Two bills moving through the state Senate seek to prevent immigration enforcement officers from isolating patients from their loved ones and interfering with their ability to get legal help. Analyses for both bills cite reporting by Ñî¹óåú´«Ã½Ò•îl Health News that found family members and attorneys have faced extreme difficulty locating and supporting patients hospitalized while in immigration custody.

Ñî¹óåú´«Ã½Ò•îl Health News found that some hospitals have facilitated patient isolation through what are known as blackout policies, which can include registering people under pseudonyms, withholding their names from the hospital directory, and preventing staff from contacting patients’ relatives to let them know their location and condition.

A bill by Democratic state Sen. Caroline Menjivar of the San Fernando Valley, , would largely prohibit the use of blackout policies for patients in immigration custody and ensure they retain the right to have their families and others notified of their whereabouts and condition. Blackout policies would be allowed when the health care provider determines the patient is a credible risk to themself or others and the risk is documented in the patient’s medical record. Patients would also be allowed to receive visitors.

It seeks to address reports of Immigration and Customs Enforcement agents guarding patients in their hospital rooms while they undergo medical exams or talk with doctors, interfering with medical decisions, and pushing for patients to be discharged prematurely to detention facilities ill-equipped to provide follow-up care.

“These are actions that have no place in health care, and it is a clear violation of the patients’ rights,” Menjivar said.

Under Menjivar’s proposal, agents would not be allowed into the rooms of patients they bring in for care unless they can show legal authorization to be there. If agents remain in the room, staff would be required to ask them to leave during medical exams and patient care discussions. If agents refuse, health care facility staff would need to document it.

, authored by state Sen. Susan Rubio, a Democrat from the San Gabriel Valley, would require health care providers to inform staff and relevant volunteers to respond when patients want their families to know where they are, and to post a notice at facility entrances with information about visitation and access policies. The law already says patients can agree to have loved ones notified they’re in the hospital, and Rubio’s bill seeks to make sure staff and others know they can do that for patients in immigration custody.

The federal Department of Homeland Security, which oversees immigration enforcement, did not respond to a request for comment.

Both bills were passed by the Senate Health and Judiciary committees along party lines and will be heard next by the Senate Appropriations Committee.

More than 20 immigrant rights advocates and health care workers voiced support for strengthened protections for patients at a hearing last week.

“This state must do everything in its power to protect against these abuses and ensure detainees have the right to contact their loved ones when they are hospitalized and in critical conditions,” said Hector Pereyra, political manager with the Inland Coalition for Immigrant Justice.

However, representatives from the California Hospital Association and California Medical Association told lawmakers last week they had concerns that directing health care workers to document agents’ badge numbers and ask them to leave patients’ rooms could create conflict and pose a safety risk.

“While we understand that this is an important issue, we want to ensure the bill strikes the right balance and does not create conflicting or unclear obligations for hospitals and their staff and clinicians, particularly in real-time interactions with federal officers,” said Vanessa Gonzalez, a vice president of state advocacy for the hospital association.

Ñî¹óåú´«Ã½Ò•îl Health News reported that one man, 43-year-old Julio César Peña, was held at a hospital in Victorville for almost two weeks before his attorney and family found out where he was. Peña, who had terminal kidney disease, was shackled to his hospital bed, guarded by immigration agents, and told he wasn’t allowed to disclose his location, according to his wife. He then suffered a seizure that left him intubated and unconscious, but no one notified his family. Peña died Feb. 25, less than two months after he was released to go home.

Advocates for immigrants and health care workers, as well as lawmakers, fear similar incidents are happening around the state.

Menjivar said her bill “seeks to close the gap between existing law and practice by empowering health care provider entities with the tools to uphold the privacy, health, and visitation rights of a patient brought in under immigration custody.”

SB 915 would prohibit hospitals and clinics from allowing immigration officers to make medical decisions for the patient or provide interpretation. Health care facilities would be required to document and verify, “to the extent possible,” the identities of immigration officers; provide patients access to communication tools; and inform patients of their rights. They would also need to complete discharge planning that includes attempts to coordinate with any receiving facility, such as a detention center, to ensure patients receive follow-up care.

The bills come on the heels of legislation passed last year that sought to limit immigration enforcement at health care facilities, including by prohibiting medical establishments from allowing federal agents without a valid search warrant or court order into private areas. However, that bill did not address situations in which patients are already in immigration custody.

“ICE has instilled fear in our hospitals and has kept us from doing our job,” said SatKartar Khalsa, an emergency medicine resident at a safety net hospital in San Francisco who has treated detained patients and testified in support of SB 915. “This has all led to worse care for our patients and has added another layer of fear among health care workers.”

This <a target="_blank" href="/health-industry/ice-custody-immigrant-patient-protection-california-legislation/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

OAKLAND, Calif. — Rosa María Carranza leaned forward to hold a 3-year-old’s back as the girl climbed a rock in the forested hills of northeast Oakland.

Dressed in hiking gear and beaded necklaces, Carranza, 67, maneuvered between trees and children on a sunny morning in December. “Hold on to that branch,” she said in Spanish. “You can do it, my love!”

Carranza, a child development professional who grew up swinging through trees and swimming in rivers in El Salvador, said she feels at home in the forest at the outdoor preschool she co-founded. She has worked with children and teens as a caregiver and educator for more than three decades, long enough to know when to lean in and when to step back to let her students find their own footing.

When she transitioned to working part-time last year, Carranza counted on getting Medicare and Social Security checks — benefits given to American workers and lawfully present immigrants when they retire, work history and age or disability requirements. She’s contributed tens of thousands of dollars into Medicare and Social Security over 24 years, according to her Social Security Administration earnings record, reviewed by El Tímpano and Ñî¹óåú´«Ã½Ò•îl Health News. But Carranza and an estimated immigrants will soon be cut out of Medicare.

The GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump, barred certain categories of lawfully present immigrants — including temporary protected status holders, refugees, asylum-seekers, survivors of domestic violence, trafficking victims, and people with work visas — from Medicare.

Those already in the program, like Carranza, will be disenrolled by Jan. 4 — a move by Republican lawmakers to rein in Medicare spending, as they and Trump have argued that taxpayer dollars should not be used to pay for the health care of immigrants in the U.S. without authorization.

“The Democrats want Illegal Aliens, many of them VIOLENT CRIMINALS, to receive FREE Healthcare,” Trump two months after he signed the bill into law. “We cannot let this happen!”

However, the categories of immigrants now losing coverage do have legal status. Neither the White House nor the Department of Health and Human Services responded to a question about whether it was fair to disenroll legal residents from Medicare.

Immigrants without legal status were already ineligible for Medicare or most other federally funded public benefits.

Carranza is worried that she could also lose legal permission to live in the United States if the Trump administration ends temporary protected status for Salvadorans, as it sought to do during .

If that happened, Carranza would lose legal residency, risking time in an immigration detention center or deportation.

“This is like a horror movie, a complete nightmare,” Carranza said. “This is not how I imagined getting old.”

‘Under Constant Attack’

Carranza left El Salvador in 1991 during a brutal civil war, leaving behind three young children, to earn money to send home to her family. She overstayed her visa until 2001, when she qualified for temporary protected status, after two earthquakes struck El Salvador, and displacing 1.3 million.

Temporary protected status, or TPS, was passed by Congress and signed into law by Republican President George H.W. Bush in 1990.

It allows people such as Carranza, from select nations undergoing armed conflict, civil war, and climate disasters, to live and work in the United States if being in their home country poses a risk.

Carranza missed her youngest daughter’s graduation from kindergarten and first medal-winning performance in track. She worked overnight shifts babysitting newborns and later substitute-taught in public schools in the San Francisco Bay Area to pay for her children’s schooling in El Salvador, and for her own classes at City College of San Francisco, where she earned a degree in child development.

And she cared for dozens of 3-, 4-, and 5-year-olds who gazed in awe as they uncovered little treasures buried in the redwood forest of the Oakland park where she co-founded Escuelita del Bosque, a Spanish immersion preschool that teaches children outdoors.

The trade-off was supposed to be a peaceful retirement. But Congress narrowed Medicare eligibility to citizens, lawful permanent residents, Cuban and Haitian nationals, and people covered under the Compacts of Free Association, agreements between the United States and Pacific island nations.

The move followed Trump’s efforts to bar some lawfully present immigrants from Medicaid, marketplace insurance subsidies, and social support services, such as food assistance, housing subsidies, and medical visits in federally funded health centers. Altogether, 1.4 million lawfully present immigrants were projected to lose health insurance, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A spokesperson for House Speaker Mike Johnson, Taylor Haulsee, did not respond to requests for comment.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said Republicans wanted to enact tax cuts and eliminate health insurance for immigrants because it wouldn’t upset their base.

“They don’t want to turn the United States into a welfare magnet,” he said. “And they resent the government for making them pay for a welfare state.”

While data on lawfully present immigrants is not available, immigrants without legal status and $25.7 billion into Social Security in 2022, according to the Institute on Taxation and Economic Policy. The Congressional Budget Office estimated that the Medicare restrictions alone would reduce federal spending by 2034.

Health experts say eliminating coverage for immigrants with legal status .

“This is actually the first time that Congress has taken away Medicare from any group,” said Drishti Pillai, director of immigrant health policy at KFF. “This change is impacting immigrants who have lawful presence in the U.S., and many of whom have already worked and paid into the system for decades.”

As older adults like Carranza lose their Medicare coverage, clinicians anticipate that they will delay their care, leading to an increase in severely ill patients, especially in hospital emergency rooms.

Seniors can become sick suddenly and quickly, and they are more vulnerable to cardiovascular diseases such as heart disease and high blood pressure, especially if they put off routine care, said Theresa Cheng, an emergency physician at Zuckerberg San Francisco General Hospital and assistant clinical professor of emergency medicine at the University of California-San Francisco.

“It’s quite easy for them to fall off the cliff,” Cheng said.

Carranza hikes and considers herself healthy, but she acknowledges that she is aging and starting to struggle to keep up with the kids in the forest.

Late last year she was diagnosed with high blood pressure, and in January she woke up with a tight chest and went to urgent care because it had spiked to dangerous levels. A few weeks later, she tripped on a curb while walking and fell to the ground. She woke up the next day with a swollen foot. A doctor at the local hospital told her she had arthritis.

These were scary moments, she said, but she was grateful to have to pay only $10 for the urgent care visit and $5 to see her primary care doctor. However, that will change when she loses Medicare by early next year.

The stress of knowing she will lose health insurance coverage, and potentially her legal status, all while masked federal agents are detaining immigrants like her across the country, has taken a toll on her mental health, she said. She is searching for a therapist and acupuncture services to treat her insomnia and anxiety — and the feeling that she is “under constant attack.”

Nowhere To Turn

In California, home to the largest number of , Carranza could have enrolled in state-sponsored insurance, but this year the state for adults 19 and older who are a TPS holder, in the U.S. without authorization, or an asylum-seeker. Other states with Democratic governors such as have also scaled back their health programs for immigrants amid budget pressures.

In January, California Gov. Gavin Newsom proposed a state budget that would not backfill federal health care cuts to about 200,000 lawfully present immigrants, noting the $1.1 billion annual price tag and state budget shortfalls.

“Given these fiscal pressures, the administration cannot backfill for this change in federal policy,” California Department of Finance spokesperson H.D. Palmer said.

But some Democratic lawmakers and consumer advocates say the state should step in. State Assembly member Mia Bonta, who chairs the Assembly’s health committee, said she is working on a legislative budget solution to bring immigrants who will lose health coverage, including older adults, into Medi-Cal, the state’s version of Medicaid.

The East Bay Democrat is especially concerned for people like Carranza, “who have lived here for decades and contributed into this economy, who have given into our cultural fabric and into our communities and who built families and lives and who are now wanting to be able to retire with dignity and live with dignity and have the health care that they need.”

A Sign of the Future

Last April, Carranza got a glimpse of what losing her health coverage and retirement benefits could look like, after the Social Security Administration sent her a letter informing her that she no longer qualified for retirement benefits because she was not lawfully present in the U.S. — even though she was. Then Medicare stopped payments to her health plan, which disenrolled her as a result.

As a TPS holder with a work permit, she knew a mistake had been made. Yet, without her check, Carranza didn’t have money to pay her rent for a month. She worked off her rent by babysitting her landlords’ children. Last May, the office of U.S. Rep. Lateefah Simon, an Oakland Democrat, helped Carranza recover her retirement benefits, but it took months for her to get her health insurance back.

The experience left her reeling.

“It’s like getting slapped on the face after more than 30 years working for the system here,” Carranza said. “And in return, this is what we have now.”

She lies awake at night imagining the future: here, where she’s spent half her life, without health insurance and possibly Social Security benefits; or in El Salvador, where two of her three children remain. Her daughter, a green-card holder who lives in Texas, hopes to become a citizen so she can petition for permanent residency for Carranza, but the process can take years. Then there’s the possibility she fears most: indefinite detention or deportation.

On a recent morning in her basement studio in Oakland, Carranza pulled a box from the back of her closet. In it was a thick stack of identification cards that included old driver’s licenses, her Social Security card, and dozens of work IDs issued by the federal government.

“My life is in that box,” she said.

This article was produced in collaboration with , a civic media organization serving and covering the Bay Area’s Latino and Mayan immigrant communities.

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Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Renuka Rayasam discussed excited delirium on Vox Media Podcast Network’s Criminal on March 6.

• Read Rayasam’s ““

On CBS News’ CBS Mornings on March 5, Céline Gounder, Ñî¹óåú´«Ã½Ò•îl Health News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

Ñî¹óåú´«Ã½Ò•îl Health News California correspondent Christine Mai-Duc discussed Affordable Care Act premium increases on CapRadio’s Insight With Vicki Gonzalez on March 2.

• Read Mai-Duc’s ““

Ñî¹óåú´«Ã½Ò•îl Health News rural health reporter Andrew Jones discussed how younger doctors are struggling to diagnose measles on KMOX’s Total Information AM on Feb. 27.

• Read Jones’ “.”

Ñî¹óåú´«Ã½Ò•îl Health News South Dakota correspondent Arielle Zionts discussed the $50 billion Rural Health Transformation Program on Marketplace’s Make Me Smart podcast on Feb. 19.

• Read Zionts’ “,” co-reported with Sarah Jane Tribble and Maia Rosenfeld.

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When federal immigration agents descended on their city, officers deported Gabi’s father and detained her aunt.

