah are trying a lot of things: One resident sells homemade lotion on Facebook, writing, “Breastmilk & Honey has been a life saver for the measles rash.”

Beyond Containment

The outbreak may have started among a fundamentalist community, but it’s spread far beyond because Utah’s vaccination rates have dropped steadily since the covid pandemic. Fewer than 80% of kindergartners in the 2024-25 school year in southwest Utah, with only 87% adequately immunized in the state as a whole — far below the 95% threshold required for herd immunity.

Several Utahns told Ñî¹óåú´«Ã½Ò•îl Health News that “alternative health” or “wellness” drives the trend, rather than religion. The state has a thriving supplement industry, , aided by deregulatory policies supported by the late Utah senator Orrin Hatch and a high concentration of people who earn income from multilevel marketing. These networks of people sell supplements, essential oils, peptides, and other alternative therapies on social media, YouTube, and podcasts, according to and .

Alternative health isn’t necessarily anti-vaccine, but many people who sell unconventional remedies online and in podcasts and mainstream medicine.

“People are suspicious, and it’s well founded,” Draper said. She described dismissive doctors, exorbitant medical bills, hospital systems that over care, and pharmaceutical companies that drove . Communities already wary of government authorities are poised to interpret failings in American healthcare as signs that medical authorities aren’t to be trusted, either, she said.

“Across America, we have entire populations who find safety in clinging to whatever confirms their deeply held beliefs,” she said.

A mistrustful disposition gave way to covid conspiracy theories in 2020 and 2021. In southwest Utah, for example, a tricked out with digital billboards showed up to covid vaccination sites to advertise Plandemic, a rife with , including that masks “activate” the coronavirus and that global elites planned covid-19 to control the population. Misinformation added fuel to anger about public health rules, and there was political backlash under the umbrella of a largely Republican “medical freedom” movement. Utah enacted laws reining in public health, including one that eases exemptions to childhood vaccinations and another that prohibits most employers from requiring vaccines.

In the wake of the covid backlash, health officials tread lightly. Rather than enforce containment measures, “we give our advice and focus on personal responsibility,” said David Heaton, public information officer at the Southwest Utah Public Health Department.

One of the most contagious diseases in the world, measles spreads with astonishing speed among the unvaccinated. One of a New York school outbreak in 1974 found that a second-grader with measles infected 28 other students in 14 classrooms because measles can spread through ventilation systems.

As cases doubled then quadrupled in southern Utah, the regional health department couldn’t keep up with calling the contacts of everyone infected. It shifted its efforts to announcements guiding the public at large. For example, it asks people to call before showing up to clinics with measles symptoms. Still, patients in plenty of hospitals have been exposed. For example, when parents brought a sick, unvaccinated child to a large pediatric hospital in Utah in September, they shared the space with 11 infants too young to be vaccinated. Doctors rushed to give the babies infusions of antibodies and they remained healthy, according to a .

On the radio and in posts on social media, Heaton warns that measles is spreading and that vaccines are the best defense. “If you’re not immunized and you’re anywhere in public,” Heaton said, “you’re fair game for this virus.”

The department doesn’t have the capacity to talk with people directly in the five counties it serves. For a few years, it leaned on community health workers who went to churches, town halls, and other gathering places, listening to people’s concerns and telling them what the science said about covid, vaccines, and other matters of public health. But these workers were laid off early last year, after the Trump administration clawed back more than $12 billion in federal public health grants to states.

“We were starting to get a little bit of traction,” Heaton said of the community workers. “And then we lost all of our team.”

The department offers free measles vaccines to children, but uptake is slow. Nursing director Mindy Bundy said that when she started the job 20 years ago, demand was so high that she would give parents tickets while they waited, as if they were crowding around a deli counter.

“Now even in an outbreak,” she said, “we aren’t seeing a huge increase of people wanting vaccination.”

As officials tried to do the best they could, the outbreak spread north, hopping from one undervaccinated community to the next. When health officials in Utah County spoke with people who had tested positive, they often had no connection to other known cases. “Pretty quickly, we started to lose the links,” said Michael Leman, the county health department’s nursing director. Contact tracing, the cornerstone of containment, was failing.

Every week, the state health department posted a growing list of locations on its website — a Trader Joe’s, a Mormon temple, an aquarium, preschools — that people had visited while contagious. But many people who tested positive hadn’t been to those places, Leman said. “They could have gotten it at Walmart. They could have gotten it walking through a mall,” he said. “I mean, just anywhere in the public they could have been exposed.”

In February, high school students throughout Utah tested positive after a state wrestling tournament at Utah Valley University in Orem. A dashboard monitoring measles viruses in wastewater lit up with notifications around the state. “Wrestling really feels like our turning point,” said Nicholas Rupp, communications director at the Salt Lake County Health Department.

Salt Lake County’s shift from containment to mitigation meant prioritizing high-risk situations and relaxing control everywhere else. When a student has a confirmed case, for example, health officials meet with the school nurse to figure out which kids are most vulnerable. Unvaccinated children in the same classroom as someone infected are asked to stay home for 21 days, but those in other classrooms might not be, said Melanie Crossland, an epidemiologist at the Salt Lake health department. Some schools with high vaccination rates have opted to monitor student temperatures daily instead of requesting quarantines. One school created a separate space for the unvaccinated.

Crossland said such bespoke strategies entail a “huge” amount of effort but have staved off blowback that deflated her during covid.

“We give everything when we’re here,” she said, “but the days of killing ourselves, when legislatively no one is going to give us any help, are done.”

Daycare Dilemma

The outbreak has lasted so long that some children who have recovered from measles have since been hospitalized for what should be mild illnesses from common bugs, said Kerri Smith, a hospital pediatrician in southwest Utah. Measles can , impairing a body’s ability to fight other viruses. “It’s making children very susceptible to getting sick again,” Smith said.

Her eyes were bloodshot, and she looked drained from a week of long shifts. Since the outbreak began, she’s treated more than a dozen babies and children severely sick from measles.

“They’re usually admitted to the hospital with measles pneumonia, so they’re struggling to breathe, pulling for air below their ribs,” she said. “High fevers, 104 to 105, absolutely miserable, extremely fatigued, really dehydrated with sunken eyes.” Most children fully recover from measles, but a fraction develop permanent , a small percentage die, and in , measles kills a person years after the infection.

No one has died so far in Utah’s outbreak. And barring that tragic outcome, Smith and other doctors said, some parents fail to grasp the gravity of measles, even as their own children have tubes inserted into their small nostrils to deliver oxygen. Despite repeated warnings, doctors said, some unvaccinated family members of patients — who could be contagious — walk around the hospital while visiting their loved one. This means the waiting room, the elevator, the cafeteria, and other places need to be shut down for cleaning, and vulnerable people alerted.

“People don’t realize how easily this spreads,” Smith said.

Morris, the pediatrician working in two counties, recalled a conversation with a nonchalant father who didn’t seem to understand the need for quarantine. “I know this is an inconvenience to you,” she said. “It’s also a huge inconvenience to the parent who has an infant who could be severely impacted by this disease.”

On top of feeling depleted, doctors with young children said they are anxious. Emily Chin, a physician in Salt Lake County, worries she’ll bring measles home to her newborn. One evening, she sat in her garage after caring for a child with a rash. The patient’s measles test was still being processed, so Chin isolated herself in a room for the night, wearing an N95 mask instead of holding her infant.

Like many mothers in Utah, Chin plans to give her baby an early dose of the measles vaccine at 6 months old because of the outbreak, in addition to two doses at ages 1 and 4. Several mothers said they avoid travel and public places because they fear their babies could be infected. Some are delaying daycare. Others, like Kandace Hyland, a marketing director in Salt Lake County, don’t have that option.

Hyland was shocked when her daycare told her that it didn’t track the vaccine status of staff, even amid the outbreak. In March, she posted an calling for the state to require daycare staff to be vaccinated against the measles when the virus is spreading. Even if daycare staff file for vaccine exemptions, she said, parents could at least find out what portion of their babies’ caretakers pose a life-threatening risk.

Hyland sent her idea to the state health department. Nolen, the state epidemiologist, said she agreed with the concern, and was “talking with the division of licensing about the issue,” in an email shared with Ñî¹óåú´«Ã½Ò•îl Health News. Hyland also wrote the Division of Licensing and Background Checks. In an email, its director, Shannon Thoman-Black, replied that the division does “not have the legislative authority to implement a mandate.”

“They always talk about parents’ choice,” Hyland said. “But I don’t feel like I have a really good ‘parents’ choice’ right now.”

Measles’ Comeback

The U.S. will almost certainly this year or next, but it could be regained if political leadership backed nationwide campaigns to boost confidence in vaccines, said Demetre Daskalakis, a former director of the Centers for Disease Control and Prevention’s national immunization center and now the chief medical officer at the Callen-Lorde community health center in New York.

“Under Secretary Kennedy’s leadership, that’s unlikely to happen,” he said. “We’re going back to a pre-vaccine era.”

HHS spokesperson Emily Hilliard defended the secretary and his agency in an email, writing that the CDC has “surged resources” to contain measles outbreaks. “The CDC, HHS principles and the Secretary have been vocal that the MMR vaccine is the best way to protect yourself against measles,” she said.

Kennedy’s words and actions suggest otherwise. He’s said that the measles vaccine leads to “deaths every year,” which is . He continues a potential link between autism and vaccines, no matter how many there is none. And he oversaw abrupt changes to the recommended childhood vaccine schedule, a move called dangerous and not backed by science. A federal judge blocked those changes in March, but Trump recently issued an executive order to reexamine the schedule.

“It’s been confusing for the public,” said Dorothy Adams, executive director of the Salt Lake County Health Department.

In May, Kennedy met with Republican Utah Gov. Spencer Cox, who has said little about the state’s ongoing outbreak. Kennedy praised Utah’s action on Make America Healthy Again priorities, such as banning fluoride in public drinking water and easing restrictions on raw milk sales, according to Salt Lake City’s . Cox declined to comment for this article.

Meanwhile, the U.S. public health system has been further weakened by the Trump administration’s cuts and delays to public health grants.

“If you’re in the thick of it and you don’t know if you will be reimbursed, you adjust your response,” said Angela Dunn, a doctor and former Utah state epidemiologist. “This outbreak is a perfect storm of disinformation, trauma from the covid pandemic, and the drop in funding.”

Measles isn’t the only preventable malady making a comeback. As children played nearby in a sun-speckled park in Salt Lake City, Morris talked about a baby in the intensive care unit who was bleeding uncontrollably after a fall. The baby’s parents had refused an injection of vitamin K that helps blood clot in newborns. As they fretted over their infant, Morris said, she felt awful for them and regretted not being able to overcome mistrust in basic, lifesaving interventions. She had the same swirl of emotions when an unvaccinated toddler in her care recently died of whooping cough.

“I was one of the only people in the room with the nurse when the child coded,” she said with tears in her eyes. “You think, ‘I wish this child was vaccinated,’ but it’s hard because I also see how much grief these parents are holding.”

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A patient from his rural Northern California county , a disease so rare there that many physicians have never treated a case.

While California has some of the strictest vaccine laws in the country, conservative Shasta County’s approach during the covid pandemic stood in stark contrast with the state’s guidance. Its local leaders opposed masking and vaccine mandates, and the county public health officer, who had sought to enforce those state policies and other safety measures.

A potential measles outbreak had “always been in my mind,” said Mu, an outspoken family physician who was to sign a opposing covid vaccine mandates. But Mu, the county’s current public health officer, said that when his department identified the first local measles case, it acted decisively: “We forgot about fear.”

They went to work, he and his team said, to painstakingly retrace the steps of sickened with measles, contacting more than 600 people who may have been exposed at Costco, a sushi restaurant, sporting events, a school, or a healthcare clinic. Just one of the nine contracted measles from one of those locations, while the others were characterized by the public health department as “close contacts.”

Two and a half months later, the Shasta County public health department had declared the measles outbreak over. Infectious disease experts say the rapid response executed in the mostly rural, vaccine-hesitant county offers a playbook for public health officers across the nation who are struggling to keep the highly contagious virus from spreading.

“To me, the story of Shasta is one of hope,” said Peter Chin-Hong, an infectious disease specialist at the University of California-San Francisco.

After more than a year of ongoing cases, measles has sickened more than in the U.S., according to the Centers for Disease Control and Prevention. For the first time in two decades, the U.S. is poised to lose its measles elimination status, a designation signaling that outbreaks are rare and rapidly contained.

673 measles cases as of late May while had seen at least 997, according to their state health departments. 74 cases.

Critical Rapid Response

In late January, when Shasta County identified the first case, Mu gathered with more than a dozen communicable-disease nurses, epidemiologists, and emergency and community relations staffers for an “initial threat assessment meeting.”

Measles is an that can linger in a room for two hours after an infected person leaves, so on-call nurses and responders faced a daunting task figuring out exactly when the patient was infectious and where they had been.

“Everything is about speed — speed in identifying the person and finding the sites where measles were occurring,” Chin-Hong said. “If you keep it down to a few cases, it’s much easier. If you wait just a little bit longer, those people would have been in contact with a lot more people.”

Roughly 9 in 10 unvaccinated people exposed to the virus become infected. All nine of Shasta County’s confirmed cases were people who were unvaccinated or had unknown vaccination status, according to the county’s public health department. Before the department called families who may have been exposed, county nurses sometimes enlisted school principals, church staff, clinic managers, or others to make first contact, said Daniel Walker, the county’s supervising epidemiologist.

Erika Piper, the head of Redding Christian School in Palo Cedro, talked to school families wary of requests by public health officials — and government in general — to provide immunization records or other personal information. She said she also had tough but respectful conversations with families to ensure exposed, unvaccinated kids stayed home from school, so their community could abide by public health guidance calling for .

“I would say to them: ‘That’s totally fine. You have a choice. You’ve made your choice. But there are still consequences to the choices we make,’” Piper said, referring to families who had opted not to vaccinate their children. “‘And so you can either be a willing helper and a partner with me in this, and we can make it work and get through it, or you can battle me on it. But either way, you can’t be in school.’”

She allowed work to be sent home to quarantined students and personally took daily attendance at the school to help ensure health guidelines were met.

The California Department of Public Health assisted with case investigation by making calls to exposed people at the county’s request and deployed a covid-era phone system, CalCONNECT, that automates symptom monitoring for exposed contacts.

Shasta officials warned people not to be wary of calls from contract tracers using a 279 area code, worrying they would dismiss them as scams.

Delicate Conversations

In Shasta County, the measles vaccination rate is just below the for community-level protection, but in pockets of the community the rates are lower and vary widely, according to . And in those vulnerable places, an outbreak can spread.

For example, more than a quarter of Shasta schools had rates below 95% in 2024-25, according to the latest state data available. Several were below 90%. Although Redding Christian School reported a kindergarten measles vaccination rate at or above 95% in 2024-25, it was 87.8% three years earlier.

When it came to talking to people who had been exposed to measles, Sharayne Loomis, a supervising public health nurse on Shasta’s communicable-disease team, described the department’s approach as “meeting people where they are.” That included nonjudgmental conversations that supported residents regardless of their stance on vaccination, Loomis said.

Mu said the same philosophy extended across the county’s health agencies, but he publicly “measles parties,” gatherings where unvaccinated children are intentionally exposed to build immunity. And he spoke against receiving high doses of vitamin A without medical supervision. Vitamin A has circulated as a measles treatment in vaccine-skeptical communities and was endorsed last year by Health and Human Services Secretary Robert F. Kennedy Jr., though the CDC website says that vitamin A “does not prevent measles and is not a substitute for vaccination.”