Gabi was born in the U.S. and is an American citizen. Her best chance to stand, or even walk, someday is a complex surgery on her legs and feet that was scheduled for January. But her mother, too terrified to take out the garbage let alone venture through the city to a hospital, canceled the procedure. Ñî¹óåú´«Ã½Ò•îl Health News agreed to only partially identify the patients and their families in this article because they fear becoming targets of President Donald Trump’s immigration crackdown.

“I want more than anything for my baby to walk,” her mother said in Spanish, as Gabi cooed and wriggled in her arms, a feeding tube snaking from her stomach to an IV pole. “But with the situation that’s happening, I canceled the surgery and all the physical therapy appointments” that would have followed. “Because I’m afraid to leave.”

The Department of Homeland Security has declared an end to what it called Operation Metro Surge, carried out by officers with the Immigration and Customs Enforcement and Customs and Border Protection agencies. Even so, health care workers say, immigration agents are still camping out in hospital parking lots. And drones fly overhead in agricultural areas beyond Minneapolis, where Somali and Latino immigrants have settled in recent years.

The Minnesota crackdown revealed the sweep of the surveillance and capture system the Trump administration is using to uproot immigrant communities in the United States, and the effect of its powerful brake on the medical system.

Similar health crises surfaced wherever immigration officers massed in the past year. In Dallas, public health clinics administered about 6,000 vaccinations to Latinos last August, half as many as during a similar program a year earlier. In Chicago, doctors rerouted patients daily from clinic to clinic depending on ICE activity. Across the country, crackdowns suppressed immigrants’ health care visits.

In Minnesota, medical systems have reported cancellation and no-show rates of up to 60% since December.

Tricia McLaughlin, a spokesperson for the Department of Homeland Security, blamed protesters for the disruption. “If anyone is impeding Americans from making appointments or picking up prescriptions,” she said, “its [sic] violent agitators who are blocking roadways, ramming vehicles, and vandalizing property.”

While Minnesotans rose up to oppose the surge in the streets, doctors and nurses have quietly operated informal, underground medical networks, dodging detection to care for patients at home.

“I used to look somebody in the eyes and say, with good faith, ‘You will be fine at the hospital,’” said Emily Carroll, a nurse practitioner at HealthFinders Collaborative, a community clinic in Faribault, some 50 miles south of Minneapolis. “But now, I can’t make that guarantee.”

As thousands of federal agents move on from Minneapolis, other communities need to prepare, said Minnesota Democratic state Sen. Alice Mann, a physician.

“I know it sounds crazy,” she said, but health care providers “need to start an underground network of how to get people care in their homes. Because letting people die at home or come close to death because they are terrified to go into the hospital, in 2026, is outrageous.”

The Surge Delivers Harm

Home visits, clinicians say, may be the only way to reach those who still feel under siege. In Los Angeles, starting last June, St. John’s Community Health brought medical care to some 2,000 immigrant families too frightened to leave home during an immigration sweep after the clinic’s no-show rates ballooned to more than 30%, said Jim Mangia, the organization’s president.

Many of Minnesota’s large health institutions have relied on telemedicine and only dabbled in home care.

Not Munira Maalimisaq, co-founder of Inspire Change Clinic in Minneapolis’ Ventura Village neighborhood. After about one-third of her patients stopped showing up for appointments, “I was like, ‘We have to do something,’” the nurse practitioner said. So she called a physician friend. What if they just started seeing patients at home?

“And she’s like, ‘You know what? Let’s do it.’”

They now have about 150 doctors — a volunteer “rapid response” team that has made more than 135 home visits. The first call was a woman whose husband had been deported. She was home with her children, was 39 weeks pregnant, and was in labor. Maalimisaq called an obstetrician volunteer, and they rushed to the patient’s house.

“She was 8 centimeters dilated,” Maalimisaq said, “and did not want us to call an ambulance. She says, ‘Can I have the baby here?’”

The woman was not a good candidate for a home birth, Maalimisaq said. They persuaded her to ride to the hospital in Maalimisaq’s car, a “small Tesla, white seats. Everything that could go wrong was there.”

But they made it to the hospital in time, and the woman had a safe, healthy delivery. “If we were not there, I can only imagine what would have happened.”

Maalimisaq’s caregiving follows a Hippocratic logic: “Someone was in need. I cannot just do nothing. And we cannot call an ambulance against her will and have her shoved in there. We had no choice but to do something, and that was the only thing that we could do safely.”

In other visits, she has seen “people so stressed out they pulled the hair out of their skull.” She said she met a mother who’d been rationing her child’s seizure medicine despite the child having experienced “one seizure after another.”

The Trump administration says its Minnesota operation improved public safety. “Since Operation Metro Surge began, our brave DHS law enforcement have arrested over 4,000 criminal illegal aliens including vicious murderers, rapists, child pedophiles and incredibly dangerous individuals,” according to McLaughlin, the DHS spokesperson. DHS announced last month that McLaughlin was leaving her post.

Minnesota correctional officials say many people accused of crimes were released directly to ICE by state or county prisons and jails. And of people arrested by ICE nationwide in January had criminal convictions, according to DHS data. Far fewer were convicted of violent crimes.

Agents Outside Hospitals, Clinics

On the first day of his second term, President Donald Trump rescinded a 2011 policy that prohibited immigration enforcement in “sensitive locations” such as schools, hospitals, and churches.

In Northfield, about 45 miles south of Minneapolis, ICE agents have been sitting in their cars for hours at least twice a week outside health clinics, including one run by the local hospital, said Carroll, the nurse practitioner. Agents have made arrests in the area almost every day, Carroll and her colleagues said.

“ICE does not conduct enforcement at hospitals — period,” McLaughlin said.

One recent morning, three ICE vehicles sat in a Baptist church parking lot across the street from an elementary school in Northfield as volunteers ferried 35 children of immigrants back and forth to the school so their parents could avoid going out, Carroll said.

“ICE is not going to schools to arrest children — we are protecting children,” McLaughlin said.

Drones that Carroll and others believe are operated by immigration agents hover most nights, and sometimes during the day, over a trailer park that mostly houses immigrants who have moved to the area to work in agriculture and manufacturing over the past 15 years. Families paper over trailer windows, Carroll said.

“You cannot feel safe anywhere,” she said. “On the way to school, on the way to clinic, you might pass ICE. The sort of crushing fear and feeling of being trapped that these families are going through is outrageous.”

That fear means patients with diabetes and heart disease are missing blood sugar and blood thinner tests. Patients aren’t getting exercise, and the chronically ill are getting sicker, said Calla Brown, a Minneapolis pediatrician.

At the Faribault clinic where Carroll works, staff members deliver medicine, food, and other necessities to patients. A staffer drives 12 middle and high school kids to and from class every day in a clinic van.

Some patients are treated at home. Carroll recently diagnosed a baby with influenza, telling the parents it wasn’t an immediate threat — yet.

“‘If you see the baby struggling to breathe, if the baby’s not eating, if the baby isn’t making wet diapers, you have to go to the hospital,’” Carroll said she told them. “‘I cannot promise it’s safe. But you’ve got to go.’”

‘We’re Nice to Each Other’

In Minneapolis, nurse-midwife Fernanda Honebrink spends most of her daylight hours calling, coordinating, and shuttling between a ballooning group of fearful people stuck in their homes. She prefers not to call it a medical underground.

“It’s more like, that’s how we function in Minnesota,” said Honebrink, a U.S. citizen who emigrated from Ecuador 23 years ago. “We’re nice to each other.”

Honebrink spent a recent afternoon at the home of a family with a baby boy. His parents, Alex and Isa, desperately want him to receive vaccinations and blood tests at his one-year well-child appointment.

But they haven’t left their apartment for more than a month. “You don’t know what is most important: whether to go out for his well-being, or to go out and think that you might not come back,” Alex said.

The couple, who were interviewed in Spanish, entered the U.S. legally from Venezuela in 2024 under a program called Humanitarian Parole, which Trump ended in May. Since then, federal agents have detained and deported workers at a company where Alex, a mechanical engineer by training, worked in construction.

Alex and Isa have seen government vehicles outside their home. They knew of a man, they said, who had legitimate work papers but was picked up while walking to church one Sunday, flown to Texas, then put on a plane to Venezuela. It was a terrifying prospect for those who’ve fled that country’s dictatorship and economic chaos.

“It feels like a psychological attack,” Alex said. “The possibility of being separated from your family.”

Isa, a lawyer back in Venezuela, has endured postpartum depression, cooped up for weeks in their apartment. The state program that provided health insurance to all immigrants ended Jan. 1. A therapist checks in occasionally by phone, free of charge.

She has tried to keep the family afloat by selling homemade cakes and necklaces, and babysitting.

Her worst fear is being separated from her son, who was born in the U.S. and is a citizen. The possibility hadn’t occurred to her until an acquaintance urged her to to designate someone to have temporary custody if she were deported.

“It was something I never imagined,” said Isa, who sobbed as she recalled the moment. “He’s my baby! He’s not someone else’s! What? My baby would remain here with someone?’’

Honebrink suddenly piped up: “I will guarantee him. I’ll sign the form.”

She later told a reporter, “I told my husband I wouldn’t do that. I’ve already signed as a sponsor for four kids.”

As soon as she left the apartment, Honebrink jumped back on the phone and traded favors with local pediatricians, clinic schedulers, and volunteers. Within hours, she’d set up a new well-child visit for the baby and found a vetted driver to transport the family.

“A white person,” Honebrink explained.

Two days later, Honebrink sent a picture of her small victory: Alex and Isa’s baby boy with a Band-Aid on his legs. “He got his vaccines,” she said via text. “I’m so happy.”

But other medical needs cannot be as swiftly addressed. One February evening, Honebrink greeted Gabi and her mother with a trunk full of donated baby wipes, diapers, and toys.

Gabi’s surgery is rescheduled for August. Her mother said she hoped by then it would be safe to leave home.

“I used to take the kids to the park, but now we don’t leave at all,” she said. “They grab people, they mistreat them. How I wish it would end soon!”

Ñî¹óåú´«Ã½Ò•îl Health News’ Jackie Fortiér contributed to this report.

This <a target="_blank" href="/race-and-health/minneapolis-immigration-crackdown-underground-medical-care-networks/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.

Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.

Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.

“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.

But the Fort Peck Tribes now limit who has access to that coverage. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.

The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment has dropped by , according to federal health officials.

The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.

Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”

The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.

“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.

Scrambling for Solutions

U.S. a temporary extension of the enhanced subsidies in January. But that measure . Lawmakers are scrambling for an alternative after President Donald Trump an extension if a bill reaches his desk. On Jan. 15, the president released that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans as an alternative to the subsidies.

A.C. Locklear, CEO of the , a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”

Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is 14 years younger than that of white Americans.

“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.

Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.

In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to funding shortfalls, the agency prioritizes which treatments it will pay for.

To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.

“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”

For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.

One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.

“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.

The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. In January, the tribe paused the employer-sponsored coverage portion of its insurance program, which at the time included 52 people.

He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.

Lives on the Line

The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, will become uninsured in 2026 due to the higher costs.

Patients at the Oyate Health Center in Rapid City, South Dakota, are already reporting sky-high premium increases for ACA plans. CEO Jerilyn Church said it’s too soon to know how many will forgo coverage. But she said more uninsured patients would further strain the IHS Purchased/Referred Care program — with officials raising the bar for how sick patients must be to cover care outside of tribal health sites.

“There will be people that will not be able to get the care they need,” Church said, adding that could translate to “people losing their lives.”

Bighorn, the game warden on the Fort Peck Reservation, is among those still covered by the tribes’ insurance program. He has put it to use.

Soon after enrolling, Bighorn needed two hip replacements, surgeries that require off-reservation care and are ranked as low-priority procedures by the Indian Health Service. Bighorn said that in pre-surgery tests, specialists found the cause for his long-standing, dangerously high blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.

“I was a miserable man, tired all the time,” he said.

Without the tribe’s coverage, Bighorn may have eventually gotten those diagnoses but said it would have likely taken years to get help through the Indian Health Service. That would have meant getting much sicker before receiving care.

Ñî¹óåú´«Ã½Ò•îl Health News correspondent Arielle Zionts contributed to this report.

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

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LODGE GRASS, Mont. — Brothers Lonny and Teyon Fritzler walked amid the tall grass and cottonwood trees surrounding their boarded-up childhood home near the Little Bighorn River and daydreamed about ways to rebuild.

The rolling prairie outside the single-story clapboard home is where Lonny learned from their grandfather how to break horses. It’s where Teyon learned from their grandmother how to harvest buffalo berries. It’s also where they watched their father get addicted to meth.

Teyon, now 34, began using the drug at 15 with their dad. Lonny, 41, started after college, which he said was partly due to the stress of caring for their grandfather with dementia. Their own addictions to meth persisted for years, outlasting the lives of both their father and grandfather.

It took leaving their home in Lodge Grass, a town of about 500 people on the Crow Indian Reservation, to recover. Here, methamphetamine use is widespread.

The brothers stayed with an aunt in Oklahoma as they learned to live without meth. Their family property has sat empty for years — the horse corral’s beams are broken and its roof caved in, the garage tilts, and the house needs extensive repairs. Such crumbling structures are common in this Native American community, hammered by the effects of meth addiction. Lonny said some homes in disrepair would cost too much to fix. It’s typical for multiple generations to crowd under one roof, sometimes for cultural reasons but also due to the area’s housing shortage.

“We have broken-down houses, a burnt one over here, a lot of houses that are not livable,” Lonny said as he described the few neighboring homes.

In Lodge Grass, an estimated 60% of the residents age 14 and older struggle with drug or alcohol addictions, according to a local survey contracted by the Mountain Shadow Association, a local, Native-led nonprofit. For many in the community, the buildings in disrepair are symbols of that struggle. But signs of renewal are emerging. In recent years, the town has torn down more than two dozen abandoned buildings. Now, for the first time in decades, new businesses are going up and have become new symbols — those of the town’s effort to recover from the effects of meth.

One of those new buildings, a day care center, arrived in October 2024. A parade of people followed the small, wooden building through town as it was delivered on the back of a truck. It replaced a formerly abandoned home that had tested positive for traces of meth.

“People were crying,” said Megkian Doyle, who heads the Mountain Shadow Association, which opened the center. “It was the first time that you could see new and tangible things that pulled into town.”

The nonprofit is also behind the town’s latest construction project: a place where families together can heal from addiction. The plan is to build an entire campus in town that provides mental health resources, housing for kids whose parents need treatment elsewhere, and housing for families working to live without drugs and alcohol.