Some community members said Mu’s department could have been more proactive before the outbreak, imploring him to emphasize the importance of vaccination in public messaging.

“Clearly, when the situation was known to be coming into our communities, that would have been a time to advise for vaccines,” Steve Kahn told county supervisors at their February board meeting. “I think he was negligent in that.”

For years, public health has been a political flash point for the region. The Board of Supervisors fired the previous public health officer, Karen Ramstrom, in May 2022 after upset with her enforcement of state covid rules.

In an effort to reach vaccine-hesitant Californians, state officials have been working in a coalition called Public Health for All Californians Together and through an effort nicknamed that uses social media monitoring and other research to tailor messaging to skeptical viewers.

Erica Pan, director of the California Department of Public Health, said the state is preparing for measles to possibly surge when it hosts World Cup soccer matches starting in June, as well as with increased summer travel.

But when it comes to mitigating an outbreak in a community, public health officials say, residents — especially those skeptical of vaccines — need to hear from the people they know.

“Trust is very important for us,” Mu said. “It is critical in getting people to follow our guidance, especially during an outbreak.”

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

The midwife is not licensed as a nurse. In Georgia, that makes what she’s doing illegal. Ñî¹óåú´«Ã½Ò•îl Health News agreed not to identify her by name.

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

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

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

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

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

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

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

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

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

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

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

HHS spokesperson Emily Hilliard declined to comment on policy proposals but told Ñî¹óåú´«Ã½Ò•îl Health News that the administration “regularly meets with a wide range of stakeholders to hear input from the American public.”

Hospitals Want Guardrails

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Becoming Part of the System

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

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

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

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

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

“Something has to change,” Haynes said.

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

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

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“They’re the folks that work at restaurants. They’re the teacher’s aides,” said Starr, a registered nurse who became Open Door’s chief executive more than six years ago. Those patients, he said, are “really the heart and soul of rural America.”

He said if his remote health centers don’t get a share of the billions of dollars Congress earmarked to transform health care in rural America, patients may soon lose services. About 50% of Open Door’s 60,000 patients are on Medicaid, the joint state and federal insurance program that, together with the related Children’s Health Insurance Program, covers with low incomes or disabilities.

When Congress approved the One Big Beautiful Bill Act last summer, it cut nearly $1 trillion from Medicaid over the next decade. Now, Starr hopes the $50 billion Rural Health Transformation Program, which was part of the same bill, will help keep his patients covered.

Yet, small community health care providers, such as Open Door, may find they are sharing the billions with an army of corporate giants before it reaches their patients.

Months after federal leaders announced that all 50 states won first-year awards, ranging from $147 million for New Jersey to $281 million for Texas, state plans reveal that a heavy dose of prescribed spending will go to companies that can increase the use of electronic health records, strengthen cybersecurity, and improve state and health system technology platforms.

And at least four large-scale coalitions of companies are now pitching multipronged services to the states. Many of the companies already work with regional health systems and states through Medicaid contracting or mobile and telehealth operations.

How those services will help improve the health care of rural Americans at places such as Open Door remains an open question.

States Stare Down Reporting Deadlines

Federal regulators were “really interested in seeing digital health investments” when they crafted the five-year rural health program rules last year, said Maya Sandalow, an associate director at the Bipartisan Policy Center, a think tank based in Washington, D.C. She co-authored a recent report on how the 50 states plan to invest in technology, including modernizing health care infrastructure and expanding virtual care options such as telehealth and remote patient monitoring.

“The rural health fund isn’t really designed to directly replace or offset the lost Medicaid funding,” Sandalow said, noting that the federal staffers in charge of the program — money that could help rural hospitals and clinics pay for patient care — at 15% of the total funding awarded to a state.

Federal regulators also established tight reporting deadlines, forcing states to move quickly.

States must file progress reports and obligate all first-year funding , according to the Centers for Medicare & Medicaid Services, the federal agency overseeing the program. States could see their awards decreased or terminated at any time if they fail to follow federal requirements, according to the .

As of early April, CMS had not approved or had only partially approved some state budgets, including those of Wyoming, Colorado, and Vermont, according to state officials. CMS spokesperson Catherine Howden, who declined to say which states still needed revised budgets approved, said the agency does not provide “state-by-state updates.”

In Alaska, the budget is approved but the state has not announced when it will release full grant proposals and awards, said Tricia Franklin, program coordinator for Alaska’s rural health transformation.

“Early summer was the target,” Franklin said. But the response from vendors and applicants has been “much greater than expected, so it may take us a little longer.”

Working with consulting companies is an established way for states to “quickly and effectively” meet federal deadlines and roll out grant money, said , national director for population health at the Milbank Memorial Fund, a nonprofit focused on state health policy work.

Upgrading Technology, Modernizing Rural Health

Science Applications International Corp., a Fortune 500 government contractor, pulled together the . SAIC does a variety of technology work such as cybersecurity and engineering support. The alliance also includes Walgreens and Mission Mobile Medical, which turns RVs into primary care clinics. A data analytics company, a telemedicine and software company, and a company that helps place medical graduates in health systems are also part of the coalition.

The SAIC alliance offers “an ecosystem” of companies that can coordinate the work states have promised, said , SAIC’s Rural Health Transformation Program lead and a former chief information officer for the Virginia Department of Health. Each of the companies has representatives focused on the rural program, he said.

A lack of digital infrastructure — such as electronic health records at different clinics and hospitals that can talk to one another — has been a consistent barrier for rural medical care teams, said the Bipartisan Policy Center’s Sandalow.

“The funding hasn’t always been there in order for rural areas to create the infrastructure that’s needed to fully adopt remote patient monitoring, telehealth, artificial intelligence in ways that will really be supportive,” Sandalow said. “It takes things like updating infrastructure, changing workflows.”

Sandalow’s found that Maine and Utah are investing in cybersecurity; Indiana, Missouri, and New Mexico plan to modernize their electronic health records; Oklahoma plans to buy hardware and software, subsidize subscriptions, and give technical support to rural providers; and states such as Arizona and South Carolina will use funds to create telehealth hubs or buy remote patient monitoring equipment.

Federal regulators, when creating the rural program’s spending rules, also said no more than 5% of a state’s total funding awarded could be used to replace electronic medical records systems that already meet federal standards. Sandalow said that means states will focus on enhancements and upgrades to their current systems.

Gainwell Technologies, which operates the systems for dozens of state Medicaid programs, is spearheading . Rushil Desai, a Gainwell senior vice president, said states’ detailed spending plans are “changing in real time.”

Maine’s Medicaid plan contracts with Gainwell, and the state’s initial application listed four contracts worth more than $16 million over five years for the company. The state confirmed it has received federal approval for only its first year of spending, which includes a to implement changes to the state’s Medicaid claims system.

James Lomastro, a senior-care advocate in rural Massachusetts with the nonprofit , said he worries that large vendors and health systems will get the state’s transformation dollars.

Clinics, home care agencies, and nursing homes that “actually provide day-to-day support in the community are mostly on the margins” of state discussions about how to spend the money, he said. A spokesperson for Massachusetts’ Executive Office of Health and Human Services, Olivia James, said state officials would “ensure that everyone has a seat at the table” with training, financial incentives, and direct investments.

Arizona’s rural fund budget, which is $167 million for the first year, allocates for medical diagnostic equipment and technology upgrades, including to electronic health records, specifically for rural health care facilities.

But it also for county public health departments, said Pima County Public Health Director Theresa Cullen. The approved budget includes up to $4 million for grants to support community health workers.

“In these rural communities, you need to be present,” Cullen said.

Alina Czekai, director of the CMS rural health transformation office, said her team plans to visit all 50 states. She spoke at the National Rural Health Association’s policy conference in Washington, D.C., in February and told the audience that her team wants “the money to go to rural communities, rural providers, rural patients.” The association’s members include rural hospitals and clinics, which are expected to suffer big losses under the Medicaid cuts.

In California, Open Door’s Starr said he provided input on his state’s initial application, which won $234 million in first-year funding, but he is not clear on what the next steps will be for getting money from the program.

For his patients, Starr said, money is needed for technology upgrades. After all, he said, updated electronic health systems could operate seamlessly and store the documentation needed to keep a patient enrolled in Medicaid.

Updated technology could be exactly what Open Door and other area clinics need to “help keep people covered,” Starr said.

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Phil Galewitz and rural health care correspondent Arielle Zionts contributed to this report.

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The CDC withheld the data for months as a team hit hard by mass layoffs and resignations sorted through the information. But now that scientists at the agency have posted their first batch of whole measles genomes — the genetic blueprint of the viruses — the rest should “start flowing more smoothly at a more rapid cadence,” said Kristian Andersen, an evolutionary virologist at the Scripps Research Institute who isn’t involved with the CDC’s effort but is following it.

The CDC did not answer queries from Ñî¹óåú´«Ã½Ò•îl Health News on its timeline for publishing measles data or analyses. However, once all the data is public, researchers can run that will signal whether outbreaks across the U.S. last year resulted from the continuous spread of the disease between states, rather than separate introductions from abroad. If there was continuous transmission for a year, that means the U.S. has lost its status as a country that has eliminated measles. That status, which the U.S. has held since 2000, reflects a country’s vaccination rates: Two doses of the measles-mumps-rubella vaccine prevent most infections and so stop outbreaks from growing.

More careful analyses take weeks.

“We should see a report in April,” Andersen said, “assuming no political interference.”

This is the first time that the U.S. has applied sophisticated genomic techniques to measles, which largely disappeared from the country a quarter-century ago because of broad vaccine uptake.

Declining , misinformation, and the Trump administration’s to outbreaks have fueled a resurgence of the disease. With at least 2,285 cases in 44 states, 2025 was the worst year for measles in more than three decades. This year is on track to surpass that, with 1,575 cases as of late March.

While welcoming the science, researchers say the government’s top priority should be to stop the virus from spreading.

“I think it’s incredibly important to do whole genome sequencing for outbreaks,” Andersen said, “but we shouldn’t need to do this for measles in the first place, because we have an extremely effective and safe vaccine.”

“That we’re even talking about this is nuts,” he added.

Health and Human Services Secretary Robert F. Kennedy Jr. and other government officials should sound an alarm about measles’ comeback and launch nationwide vaccine campaigns, said Rekha Lakshmanan, executive director of , a nonprofit in Houston that advocates for vaccine access.

“I applaud the science,” she said, “but the more urgent need is to get measles under control as quickly as possible.”

Top officials have instead , and false notions about vaccines have been granted new life in Kennedy’s CDC. This includes abrupt changes to vaccine information on CDC websites that say aren’t based on evidence and endanger lives. 

Kennedy continues to promote unproven remedies that could mislead parents into believing that they can avoid vaccines without consequence. On the podcast in late February, Kennedy spoke at length about measures to improve America’s health but didn’t mention vaccines. He said preventive measures could entail “holistic medicine, or take vitamins, or take vitamin D, which is, as you know, it’s kind of miraculous.”

“The risk of measles remains low for most of the United States,” HHS spokesperson Emily Hilliard wrote. “CDC has made $8.5 million available to address measles response activities in 7 jurisdictions experiencing outbreaks,” she wrote. “The CDC, HHS principles, and the Secretary have been vocal that the MMR vaccine is the best way to protect yourself against measles.”

1,000 Genomes

In December, the CDC enlisted the help of one of the country’s leading centers for virus sequencing, the Broad Institute in Cambridge, Massachusetts. Major outbreaks in Texas, Utah, and South Carolina had been fueled by the same type of measles virus, labeled D8-9171. But since that type also circulates in Canada and Mexico, researchers need more data to discern whether it spread among states or entered the U.S. multiple times.

Whole genome sequencing provides that information because viruses evolve over time. The measles virus acquires a mutation every two to four transmissions between people, said Bronwyn MacInnis, director of pathogen surveillance at the Broad.

“There is enough signal in this data to tease apart questions at hand,” MacInnis said, “the main one being sustained transmission within this country.”

MacInnis’ team worked overtime to sequence the entire genomes of inactivated measles viruses that had been collected from states in 2025 and 2026.

“We’ve done about 1,000 samples and delivered the genome data back to the CDC,” sending it on a rolling basis since December, MacInnis said. “This is the CDC’s data to publish.”

The CDC didn’t post a single one of those genomes until late March, when eight appeared on a public database hosted by the National Center for Biotechnology Information. By April 1, an additional 154 had gone online.

“It should be on NCBI within a couple of weeks of being produced,” Andersen said, “and certainly not take longer than a month when you have an active outbreak.”

Genomic data holds clues about how outbreaks start and spread. It allows researchers to develop tests, treatments, and vaccines — and detect variants that might evade them.

Such data was critical in the covid pandemic. Chinese and Australian scientists online on Jan. 10, 2020, of sequencing it. “It definitely shouldn’t take the CDC months,” said Eddie Holmes, the Australian virologist who helped publish the first coronavirus sequence.

One reason for the delay is that the CDC’s measles lab has been sorely understaffed amid mass layoffs and other turmoil at the agency over the past year, a CDC scientist told Ñî¹óåú´«Ã½Ò•îl Health News. Another reason, the researcher added, is a learning curve: The CDC and health departments haven’t needed to sequence hundreds of whole measles genomes before now. (Ñî¹óåú´«Ã½Ò•îl Health News agreed not to identify the scientist, who feared retaliation.)

In contrast with the CDC, the Utah Public Health Lab has shared measles genomes rapidly. Most of some 970 measles genomes posted online since Jan. 1, 2025, were sequenced by the state, hailing from Utah, Arizona, South Carolina, and other states willing to share them.

“We’ve only got a handful of samples from Texas that were collected kind of in the middle of their outbreak,” said Kelly Oakeson, a genomics researcher at the Utah Department of Health and Human Services. The genomes of the Texas and Utah measles viruses are similar but distinct, Oakeson said, meaning that intermediate versions of the virus are missing.

If the genetic code of viruses collected late in the Texas outbreak are a closer match to those from Utah’s, that will suggest that spread was continuous and the country has lost its measles-free status. The hundreds of genome sequences still sitting at the CDC probably hold the answer.

Waiting on the CDC

The CDC expected to finish its analysis before April, said Daniel Salas, executive manager of the immunization program at the Pan American Health Organization, which works with the World Health Organization. That’s when PAHO was slated to evaluate the United States’ measles status.

He said PAHO delayed its evaluation until the organization’s annual meeting in November, partly because the CDC needed more time to do the genomic analysis and partly because the measles status of Mexico, Bolivia, and other countries is also under review, and holding staggered meetings for each country is inefficient.

The U.S. is the only country using whole genome sequencing to answer the elimination question, Salas said. Typically, countries classify measles viruses according to a tiny snippet of genes, then assume that large outbreaks caused by the same type are linked. Whole genomes provide a more accurate view.

“If the U.S. can fill in the blanks with genomic data, that’s a sort of breakthrough,” Salas said. “That doesn’t mean other countries are going to be able to pull off this kind of analysis,” he added. “It takes a lot of specialized knowledge and resources.”

Equipment to sequence and analyze genomes costs upward of $100,000, and the cost to process each sample, including paying the researchers involved, typically ranges from $100 to $500 per sequence.

“I’m pro-science, but we shouldn’t have to do this,” said Theresa McCarthy Flynn, president of the North Carolina Pediatrics Society. “We don’t have to have a measles epidemic.”