Though the project is years away from completion, locals often stop by to watch the progress.

“There is a ground-level swell of hope that’s starting to come up around your ankles,” Doyle said.

Two of the builders on that project are Lonny and Teyon Fritzler. They see the work as a chance to help rebuild their community within the Apsáalooke Nation, also known as the Crow Tribe.

“When I got into construction work, I actually thought God was punishing me,” Lonny said. “But now, coming back, building these walls, I’m like, ‘Wow. This is ours now.’”

Meth ‘Never Left’

Meth use is a throughout the U.S. and a growing contributor to the nation’s . The drug had been devastating in Indian Country, that encompasses tribal jurisdictions and certain areas with Native American populations.

Native Americans face the in the U.S. compared with any other demographic group.

“Meth has never left our communities,” said A.C. Locklear, CEO of the , a nonprofit that works to improve health in Indian Country.

Many reservations are in rural areas, which have of meth use compared with cities. As a group, Native Americans face high rates of poverty, chronic disease, and mental illness — all are . These conditions are rooted in , a byproduct of colonization. Meanwhile, the Indian Health Service, which provides health care to Native Americans, has been chronically underfunded. Cutbacks under the Trump administration have shrunk health programs nationwide.

LeeAnn Bruised Head, a recently retired public health adviser with the U.S. Public Health Service Commissioned Corps, said that despite the challenges, tribal nations have developed strong survival skills drawing from their traditions. For example, Crow people have held onto their nation’s language; neighbors are often family, or considered such; and many tribal members rely on their clans to mentor children, who eventually become mentors themselves for the next generation.

“The strength here, the support here,” said Bruised Head, who is part of the Crow Tribe. “You can’t get that anywhere else.”

Signs of Rebuilding

On a fall day, Quincy Dabney greeted people arriving for lunch at the Lodge Grass drop-in center. The center recently opened in a former church as a place where people can come for help to stay sober or for a free meal. Dabney volunteers at the center. He’s also the town’s mayor.

Dabney helped organize community cleanup days starting in 2017, during which people picked up trash in yards and alongside roads. The focus eventually shifted to tearing down empty, condemned houses, which Dabney said had become spots to sell, distribute, and use meth, often during the day as children played nearby.

“There was nothing stopping it here,” Dabney said.

The problem hasn’t disappeared, though. In 2024, officials broke up a multistate based on the Crow reservation that distributed drugs to other Montana reservations. It was one example of how drug traffickers as sales and distribution hubs.

A few blocks from where Dabney spoke stood the remains of a stone building where someone had spray-painted “Stop Meth” on its roofless walls. Still, there are signs of change, he said.

Dabney pointed across the street to a field where a trailer had sat empty for years before the town removed it. The town was halfway through tearing down another home in disrepair on the next block. Another house on the same street was being cleaned up for an incoming renter: a new mental health worker at the drop-in center.

Just down the road, work was underway on the new campus for addiction recovery, called Kaala’s Village. Kaala means “grandmother” in Crow.

The site’s first building going up is a therapeutic foster home. Plans include housing to gradually reunite families, a community garden, and a place to hold ceremonies. Doyle said the goal is that, eventually, residents can help build their own small homes, working with experienced builders trained to provide mental health support.

She said one of the most important aspects of this work “is that we finish it.”

Tribal citizens and organizations have said the political chaos of Trump’s first year back in office shows the problem with relying on federal programs. It underscores the need for more grassroots efforts, like what’s unfolding in Lodge Grass. But a reliable system to fund those efforts still doesn’t exist. Last year’s federal grant and program cuts also fueled competition for philanthropic dollars.

Kaala’s Village is expected to cost $5 million. The association is building in phases as money comes in. Doyle said the group hopes to open the foster home by spring, and family housing the following year.

The site is a few minutes’ drive from Lonny and Teyon’s childhood home. In addition to building the new facility’s walls, they’re getting training to offer mental health support. Eventually, they hope to work alongside people who come home to Kaala’s Village.

As for their own home, they hope to restore it — one room at a time.

“Just piece by piece,” Lonny said. “We’ve got to do something. We’ve got these young ones watching.”

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NEW ORLEANS — Elyse Stevens had a reputation for taking on complex medical cases. People who’d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.

“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” said Stevens, a primary care and addiction medicine doctor.

While other doctors avoided these patients, Stevens — who was familiar with the city from her time in medical school at Tulane University — sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.

One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.

Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.

She agreed to prescribe Harrell pain medication — an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.

But Stevens was confident Harrell could hold up her end of the deal.

“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday evening in October. So, “I’m no longer on cocaine.”

Stevens’ approach to patient care has won her awards and nominations in , , and . Instead of seeing patients in binaries — addicted or sober, with a positive or negative drug test — she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?

But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn’t one of them. And it came to a head in the summer of 2024.

“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens said.

Flexible Care or Slippery Slope?

More than who need substance use treatment don’t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.

Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.

The result?

“Patients did OK and we actually reached more people,” said , immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by of addiction medication and focusing on recovery goals .

But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don’t meet their doctors’ expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.

Progress should be more than keeping patients in care, said , a Stanford psychologist, who has treated and researched addiction for decades and .

“If you give addicted people lots of drugs, they like it, and they may come back,” he said. “But that doesn’t mean that that is promoting their health over time.”

Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics — — say enables illegal drug use.

The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summer of 2024, supervisors started questioning Stevens’ approach.

In emails reviewed by Ñî¹óåú´«Ã½Ò•îl Health News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered to treat opioid addiction.

Supervisors worried Stevens wasn’t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.

“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer at the time wrote to Stevens’ supervisor, . “Note that this is the only standard of care which would likely be considered should a legal concern arise.”

Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the general practice but couldn’t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?

Stevens sent her supervisors of and backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn’t disappear.

“They just wouldn’t be getting care and perhaps they’d be dead,” she said in an interview with Ñî¹óåú´«Ã½Ò•îl Health News.

Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens’ practices.

Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.

“We are not at liberty to comment publicly on internal personnel issues,” they wrote.

“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they said. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”

Not Black-and-White

Ñî¹óåú´«Ã½Ò•îl Health News shared the complaints against Stevens and the responses she’d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.

, an addiction medicine doctor and the , said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens’ notes detailed patients’ life circumstances and the intricate decisions she was making with them.

“To me, that’s the big difference,” Loyd said.

Some people think the “only good answer is no opioids,” such as oxycodone or hydrocodone, for any patients, said , an addiction medicine doctor and associate professor at Michigan State University. But patients may need them — sometimes for things like cancer pain — or require months to lower their doses safely, she said. “It’s not as black-and-white as people outside our field want it to be.”

Humphreys, the Stanford psychologist, had a different take. He did not review Stevens’ case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today’s lethal street drugs too.

Overprescribing fueled the opioid crisis, he said. “It’s not going to go away if we do that again.”

‘The Thing That Kills People’

After months of tension, Stevens’ supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by Ñî¹óåú´«Ã½Ò•îl Health News.

Overnight, hundreds of her patients were moved to other providers.

Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.

After Stevens’ departure, Bair was left without medication for three days. The withdrawal symptoms were severe — headache, nausea, muscle cramps.

“I was just in physical hell,” said Bair, who works for the National Harm Reduction Coalition and uses they/them pronouns.

Although Bair eventually got a refill, Springgate, Stevens’ supervisor, didn’t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair’s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in patient portal notes reviewed by Ñî¹óåú´«Ã½Ò•îl Health News.

But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.

“This is the thing that kills people,” said Bair, who eventually found another doctor willing to prescribe.

Springgate did not respond to repeated calls and emails requesting comment.

University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens’ patients.

‘Reckless Behavior’

About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens’ return.

One student wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran , called Stevens a “lifeline” for vulnerable patients.

Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.

In May, the hospital’s review committee determined Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” according to a letter sent to Stevens.

The hospital did not answer Ñî¹óåú´«Ã½Ò•îl Health News’ questions about how it reached this conclusion or if it identified any patient harm.

Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state’s medical licensing board.

The medical board began its own investigation — a development that eventually cost Stevens the other job offer.

In presenting her side to the medical board, Stevens repeated many arguments she’d made before. Yes, she was prescribing powerful medications. No, she wasn’t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients’ circumstances, she said. Her response included a 10-page bibliography with 98 citations.

Liability

The board’s investigation into Stevens is ongoing. shows no action taken against her license as of late December.

The board declined to comment on both Stevens’ case and its definition of appropriate addiction treatment.

In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she’s grateful for the welcoming locals and the financial stability to support herself and her parents.

But it hurts to think of her former patients in New Orleans.

Before leaving, Stevens packed away handwritten letters from several of them — one was 15 pages long, written in alternating green and purple marker — in which they shared childhood traumas and small successes they had while in treatment with her.

Stevens doesn’t know what happened to those patients after she left.

She believes the scrutiny of her practices centers on liability more than patient safety.

But, she said, “liability is in abandoning people too.”

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

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

Over the past year, The Marshall Project – Cleveland and Ñî¹óåú´«Ã½Ò•îl Health News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

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

Patients Wait or Are Turned Away

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

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

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

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

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

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

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

‘It’s Heartbreaking’

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

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

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

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

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

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

High-Profile Incidents

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

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

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

37-Day Wait for a Bed

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

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

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

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

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

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

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

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

Yet backlogs at the Ohio hospitals mounted.

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

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

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

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

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

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

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

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

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

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

Sick System

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

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

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

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

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

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

Escapes and a Lockdown

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

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

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

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

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

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

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

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

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

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

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

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

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

A Disaster That Wasn’t Averted

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

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

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

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

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

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

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

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

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

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

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

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

‘He’s Not a Throwaway Child’

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

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

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

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

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

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

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

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

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The effort, part of Baltimore’s more than $100 million gun violence prevention plan, relies on staffers like Fitzgerald to build trust with people at risk of such violence and offer them resources like housing or food. Researchers believe these programs reduce gun deaths.

Yet one morning in 2019, Fitzgerald said, his oldest son, Deshawn McCoy, then 26, was shot just outside of the neighborhood he patrolled at the time. Fitzgerald said McCoy was a “really beautiful soul,” who fixed dirt bikes at a local garage. McCoy became the city’s , one of 348 that year, among the city’s deadliest. He left behind three daughters.

“This is our zone,” said Fitzgerald, pointing toward McElderry Park. “My son got cooked over here.”

For years, violence intervention was the work of loosely organized, underfunded groups. Then gun violence spiked during the covid pandemic and the Biden administration and Congress poured in money to better integrate such programs within cities. It appeared to help: In Baltimore and beyond, gun violence has plummeted.

The number of homicides in the city dropped 41%, from more than 300 a year in 2021 to 201 in 2024, according to the U.S. attorney’s office in Maryland.

“Gun violence is a sticky, hard problem to solve,” said Daniel Webster, a researcher at the Johns Hopkins Center for Gun Violence Solutions in Baltimore. “We’re getting it right finally.”

Now President Donald Trump’s administration has gutted funding for that work.

Webster said it could take years to untangle what led to the city’s gun violence drop. Among the factors, he said: the pandemic’s end, investments in violence intervention, improvements that have given police more legitimacy in neighborhoods, targeted prosecutions, and an aggressive effort to remove untraceable ghost guns.

“You need all of these systems working well to have systemic reductions in gun violence,” he said.

The Trump administration has slashed funding for and research, cutting about $500 million in grants to organizations that support public safety.

At the same time, Trump has loosened gun laws the Bureau of Alcohol, Tobacco, Firearms and Explosives, which oversees gun dealers. He has also sent federal troops into the Democratic-led cities of Chicago; Los Angeles; Memphis, Tennessee; Portland, Oregon; and Washington, D.C.

Webster said cities are still benefiting from pandemic-era efforts to address gun deaths. But given the Trump policy changes, if violence escalates, city leaders could have a hard time keeping it from spiraling out of control.

Trying Something Different

Safe Streets is among the promising violence prevention programs that could lose funding. Staffers in the city’s most violent neighborhoods operate like community health workers.

During the pandemic, the Biden administration provided billions of dollars to local governments through the American Rescue Plan Act. Biden urged them to deploy money to community violence intervention programs, which have been shown to by as much as 60%. His administration to spend Medicaid dollars on such programs. The goal: Stop gun deaths.

Few cities seized the opportunity.

Analyzing federal data, professors Philip Rocco of Marquette University and Amanda Kass of DePaul University found local governments used the ARPA money for 132,451 projects. Yet only 231, less than 0.2%, involved community violence intervention, they said.

In Baltimore, then-newly elected mayor Brandon Scott was ready for the federal influx.

Baltimore’s homicide rate had been high since 2015, when a 25-year-old Black man named Freddie Gray died in police custody. Protests erupted and fractures between residents and police deepened. Baltimore ended the year with 342 homicides, the first time since 1999 that more than 300 were recorded in the city.

“We got really good at our jobs” in the years after Gray’s death, said James Gannon, trauma program manager at Sinai Hospital of Baltimore.

Gun deaths tracked what public health researcher Lawrence T. Brown called the : racially segregated areas that fanned out across Baltimore’s eastern and western neighborhoods around a wealthy central strip. People who faced years of forced displacement and disinvestment , which fueled the cycle.

Every year from 2015 to 2022, the city recorded at least 300 homicides.

“We had to try something different,” said Stefanie Mavronis, director of the Mayor’s Office of Neighborhood Safety and Engagement. Scott created the agency weeks after he was sworn into office in 2020, later with $50 million in ARPA money and $20 million annually from the city’s budget.

Containing an Outbreak

The office’s budget — $22 million in fiscal year 2026 — is a fraction of the city’s .

Still, the money allowed Baltimore’s leaders to scale up a new approach: addressing gun violence the way public health officials might handle an infectious disease outbreak, Mavronis said.

City staffers identified the small subset of people most at risk of being shot or becoming the next shooter through crime data and referrals from social service workers, hospitals, and violence intervention staff, she said. Mavronis said that gangs, friends willing to engage in violence for each other, and retaliation had been driving gun deaths in the city.

“This never-ending cycle of violence and loss and trauma,” Mavronis said, “comes from that.”

The city convened hospital presidents to connect gunshot victims and their friends and family to counseling, crisis support, and city services.

It offered people help finding therapy, a job, or emergency relocation — and threatened arrest and prosecution if they retaliated.

“We decided that we were no longer going to subscribe to the belief that one thing, one agency, one part of government, one program was going to help cure Baltimore of this disease of gun violence that has had a stranglehold on this city for the entirety of my life,” Scott said.

The Coming Cliff

Baltimore is on pace this year to post its fewest gun deaths since Richard Nixon was president.

“Some of it is the national zeitgeist of the moment,” said Adam Rosenberg, executive director of Center for Hope at LifeBridge Health, which operates Safe Streets sites and the Violence Response Team at Sinai Hospital. He credits mainly the infusion of funding that allowed more resources and hands-on engagement with high-risk communities.

“We typically talk about how poverty affects homicides, but it works in reverse too,” Webster said. “People don’t invest in homes and businesses or, frankly, in people, where people get shot regularly.”

Fitzgerald, who grew up in East Baltimore, said he started working for Safe Streets in 2010 for the paycheck.

He’s been on both sides of gun violence, he said, as someone hit more than a dozen times in shootings — first when he was 12. At 13, Fitzgerald said, he shot a cousin in the leg. Over years, he was in and out of the criminal justice system, including for charges of attempted murder, which helped him understand the people he now works with every day, he said.

No college “can certify you in my experiences in violence,” he said. “That’s what allows me to identify and detect potentially violent situations.”

Today, Fitzgerald, 49, believes that teaching kids trauma coping mechanisms can drive culture change and stop shootings.

“Our kids see more death than soldiers,” he said.

But federal funding is drying up. Anthony Smith, executive director of , which supports local leaders on gun violence reduction, estimates that about 65 groups have lost funding this year. And Trump’s signature legislation slashes nearly $1 trillion in anticipated federal Medicaid spending over the next decade.

Center for Hope lost $1.2 million from federal cuts.

“It’s like a car racing along, and you see the cliff coming,” Rosenberg said. “I don’t know if the resources are there anymore, but the need certainly is.”

Rosenberg said that, because of their experiences, staffers such as Fitzgerald are “incredible messengers” for people involved in gun violence, and he noted that they are thoroughly vetted.

Fitzgerald put it this way: “I’m trying to save my kids, the community. The people we’re trying to save is our friends and our family, and ourselves.”

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Fred Clasen-Kelly contributed to this report.

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“When you get shot,” he said, “you stop thinking about the future.”

He is anchored by his wife and child and faith. He once wanted to work as a forklift driver but has built a stable career in information technology. He finds camaraderie with other gunshot survivors and in advocacy.

Still, trauma remains lodged in his daily life. As gun violence surged in the shadows of the covid pandemic, it shook Harris’ fragile sense of security. He moved his family out of Philadelphia to a leafy suburb in Delaware. But a nagging fear of crime persists.

Now he is thinking about buying a gun.

Harris is one of tens of thousands of Americans killed or injured each year by gun violence, a public health crisis that escalated in the pandemic and churns a into a hospital emergency room every half hour.

Over the past two decades, the firearm industry has and stepped up sales campaigns through social media influencers, conference presentations, . An industry trade group acknowledged that its traditional customer was “” and in recent years began targeting and who are disproportionately victimized by gun violence.

The Trump administration has moved to reduce federal oversight of gun businesses, announced by the Bureau of Alcohol, Tobacco, Firearms and Explosives as “marked by transparency, accountability, and partnership with the firearms industry.”

The pain of gun violence crosses political, cultural, and geographic divides — but no group has suffered as much as Black people, such as Harris. They were nearly 14 times as likely to die by gun homicide than white people in 2021, , citing federal data. Black men and boys are 6% of the population but of homicide victims.

Washington has offered little relief: Guns remain one of few consumer products the federal government for health and safety.

“The politics of guns in the U.S. are so out of whack with proper priorities that should focus on health and safety and most fundamental rights to live,” said attorney Jon Lowy, founder of , who helped represent Mexico in an unsuccessful lawsuit against Smith & Wesson and other gunmakers that reached the Supreme Court. “The U.S. allows and enables gun industry practices that would be totally unacceptable anywhere else in the world.”

Ñî¹óåú´«Ã½Ò•îl Health News undertook an examination of gun violence during the pandemic, a period when firearm deaths reached an all-time high. Reporters reviewed academic research, congressional reports, and hospital data and interviewed dozens of gun violence and public health experts, gun owners, and victims or their relatives.

The examination found that while public officials imposed restrictions intended to prevent covid’s spread, politicians and regulators helped fuel gun sales — and another public health crisis.

As state and local governments schools, advised residents to stay home, and closed gyms, theaters, malls, and other businesses to stop covid’s spread, President Donald Trump kept gun stores open, critical to the functioning of society.

White House spokesperson Kush Desai did not respond to interview requests or answer questions about the Trump administration’s efforts to reduce regulation of the firearm industry.

During the pandemic, the federal government gave firearm businesses and groups more than $150 million in financial assistance through the Paycheck Protection Program, even as some businesses reported brisk sales, according to from Everytown for Gun Safety, an advocacy group.

Federal officials said the program would keep people employed, but millions of dollars went to firearm companies that did not say whether it would save any jobs, the report said.

About bought a gun during the first two years of the pandemic, including millions of first-time buyers, according to survey data from NORC at the University of Chicago.

Harris is keenly aware of what drives the demand.

“Guns aren’t going away unless we get to the root of people’s fears,” he said.

most Americans who own a gun feel it makes them safer. But public health data suggests that owning a gun of homicide and triples chances of suicide in a home.

“There’s no evidence that guns provide an increase in protection,” said Kelly Drane, research director for the . “We have been told a fundamental lie.”

Record Deaths

Less than a year into the pandemic, 20-year-old Jacquez Anlage was shot dead in a Jacksonville, Florida, apartment. Five years later, the killing remains unsolved.

His mother, Crystal Anlage, said she fell to her knees and wailed in grief on her lawn when police delivered the news.

She said Jacquez overcame years in the foster care system — living in 36 homes — before she and her husband, Matt, adopted him at age 16.

Jacquez Anlage had just moved into his own apartment when he was shot. He loved animals and wanted to become a veterinary technician. He was kind and loving, Crystal Anlage said, with the 6-foot-4, 215-pound physique of the football and basketball player he’d been.

“He was just getting to a point in life where he felt safe,” Crystal Anlage said.

Gun violence researchers say parents like Crystal Anlage carry trauma that destroys their sense of security.

Anlage said she endures post-traumatic stress disorder and anxiety. She is terrified of guns and fireworks.

But she has made something meaningful of her son’s killing: She co-founded the Jacksonville Survivors Foundation, which works to raise awareness about the impact of homicide and to support grieving parents.

“Jacquez’s death can’t be in vain,” she said. “I want his legacy to be love.”

His legacy and that of other young men killed by guns is muted by firearm manufacturers’ powerful message of fear.

During the pandemic, gun marketers told Americans they needed firearms to defend themselves against criminals, protesters, unreliable cops, and , filed by gun control advocacy groups with the Federal Trade Commission.

In a since-deleted June 18, 2020, from Lone Wolf Arms, an Idaho-based manufacturer, a protester is depicted being confronted by police officers in riot gear between the words “Defund Police? Defend Yourself,” the petition shows. The caption says, “10% to 25% off demo guns and complete pistols.”

Impact Arms, an online gun seller, on Instagram on Aug. 3, 2020, showing a person putting a rifle in a backpack, the document says. “The world is pretty crazy right now,” the caption reads. “Not a bad idea to pack something more efficient than a handgun.”

The National Rifle Association in 2020 posted on YouTube a of a Black woman holding a rifle and telling viewers they need a gun in the pandemic. “You might be stockpiling up on food right now to get through this current crisis,” she said, “but if you aren’t preparing to defend your property when everything goes wrong, you’re really just stockpiling for somebody else.”

The messaging worked. Background checks for firearm sales soared 60% from , the year the federal government declared a public health emergency.

The same year, more than , the highest number up till then. In 2021, was broken again.

Weapons sold at the beginning of the pandemic were more likely to wind up at crime scenes within a year than in any previous period, according to by Democrats on Congress’ Joint Economic Committee, citing ATF data.

Gun manufacturers “used disturbing sales tactics” following mass shootings in Buffalo, New York, and Uvalde, Texas, “while failing to take even basic steps to monitor the violence and destruction their products have unleashed,” according to a released by congressional Democrats in July 2022 following a House Oversight and Reform Committee investigation of industry practices and profits.

The firearm industry has marketed “to white supremacist and extremist organizations for years, playing on fears of government repression against gun owners and fomenting racial tensions,” the House investigation said. “The increase in racially motivated violence has also led to rising rates of gun ownership among Black Americans, allowing the industry to profit from both white supremacists and their targets.”

In 2024, then-President Joe Biden’s Department of the Interior provided a to the National Shooting Sports Foundation, a leading , to help companies market guns to Black Americans.

The Federal Trade Commission is responsible for protecting consumers from deceptive and unfair business practices and has the power to take enforcement action. It issued warnings to companies that made unsubstantiated claims their products could prevent or treat covid, for instance.

But when families of gun violence victims, lawmakers, and advocacy groups in 2022, during Biden’s term, how firearms were marketed to children, people of color, and groups that espouse white supremacy, officials did not announce any public action.

This summer, the National Shooting Sports Foundation pressed its and derided “a coordinated ‘lawfare’ campaign” that it said gun control groups have waged against “constitutionally-protected firearm advertising.”

FTC spokesperson Mitchell Katz declined to comment, saying in an email that the agency does not acknowledge or deny the existence of investigations.

Serena Viswanathan, who retired as an FTC associate director in June, told Ñî¹óåú´«Ã½Ò•îl Health News that the agency lost at least a quarter of the staff in its advertising practices division after Trump came into office in January.

Gun companies Smith & Wesson, Lone Wolf Arms, and Impact Arms did not respond to requests for comment. Neither did the National Shooting Sports Foundation or the NRA.

In an August 2022 , Smith & Wesson President and CEO Mark Smith said gun manufacturers were being wrongly blamed by some politicians for the pandemic surge in violence, saying cities experiencing violent crime had “promoted irresponsible, soft-on-crime policies that often treat criminals as victims and victims as criminals.”

He added, “Some now seek to prohibit firearm manufacturers and supporters of the 2nd Amendment from advertising products in a manner designed to remind law-abiding citizens that they have a Constitutional right to bear arms in defense of themselves and their families.”

Guns and Race

In 2015, the National Shooting Sports Foundation gathered supporters at a conference in Savannah, Georgia, and urged the firearm industry to diversify its customer base, according to a and reports from and the .

Competitive shooter Chris Cheng gave a presentation called “Diversity: The Next Big Opportunity.” Screenshots from the conference include slides purporting to show “demographics,” “psychographics,” and “technographics” of Black and Hispanic shooters.

The slides described Black shooters as “expressive and confident socially, in a crowd” and “less likely to be married and to be a college grad.” They said Hispanic shooters were “much more trusting of advertising and celebrities.”

Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety, said industry marketing shifted in the latter half of the 20th century as the popularity of hunting declined. The new sales pitch: guns for personal safety.

“They said, ‘We need to break into new markets,’” Suplina said. “They identified women and people of color. They didn’t have a lot of success until the pandemic, the Black Lives Matter movement, and the death of George Floyd. The marketing says, ‘You deserve the Second Amendment too.’ They are selling the product as an antidote to fear and anxiety.”

Gun manufacturers were harshly criticized in the Oversight Committee’s 2022 investigation for marketing products to people of color, as gun violence remains a leading cause of death for young Black and Latino men.

At the same time, some companies also promoted assault rifles to white supremacist groups who believe a race war is imminent, the investigation found. One company sold an AK-47-style rifle called the “Big Igloo Aloha,” a reference to an anti-government movement, it said.

Still, Philip Smith wants more Black people to get guns for protection.

Smith said he was working as a human resources consultant a decade ago when he got the idea to form the , which helped the National Shooting Sports Foundation compile its report on communicating with Black consumers.

Smith encourages Black people to buy firearms for self-defense and get proper training on how to use them.

After 10 years, Smith said, his group has about 45,000 members nationwide. Single members pay $39 a year and couples $59, which gives them access to discounts from the organization’s corporate partners, including gunmakers, and raffles for gun giveaways, according to its website.

The police killing of Michael Brown in Ferguson, Missouri, and the shooting death of Florida teenager Trayvon Martin helped spark early interest from doctors, lawyers, and others in joining the group, he said. But interest took off during the pandemic, he said, even among Democrats who had resisted the idea of owning a gun.

“Hundreds of people called me and said, ‘I don’t agree with anything you’re saying, but what kind of gun should I buy,’” Smith recalled.

Smith, describing himself as “quiet, nerdy, and Afrocentric,” said criticism of guns misses the point.

“My ancestors bled for us to have this right,” he said. “Are there some racist white people? Yes. But we should buy guns because there is a need. No one is forcing us to buy guns.”

‘American Amnesia’

During the pandemic, gun violence took its greatest toll on racially segregated neighborhoods in places such as Philadelphia, where roughly residents live in poverty.

A says a one-year period in the pandemic saw more than 2,300 shootings, or about six a day. Many of the cases haven’t been solved by police.

City officials cited the boom in gun sales in the report: Fewer than 400,000 sales took place in Pennsylvania in 2000, but in 2020 it was more than 1 million.

Gun sales since the pandemic ended, but the harm they’ve caused persists.

At a conference last year inside the Eagles’ football stadium, victims of firearm violence or their relatives joined activists to share accounts of near-death experiences and the grief of losing loved ones.

Paintings flanked the stage and the meeting space to commemorate people who had been fatally shot, nearly all young people of color, under messages such as “You are loved and missed forever” and “Those we love never leave.”

Marion Wilson, a community activist, said he believes the nation has forgotten the suffering Philadelphia and other cities endured during the pandemic.

“We suffer from the disease of American amnesia,” he said.

Harris was on his way home from a job at Burlington Coat Factory nearly two decades ago when robbers followed him from a bus stop and demanded money. He said he had none and was shot.

Harris had spent his early life fixing cars with his grandfather, when he wasn’t at school or attending church. He remembers lying in a hospital bed, overcome with a sense of helplessness.

“I had to learn to feed myself again,” he said. “I was like a baby. I had to learn to sit up so I could use a wheelchair. The only way I got through it was my faith in God.”

Harris endured years of rehabilitation and counseling for PTSD. As someone in a wheelchair, he said, he sometimes fears for his safety — and a gun may be one of the few ways to protect himself and his family.

“I’m mulling it over,” Harris said. “I’m afraid of my trauma hurting someone else. That’s the only reason I haven’t gotten one yet.”