Flynn said she regularly fields questions from parents concerned by misinformation spread by Kennedy and anti-vaccine groups, including the one he founded before joining the Trump administration. Parents have also pointed to changes in the CDC’s recommendations and to its websites that are at odds with the scientific consensus.

Before Kennedy took the helm, a said “Vaccines do not cause autism” in prominent type, and listed in premier scientific journals that refuted a link between vaccines and developmental disorders.

Last year, shifted to saying, “Studies supporting a link have been ignored by health authorities.” The high-quality studies were replaced with a report from a single investigator who has ties to anti-vaccine groups. In an email to Ñî¹óåú´«Ã½Ò•îl Health News, HHS spokesperson Hilliard echoed the altered website’s claims about vaccines, disregarding extensive studies on the topic.

Flynn, of the pediatrics association, said, “The CDC itself is spreading misinformation about vaccines. I cannot overstate the seriousness of this.”

Although the acting director of the CDC, Jay Bhattacharya, says vaccines are the best way to prevent measles, he too has undermined vaccine policy. He said the controversial to reduce the number of vaccines recommended to children was based on “gold standard science.” In fact, the new schedule makes the among peer nations. Hilliard wrote that the updated schedule was “aligning U.S. guidance with international norms.”

A federal court temporarily invalidated the change last month in a lawsuit brought by the American Academy of Pediatrics and other groups.

Bhattacharya hasn’t held briefings with the public or the press on the surge of measles this year or activated the CDC’s emergency capabilities.

“Normally, we’d have a big push to get vaccination rates up in areas where it’s low. We’d do a big social media push, put out ads on getting vaccinated,” said another CDC scientist whom Ñî¹óåú´«Ã½Ò•îl Health News agreed not to identify, because of fears of retaliation. “People at the CDC want to do this, but political leadership at the agency has not allowed the CDC to do it.”

Further, the Trump administration’s to public health funds have made it hard for local health officials to protect communities. Philip Huang, director at Dallas County Health and Human Services in Texas, said the department lost over $4 million when the administration clawed back about $11 billion from health departments early last year as a measles outbreak surged in the state.

“We lost 27 staff and had to cancel over 20 of our community vaccination efforts, including to schools identified as having low vaccination rates,” he said. “There are simultaneous attacks on immunizations that are making our jobs harder.”

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But seven months later, findings from five states shared with Ñî¹óåú´«Ã½Ò•îl Health News show that the reviews have uncovered little evidence of a widespread problem.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers health care costs for people with low incomes and disabilities, and the closely related Children’s Health Insurance Program. Both programs are administered by states.

Spokespeople from Pennsylvania’s and Colorado’s Medicaid agencies said, as of March, the states had found no one who needed to be terminated from Medicaid. That was after checking a combined 79,000 names.

Texas has reviewed records of more than 28,000 Medicaid enrollees at the Trump administration’s request and terminated coverage for 77 of them, according to Jennifer Ruffcorn, a spokesperson for the Texas Department of Human Services.

Ohio has checked 65,000 Medicaid enrollees, of which 260 people were disenrolled from the program, said Stephanie O’Grady, a spokesperson for the Ohio Department of Medicaid.

In Utah, 42 of the 8,000 enrollees identified by the Trump administration had their Medicaid coverage terminated, said Becky Wickstrom, a spokesperson for the state’s Department of Workforce Services.

In announcing the reviews, Health and Human Services Secretary Robert F. Kennedy Jr. said: “We are tightening oversight of enrollment to safeguard taxpayer dollars and guarantee that these vital programs serve only those who are truly eligible under the law.”

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, said the reviews ordered by the federal Centers for Medicare & Medicaid Services were unneeded because states check immigration status when people sign up.

“It is entirely predictable that all of these burdensome reviews that the federal government is forcing upon states would yield no pay dirt,” Cuello said. “The states had already done the reviews once, and CMS was just making them reverify the same information they had already checked. Making states go through the same bureaucratic process twice is incredibly wasteful and inefficient.”

CMS spokesperson Chris Krepich said in a statement to Ñî¹óåú´«Ã½Ò•îl Health News that the ongoing checks are verifying eligibility “for certain enrollees whose status could not be confirmed through federal data sources.”

“CMS provides states with regular reports for follow-up review, and states are responsible for independently verifying eligibility and taking appropriate action consistent with federal requirements,” he said.

But the findings shared with Ñî¹óåú´«Ã½Ò•îl Health News also suggest that many of the enrollees whose eligibility the Trump administration said it could not confirm are indeed U.S. citizens. O’Grady said Ohio found that, of the 65,000 names referred by the federal government, the state already had information on 53,000 confirming them as citizens and an additional 11,000 showing appropriate immigration status for Medicaid.

Caseworkers then worked on the remaining 1,000 names to review their information or reach out for more details, she said.

CMS did not answer questions about the findings from the states sampled by Ñî¹óåú´«Ã½Ò•îl Health News or provide information about responses it received from all 50 states and the District of Columbia, which were instructed to perform verification checks.

The agency also did not respond to a question about whether it’s forwarding the names of those whose Medicaid coverage was terminated to federal immigration officials.

In June, advisers to Kennedy ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, prompting a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against residents living in the U.S. without authorization.

A federal judge that Immigration and Customs Enforcement workers could access information only about people in the country unlawfully in the Medicaid databases of the states that sued.

CMS continues to send states lists of names at least every few months, though state officials say the numbers have declined since the first batch last summer.

People without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces. Medicaid does reimburse hospitals for providing emergency care to people without legal status if they meet income and other program requirements.

Seven states and the District of Columbia provide health coverage regardless of immigration status, funding the programs with their own money.

In March 2025, CMS began financial reviews of those programs. “CMS has identified over $1.8 billion in federal funds that are being recouped through voluntary returns and deferrals of future federal Medicaid payments,” Krepich said. He did not answer how much has been collected so far or from which states.

Medicaid’s overall spending topped $900 billion in fiscal year 2024.

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While taking her history and vital signs, Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148/86, above normal despite her taking two medications intended to lower it. “Clearly that was too high,” he said recently.

Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet, and a lack of regular exercise. She had also told Supiano that she typically drank a couple of glasses of wine each evening.

After Supiano discussed ways to lower her risk, the woman and her husband joined a gym. She stopped taking the anti-inflammatory and cut back on salt and alcohol, bringing her systolic blood pressure readings into the 130-to-140 range — still hypertension, according to  issued by the American Heart Association and the American College of Cardiology later that year, but more acceptable. (Systolic is the top number in the blood pressure ratio and the more clinically important number.)

By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. “I was not as aggressive as I should have been,” Supiano recalled. He added a third drug for high blood pressure to the woman’s regimen, and her readings fell to 120 or lower.

The shifting guidelines for blood pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, “How low can you go?”

For more than 25 years, a reading of 140/90 or below was considered normal, according to the AHA/ACC guidelines. But the 2017 update introduced major changes, backed by results from the , which enrolled adults over 50 who were at high cardiovascular risk.

The SPRINT trial found that intensive treatment aimed at bringing the systolic number below 120 reduced the risk of heart attacks, strokes, other cardiovascular illnesses, and overall mortality so substantially that the investigators .

It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.

°Õ³ó±ðÌý, issued last year, encourage still tighter control. They call for patients at cardiovascular risk to strive for systolic readings below 120, and they also call that target “reasonable” even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.

Blood pressure normally rises with age because “with stiffening of the arteries, the heart has to pump harder,” said Erica Spatz, the director of the preventive cardiovascular health program at the Yale School of Medicine. From 2021 to 2023, about  had hypertension, according to the operative definition at the time.

But recent revisions could “define a lot more people as having high blood pressure,” said Rita Redberg, a cardiologist at the University of California-San Francisco.