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Two bills moving through the state Senate seek to prevent immigration enforcement officers from isolating patients from their loved ones and interfering with their ability to get legal help. Analyses for both bills cite reporting by Ñî¹óåú´«Ã½Ò•îl Health News that found family members and attorneys have faced extreme difficulty locating and supporting patients hospitalized while in immigration custody.

Ñî¹óåú´«Ã½Ò•îl Health News found that some hospitals have facilitated patient isolation through what are known as blackout policies, which can include registering people under pseudonyms, withholding their names from the hospital directory, and preventing staff from contacting patients’ relatives to let them know their location and condition.

A bill by Democratic state Sen. Caroline Menjivar of the San Fernando Valley, , would largely prohibit the use of blackout policies for patients in immigration custody and ensure they retain the right to have their families and others notified of their whereabouts and condition. Blackout policies would be allowed when the health care provider determines the patient is a credible risk to themself or others and the risk is documented in the patient’s medical record. Patients would also be allowed to receive visitors.

It seeks to address reports of Immigration and Customs Enforcement agents guarding patients in their hospital rooms while they undergo medical exams or talk with doctors, interfering with medical decisions, and pushing for patients to be discharged prematurely to detention facilities ill-equipped to provide follow-up care.

“These are actions that have no place in health care, and it is a clear violation of the patients’ rights,” Menjivar said.

Under Menjivar’s proposal, agents would not be allowed into the rooms of patients they bring in for care unless they can show legal authorization to be there. If agents remain in the room, staff would be required to ask them to leave during medical exams and patient care discussions. If agents refuse, health care facility staff would need to document it.

, authored by state Sen. Susan Rubio, a Democrat from the San Gabriel Valley, would require health care providers to inform staff and relevant volunteers to respond when patients want their families to know where they are, and to post a notice at facility entrances with information about visitation and access policies. The law already says patients can agree to have loved ones notified they’re in the hospital, and Rubio’s bill seeks to make sure staff and others know they can do that for patients in immigration custody.

The federal Department of Homeland Security, which oversees immigration enforcement, did not respond to a request for comment.

Both bills were passed by the Senate Health and Judiciary committees along party lines and will be heard next by the Senate Appropriations Committee.

More than 20 immigrant rights advocates and health care workers voiced support for strengthened protections for patients at a hearing last week.

“This state must do everything in its power to protect against these abuses and ensure detainees have the right to contact their loved ones when they are hospitalized and in critical conditions,” said Hector Pereyra, political manager with the Inland Coalition for Immigrant Justice.

However, representatives from the California Hospital Association and California Medical Association told lawmakers last week they had concerns that directing health care workers to document agents’ badge numbers and ask them to leave patients’ rooms could create conflict and pose a safety risk.

“While we understand that this is an important issue, we want to ensure the bill strikes the right balance and does not create conflicting or unclear obligations for hospitals and their staff and clinicians, particularly in real-time interactions with federal officers,” said Vanessa Gonzalez, a vice president of state advocacy for the hospital association.

Ñî¹óåú´«Ã½Ò•îl Health News reported that one man, 43-year-old Julio César Peña, was held at a hospital in Victorville for almost two weeks before his attorney and family found out where he was. Peña, who had terminal kidney disease, was shackled to his hospital bed, guarded by immigration agents, and told he wasn’t allowed to disclose his location, according to his wife. He then suffered a seizure that left him intubated and unconscious, but no one notified his family. Peña died Feb. 25, less than two months after he was released to go home.

Advocates for immigrants and health care workers, as well as lawmakers, fear similar incidents are happening around the state.

Menjivar said her bill “seeks to close the gap between existing law and practice by empowering health care provider entities with the tools to uphold the privacy, health, and visitation rights of a patient brought in under immigration custody.”

SB 915 would prohibit hospitals and clinics from allowing immigration officers to make medical decisions for the patient or provide interpretation. Health care facilities would be required to document and verify, “to the extent possible,” the identities of immigration officers; provide patients access to communication tools; and inform patients of their rights. They would also need to complete discharge planning that includes attempts to coordinate with any receiving facility, such as a detention center, to ensure patients receive follow-up care.

The bills come on the heels of legislation passed last year that sought to limit immigration enforcement at health care facilities, including by prohibiting medical establishments from allowing federal agents without a valid search warrant or court order into private areas. However, that bill did not address situations in which patients are already in immigration custody.

“ICE has instilled fear in our hospitals and has kept us from doing our job,” said SatKartar Khalsa, an emergency medicine resident at a safety net hospital in San Francisco who has treated detained patients and testified in support of SB 915. “This has all led to worse care for our patients and has added another layer of fear among health care workers.”

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OAKLAND, Calif. — Rosa María Carranza leaned forward to hold a 3-year-old’s back as the girl climbed a rock in the forested hills of northeast Oakland.

Dressed in hiking gear and beaded necklaces, Carranza, 67, maneuvered between trees and children on a sunny morning in December. “Hold on to that branch,” she said in Spanish. “You can do it, my love!”

Carranza, a child development professional who grew up swinging through trees and swimming in rivers in El Salvador, said she feels at home in the forest at the outdoor preschool she co-founded. She has worked with children and teens as a caregiver and educator for more than three decades, long enough to know when to lean in and when to step back to let her students find their own footing.

When she transitioned to working part-time last year, Carranza counted on getting Medicare and Social Security checks — benefits given to American workers and lawfully present immigrants when they retire, work history and age or disability requirements. She’s contributed tens of thousands of dollars into Medicare and Social Security over 24 years, according to her Social Security Administration earnings record, reviewed by El Tímpano and Ñî¹óåú´«Ã½Ò•îl Health News. But Carranza and an estimated immigrants will soon be cut out of Medicare.

The GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump, barred certain categories of lawfully present immigrants — including temporary protected status holders, refugees, asylum-seekers, survivors of domestic violence, trafficking victims, and people with work visas — from Medicare.

Those already in the program, like Carranza, will be disenrolled by Jan. 4 — a move by Republican lawmakers to rein in Medicare spending, as they and Trump have argued that taxpayer dollars should not be used to pay for the health care of immigrants in the U.S. without authorization.

“The Democrats want Illegal Aliens, many of them VIOLENT CRIMINALS, to receive FREE Healthcare,” Trump two months after he signed the bill into law. “We cannot let this happen!”

However, the categories of immigrants now losing coverage do have legal status. Neither the White House nor the Department of Health and Human Services responded to a question about whether it was fair to disenroll legal residents from Medicare.

Immigrants without legal status were already ineligible for Medicare or most other federally funded public benefits.

Carranza is worried that she could also lose legal permission to live in the United States if the Trump administration ends temporary protected status for Salvadorans, as it sought to do during .

If that happened, Carranza would lose legal residency, risking time in an immigration detention center or deportation.

“This is like a horror movie, a complete nightmare,” Carranza said. “This is not how I imagined getting old.”

‘Under Constant Attack’

Carranza left El Salvador in 1991 during a brutal civil war, leaving behind three young children, to earn money to send home to her family. She overstayed her visa until 2001, when she qualified for temporary protected status, after two earthquakes struck El Salvador, and displacing 1.3 million.

Temporary protected status, or TPS, was passed by Congress and signed into law by Republican President George H.W. Bush in 1990.

It allows people such as Carranza, from select nations undergoing armed conflict, civil war, and climate disasters, to live and work in the United States if being in their home country poses a risk.

Carranza missed her youngest daughter’s graduation from kindergarten and first medal-winning performance in track. She worked overnight shifts babysitting newborns and later substitute-taught in public schools in the San Francisco Bay Area to pay for her children’s schooling in El Salvador, and for her own classes at City College of San Francisco, where she earned a degree in child development.

And she cared for dozens of 3-, 4-, and 5-year-olds who gazed in awe as they uncovered little treasures buried in the redwood forest of the Oakland park where she co-founded Escuelita del Bosque, a Spanish immersion preschool that teaches children outdoors.

The trade-off was supposed to be a peaceful retirement. But Congress narrowed Medicare eligibility to citizens, lawful permanent residents, Cuban and Haitian nationals, and people covered under the Compacts of Free Association, agreements between the United States and Pacific island nations.

The move followed Trump’s efforts to bar some lawfully present immigrants from Medicaid, marketplace insurance subsidies, and social support services, such as food assistance, housing subsidies, and medical visits in federally funded health centers. Altogether, 1.4 million lawfully present immigrants were projected to lose health insurance, according to KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A spokesperson for House Speaker Mike Johnson, Taylor Haulsee, did not respond to requests for comment.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said Republicans wanted to enact tax cuts and eliminate health insurance for immigrants because it wouldn’t upset their base.

“They don’t want to turn the United States into a welfare magnet,” he said. “And they resent the government for making them pay for a welfare state.”

While data on lawfully present immigrants is not available, immigrants without legal status and $25.7 billion into Social Security in 2022, according to the Institute on Taxation and Economic Policy. The Congressional Budget Office estimated that the Medicare restrictions alone would reduce federal spending by 2034.

Health experts say eliminating coverage for immigrants with legal status .

“This is actually the first time that Congress has taken away Medicare from any group,” said Drishti Pillai, director of immigrant health policy at KFF. “This change is impacting immigrants who have lawful presence in the U.S., and many of whom have already worked and paid into the system for decades.”

As older adults like Carranza lose their Medicare coverage, clinicians anticipate that they will delay their care, leading to an increase in severely ill patients, especially in hospital emergency rooms.

Seniors can become sick suddenly and quickly, and they are more vulnerable to cardiovascular diseases such as heart disease and high blood pressure, especially if they put off routine care, said Theresa Cheng, an emergency physician at Zuckerberg San Francisco General Hospital and assistant clinical professor of emergency medicine at the University of California-San Francisco.

“It’s quite easy for them to fall off the cliff,” Cheng said.

Carranza hikes and considers herself healthy, but she acknowledges that she is aging and starting to struggle to keep up with the kids in the forest.

Late last year she was diagnosed with high blood pressure, and in January she woke up with a tight chest and went to urgent care because it had spiked to dangerous levels. A few weeks later, she tripped on a curb while walking and fell to the ground. She woke up the next day with a swollen foot. A doctor at the local hospital told her she had arthritis.

These were scary moments, she said, but she was grateful to have to pay only $10 for the urgent care visit and $5 to see her primary care doctor. However, that will change when she loses Medicare by early next year.

The stress of knowing she will lose health insurance coverage, and potentially her legal status, all while masked federal agents are detaining immigrants like her across the country, has taken a toll on her mental health, she said. She is searching for a therapist and acupuncture services to treat her insomnia and anxiety — and the feeling that she is “under constant attack.”

Nowhere To Turn

In California, home to the largest number of , Carranza could have enrolled in state-sponsored insurance, but this year the state for adults 19 and older who are a TPS holder, in the U.S. without authorization, or an asylum-seeker. Other states with Democratic governors such as have also scaled back their health programs for immigrants amid budget pressures.

In January, California Gov. Gavin Newsom proposed a state budget that would not backfill federal health care cuts to about 200,000 lawfully present immigrants, noting the $1.1 billion annual price tag and state budget shortfalls.

“Given these fiscal pressures, the administration cannot backfill for this change in federal policy,” California Department of Finance spokesperson H.D. Palmer said.

But some Democratic lawmakers and consumer advocates say the state should step in. State Assembly member Mia Bonta, who chairs the Assembly’s health committee, said she is working on a legislative budget solution to bring immigrants who will lose health coverage, including older adults, into Medi-Cal, the state’s version of Medicaid.

The East Bay Democrat is especially concerned for people like Carranza, “who have lived here for decades and contributed into this economy, who have given into our cultural fabric and into our communities and who built families and lives and who are now wanting to be able to retire with dignity and live with dignity and have the health care that they need.”

A Sign of the Future

Last April, Carranza got a glimpse of what losing her health coverage and retirement benefits could look like, after the Social Security Administration sent her a letter informing her that she no longer qualified for retirement benefits because she was not lawfully present in the U.S. — even though she was. Then Medicare stopped payments to her health plan, which disenrolled her as a result.

As a TPS holder with a work permit, she knew a mistake had been made. Yet, without her check, Carranza didn’t have money to pay her rent for a month. She worked off her rent by babysitting her landlords’ children. Last May, the office of U.S. Rep. Lateefah Simon, an Oakland Democrat, helped Carranza recover her retirement benefits, but it took months for her to get her health insurance back.

The experience left her reeling.

“It’s like getting slapped on the face after more than 30 years working for the system here,” Carranza said. “And in return, this is what we have now.”

She lies awake at night imagining the future: here, where she’s spent half her life, without health insurance and possibly Social Security benefits; or in El Salvador, where two of her three children remain. Her daughter, a green-card holder who lives in Texas, hopes to become a citizen so she can petition for permanent residency for Carranza, but the process can take years. Then there’s the possibility she fears most: indefinite detention or deportation.

On a recent morning in her basement studio in Oakland, Carranza pulled a box from the back of her closet. In it was a thick stack of identification cards that included old driver’s licenses, her Social Security card, and dozens of work IDs issued by the federal government.

“My life is in that box,” she said.

This article was produced in collaboration with , a civic media organization serving and covering the Bay Area’s Latino and Mayan immigrant communities.

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Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Renuka Rayasam discussed excited delirium on Vox Media Podcast Network’s Criminal on March 6.

• Read Rayasam’s ““

On CBS News’ CBS Mornings on March 5, Céline Gounder, Ñî¹óåú´«Ã½Ò•îl Health News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

Ñî¹óåú´«Ã½Ò•îl Health News California correspondent Christine Mai-Duc discussed Affordable Care Act premium increases on CapRadio’s Insight With Vicki Gonzalez on March 2.

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Ñî¹óåú´«Ã½Ò•îl Health News rural health reporter Andrew Jones discussed how younger doctors are struggling to diagnose measles on KMOX’s Total Information AM on Feb. 27.

• Read Jones’ “.”

Ñî¹óåú´«Ã½Ò•îl Health News South Dakota correspondent Arielle Zionts discussed the $50 billion Rural Health Transformation Program on Marketplace’s Make Me Smart podcast on Feb. 19.

• Read Zionts’ “,” co-reported with Sarah Jane Tribble and Maia Rosenfeld.

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When federal immigration agents descended on their city, officers deported Gabi’s father and detained her aunt.

Gabi was born in the U.S. and is an American citizen. Her best chance to stand, or even walk, someday is a complex surgery on her legs and feet that was scheduled for January. But her mother, too terrified to take out the garbage let alone venture through the city to a hospital, canceled the procedure. Ñî¹óåú´«Ã½Ò•îl Health News agreed to only partially identify the patients and their families in this article because they fear becoming targets of President Donald Trump’s immigration crackdown.

“I want more than anything for my baby to walk,” her mother said in Spanish, as Gabi cooed and wriggled in her arms, a feeding tube snaking from her stomach to an IV pole. “But with the situation that’s happening, I canceled the surgery and all the physical therapy appointments” that would have followed. “Because I’m afraid to leave.”

The Department of Homeland Security has declared an end to what it called Operation Metro Surge, carried out by officers with the Immigration and Customs Enforcement and Customs and Border Protection agencies. Even so, health care workers say, immigration agents are still camping out in hospital parking lots. And drones fly overhead in agricultural areas beyond Minneapolis, where Somali and Latino immigrants have settled in recent years.

The Minnesota crackdown revealed the sweep of the surveillance and capture system the Trump administration is using to uproot immigrant communities in the United States, and the effect of its powerful brake on the medical system.

Similar health crises surfaced wherever immigration officers massed in the past year. In Dallas, public health clinics administered about 6,000 vaccinations to Latinos last August, half as many as during a similar program a year earlier. In Chicago, doctors rerouted patients daily from clinic to clinic depending on ICE activity. Across the country, crackdowns suppressed immigrants’ health care visits.

In Minnesota, medical systems have reported cancellation and no-show rates of up to 60% since December.

Tricia McLaughlin, a spokesperson for the Department of Homeland Security, blamed protesters for the disruption. “If anyone is impeding Americans from making appointments or picking up prescriptions,” she said, “its [sic] violent agitators who are blocking roadways, ramming vehicles, and vandalizing property.”

While Minnesotans rose up to oppose the surge in the streets, doctors and nurses have quietly operated informal, underground medical networks, dodging detection to care for patients at home.

“I used to look somebody in the eyes and say, with good faith, ‘You will be fine at the hospital,’” said Emily Carroll, a nurse practitioner at HealthFinders Collaborative, a community clinic in Faribault, some 50 miles south of Minneapolis. “But now, I can’t make that guarantee.”

As thousands of federal agents move on from Minneapolis, other communities need to prepare, said Minnesota Democratic state Sen. Alice Mann, a physician.

“I know it sounds crazy,” she said, but health care providers “need to start an underground network of how to get people care in their homes. Because letting people die at home or come close to death because they are terrified to go into the hospital, in 2026, is outrageous.”

The Surge Delivers Harm

Home visits, clinicians say, may be the only way to reach those who still feel under siege. In Los Angeles, starting last June, St. John’s Community Health brought medical care to some 2,000 immigrant families too frightened to leave home during an immigration sweep after the clinic’s no-show rates ballooned to more than 30%, said Jim Mangia, the organization’s president.

Many of Minnesota’s large health institutions have relied on telemedicine and only dabbled in home care.

Not Munira Maalimisaq, co-founder of Inspire Change Clinic in Minneapolis’ Ventura Village neighborhood. After about one-third of her patients stopped showing up for appointments, “I was like, ‘We have to do something,’” the nurse practitioner said. So she called a physician friend. What if they just started seeing patients at home?

“And she’s like, ‘You know what? Let’s do it.’”

They now have about 150 doctors — a volunteer “rapid response” team that has made more than 135 home visits. The first call was a woman whose husband had been deported. She was home with her children, was 39 weeks pregnant, and was in labor. Maalimisaq called an obstetrician volunteer, and they rushed to the patient’s house.

“She was 8 centimeters dilated,” Maalimisaq said, “and did not want us to call an ambulance. She says, ‘Can I have the baby here?’”

The woman was not a good candidate for a home birth, Maalimisaq said. They persuaded her to ride to the hospital in Maalimisaq’s car, a “small Tesla, white seats. Everything that could go wrong was there.”

But they made it to the hospital in time, and the woman had a safe, healthy delivery. “If we were not there, I can only imagine what would have happened.”

Maalimisaq’s caregiving follows a Hippocratic logic: “Someone was in need. I cannot just do nothing. And we cannot call an ambulance against her will and have her shoved in there. We had no choice but to do something, and that was the only thing that we could do safely.”

In other visits, she has seen “people so stressed out they pulled the hair out of their skull.” She said she met a mother who’d been rationing her child’s seizure medicine despite the child having experienced “one seizure after another.”

The Trump administration says its Minnesota operation improved public safety. “Since Operation Metro Surge began, our brave DHS law enforcement have arrested over 4,000 criminal illegal aliens including vicious murderers, rapists, child pedophiles and incredibly dangerous individuals,” according to McLaughlin, the DHS spokesperson. DHS announced last month that McLaughlin was leaving her post.

Minnesota correctional officials say many people accused of crimes were released directly to ICE by state or county prisons and jails. And of people arrested by ICE nationwide in January had criminal convictions, according to DHS data. Far fewer were convicted of violent crimes.

Agents Outside Hospitals, Clinics

On the first day of his second term, President Donald Trump rescinded a 2011 policy that prohibited immigration enforcement in “sensitive locations” such as schools, hospitals, and churches.

In Northfield, about 45 miles south of Minneapolis, ICE agents have been sitting in their cars for hours at least twice a week outside health clinics, including one run by the local hospital, said Carroll, the nurse practitioner. Agents have made arrests in the area almost every day, Carroll and her colleagues said.

“ICE does not conduct enforcement at hospitals — period,” McLaughlin said.

One recent morning, three ICE vehicles sat in a Baptist church parking lot across the street from an elementary school in Northfield as volunteers ferried 35 children of immigrants back and forth to the school so their parents could avoid going out, Carroll said.

“ICE is not going to schools to arrest children — we are protecting children,” McLaughlin said.

Drones that Carroll and others believe are operated by immigration agents hover most nights, and sometimes during the day, over a trailer park that mostly houses immigrants who have moved to the area to work in agriculture and manufacturing over the past 15 years. Families paper over trailer windows, Carroll said.

“You cannot feel safe anywhere,” she said. “On the way to school, on the way to clinic, you might pass ICE. The sort of crushing fear and feeling of being trapped that these families are going through is outrageous.”

That fear means patients with diabetes and heart disease are missing blood sugar and blood thinner tests. Patients aren’t getting exercise, and the chronically ill are getting sicker, said Calla Brown, a Minneapolis pediatrician.

At the Faribault clinic where Carroll works, staff members deliver medicine, food, and other necessities to patients. A staffer drives 12 middle and high school kids to and from class every day in a clinic van.

Some patients are treated at home. Carroll recently diagnosed a baby with influenza, telling the parents it wasn’t an immediate threat — yet.

“‘If you see the baby struggling to breathe, if the baby’s not eating, if the baby isn’t making wet diapers, you have to go to the hospital,’” Carroll said she told them. “‘I cannot promise it’s safe. But you’ve got to go.’”

‘We’re Nice to Each Other’

In Minneapolis, nurse-midwife Fernanda Honebrink spends most of her daylight hours calling, coordinating, and shuttling between a ballooning group of fearful people stuck in their homes. She prefers not to call it a medical underground.

“It’s more like, that’s how we function in Minnesota,” said Honebrink, a U.S. citizen who emigrated from Ecuador 23 years ago. “We’re nice to each other.”

Honebrink spent a recent afternoon at the home of a family with a baby boy. His parents, Alex and Isa, desperately want him to receive vaccinations and blood tests at his one-year well-child appointment.

But they haven’t left their apartment for more than a month. “You don’t know what is most important: whether to go out for his well-being, or to go out and think that you might not come back,” Alex said.

The couple, who were interviewed in Spanish, entered the U.S. legally from Venezuela in 2024 under a program called Humanitarian Parole, which Trump ended in May. Since then, federal agents have detained and deported workers at a company where Alex, a mechanical engineer by training, worked in construction.

Alex and Isa have seen government vehicles outside their home. They knew of a man, they said, who had legitimate work papers but was picked up while walking to church one Sunday, flown to Texas, then put on a plane to Venezuela. It was a terrifying prospect for those who’ve fled that country’s dictatorship and economic chaos.

“It feels like a psychological attack,” Alex said. “The possibility of being separated from your family.”

Isa, a lawyer back in Venezuela, has endured postpartum depression, cooped up for weeks in their apartment. The state program that provided health insurance to all immigrants ended Jan. 1. A therapist checks in occasionally by phone, free of charge.

She has tried to keep the family afloat by selling homemade cakes and necklaces, and babysitting.

Her worst fear is being separated from her son, who was born in the U.S. and is a citizen. The possibility hadn’t occurred to her until an acquaintance urged her to to designate someone to have temporary custody if she were deported.

“It was something I never imagined,” said Isa, who sobbed as she recalled the moment. “He’s my baby! He’s not someone else’s! What? My baby would remain here with someone?’’

Honebrink suddenly piped up: “I will guarantee him. I’ll sign the form.”

She later told a reporter, “I told my husband I wouldn’t do that. I’ve already signed as a sponsor for four kids.”

As soon as she left the apartment, Honebrink jumped back on the phone and traded favors with local pediatricians, clinic schedulers, and volunteers. Within hours, she’d set up a new well-child visit for the baby and found a vetted driver to transport the family.

“A white person,” Honebrink explained.

Two days later, Honebrink sent a picture of her small victory: Alex and Isa’s baby boy with a Band-Aid on his legs. “He got his vaccines,” she said via text. “I’m so happy.”

But other medical needs cannot be as swiftly addressed. One February evening, Honebrink greeted Gabi and her mother with a trunk full of donated baby wipes, diapers, and toys.

Gabi’s surgery is rescheduled for August. Her mother said she hoped by then it would be safe to leave home.

“I used to take the kids to the park, but now we don’t leave at all,” she said. “They grab people, they mistreat them. How I wish it would end soon!”

Ñî¹óåú´«Ã½Ò•îl Health News’ Jackie Fortiér contributed to this report.

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After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.

Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.

Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.

“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.

But the Fort Peck Tribes now limit who has access to that coverage. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.

The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment has dropped by , according to federal health officials.

The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.

Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”

The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.

“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.

Scrambling for Solutions

U.S. a temporary extension of the enhanced subsidies in January. But that measure . Lawmakers are scrambling for an alternative after President Donald Trump an extension if a bill reaches his desk. On Jan. 15, the president released that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans as an alternative to the subsidies.

A.C. Locklear, CEO of the , a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”

Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is 14 years younger than that of white Americans.

“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.

Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.

In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to funding shortfalls, the agency prioritizes which treatments it will pay for.

To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.

“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”

For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.

One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.

“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.

The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. In January, the tribe paused the employer-sponsored coverage portion of its insurance program, which at the time included 52 people.

He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.

Lives on the Line

The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, will become uninsured in 2026 due to the higher costs.

Patients at the Oyate Health Center in Rapid City, South Dakota, are already reporting sky-high premium increases for ACA plans. CEO Jerilyn Church said it’s too soon to know how many will forgo coverage. But she said more uninsured patients would further strain the IHS Purchased/Referred Care program — with officials raising the bar for how sick patients must be to cover care outside of tribal health sites.

“There will be people that will not be able to get the care they need,” Church said, adding that could translate to “people losing their lives.”

Bighorn, the game warden on the Fort Peck Reservation, is among those still covered by the tribes’ insurance program. He has put it to use.

Soon after enrolling, Bighorn needed two hip replacements, surgeries that require off-reservation care and are ranked as low-priority procedures by the Indian Health Service. Bighorn said that in pre-surgery tests, specialists found the cause for his long-standing, dangerously high blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.

“I was a miserable man, tired all the time,” he said.

Without the tribe’s coverage, Bighorn may have eventually gotten those diagnoses but said it would have likely taken years to get help through the Indian Health Service. That would have meant getting much sicker before receiving care.

Ñî¹óåú´«Ã½Ò•îl Health News correspondent Arielle Zionts contributed to this report.

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LODGE GRASS, Mont. — Brothers Lonny and Teyon Fritzler walked amid the tall grass and cottonwood trees surrounding their boarded-up childhood home near the Little Bighorn River and daydreamed about ways to rebuild.

The rolling prairie outside the single-story clapboard home is where Lonny learned from their grandfather how to break horses. It’s where Teyon learned from their grandmother how to harvest buffalo berries. It’s also where they watched their father get addicted to meth.

Teyon, now 34, began using the drug at 15 with their dad. Lonny, 41, started after college, which he said was partly due to the stress of caring for their grandfather with dementia. Their own addictions to meth persisted for years, outlasting the lives of both their father and grandfather.

It took leaving their home in Lodge Grass, a town of about 500 people on the Crow Indian Reservation, to recover. Here, methamphetamine use is widespread.

The brothers stayed with an aunt in Oklahoma as they learned to live without meth. Their family property has sat empty for years — the horse corral’s beams are broken and its roof caved in, the garage tilts, and the house needs extensive repairs. Such crumbling structures are common in this Native American community, hammered by the effects of meth addiction. Lonny said some homes in disrepair would cost too much to fix. It’s typical for multiple generations to crowd under one roof, sometimes for cultural reasons but also due to the area’s housing shortage.

“We have broken-down houses, a burnt one over here, a lot of houses that are not livable,” Lonny said as he described the few neighboring homes.

In Lodge Grass, an estimated 60% of the residents age 14 and older struggle with drug or alcohol addictions, according to a local survey contracted by the Mountain Shadow Association, a local, Native-led nonprofit. For many in the community, the buildings in disrepair are symbols of that struggle. But signs of renewal are emerging. In recent years, the town has torn down more than two dozen abandoned buildings. Now, for the first time in decades, new businesses are going up and have become new symbols — those of the town’s effort to recover from the effects of meth.

One of those new buildings, a day care center, arrived in October 2024. A parade of people followed the small, wooden building through town as it was delivered on the back of a truck. It replaced a formerly abandoned home that had tested positive for traces of meth.

“People were crying,” said Megkian Doyle, who heads the Mountain Shadow Association, which opened the center. “It was the first time that you could see new and tangible things that pulled into town.”

The nonprofit is also behind the town’s latest construction project: a place where families together can heal from addiction. The plan is to build an entire campus in town that provides mental health resources, housing for kids whose parents need treatment elsewhere, and housing for families working to live without drugs and alcohol.

Though the project is years away from completion, locals often stop by to watch the progress.

“There is a ground-level swell of hope that’s starting to come up around your ankles,” Doyle said.