To Supiano, recent  and  that show cognitive benefit for the lower readings “have tipped the scales” for older adults. “What’s good for the heart is good for the brain,” he said, calling those findings “a lever to get people to pay more attention to their blood pressure. They may not want to live longer, but they want to hold on to their cognition longer.”

Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization’s board), have endorsed the latest guidelines.

“I used to be lenient in many of my older patients,” said John Dodson, a cardiologist and researcher at NYU Langone Health. “If I overtreated high blood pressure, bad things were going to happen.”

Blood pressure that drops too low — hypotension — can cause dizziness and fainting or injuries from falls.

Now, Dodson said, “I’m treating my older patients more aggressively.” Studies have shown that treating high blood pressure . And while older adults in the SPRINT trial had more fall injuries, the rate wasn’t higher  than in those undergoing standard treatment. Among those over 75, it was  for both groups.

Another significant change: The new guidelines recommend at-home monitoring.

“Blood pressure is tricky,” Spatz pointed out. “It varies throughout the day, depending on whether a person is just waking up or just ate or it’s hot outside.” Systolic readings can bounce around by 30 points or more in a single day.

And they’re almost always higher in a doctor’s office. “I don’t want to put much stock in one reading,” Spatz said.

“Maybe the patient has white-coat syndrome,” she added, referring to anxiety about doctors and testing, “or they had a fight with the parking attendant” on the way in.

She asks patients to record their blood pressure twice a day for a week or two before their appointments. Some doctors prescribe a 24-hour home monitor.

Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.

Price is not likely to present an obstacle. Most patients need two or three drugs to lower blood pressure, but as generics they’re “dirt cheap, about $5 a month,” and rarely interact with the other drugs that are often prescribed for older people, Supiano said. A blood pressure monitor for home use , or more for those that digitally transmit data.

Although some side effects are serious — a fall can be life-altering — most complications “thankfully are transient and reversible and rather mild,” he said.

Yet the guidelines have skeptics, too. Redberg, for example, counsels older patients about diet, exercise, and weight loss but does not urge them to start medication to reduce a 135 systolic reading to below 120.

They already seem overanxious about their blood pressure, she said, adding, “I encourage them to go out and enjoy themselves.”

“Take a class! Go to a museum!” she said. “You can’t do that if you’re at home taking your blood pressure five times a day.”

While trials and guidelines address benefits for the population as a whole — even small reductions in dementia would have an enormous impact — they are not useful for predicting individual outcomes. The , used to gauge whether someone would see cardiovascular benefit from hypertension treatment, has not been validated for people over 79 and does not factor in cognitive benefits, Supiano noted.

For people with other serious illnesses — cancer patients or frail nursing home residents with dementia, for instance — controlling blood pressure may be far down the list of concerns.

Time is also a factor in weighing risks versus benefits. A meta-analysis of older patients by Sei Lee, a geriatrician at UCSF, and colleagues found that for 200 patients in intensive treatment for hypertension, it would .

Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. “You’d have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher.”

Supiano’s 78-year-old patient did hit that target and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and eventually received an Alzheimer’s diagnosis.

Given what researchers are reporting about the cognitive benefits of treating high blood pressure, “maybe it gave her another couple of good years,” he mused. “Maybe it delayed the progression.” Or maybe, he added, he should have started intensive treatment earlier.

The New Old Age is produced through a partnership with .

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Within a few days, Reynolds became so desperate that she and her husband had to physically restrain Jonah, dumping pain medication down his throat as he screamed in pain.

“It broke our hearts,” said Reynolds, who lived in Georgetown, Kentucky, at the time. “And I remember just thinking that it shouldn’t have to come to that.”

Reynolds couldn’t find a dentist with an opening who could treat Jonah, who is autistic and often resists dental exams due to hypersensitivity and anxiety. Over the course of five days, Reynolds took Jonah twice to a nearby emergency room as he struggled with persistent pain and a fever due to a likely infected tooth with an exposed nerve. The ER had no dentists; both times, the family was sent home with only pain medication and an ice pack.

Across the nation, more children are entering ERs for preventable tooth problems. Dentists, hygienists, and researchers attributed that trend to a shortage of pediatric dental care professionals in and worsening oral hygiene since the covid-19 pandemic. Tens of thousands of kids end up in the hospital for dental emergencies each year, according to Melissa Burroughs, senior director of policy and advocacy at the national health nonprofit CareQuest Institute for Oral Health.

ER visits for tooth problems unrelated to physical injuries for children under 15 years old from 2019 to 2022, according to a report released late last year by CareQuest. And local data reflects that national trend: At Children’s Hospital Colorado in the Denver area, nontraumatic dental cases, such as cavities or gum infections, in its ER increased 175% from 2010 to 2025, according to hospital spokesperson Sarah Bonar. In Kentucky, where Jonah lives, children’s visits to the ER for dental problems rose 72% from 2020 to 2024, according to the state.

Policy changes under the Trump administration are poised to worsen the trend. President Donald Trump’s 2025 federal budget reconciliation law, known as the One Big Beautiful Bill Act, called for billions in cuts from Medicaid, which may force states to limit or drop dental coverage from the public insurance program for those with low incomes or disabilities. New eligibility requirements for Medicaid in some states could affect kids’ access to dental care, even though children are guaranteed dental coverage under the program. Research shows that when parents lose Medicaid, even kids with coverage are more likely to have and to go to a dentist.

The Trump administration has also promoted skepticism about fluoride. show that fluoride in drinking water and topical fluoride treatments dramatically reduce tooth decay and prevent cavities. In recent months, the Food and Drug Administration against the use of fluoride supplements and the Environmental Protection Agency of “potential health risks of fluoride in drinking water.” Health and Human Services Secretary Robert F. Kennedy Jr. has called fluoride a “” and “.” A 2025 study in JAMA Pediatrics linked high levels of fluoride with lower IQ in children — but only at concentrations the recommended level in public drinking water.

, a pediatric dentist at the University of Washington who studies fluoride hesitancy, worries that these anti-fluoride stances will further erode trust in fluoride treatment. Since the start of 2026, lawmakers in at least 15 states have introduced bills prohibiting or limiting fluoride in public drinking water. Utah and Florida in 2025 became the first states to enact fluoride bans.

“Will that have an effect on cavity rates?” Chi asked. “Absolutely.”

Severe Dental Cases Rise

Pediatric dentists Katherine Chin and Chaitanya Puranik said they are treating more patients like Jonah at Children’s Hospital Colorado. More severe cases have become more common, too. Puranik said he used to typically see patients with only one cavity, but now his patients are often coming in with tooth decay throughout their mouth.

During the pandemic, many dental offices , and studies show children also increased , a major risk factor for cavities. Severe cavities that lead to tooth extraction can affect , sometimes causing long-term problems with or .

Millions of people live in in the U.S., with scant dentists within driving distance. On top of that, only treat Medicaid patients, due to low reimbursement rates, which are on average of their typical dental charges, according to the American Dental Association.

Children with intellectual or developmental disabilities may especially struggle to access quality dental care. Few general dentists have sufficient pediatric training to care for kids with disabilities such as Jonah, who are easily overwhelmed or need to be sedated for an exam, , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. Over have special health care needs, and those children are to have unmet dental needs. Their parents are also to finding a dentist.

When he was younger, Jonah would not let his parents brush his teeth, which led to cavities in his baby teeth, his mother said. After Jonah’s first visit to the ER, Reynolds found a general dentist with an opening. But unlike a trained pediatric dentist, she said, the dentist did not know how to examine Jonah in a way he could tolerate and wasn’t prepared to provide sedation. Jonah left without treatment and was soon back in the ER when his fever returned.

ERs Rarely Provide Solutions

, a pediatrician in Washington County, Maine, said he is fielding “the most horrifying cavities” at Down East Community Hospital.