Two of the builders on that project are Lonny and Teyon Fritzler. They see the work as a chance to help rebuild their community within the Apsáalooke Nation, also known as the Crow Tribe.

“When I got into construction work, I actually thought God was punishing me,” Lonny said. “But now, coming back, building these walls, I’m like, ‘Wow. This is ours now.’”

Meth ‘Never Left’

Meth use is a throughout the U.S. and a growing contributor to the nation’s . The drug had been devastating in Indian Country, that encompasses tribal jurisdictions and certain areas with Native American populations.

Native Americans face the in the U.S. compared with any other demographic group.

“Meth has never left our communities,” said A.C. Locklear, CEO of the , a nonprofit that works to improve health in Indian Country.

Many reservations are in rural areas, which have of meth use compared with cities. As a group, Native Americans face high rates of poverty, chronic disease, and mental illness — all are . These conditions are rooted in , a byproduct of colonization. Meanwhile, the Indian Health Service, which provides health care to Native Americans, has been chronically underfunded. Cutbacks under the Trump administration have shrunk health programs nationwide.

LeeAnn Bruised Head, a recently retired public health adviser with the U.S. Public Health Service Commissioned Corps, said that despite the challenges, tribal nations have developed strong survival skills drawing from their traditions. For example, Crow people have held onto their nation’s language; neighbors are often family, or considered such; and many tribal members rely on their clans to mentor children, who eventually become mentors themselves for the next generation.

“The strength here, the support here,” said Bruised Head, who is part of the Crow Tribe. “You can’t get that anywhere else.”

Signs of Rebuilding

On a fall day, Quincy Dabney greeted people arriving for lunch at the Lodge Grass drop-in center. The center recently opened in a former church as a place where people can come for help to stay sober or for a free meal. Dabney volunteers at the center. He’s also the town’s mayor.

Dabney helped organize community cleanup days starting in 2017, during which people picked up trash in yards and alongside roads. The focus eventually shifted to tearing down empty, condemned houses, which Dabney said had become spots to sell, distribute, and use meth, often during the day as children played nearby.

“There was nothing stopping it here,” Dabney said.

The problem hasn’t disappeared, though. In 2024, officials broke up a multistate based on the Crow reservation that distributed drugs to other Montana reservations. It was one example of how drug traffickers as sales and distribution hubs.

A few blocks from where Dabney spoke stood the remains of a stone building where someone had spray-painted “Stop Meth” on its roofless walls. Still, there are signs of change, he said.

Dabney pointed across the street to a field where a trailer had sat empty for years before the town removed it. The town was halfway through tearing down another home in disrepair on the next block. Another house on the same street was being cleaned up for an incoming renter: a new mental health worker at the drop-in center.

Just down the road, work was underway on the new campus for addiction recovery, called Kaala’s Village. Kaala means “grandmother” in Crow.

The site’s first building going up is a therapeutic foster home. Plans include housing to gradually reunite families, a community garden, and a place to hold ceremonies. Doyle said the goal is that, eventually, residents can help build their own small homes, working with experienced builders trained to provide mental health support.

She said one of the most important aspects of this work “is that we finish it.”

Tribal citizens and organizations have said the political chaos of Trump’s first year back in office shows the problem with relying on federal programs. It underscores the need for more grassroots efforts, like what’s unfolding in Lodge Grass. But a reliable system to fund those efforts still doesn’t exist. Last year’s federal grant and program cuts also fueled competition for philanthropic dollars.

Kaala’s Village is expected to cost $5 million. The association is building in phases as money comes in. Doyle said the group hopes to open the foster home by spring, and family housing the following year.

The site is a few minutes’ drive from Lonny and Teyon’s childhood home. In addition to building the new facility’s walls, they’re getting training to offer mental health support. Eventually, they hope to work alongside people who come home to Kaala’s Village.

As for their own home, they hope to restore it — one room at a time.

“Just piece by piece,” Lonny said. “We’ve got to do something. We’ve got these young ones watching.”

This <a target="_blank" href="/mental-health/tribal-health-meth-epidemic-recovery-montana-town-rebuilds-crow-reservation/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

NEW ORLEANS — Elyse Stevens had a reputation for taking on complex medical cases. People who’d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.

“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” said Stevens, a primary care and addiction medicine doctor.

While other doctors avoided these patients, Stevens — who was familiar with the city from her time in medical school at Tulane University — sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.

One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.

Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.

She agreed to prescribe Harrell pain medication — an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.

But Stevens was confident Harrell could hold up her end of the deal.

“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday evening in October. So, “I’m no longer on cocaine.”

Stevens’ approach to patient care has won her awards and nominations in , , and . Instead of seeing patients in binaries — addicted or sober, with a positive or negative drug test — she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?

But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn’t one of them. And it came to a head in the summer of 2024.

“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens said.

Flexible Care or Slippery Slope?

More than who need substance use treatment don’t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.

Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.

The result?

“Patients did OK and we actually reached more people,” said , immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by of addiction medication and focusing on recovery goals .

But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don’t meet their doctors’ expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.

Progress should be more than keeping patients in care, said , a Stanford psychologist, who has treated and researched addiction for decades and .

“If you give addicted people lots of drugs, they like it, and they may come back,” he said. “But that doesn’t mean that that is promoting their health over time.”

Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics — — say enables illegal drug use.

The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summer of 2024, supervisors started questioning Stevens’ approach.

In emails reviewed by Ñî¹óåú´«Ã½Ò•îl Health News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered to treat opioid addiction.

Supervisors worried Stevens wasn’t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.

“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer at the time wrote to Stevens’ supervisor, . “Note that this is the only standard of care which would likely be considered should a legal concern arise.”

Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the general practice but couldn’t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?

Stevens sent her supervisors of and backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn’t disappear.

“They just wouldn’t be getting care and perhaps they’d be dead,” she said in an interview with Ñî¹óåú´«Ã½Ò•îl Health News.

Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens’ practices.

Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.

“We are not at liberty to comment publicly on internal personnel issues,” they wrote.

“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they said. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”

Not Black-and-White

Ñî¹óåú´«Ã½Ò•îl Health News shared the complaints against Stevens and the responses she’d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.

, an addiction medicine doctor and the , said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens’ notes detailed patients’ life circumstances and the intricate decisions she was making with them.

“To me, that’s the big difference,” Loyd said.

Some people think the “only good answer is no opioids,” such as oxycodone or hydrocodone, for any patients, said , an addiction medicine doctor and associate professor at Michigan State University. But patients may need them — sometimes for things like cancer pain — or require months to lower their doses safely, she said. “It’s not as black-and-white as people outside our field want it to be.”

Humphreys, the Stanford psychologist, had a different take. He did not review Stevens’ case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today’s lethal street drugs too.

Overprescribing fueled the opioid crisis, he said. “It’s not going to go away if we do that again.”

‘The Thing That Kills People’

After months of tension, Stevens’ supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by Ñî¹óåú´«Ã½Ò•îl Health News.

Overnight, hundreds of her patients were moved to other providers.

Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.

After Stevens’ departure, Bair was left without medication for three days. The withdrawal symptoms were severe — headache, nausea, muscle cramps.

“I was just in physical hell,” said Bair, who works for the National Harm Reduction Coalition and uses they/them pronouns.

Although Bair eventually got a refill, Springgate, Stevens’ supervisor, didn’t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair’s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in patient portal notes reviewed by Ñî¹óåú´«Ã½Ò•îl Health News.

But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.

“This is the thing that kills people,” said Bair, who eventually found another doctor willing to prescribe.

Springgate did not respond to repeated calls and emails requesting comment.

University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens’ patients.

‘Reckless Behavior’

About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens’ return.

One student wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran , called Stevens a “lifeline” for vulnerable patients.

Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.

In May, the hospital’s review committee determined Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” according to a letter sent to Stevens.

The hospital did not answer Ñî¹óåú´«Ã½Ò•îl Health News’ questions about how it reached this conclusion or if it identified any patient harm.

Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state’s medical licensing board.

The medical board began its own investigation — a development that eventually cost Stevens the other job offer.

In presenting her side to the medical board, Stevens repeated many arguments she’d made before. Yes, she was prescribing powerful medications. No, she wasn’t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients’ circumstances, she said. Her response included a 10-page bibliography with 98 citations.

Liability

The board’s investigation into Stevens is ongoing. shows no action taken against her license as of late December.

The board declined to comment on both Stevens’ case and its definition of appropriate addiction treatment.

In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she’s grateful for the welcoming locals and the financial stability to support herself and her parents.

But it hurts to think of her former patients in New Orleans.

Before leaving, Stevens packed away handwritten letters from several of them — one was 15 pages long, written in alternating green and purple marker — in which they shared childhood traumas and small successes they had while in treatment with her.

Stevens doesn’t know what happened to those patients after she left.

She believes the scrutiny of her practices centers on liability more than patient safety.

But, she said, “liability is in abandoning people too.”

This <a target="_blank" href="/mental-health/addiction-medicine-harm-reduction-opioids-louisiana-doctor-battle/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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

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

Over the past year, The Marshall Project – Cleveland and Ñî¹óåú´«Ã½Ò•îl Health News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

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

Patients Wait or Are Turned Away

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

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

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

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

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

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

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

‘It’s Heartbreaking’

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

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

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

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

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

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

High-Profile Incidents

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

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

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

37-Day Wait for a Bed

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

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

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

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

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

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

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

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

Yet backlogs at the Ohio hospitals mounted.

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

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

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

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

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

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

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

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

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

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

Sick System

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

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

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

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

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

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

Escapes and a Lockdown

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

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

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

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

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

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

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

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

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

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

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

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

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

A Disaster That Wasn’t Averted

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

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

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

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

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

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

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

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

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

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

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

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

‘He’s Not a Throwaway Child’

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

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

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

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

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

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

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

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

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The effort, part of Baltimore’s more than $100 million gun violence prevention plan, relies on staffers like Fitzgerald to build trust with people at risk of such violence and offer them resources like housing or food. Researchers believe these programs reduce gun deaths.

Yet one morning in 2019, Fitzgerald said, his oldest son, Deshawn McCoy, then 26, was shot just outside of the neighborhood he patrolled at the time. Fitzgerald said McCoy was a “really beautiful soul,” who fixed dirt bikes at a local garage. McCoy became the city’s , one of 348 that year, among the city’s deadliest. He left behind three daughters.

“This is our zone,” said Fitzgerald, pointing toward McElderry Park. “My son got cooked over here.”

For years, violence intervention was the work of loosely organized, underfunded groups. Then gun violence spiked during the covid pandemic and the Biden administration and Congress poured in money to better integrate such programs within cities. It appeared to help: In Baltimore and beyond, gun violence has plummeted.

The number of homicides in the city dropped 41%, from more than 300 a year in 2021 to 201 in 2024, according to the U.S. attorney’s office in Maryland.

“Gun violence is a sticky, hard problem to solve,” said Daniel Webster, a researcher at the Johns Hopkins Center for Gun Violence Solutions in Baltimore. “We’re getting it right finally.”

Now President Donald Trump’s administration has gutted funding for that work.

Webster said it could take years to untangle what led to the city’s gun violence drop. Among the factors, he said: the pandemic’s end, investments in violence intervention, improvements that have given police more legitimacy in neighborhoods, targeted prosecutions, and an aggressive effort to remove untraceable ghost guns.

“You need all of these systems working well to have systemic reductions in gun violence,” he said.

The Trump administration has slashed funding for and research, cutting about $500 million in grants to organizations that support public safety.

At the same time, Trump has loosened gun laws the Bureau of Alcohol, Tobacco, Firearms and Explosives, which oversees gun dealers. He has also sent federal troops into the Democratic-led cities of Chicago; Los Angeles; Memphis, Tennessee; Portland, Oregon; and Washington, D.C.

Webster said cities are still benefiting from pandemic-era efforts to address gun deaths. But given the Trump policy changes, if violence escalates, city leaders could have a hard time keeping it from spiraling out of control.

Trying Something Different

Safe Streets is among the promising violence prevention programs that could lose funding. Staffers in the city’s most violent neighborhoods operate like community health workers.

During the pandemic, the Biden administration provided billions of dollars to local governments through the American Rescue Plan Act. Biden urged them to deploy money to community violence intervention programs, which have been shown to by as much as 60%. His administration to spend Medicaid dollars on such programs. The goal: Stop gun deaths.

Few cities seized the opportunity.

Analyzing federal data, professors Philip Rocco of Marquette University and Amanda Kass of DePaul University found local governments used the ARPA money for 132,451 projects. Yet only 231, less than 0.2%, involved community violence intervention, they said.

In Baltimore, then-newly elected mayor Brandon Scott was ready for the federal influx.

Baltimore’s homicide rate had been high since 2015, when a 25-year-old Black man named Freddie Gray died in police custody. Protests erupted and fractures between residents and police deepened. Baltimore ended the year with 342 homicides, the first time since 1999 that more than 300 were recorded in the city.

“We got really good at our jobs” in the years after Gray’s death, said James Gannon, trauma program manager at Sinai Hospital of Baltimore.

Gun deaths tracked what public health researcher Lawrence T. Brown called the : racially segregated areas that fanned out across Baltimore’s eastern and western neighborhoods around a wealthy central strip. People who faced years of forced displacement and disinvestment , which fueled the cycle.

Every year from 2015 to 2022, the city recorded at least 300 homicides.

“We had to try something different,” said Stefanie Mavronis, director of the Mayor’s Office of Neighborhood Safety and Engagement. Scott created the agency weeks after he was sworn into office in 2020, later with $50 million in ARPA money and $20 million annually from the city’s budget.

Containing an Outbreak

The office’s budget — $22 million in fiscal year 2026 — is a fraction of the city’s .

Still, the money allowed Baltimore’s leaders to scale up a new approach: addressing gun violence the way public health officials might handle an infectious disease outbreak, Mavronis said.

City staffers identified the small subset of people most at risk of being shot or becoming the next shooter through crime data and referrals from social service workers, hospitals, and violence intervention staff, she said. Mavronis said that gangs, friends willing to engage in violence for each other, and retaliation had been driving gun deaths in the city.

“This never-ending cycle of violence and loss and trauma,” Mavronis said, “comes from that.”

The city convened hospital presidents to connect gunshot victims and their friends and family to counseling, crisis support, and city services.

It offered people help finding therapy, a job, or emergency relocation — and threatened arrest and prosecution if they retaliated.

“We decided that we were no longer going to subscribe to the belief that one thing, one agency, one part of government, one program was going to help cure Baltimore of this disease of gun violence that has had a stranglehold on this city for the entirety of my life,” Scott said.