ERs are often ill-equipped to treat dental concerns, Weitz said. Similar to the ER Jonah went to in Kentucky, Down East has no dentists on staff. Weitz often finds himself prescribing antibiotics as a temporary measure.

“But a month later, they’re back again because it’s flaring up again,” Weitz said.

As a potential solution, states such as Maine and Alaska are proposing to use money from the $50 billion to develop the oral health workforce or to create specialized dental care centers, which can better serve children with special health care needs on short notice. But those initiatives won’t address the loss of coverage anticipated from Medicaid cuts. California last year in state grants to develop or expand over 120 dental facilities to serve patients with special health care needs.

Jonah’s dental emergency cost Reynolds a week of work from her job as a dog groomer and Jonah three days of third grade, plus hundreds of dollars in out-of-pocket costs.

Eventually, Reynolds found an oral surgeon who extracted the tooth. But even that went poorly, she said. When Jonah became upset over a needle stick, the surgeon threatened to hold him down, Reynolds said. She said the surgeon left quickly after the procedure and never gave her a clear diagnosis of what caused Jonah’s pain. The procedure did resolve his toothache, but Reynolds said more professionals should know how to handle cases like Jonah’s, with sensitivity to the families. Four years later, forcing Jonah to take his pain meds still lives fresh in her memory.

“That will never leave my mind,” Reynolds said.

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The boys sat in one waiting room and then another. Two hours and 20 minutes passed before the two were isolated, according to obtained by Ñî¹óåú´«Ã½Ò•îl Health News. Then two more hours ticked by.

As the sun rose, an emergency room doctor called the state epidemiologist and described the symptoms. The public health official told him to keep the kids in the hospital and quarantine them. Shortly after that call, the patients were diagnosed.

It was measles.

Hospital staff gave the father instructions on how to quarantine the family and sent them home.

The virus exposed at least 26 other people in the hospital that January day, federal investigators determined. Health inspectors for CMS investigated the measles infections and other failures in care and concluded that the twins’ symptoms should have triggered an isolation procedure for which Mission Hospital staffers had trained seven months earlier. CMS designated Mission in “” for the exposures and other unrelated issues, one of the most severe sanctions a hospital can face, threatening to pull federal funding unless it remedied the problems.

A spokesperson for Mission said its staff was trained to manage airborne sickness and is following federal rules.

As U.S. hospitals face an increasing risk of encountering measles, and pressure to immediately spot it, health care workers face an unusual barrier: Many don’t know what it looks like.

“There’s a word, ‘morbilliform’ — it means measles-like, and there are lots of viruses that can cause a rash that looks like a measles rash in children,” said Theresa Flynn, a pediatrician in Raleigh and the president of the North Carolina Pediatric Society. In 30 years in health care, she’s never seen a measles case, she said.

North Carolina has reported more than 20 cases since mid-December, and more than 3,000 people nationwide have been infected since the beginning of 2025.

Children in areas with low immunization rates to outbreaks, triggering public health campaigns to promote the measles vaccine. CMS Administrator Mehmet Oz encouraged vaccination in a .

, mumps, and rubella vaccine, a person has a 3% chance of getting the virus after exposure. If exposed, an unvaccinated person has a 90% chance of being infected, according to the CDC. It can take a week or two before someone infected with measles shows symptoms.

But for the past year, the Trump administration has . Health and Human Services Secretary Robert F. Kennedy Jr. was a longtime anti-vaccine activist before taking office, and under his leadership the Centers for Disease Control and Prevention has reduced the number of shots recommended to children.

After measles erupted in West Texas last year, Kennedy publicly for the virus, including steroids, antibiotics, and cod liver oil.

Infectious disease experts and doctors said federal policies have left health care workers to lean on their own experience or guidance from their state public health systems to fight a disease that many are preparing to see for the first time and that initially may behave like the common cold.

“As measles becomes more common, all of us are leveling up in our ability to recognize and immediately respond to suspected measles,” Flynn said.

Three C’s

Officially, the U.S. has maintained “measles elimination status” since 2000, meaning the U.S. has avoided significant spread of the virus. After outbreaks in Texas, Arizona, Utah, and now South Carolina, the nation is on track to lose that designation before the year is out. tie elimination status to a lack of a continuous viral spread persisting for 12 months.

One county in South Carolina, an hour’s drive from Asheville, has had in the current outbreak — more than Texas reported in all of 2025.

Symptoms of measles, a virus that , can include fever, cough, a blotchy rash, and red, watery eyes. Researchers consider measles among the most contagious diseases, and the virus may remain active for up to two hours after an infected person leaves a room.

It can be lethal, with .

In 2025, two children in Texas and one adult in New Mexico died of measles.

Along with tracking data, the CDC on its website for diagnosing measles. State public health agencies and some counties have developed dashboards tracing the disease as it surfaces in such places as hospitals, schools, grocery stores, and airports. Large hospital systems developed staff training protocols last year and shared them with area clinics.

Look for the three C’s, : cough, coryza (cold symptoms), and conjunctivitis (pink eye). According to CMS inspection records, HCA Healthcare, which owns Mission Hospital, trained Mission staff on the three C’s early last year. On top of failing to isolate the twin patients right away, Mission staff didn’t have a designated area for patients with respiratory symptoms, federal inspectors found.

The CDC advises health workers to immediately place patients with measles or suspicious symptoms in a special isolation room, where airflow is controlled inward. The Mission patients were separated from other patients only by plastic partitions, according to the CMS records.

Mission spokesperson Nancy Lindell said the hospital was equipped and staffed to manage airborne illnesses like measles.

“Our hospital has been working with state and federal health officials on proactive preparedness, and we are following guidance provided by the CDC,” Lindell said.

(Dogwood Health Trust, a private foundation established as part of HCA’s purchase of Mission Health, helps fund Ñî¹óåú´«Ã½Ò•îl Health News coverage.)

Most U.S. clinics and hospitals have never experienced measles cases, said Patsy Stinchfield, a former president of the National Foundation for Infectious Diseases and a nurse practitioner. She called CMS’ Immediate Jeopardy penalty for Mission “extreme,” given the virus can be so difficult to identify.

“In the middle of winter right now, measles looks like every other viral respiratory infection that kids come in with,” Stinchfield said.

The CDC has been less communicative in the past year with clinics about their response to outbreaks, said health workers and infectious disease experts. This disconnect began soon after Trump took office, according to a Ñî¹óåú´«Ã½Ò•îl Health News investigation finding that health officials in West Texas were unable to talk with CDC scientists as measles surged last February and March.

“We certainly do not feel the support or guidance from the CDC right now,” said Brigette Fogleman, a pediatrician at Asheville Children’s Medical Center, where staff members have come up with their own method of staving off the virus: screening patients over the phone and in their cars before a visit.

In response to questions about how the CDC is supporting health care organizations during the measles resurgence, spokesperson Andrew Nixon said that “state and local health departments have the lead in investigating measles cases and outbreaks” and that the CDC provides support “as requested.” He pointed to numerous guides and simulation tools the agency has developed as the virus has spread.

Jennifer Nuzzo, an epidemiologist and director of the Pandemic Center at Brown University, acknowledged that diagnosing measles is a major challenge, emphasizing that coordination among public health agencies is critical in overcoming that challenge.

Stinchfield attributed the spread of measles to CDC leaders’ lack of communication to clinics and to the public — no ads on buses, no social media campaigns, no sense of urgency. “When you are at the highest level of measles cases in 30 years, we should be seeing lots more from our federal government,” Stinchfield said. “And I think it’s harming kids and causing an inordinate amount of work and expense that really doesn’t belong in health care right now.”

State Prepares for More Measles Cases

In North Carolina’s Buncombe County, home to Asheville and Mission Hospital, health officials had counted seven measles cases by mid-February and anticipated many more, according to state epidemiologist Zack Moore. It’s unclear how many of those are connected to the Mission exposure.

“We are preparing for a future in which we follow a trajectory like South Carolina,” Moore said, “where we see sort of a gradual accumulation of cases, and then all of a sudden it reaches kind of a tipping point, and we see a more explosive growth in the outbreak and spread across the state.”

Fogleman, who is also a pediatrician, and Buncombe health department director Jennifer Mullendore spoke during a hosted by the county, urging families to get their children vaccinated, debunking vaccine misinformation, and updating parents on local case numbers.

Days before, a local private school had quarantined about 100 students after an exposure. were immunized, according to state data.

At Fogleman’s clinic, parents are asked to wait in their vehicles with their children, and staffers come out to screen them there. Some parents resist vaccination and note recently weakened federal recommendations around measles vaccines , she said.

Kennedy handpicked the committee members who made those recommendations, with several members having spread medical misinformation in the past.

One parent recently told a nurse, “It’s only measles. It doesn’t kill anybody,” Fogleman said.

That’s not true, her team must explain.

As the clinic holds families in the parking lot, trying to figure out whether symptoms point to the dangerous virus, it’s difficult to get the message across, Fogleman said, especially when the nation’s top disease agency hasn’t conducted a widespread information campaign about the risks from measles — or the vaccine’s ability to almost entirely prevent it.

“We can’t change the past,” Fogleman said. “All we can do is try to educate and move forward.”

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Warning patients could deter them from signing up for a program called Emergency Medicaid, through which the government reimburses hospitals for the cost of emergency treatment for immigrants who are ineligible for standard Medicaid coverage.

But if hospitals don’t disclose that the patients’ information is shared with federal law enforcement, they might not know that their medical coverage puts them at risk of being located by Immigration and Customs Enforcement.

“If hospitals tell people that their Emergency Medicaid information will be shared with ICE, it is foreseeable that many immigrants would simply stop getting emergency medical treatment,” said , a research professor at Georgetown University’s Center for Children and Families. “Half of the Emergency Medicaid cases are for the delivery of U.S. citizen babies. Do we want these mothers avoiding the hospital when they go into labor?”

For more than a decade, hospitals and states have assured patients that their personal information, including their home addresses and immigration status, would not be shared with immigration enforcement officials when they apply for federal health care coverage. guaranteed the agency would not use information from health coverage applications for enforcement activities.

But that changed last year, after President Donald Trump returned to the White House and ordered one of the most aggressive immigration crackdowns in recent history. His administration began funneling data from a variety of government agencies to the Department of Homeland Security, including filed with the IRS.

The Centers for Medicare & Medicaid Services, part of the Department of Health and Human Services, agreed last spring to give ICE officials direct access to a Medicaid database that includes enrollees’ addresses and citizenship status.

Twenty-two states, all but one led by Democratic governors, the Medicaid data-sharing agreement, which the administration did not formally announce until a federal judge ordered it to do so last summer. The judge that in those states, ICE could access information in the Medicaid database only about people in the country unlawfully. Ñî¹óåú´«Ã½Ò•îl Health News contacted more than a dozen hospitals and hospital associations in states and cities that have been targets of ICE sweeps. Many declined to comment on whether they’ve updated their disclosure policies after the ruling.

Of those that responded, none said they are directly warning patients that their personal information may be shared with ICE when they apply for Medicaid coverage.

“We do not provide legal advice about federal government data-sharing between agencies,” Aimee Jordon, a spokesperson for M Health Fairview, a Minneapolis-based hospital system, said in an email to Ñî¹óåú´«Ã½Ò•îl Health News. “We encourage patients with questions about benefits or immigration-related concerns to seek guidance from appropriate state resources and qualified legal counsel.”

Information on Applications

Some states’ Emergency Medicaid applications specifically ask for a patient’s immigration status — and still assure people that their information will be kept secure and out of the hands of immigration enforcement officials.

For example, as of Feb. 3, California’s application still included language advising applicants that their immigration information is “confidential.”

“We only use it to see if you qualify for health insurance,” states the 44-page form, which the state’s Medicaid program, known as Medi-Cal, in January.

California Department of Health Care Services spokesperson Anthony Cava said in a statement that the agency, which oversees Medi-Cal, will “ensure that Californians have accurate information on the privacy of their data, including by revising additional publications as necessary.”

Until late January, Utah’s Medicaid website also claimed its Emergency Medicaid program did not share its information with immigration officials. After Ñî¹óåú´«Ã½Ò•îl Health News contacted the state agency, Kolbi Young, a spokesperson, said Jan. 23 that the language would be taken down immediately. It was removed that day.

Oregon Health & Science University, a hospital system based in Portland, offers immigrant patients developed by the state Medicaid program for those with concerns about how their information might be used. The document does not directly say that Medicaid enrollees’ information is shared with ICE officials.

Hospitals rely on Emergency Medicaid to reimburse them for treating people who would qualify for Medicaid if not for their citizenship status — those in the country illegally and lawfully present immigrants, such as those with a student or work visa. The coverage pays only for emergency medical and pregnancy care. Typically, hospital representatives help patients apply while they are still in the medical facility.

The main Medicaid program, which covers a much broader range of services for over 77 million low-income and disabled people, does not cover people living in the country illegally.

Examining Emergency Medicaid enrollment is the most obvious way, then, for deportation officials to identify immigrants, including those who might not reside in the U.S. lawfully.

HHS spokesperson Rich Danker said in an email that CMS — which oversees Medicaid, a joint state-federal program — is sharing data with ICE after the judge’s ruling. But he would not answer how the agency is ensuring it is sharing information only on people who are not lawfully present, as the judge required.

With ICE now getting direct access to the personal information of millions of Medicaid enrollees, hospitals — while “definitely in a tough position” — should be up-front about the changes, said Sarah Grusin, at the National Health Law Program, an advocacy group.

“They need to be telling people that the judge has permitted sharing of information, including their address, for people who are not lawfully residing,” she said. “Once this information is submitted, you can’t protect it from disclosure at this point.”

Grusin said she advises families to weigh the importance of seeking medical care against the risk of having their information shared with ICE.

“We want to give candid, honest information even if it means the decision people have to make is really hard,” she said.

Those who have previously enrolled in Medicaid or can easily search their address online should assume that immigration officials already have their information, she added.

Emergency Medicaid

Emergency Medicaid coverage was established in the mid-1980s, when a federal law began requiring hospitals to treat and stabilize all patients who show up at their doors with a life-threatening condition.

Federal government spending on Emergency Medicaid accounted for nearly $4 billion in 2023, or of total federal spending on Medicaid.

States send monthly reports to the federal government with detailed information about who enrolls in Medicaid and what services they receive. The judge’s ruling in December limited what CMS can share with ICE to only basic information, including addresses, about Medicaid enrollees in the 22 states that sued over the data-sharing arrangement. ICE officials are not supposed to access information about the medical services people receive, per the judge’s order.

The judge also prohibited the agency from sharing the data of U.S. citizens or lawfully present immigrants from those states.

Deportation officials have access to personal Medicaid information of all enrollees in the remaining 28 states.

The federal health agency has not clarified how it is ensuring that certain states’ information on citizens and legal residents is not shared with ICE. But Medicaid experts say it would be nearly impossible for the agency to separate the data, raising questions about whether the Trump administration is complying with the judge’s order.

The Trump administration’s efforts to deport immigrants living in the country illegally have had implications on immigrant families seeking care. About a third of adult immigrants reported skipping or postponing health care in the past year, according to a released in November. (KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

Bethany Pray, the chief legal and policy officer at the Colorado Center on Law and Policy, warned that sharing Medicaid data directly with deportation officials will force even tougher decisions upon some families.

“This is very concerning,” Pray said. “People should not have to choose between giving birth in a hospital and wondering if that means they risk deportation.”

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