The Coming Cliff

Baltimore is on pace this year to post its fewest gun deaths since Richard Nixon was president.

“Some of it is the national zeitgeist of the moment,” said Adam Rosenberg, executive director of Center for Hope at LifeBridge Health, which operates Safe Streets sites and the Violence Response Team at Sinai Hospital. He credits mainly the infusion of funding that allowed more resources and hands-on engagement with high-risk communities.

“We typically talk about how poverty affects homicides, but it works in reverse too,” Webster said. “People don’t invest in homes and businesses or, frankly, in people, where people get shot regularly.”

Fitzgerald, who grew up in East Baltimore, said he started working for Safe Streets in 2010 for the paycheck.

He’s been on both sides of gun violence, he said, as someone hit more than a dozen times in shootings — first when he was 12. At 13, Fitzgerald said, he shot a cousin in the leg. Over years, he was in and out of the criminal justice system, including for charges of attempted murder, which helped him understand the people he now works with every day, he said.

No college “can certify you in my experiences in violence,” he said. “That’s what allows me to identify and detect potentially violent situations.”

Today, Fitzgerald, 49, believes that teaching kids trauma coping mechanisms can drive culture change and stop shootings.

“Our kids see more death than soldiers,” he said.

But federal funding is drying up. Anthony Smith, executive director of , which supports local leaders on gun violence reduction, estimates that about 65 groups have lost funding this year. And Trump’s signature legislation slashes nearly $1 trillion in anticipated federal Medicaid spending over the next decade.

Center for Hope lost $1.2 million from federal cuts.

“It’s like a car racing along, and you see the cliff coming,” Rosenberg said. “I don’t know if the resources are there anymore, but the need certainly is.”

Rosenberg said that, because of their experiences, staffers such as Fitzgerald are “incredible messengers” for people involved in gun violence, and he noted that they are thoroughly vetted.

Fitzgerald put it this way: “I’m trying to save my kids, the community. The people we’re trying to save is our friends and our family, and ourselves.”

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Fred Clasen-Kelly contributed to this report.

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“When you get shot,” he said, “you stop thinking about the future.”

He is anchored by his wife and child and faith. He once wanted to work as a forklift driver but has built a stable career in information technology. He finds camaraderie with other gunshot survivors and in advocacy.

Still, trauma remains lodged in his daily life. As gun violence surged in the shadows of the covid pandemic, it shook Harris’ fragile sense of security. He moved his family out of Philadelphia to a leafy suburb in Delaware. But a nagging fear of crime persists.

Now he is thinking about buying a gun.

Harris is one of tens of thousands of Americans killed or injured each year by gun violence, a public health crisis that escalated in the pandemic and churns a into a hospital emergency room every half hour.

Over the past two decades, the firearm industry has and stepped up sales campaigns through social media influencers, conference presentations, . An industry trade group acknowledged that its traditional customer was “” and in recent years began targeting and who are disproportionately victimized by gun violence.

The Trump administration has moved to reduce federal oversight of gun businesses, announced by the Bureau of Alcohol, Tobacco, Firearms and Explosives as “marked by transparency, accountability, and partnership with the firearms industry.”

The pain of gun violence crosses political, cultural, and geographic divides — but no group has suffered as much as Black people, such as Harris. They were nearly 14 times as likely to die by gun homicide than white people in 2021, , citing federal data. Black men and boys are 6% of the population but of homicide victims.

Washington has offered little relief: Guns remain one of few consumer products the federal government for health and safety.

“The politics of guns in the U.S. are so out of whack with proper priorities that should focus on health and safety and most fundamental rights to live,” said attorney Jon Lowy, founder of , who helped represent Mexico in an unsuccessful lawsuit against Smith & Wesson and other gunmakers that reached the Supreme Court. “The U.S. allows and enables gun industry practices that would be totally unacceptable anywhere else in the world.”

Ñî¹óåú´«Ã½Ò•îl Health News undertook an examination of gun violence during the pandemic, a period when firearm deaths reached an all-time high. Reporters reviewed academic research, congressional reports, and hospital data and interviewed dozens of gun violence and public health experts, gun owners, and victims or their relatives.

The examination found that while public officials imposed restrictions intended to prevent covid’s spread, politicians and regulators helped fuel gun sales — and another public health crisis.

As state and local governments schools, advised residents to stay home, and closed gyms, theaters, malls, and other businesses to stop covid’s spread, President Donald Trump kept gun stores open, critical to the functioning of society.

White House spokesperson Kush Desai did not respond to interview requests or answer questions about the Trump administration’s efforts to reduce regulation of the firearm industry.

During the pandemic, the federal government gave firearm businesses and groups more than $150 million in financial assistance through the Paycheck Protection Program, even as some businesses reported brisk sales, according to from Everytown for Gun Safety, an advocacy group.

Federal officials said the program would keep people employed, but millions of dollars went to firearm companies that did not say whether it would save any jobs, the report said.

About bought a gun during the first two years of the pandemic, including millions of first-time buyers, according to survey data from NORC at the University of Chicago.

Harris is keenly aware of what drives the demand.

“Guns aren’t going away unless we get to the root of people’s fears,” he said.

most Americans who own a gun feel it makes them safer. But public health data suggests that owning a gun of homicide and triples chances of suicide in a home.

“There’s no evidence that guns provide an increase in protection,” said Kelly Drane, research director for the . “We have been told a fundamental lie.”

Record Deaths

Less than a year into the pandemic, 20-year-old Jacquez Anlage was shot dead in a Jacksonville, Florida, apartment. Five years later, the killing remains unsolved.

His mother, Crystal Anlage, said she fell to her knees and wailed in grief on her lawn when police delivered the news.

She said Jacquez overcame years in the foster care system — living in 36 homes — before she and her husband, Matt, adopted him at age 16.

Jacquez Anlage had just moved into his own apartment when he was shot. He loved animals and wanted to become a veterinary technician. He was kind and loving, Crystal Anlage said, with the 6-foot-4, 215-pound physique of the football and basketball player he’d been.

“He was just getting to a point in life where he felt safe,” Crystal Anlage said.

Gun violence researchers say parents like Crystal Anlage carry trauma that destroys their sense of security.

Anlage said she endures post-traumatic stress disorder and anxiety. She is terrified of guns and fireworks.

But she has made something meaningful of her son’s killing: She co-founded the Jacksonville Survivors Foundation, which works to raise awareness about the impact of homicide and to support grieving parents.

“Jacquez’s death can’t be in vain,” she said. “I want his legacy to be love.”

His legacy and that of other young men killed by guns is muted by firearm manufacturers’ powerful message of fear.

During the pandemic, gun marketers told Americans they needed firearms to defend themselves against criminals, protesters, unreliable cops, and , filed by gun control advocacy groups with the Federal Trade Commission.

In a since-deleted June 18, 2020, from Lone Wolf Arms, an Idaho-based manufacturer, a protester is depicted being confronted by police officers in riot gear between the words “Defund Police? Defend Yourself,” the petition shows. The caption says, “10% to 25% off demo guns and complete pistols.”

Impact Arms, an online gun seller, on Instagram on Aug. 3, 2020, showing a person putting a rifle in a backpack, the document says. “The world is pretty crazy right now,” the caption reads. “Not a bad idea to pack something more efficient than a handgun.”

The National Rifle Association in 2020 posted on YouTube a of a Black woman holding a rifle and telling viewers they need a gun in the pandemic. “You might be stockpiling up on food right now to get through this current crisis,” she said, “but if you aren’t preparing to defend your property when everything goes wrong, you’re really just stockpiling for somebody else.”

The messaging worked. Background checks for firearm sales soared 60% from , the year the federal government declared a public health emergency.

The same year, more than , the highest number up till then. In 2021, was broken again.

Weapons sold at the beginning of the pandemic were more likely to wind up at crime scenes within a year than in any previous period, according to by Democrats on Congress’ Joint Economic Committee, citing ATF data.

Gun manufacturers “used disturbing sales tactics” following mass shootings in Buffalo, New York, and Uvalde, Texas, “while failing to take even basic steps to monitor the violence and destruction their products have unleashed,” according to a released by congressional Democrats in July 2022 following a House Oversight and Reform Committee investigation of industry practices and profits.

The firearm industry has marketed “to white supremacist and extremist organizations for years, playing on fears of government repression against gun owners and fomenting racial tensions,” the House investigation said. “The increase in racially motivated violence has also led to rising rates of gun ownership among Black Americans, allowing the industry to profit from both white supremacists and their targets.”

In 2024, then-President Joe Biden’s Department of the Interior provided a to the National Shooting Sports Foundation, a leading , to help companies market guns to Black Americans.

The Federal Trade Commission is responsible for protecting consumers from deceptive and unfair business practices and has the power to take enforcement action. It issued warnings to companies that made unsubstantiated claims their products could prevent or treat covid, for instance.

But when families of gun violence victims, lawmakers, and advocacy groups in 2022, during Biden’s term, how firearms were marketed to children, people of color, and groups that espouse white supremacy, officials did not announce any public action.

This summer, the National Shooting Sports Foundation pressed its and derided “a coordinated ‘lawfare’ campaign” that it said gun control groups have waged against “constitutionally-protected firearm advertising.”

FTC spokesperson Mitchell Katz declined to comment, saying in an email that the agency does not acknowledge or deny the existence of investigations.

Serena Viswanathan, who retired as an FTC associate director in June, told Ñî¹óåú´«Ã½Ò•îl Health News that the agency lost at least a quarter of the staff in its advertising practices division after Trump came into office in January.

Gun companies Smith & Wesson, Lone Wolf Arms, and Impact Arms did not respond to requests for comment. Neither did the National Shooting Sports Foundation or the NRA.

In an August 2022 , Smith & Wesson President and CEO Mark Smith said gun manufacturers were being wrongly blamed by some politicians for the pandemic surge in violence, saying cities experiencing violent crime had “promoted irresponsible, soft-on-crime policies that often treat criminals as victims and victims as criminals.”

He added, “Some now seek to prohibit firearm manufacturers and supporters of the 2nd Amendment from advertising products in a manner designed to remind law-abiding citizens that they have a Constitutional right to bear arms in defense of themselves and their families.”

Guns and Race

In 2015, the National Shooting Sports Foundation gathered supporters at a conference in Savannah, Georgia, and urged the firearm industry to diversify its customer base, according to a and reports from and the .

Competitive shooter Chris Cheng gave a presentation called “Diversity: The Next Big Opportunity.” Screenshots from the conference include slides purporting to show “demographics,” “psychographics,” and “technographics” of Black and Hispanic shooters.

The slides described Black shooters as “expressive and confident socially, in a crowd” and “less likely to be married and to be a college grad.” They said Hispanic shooters were “much more trusting of advertising and celebrities.”

Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety, said industry marketing shifted in the latter half of the 20th century as the popularity of hunting declined. The new sales pitch: guns for personal safety.

“They said, ‘We need to break into new markets,’” Suplina said. “They identified women and people of color. They didn’t have a lot of success until the pandemic, the Black Lives Matter movement, and the death of George Floyd. The marketing says, ‘You deserve the Second Amendment too.’ They are selling the product as an antidote to fear and anxiety.”

Gun manufacturers were harshly criticized in the Oversight Committee’s 2022 investigation for marketing products to people of color, as gun violence remains a leading cause of death for young Black and Latino men.

At the same time, some companies also promoted assault rifles to white supremacist groups who believe a race war is imminent, the investigation found. One company sold an AK-47-style rifle called the “Big Igloo Aloha,” a reference to an anti-government movement, it said.

Still, Philip Smith wants more Black people to get guns for protection.

Smith said he was working as a human resources consultant a decade ago when he got the idea to form the , which helped the National Shooting Sports Foundation compile its report on communicating with Black consumers.

Smith encourages Black people to buy firearms for self-defense and get proper training on how to use them.

After 10 years, Smith said, his group has about 45,000 members nationwide. Single members pay $39 a year and couples $59, which gives them access to discounts from the organization’s corporate partners, including gunmakers, and raffles for gun giveaways, according to its website.

The police killing of Michael Brown in Ferguson, Missouri, and the shooting death of Florida teenager Trayvon Martin helped spark early interest from doctors, lawyers, and others in joining the group, he said. But interest took off during the pandemic, he said, even among Democrats who had resisted the idea of owning a gun.

“Hundreds of people called me and said, ‘I don’t agree with anything you’re saying, but what kind of gun should I buy,’” Smith recalled.

Smith, describing himself as “quiet, nerdy, and Afrocentric,” said criticism of guns misses the point.

“My ancestors bled for us to have this right,” he said. “Are there some racist white people? Yes. But we should buy guns because there is a need. No one is forcing us to buy guns.”

‘American Amnesia’

During the pandemic, gun violence took its greatest toll on racially segregated neighborhoods in places such as Philadelphia, where roughly residents live in poverty.

A says a one-year period in the pandemic saw more than 2,300 shootings, or about six a day. Many of the cases haven’t been solved by police.

City officials cited the boom in gun sales in the report: Fewer than 400,000 sales took place in Pennsylvania in 2000, but in 2020 it was more than 1 million.

Gun sales since the pandemic ended, but the harm they’ve caused persists.

At a conference last year inside the Eagles’ football stadium, victims of firearm violence or their relatives joined activists to share accounts of near-death experiences and the grief of losing loved ones.

Paintings flanked the stage and the meeting space to commemorate people who had been fatally shot, nearly all young people of color, under messages such as “You are loved and missed forever” and “Those we love never leave.”

Marion Wilson, a community activist, said he believes the nation has forgotten the suffering Philadelphia and other cities endured during the pandemic.

“We suffer from the disease of American amnesia,” he said.

Harris was on his way home from a job at Burlington Coat Factory nearly two decades ago when robbers followed him from a bus stop and demanded money. He said he had none and was shot.

Harris had spent his early life fixing cars with his grandfather, when he wasn’t at school or attending church. He remembers lying in a hospital bed, overcome with a sense of helplessness.

“I had to learn to feed myself again,” he said. “I was like a baby. I had to learn to sit up so I could use a wheelchair. The only way I got through it was my faith in God.”

Harris endured years of rehabilitation and counseling for PTSD. As someone in a wheelchair, he said, he sometimes fears for his safety — and a gun may be one of the few ways to protect himself and his family.

“I’m mulling it over,” Harris said. “I’m afraid of my trauma hurting someone else. That’s the only reason I haven’t gotten one yet.”

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